"Along with many infertility specialists, we have been alarmed by the large numbers of twin pregnancies resulting from infertility treatment, and especially IVF", she said. "But we also noted that patients seemed much less concerned by twin pregnancies than we are and, indeed, many desire this outcome."
Dr. Ryan and her team had previously researched infertility patients' wishes for the outcome of pregnancies, and found that desire for multiple births was associated with having no previous children, lower family income, younger patient age, longer duration of fertility and lack of knowledge regarding the risk of having twins. The team decided to evaluate whether improving education on these risks could improve understanding and have an effect on IVF patients' desire for multiple pregnancies.
110 couples took part and completed 2 questionnaires; after the first, which asked, among other things, how many children were desired from a pregnancy, a one page description of the risks of twins to the children and the mother was distributed and discussed. Afterwards, the questionnaire was completed again.
Following discussion of twin risks, significantly more patients ranked singletons as their most desired treatment outcome (86% as opposed to 69% first time round); and significantly fewer chose twins (14%, versus 29% first time round). "On both pre and post-education questionnaires, the most common reason for preferring twins was 'I want to reach my ideal family size more quickly'", said Dr. Ryan. "There was still a significant minority that preferred this option, even having been informed of the risks."
Dr. Ryan has been unable to study whether this increased theoretical desire to avoid twins by some patients has translated into action, since her IVF clinic has now instituted a mandatory policy of single embryo transfer. The team intend to follow this up by studying overall pregnancy and delivery rates, and twin rates, and by evaluating patient satisfaction with the new policy.
"The clash we have noted between patient desires for twins and physicians' concerns for twin risks comes at an interesting time for biomedical ethics", she said. "Patient autonomy has become the most valued ethical principle in today's medical decision-making process. However, doctors feel that their principles of non-maleficence – 'do no harm' – and integrity – 'do what you feel is best given your medical knowledge and training' - are equally important. Added to this there is the burden caused by multiple births both to society and to healthcare systems, which have to operate with finite resources. All these are important ethical considerations and a way to balance them needs to be found", Dr. Ryan said.
In another presentation to the conference, a scientist explained that, despite health professionals' desire to transfer only one embryo per IVF cycle, patients often felt quite differently. Professor Jakob Ingerslev, from the Fertility Clinic at Aarhus University Hospital, Aarhus, Denmark, said that he had carried out the biggest ever study to ascertain patients' attitudes to the question of singleton babies versus twins and had found that most infertile patients preferred to have twins as a way of completing their family more quickly and with a minimal number of treatments.
In response to a questionnaire, 58.7% of the 414 women and 404 men from couples undergoing treatment at his clinic said that they would prefer to have twins to have one child at a time (37.9%), while only 3.5% claimed to be indifferent. 78.5% wished to have two embryos transferred in future treatments, while only 6.2% wanted to have single embryo transfer (SET). Even among the 229 respondents who preferred one child at a time, 81.2% wanted to have double embryo transfer in their next treatment.
Patients did not simply opt for double embryo transfer because of the wish for a high success rate or in order to avoid more treatments; our study shows that there is a deliberate wish to have twins in the majority of couples", said Professor Ingerslev. "This means that patient attitudes are often in conflict with the present trend for SET, and the fertility specialist has a difficult task to navigate between respect for patient autonomy and professional considerations when it comes to twin births."
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