Multiple Births with Fertility Drugs

As a Fertility Physician, one of the most frequently asked questions, and one of the largest concerns expressed by Fertility Patients regards the risk of multiple births. This concern has been exacerbated by the recent publicity associated with the birth of octuplets in California.

Why do fertility physicians not want to have pregnancies that result in multiple births?

Multiple births including twins can be associated with prematurity and other complications that jeopardize the health of the baby or babies. The higher the number of multiples, the higher the risk there is of prematurity and all of its associated complications. The bad outcomes associated with multiple births are associated with both immediate and long term problems. Immediate problems can include difficulties with breathing associated with poorly developed lung function. This often jeopardizes the immediate survival of these infants. Longer term problems may include poor development of the baby with possible long term physical and learning disabilities.

Fertility physicians are constantly walking the thin line between assisting the couple to achieve a pregnancy, but more importantly to ensure that the pregnancy produces a healthy infant that will live and develop a normal life. Unfortunately, in many cases, more aggressive treatment will lead to a higher pregnancy rate, but the downside of more aggressive therapy is the possibility of high order multiple pregnancies with all of their negative outcomes. Unfortunately, the Fertility Industry in the United States is a highly competitive field, with many of the treatments not covered by Insurance. Overheads associated with high tech fertility clinics are high, and clinics can be motivated by financial factors to "push the envelope" of therapy to ensure high rates of success. It is very important that the philosophy of the particular clinic encompasses the larger picture of not only producing a pregnancy, but producing a healthy baby by not compromising the health of either the mother or child.

Until recently, the Fertility Industry in the United States has been largely unregulated. ART clinics are now mostly reporting their results to the CDC in Atlanta Georgia. The CDC in conjunction with the Society for Assisted Reproductive Technologies has made major efforts to standardize the success rates of various clinics, so that consumers are able to make an "apple to apple" comparison of the outcomes of various clinics. In spite of these efforts, other variables that are not reportable may come into play in regard to measuring the outcomes of various clinics. An example may be that Clinic A is not willing to fertilize a small select number of eggs in Roman Catholic patients or other religious persuasions that may not want to deal with the ethical and moral issues of multiple embryos. Clinic A may want to be able to report higher success rates to drive further business and may not allow patients this therapeutic option. Clinic B, on the other hand may offer this type of therapy, knowing full and well that this may not lead to optimal embryo selection. With proper counseling, there are patients who may opt for the second option, knowing full and well that they may be compromising their chances of success.

What are some of the risks of multiples associated with various fertility treatments?

  • Clomiphene citrate (Clomid, Serophene) is the only FDA approved oral drug for ovulation induction. The generally accepted twin rate in patients using this medication is 10%.
  • Letrezole or Femara, which is frequently used for ovulation induction in North American, is not FDA approved for this indication. Twin rates with this medication approximate that with Clomid. The risk of triplets with either of these medications is rare, but not unknown.
  • Gonadotrophin therapy or Controlled Ovarian Hyperstimulation uses more physiologic or "natural" medications to induce ovulation. These medications have a much higher predilection for producing multiple pregnancies, particularly in women with Polycystic Ovarian Syndrome.
It is imperative that these cycles be closely monitored with ultrasound and blood tests, and that patients undergoing this therapy be counselled regarding the risk of unprotected intercourse in the treatment cycle until the number of developing follicles can be assessed. Most clinics will not proceed with these cycles unless there are two or fewer developing follicles. There may be extenuating circumstances where conception might be encouraged with three follicles, but that decision would only be made after considering a number of extenuating circumstances. The risk of multiple gestation in this instance should be clearly stated to the patient. In order to lessen the financial burden of these cycles, our clinics provide these cycles using a "global fee," so that couples will be aware of the exact cost of the cycle, regardless of the number of ultrasounds or blood tests required for those cycles.

In some ways In Vitro Fertilization can potentially lead to fewer multiple gestations than COH treatment. The American Association of Reproductive Medicine has published "Guidelines on number of embryos transferred." These are based on CDC/ASRM/ART data available in 2006.

The Guideline reviewed June 2008 includes the following considerations:

"The number of embryos transferred should be agreed upon by the physician and the treated patient(s), informed consent documents completed, and the information recorded in the clinical record. In the absence of data generated by the individual program, and based on data generated by all clinics providing ART services, the following guidelines are recommended.
  • A. For patients under the age of 35 who have a more favorable prognosis, consideration should be given to transferring only single embryo. All others in this age group should have no more than 2 embryos (cleavage-stage or blastocyst) transferred in the absence of extraordinary circumstances.
  • B. For patients between 35 and 37 years of age who have a more favorable prognosis, no more than 2 cleavage-stage embryos should be transferred. All others in this age group should have no more than 3 cleavage-stage embryos transferred. If extended culture is performed, no more than 2 blastocysts should be transferred to women in this age group.
  • C. For patients between 38 and 40 years of age who have a more favorable prognosis, no more than 2 blastocysts should be transferred. All others in this age group should have no more than 4 cleavage-stage embryos or 3 blastocysts transferred.
  • D. For patients greater thana 40 years of age, no more than 5 cleavage-stage embryos or 3 blastocysts hould be transferred.
  • E. For patients with 2 or more previous failed IVF cycles, or a less favorable prognosis, additional embryos may be transferred according to individual circumstances after appropriate consultation.
  • F. In donor egg cycles, the age of the donor should be used to determine the appropriate number of embryos to transfer.
These recommendations are voluntary at the current time. However, if physicians violate these recommendations, it certainly invites future Governmental intervention, and places the physician and program at risk for legal liability.

In summary, then, the ideal goal of fertility treatment should be the production of a healthy, low risk pregnancy. While many circumstances prevail that may mitigate more aggressive therapy, one should never lose sight of the fact that multiple pregnancies are often associated with undesirable outcomes, and that the higher the order of multiples, the greater the risk of poor outcomes.

Successful Breastfeeding

Choosing to Breastfeed

You have most likely heard of the benefits of breastfeeding. The World Health Organization and the American Academy of Pediatrics, as well as other organizations such as La Leche League, all promote breastfeeding as best for your baby. While infant formulas are safe, effective, and vastly improved over previous formulations, breastmilk is superior in that it is easy to digest, nutritionally complete, and contains components to help fight disease which are not able to be reproduced in even the best infant formula. Additionally, breastfed babies have a lower incidence of Sudden Infant Death Syndrome (SIDS). 

Hormonal changes in the mother who breastfeeds are reported to improve healing and slow bleeding after delivery. For some, it is important to know that breastfeeding is less expensive than formula feeding, even for those who purchase a high quality breastpump. Also, breastfed babies usually spend less time at the pediatrician's office for illnesses. Most mothers are able to breastfeed and most babies will breastfeed without difficulty. However, there are some mothers for whom breastfeeding may not be the best choice. Occasionally, your doctor or pediatrician may recommend formula feeding if you are on certain medications or have certain medical conditions.

It is generally best to allow 2 weeks of exclusive breastfeeding to establish a good feeding relationship with your baby. However, as important as exclusive breastfeeding is, it is not the only option. Feeding your baby an occasional bottle of formula or expressed milk after the first two weeks of breastfeeding should be possible. This will allow other family members to participate in caring for the baby and give you a much needed break. This may be especially important if you have twins , triplets, or a high-needs infant.

What to Expect in the Hospital

Generally, if your labor and delivery was uncomplicated, you should be able to initiate breastfeeding within the first hour after delivery. You should communicate with your health care team your desire to breastfeed and how soon you wish to initiate a feeding. Often, visitors wish to come into the room as soon as possible. You should discuss any special wishes regarding visitors with your nurse and doctor. Some newborns are ready to breastfeed within minutes of delivery, while others show no interest in the breast for hours. Offering the breast to your baby in a quiet room with limited visitors is usually more comfortable for the mother. 

Your needs will vary and it is important to be flexible. Some new mothers benefit from 1-2 hours alone with their infants prior to letting visitors in the room, but this is not mandatory for a successful breastfeeding relationship. It is important that your family and friends understand you may need to be alone at frequent intervals to feed the baby, as often as every three hours and for as long as an hour at a time. You should also remember that you will require some private time for special treatments, medications, or discussions with your nurses and/or physicians.

In the early days, your baby will be getting colostrum from your breasts. This is exactly what the baby needs at this time. Most hospital stays are 1-2 days for a vaginal delivery. In this situation, you will most likely be producing colostrum until you leave the hospital. Breastfeeding your baby on demand will give you the most successful experience. If the baby is awake, chewing on his hands, or rooting (turning his head and opening his mouth), he is ready to breastfeed. It is very common for babies to "cluster feed" – feeding every one or two hours for several feedings and then taking a longer 4-6 hour break to sleep. This is normal. Use these longer breaks to rest or snuggle with the baby. As long as the baby is healthy, having the appropriate number of wet diapers, and sleeping between feedings, she should be getting enough to eat.

It is very common for newborns to lose some weight in the early days of life. You will notice that the baby has a very dark, sticky stool called meconium. Some babies stool once a day, others will pass meconium with every feeding. Babies are also born with extra fluid stores. Passage of the meconium and extra fluid accounts for the weight loss in the early days of life. As long as your baby does not lose too much weight too fast, and has regained to his birth weight by 2 weeks of age, then breastfeeding is going well. Your health care providers will usually weigh the baby often and alert you to problems. They will also wish to examine the baby. Try to work with them to schedule or allow these exams at a time when the baby is getting ready to eat but not too hungry.

If you have a boy and he is circumcised, you may notice that he is especially tired after the procedure. This is common. Continue to breastfeed on demand, but alert your nurses to any concerns you may have.

One common experience is the second night "fussies." At about 12-24 hours of age, many babies will wake up frequently, but fall asleep as soon as they are put to the breast. This pattern will repeat as soon as you try to lay the baby in the crib. Ask the nurses or your support person to help you by snuggling with the baby, offering the pacifier to the baby if you desire, or soothing the baby while you rest. You may also trying putting the baby to the breast and gently unlatching the baby by sliding your finger into his mouth to break suction after he has entered deeper sleep. Easing the baby into the crib may be easier at this point.

Special Cases

If you have had a complicated labor and delivery, or if your baby requires special care, you may not be able to initiate breastfeeding for hours, days, or, in rare cases, for weeks, or it may become necessary to supplement your newborn with infant formula. You may be concerned about bonding with the baby or how this will affect your breastfeeding experience, especially if you are separated from your baby. In even the most complicated cases, it is usually possible to begin using the breastpump within 24 hours of delivery. Using a double electric pump for 15 minutes every three to four hours will encourage milk production. You will probably express very small amounts of colostrum for a few days (as small as a few tablespoons each day). This is normal. Any expressed milk can be saved for feedings. 

When your baby begins oral feedings, these are usually done with syringes, feeding tubes, or finger feedings by staff or parents, and will advance over hours to days to feedings at the breast or by bottle. Try to rest as much as possible, and focus on other ways of caring for and bonding with your baby as the occasion allows.

What to Expect at Home

If you are discharged home with your baby within 2 days, you will most likely not be producing milk. This is normal. By the fourth or fifth day after delivery, you will notice that your breasts are engorged, which means they are full of milk. You may also feel very irritable and cry easily. Often, the baby will have difficulty latching on because of the engorgement. It is a good idea to gently express some milk with your hand or massage your nipple until it is soft enough for the baby to latch on. Usually, the engorgement will resolve in 24-72 hours. Pumping at this time will only increase your milk supply and prolong the engorgement. However, if you are unable to tolerate the discomfort, you can try pumping just enough to feel better. This will also make it easier for the baby to latch on. It is important to remember that this is a difficult, stressful time for some new moms, as they may feel overwhelmed. It usually only takes 1-2 days before the engorgement has passed and you will be feeling more confident in your breastfeeding abilities.

You will probably also experience nipple discomfort if you are having difficulty getting the baby to latch on. Applying lanolin cream to your nipples after feedings, using breast shells to keep your bra from rubbing on your nipples, and avoiding using soap on your nipples may help with the discomfort. Finally, your hospital or pediatrician may be able to provide advice over the telephone if you need it. See if your hospital or pediatrician has a lactation consultant or nurse line where you can ask advice.

Special Cases

If your baby was premature, or if you had a cesarean delivery, you may find recovering at home more difficult than you expected. Try to arrange for help from family and friends prior to leaving the hospital and allow people to help you. Your own recovery, combined with the demands of caring for a newborn, can be tiring. You may have frequent follow-up visits for yourself and/or your baby. Some newborns may require special medications or supplemental feedings. Often, you will have to return to the pediatrician's office several times in the first few weeks. Your pediatrician or care provider should ask you about breastfeeding and provide information and support as well as evaluate the baby's growth, frequency of feedings, wet diapers, and general well-being. You should have a support person present for these visits. This support person can help you remember pertinent information, provide assistance, keep records, and notify other family and friends about yours and the baby's progress.

Helpful Tips

Breastfeeding is a natural process and can come easily to some women, while others may need help. Almost all breastfeeding mothers require some type of support and encouragement. You can do it. Here are a few helpful tips:

  • Allow the nurses to help you as much as you need it while in the hospital. You will need at least 1 hour of quiet time to feed the baby and care for yourself every 2-3 hours.
  • Try to feed on demand. Look for early feeding clues, such as rooting, sucking on hands or fingers, or quiet awake times. Your best success will be if the baby initiates the feeding. Often, these periods will last only 20 minutes, so its best to initiate the feeding as soon as possible.
  • Most babies are very sleepy in the 12-24 hours after birth. Try waking the baby every 3 hours during the daytime if he does not awaken on his own. If the baby is ill-appearing or lethargic, alert your nurse or pediatrician immediately.
  • Check for wet diapers and stools. If the baby has 2-3 wet diapers in a 24 hour period and at least one stool, this is normal for the first 2-3 days. Once your milk comes in or by the fourth day, the baby should have 6-8 wet diapers in a 24 hour period. This should reassure you that feeding is going well.
  • Before you begin feeding, make sure you are in a comfortable position. It is helpful to have a large glass of water nearby, as you will probably notice that you become thirsty while feeding. Drinking plenty of water is important (usually 2 liters or more a day).
  • Bring the baby to your breast in the hold that is most comfortable for you – cradle, football, or cross-cradle holds are most common. If you are able, you can breastfeed very comfortably in a side-lying position. Tickle the baby's lips with your nipple. When the baby opens his mouth, bring his head to your nipple. Do not stretch your breast to reach his mouth. Most babies begin sucking immediately. Relax your shoulders and arms and rest as much as possible during the feeding. Allow the baby to suckle as long as he desires. After 20 minutes, if he is still feeding, gently break suction with your finger and try to burp him. Then allow him to nurse on the other side if he wants to. Some babies will nurse for 20 minutes on each side for every feeding. Some babies will be full after 10 minutes of feeding, but feed more frequently. Getting to know your baby takes time.
  • Burp your baby after the feeding by gently patting his back and holding him upright for about 10 minutes. This will also help prevent the baby from spitting up. A small amount of milk may come up with a burp. Sometimes the baby will regurgitate some milk and swallow it without problem. This should subside as the baby gets older.
  • Remember which side you started the feeding and start the next feeding on the opposite side.
  • It is usually best to change your baby's diaper after a feeding instead of before the feeding.
When to Call Your Doctor

You should call your obstetrician if you have signs of mastitis, which is an infection of the breast. This is more likely if you have cracked and bleeding nipples and feeding difficulties. These signs include:
  • Severe pain in the breast.
  • Redness or streaking in the breast.
  • Chills and a fever above 101.
  • Flu-like symptoms including malaise, aches and pains.
Call your pediatrician for questions or concerns, or if the baby has any of the following:
  • Less than 3 wet diapers in 24 hours by the second day.
  • Less than 6 wet diapers in a 24 hour period by the fourth day.
  • Refusal to eat for 2 feedings.
  • Vomiting (occasional spitting up should not concern you.)
  • Difficulty waking for feedings.
  • Very irritable or inconsolable.
  • High-pitched cry.
  • Fever.
  • Yellow color of the skin or eyes (jaundice).
  • If you think the baby is very hungry or not getting enough to eat.