Multiple pregnancies and assisted reproductive technologies

We are in the midst of an historically unprecedented increase in the incidence of multiple pregnancy. Throughout the 20th century, infant mortality has declined more than 90%, to 7.2/1000 live births. However, in the latter part of the 20th century, the decline in neonatal mortality is more attributable to improved rates of survival of low birth weight infants than to the reduction in incidence of low birth weight. Low birth weight is associated with longterm effects, such as neurological disorders, learning disabilities, and delayed development. Multiple births are 8 times more likely to be low birth weight than are singleton births. Half of all twins and 90% of all triplets and higher multiple births are low birth weight. Two possible sources of the observed increase in multiple births are increasing use of ovulation induction and increasing use of assisted reproductive technology (ART) procedures to treat infertility. In 1990, the Centers for Disease Control and Prevention (CDC) estimated that liveborn infants delivered as a result of ART procedures represented only 17.3% of quadruplet and 11.4% of quintuplet infants born in the United States. The costs of caring for the premature and low birth weight infant can range from $20,000 to $400,000 per baby, compared with less than $7000 for an uncomplicated birth. It is time to recognize that the cost of management of multiple pregnancy is an integral part of the cost of infertility treatment. Investigation into factors that could decrease the risk of generating multiple pregnancies while still optimizing the possibility of achieving pregnancy is essential. We should discourage insurance policies that favor such procedures as controlled ovarian hyperstimulation/intrauterine insemination (COH/IUI) over other ART interventions that are less likely to result in multiple pregnancies.