High-Order Multiples.

Septuplets were recently born at 28 1/2 weeks' gestation at a Washington, D.C., hospital. While some celebrated their arrival, they actually represent a medical tragedy, the result of a mostly outdated fertility method practiced by an admittedly inexperienced physician. Their birth was a consequence of a medical mistake that, sadly, is likely to be repeated.

Had this family come to me, I would have given them two options: If possible, go straight to in vitro fertilization (IVF), which is the preferred method because we decide how many embryos to transfer back into the uterus. Ovulation induction, with or without intrauterine insemination, is the other option, and that was what the mother of the septuplets had.

We place major emphasis on preventing multiple births, and induction is done only under certain circumstances. I cancel cycles if peak serum estradiol concentrations reach over 1,300 pg/mL or if the woman has seven to eight follicles. Our study of more than 3,000 treatment cycles showed that the risk of higher-order multiples--defined as three or more fetuses--increased when levels were above 1,385 pg/mL or when there were seven or more follicles (N. Engl. J. Med. 343[1]:2-7, 2000).

Following this criteria may mean that many cycles will get canceled and overall costs will increase. That's why we prefer women to go straight to IVF.

All of this is discussed with our patients before the start of treatment. Because higher-order multiples can occur even under the strictest possible criteria, I also raise the issue of selective embryo reduction as a last resort. If patients are opposed to selective reduction, one must be even more cautious during ovulation induction.

Our practice instigated a switch from ovulation induction to IVF in 1999. At that time about 70%-75% of our practice used to be ovulation induction, with the balance being IVF. Now it is completely the opposite--only about 25% is ovulation induction. IVF nor only controls the multiples risk better, but also yields significantly greater ...