THE DESIRE OF INFERTILE PATIENTS FOR MULTIPLE BIRTHS: A RE-EXAMINATION WITH UPDATED SOCIETAL GUIDELINES AND AN EVOLVING INFERTILITY INSURANCE LANDSCAPE

Twin pregnancies represent a serious complication of assisted reproductive technologies (ART). Twins have significant additional morbidity compared to singletons, including higher rates of preterm birth and perinatal complications including anemia, pregnancy-induced hypertension, antepartum and postpartum hemorrhage, and maternal mortality (1, 2). Physicians are acutely aware of the inherent risks of pregnancies and deliveries involving multiple fetuses. However, patients do not always share these concerns. A survey study published in 2004 from the University of Iowa showed that a sizeable number of infertile patients desired a multiple birth as a pregnancy outcome (3). Since this study was published, advancing techniques and technology have improved pregnancy and live birth rates in patients undergoing ART. Because of this, in 2017 the American Society for Reproductive Medicine (ASRM) and Society for Assisted Reproductive Technology (SART) updated their embryo transfer guidelines to promote singleton pregnancies and reduce multiple pregnancies. To re-assess the desire and examine predictors for multifetal gestation in an insurance mandated state and understand patient perceptions regarding maternal and fetal risks inherent in these pregnancies. This was a cross-sectional study of couples undergoing treatment at a university-based infertility clinic between February 2019 and September 2019. The study consisted of a 40-question previously validated digital survey (3) assessing baseline characteristics, demographic data, and knowledge regarding insurance coverage for fertility care. Patients were asked to rank treatment outcomes in order of preference (no child, singleton pregnancy, twin pregnancy, triplet pregnancy). Patients were asked true/false questions pertaining to risks associated with multifetal gestation to gauge understanding. Fisher’s exact and chi-square analysis were used to compare categorical variables and t-tests to compare two means were used to analyze continuous variables. 200 patients completed our survey, with a mean age of 35.5 (SD 4.0) years. 81% (162/200) were married with a mean partner age of 36.7 (SD 5.4) years. 31.5% (63/200) reported a multifetal gestation of twins or greater as the ideal treatment outcome, while 68.5% (137/200) preferred a singleton gestation. There was no significant difference in the mean age, partner age, marital status, education, religious affiliation or length of time trying to achieve pregnancy between women who preferred a multifetal gestation and women who preferred a singleton gestation (Table 1). The ideal family size was significantly different between women desiring a multifetal gestation and those desiring a singleton, 2.71 (0.75) children vs 2.33 (0.74), p=0.0008. Women who preferred a multifetal gestation were less likely to have an income > $100,000 per year, 59% (37/63) vs 78% (107/137), p=0.0065. Infertility insurance coverage is associated with differential preferences for pregnancy outcomes (p=0.001). 66% (90/137) of women who desired a singleton pregnancy were aware of their insurance coverage vs 43% (27/63) of women who desired multiples, (p=0.003). 89% (80/90) of women who desired a singleton pregnancy had infertility coverage as oppose to no coverage vs 67% (18/27) of women who desired multiples, (p=0.014). Both groups showed similar understanding of increased risk of preterm birth in twin (95.6% vs 93.8%) and triplet pregnancies (95.6% vs 95.4%). Patients desiring twin and triplet pregnancies, however, showed less understanding of increased maternal risk in twin pregnancy (63.1% vs 81.5, p<0.05), and increased risk of neonatal morbidity in twin pregnancy (18.5% vs 41.5% p<0.05) and triplet pregnancy (30.8% vs 53.3%, p<0.05). In this study we demonstrate that a significant number of patients undergoing fertility treatment still desire twin and triplet gestation. Interestingly, patients with a higher income and insurance coverage for fertility care are more likely to desire singleton gestation. This data suggests that patients perceive multifetal gestation as a cost-effective treatment strategy. Future research should evaluate if improved access to insurance coverage decreases multiple pregnancy rates. Additionally, the desire for multiples seems to also be associated with incomplete understanding of maternal and neonatal risks associated with multifetal gestation. We believe that targeted patient education regarding these risks may decrease patient desire for multiple pregnancy and help to bring patient and provider goals into better alignment