Obstetrics
Improvement in outcomes of multifetal pregnancy reduction with increased experience

https://doi.org/10.1067/mob.2001.108074Get rights and content

Abstract

Objective: This study was undertaken to evaluate a decade of data on multifetal pregnancy reductions at centers with extensive experiences. Study Design: A total of 3513 completed cases from 11 centers in 5 countries were analyzed according to year (before 1990, 1991-1994, and 1995-1998), starting and finishing numbers of embryos or fetuses, and outcomes. Results: With increasing experience there has been a considerable improvement in outcomes, with decreases in rates of both pregnancy loss and prematurity. Overall loss rates in the last few years were correlated strongly with starting and finishing numbers (starting number ≥6, 15.4%; starting number 5, 11.4%; starting number 4, 7.3%; starting number 3, 4.5%; starting number 2, 6.2%: finishing number 3, 18.4%; finishing number 2, 6.0%; finishing number 1, 6.7%). Birth weight discordance between surviving twins was increased with greater starting number. The proportion of cases with starting number ≥5 diminished from 23.4% to 15.9% to 12.2%. The proportion of patients >40 years old increased in the last 6 years to 9.3%. Gestational age at delivery did not vary with increasing maternal age but was inversely correlated with starting number. Conclusion: Multifetal pregnancy reduction outcomes at our centers for both losses and early prematurity have improved considerably with experience. Reductions from triplets to twins and now from quadruplets to twins carry outcomes as good as those of unreduced twin gestations. Patient demographic characteristics continues to change as more older women use assisted reproductive technologies. In terms of losses, prematurity, and growth, higher starting numbers carry worse outcomes. (Am J Obstet Gynecol 2001;184:97-103.)

Section snippets

Material and methods

A total of 3513 patients undergoing multifetal pregnancy reduction at 11 centers in 5 countries and their pregnancy outcomes formed the study material. There has been some evolution in centers and physicians with time, but the vast majority of procedures have been performed by a limited number of physicians throughout this series. Multifetal pregnancy reduction cases were considered to be reductions performed for the indication of fetal number per se. Those cases in which a fetal anomaly was

Results

The use of multifetal pregnancy reduction has steadily risen through the years, doubling in our study during the last 3 years. At some centers, however, there has been a plateauing during the past few years, which probably reflects the entry into the field of newer centers. The proportion of pregnancies initiated with assisted reproductive technologies has risen through the years to 70%, but the proportion of those cases resulting in quintuplets or higher-order multiples has fallen.

With

Comment

During the past 15 years, multifetal pregnancy reduction has become a well-established and integral adjunct to infertility therapy and subsequent attempts to deal with its sequelae. Our multicenter group has allowed us to follow the outcomes of the same physicians across time. In the mid 1980s the risks and benefits of multifetal pregnancy reduction could only be surmised.2, 3 We now have clear and precise data on the direct risks and benefits of the procedure and an understanding that the

Acknowledgements

Additional coinvestigators were as follows: Joanne Stone and Keith Eddelman, Mt Sinai Medical Center, New York; Rosalinde Snijders, King’s College, London; Lucia Tuliu, University of Milan; Jodi Lerner, Columbia University, New York; Yves Dumez, Nekker Hospital, Paris; Ana Monteagudo, New York University; and Alex Shalhoub, Mazin Ayoub, and Mark P. Johnson, Wayne State University, Detroit.

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Reprint requests: Mark I. Evans, MD, Department of Obstetrics and Gynecology, MCP/Hahnemann University, 245 N 15th St-MS495, Philadelphia, PA 19102.

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