Reducing multiple births: giving patients the best chance of a healthy baby

The most important message about reducing multiple births from In vitro fertilsation (IVF), is that our aim is to give patients the best chance of a live, healthy baby. At the heart of all we do are the patients, and ensuring the safest, high quality care, and best outcomes

As someone with a background in nursing and midwifery I know the challenges of multiple births for families, maternity and neonatal services, and staff in fertility centres. The most important message about reducing multiple births from In vitro fertilsation (IVF), is that our aim is to give patients the best chance of a live, healthy baby. At the heart of all we do are the patients, and ensuring the safest, high quality care, and best outcomes.

The recent Multiple births in fertility treatment 2019 report is an excellent review of how the HFEA and the fertility sector have successfully collaborated to reduce the IVF multiple birth rate from about 28% in the 1990s, to 6% in 2019.

Multiple births were recognised as a risk factor with IVF by Robert Edwards, the pioneer who, with his colleague Patrick Steptoe achieved the first successful IVF birth of Louise Brown 1974. His prediction proved correct and the birth rate of twins, and particularly triplets and quads, rose dramatically from the mid-1980s onwards in all countries where IVF treatment services were developing. The consequences of the over three-fold rise in triplets were revealed in The National Triplet Study (1991), published the year the HFEA was set up. The health risks for mothers and babies, the practical, financial, and emotional challenges for families, and the pressures on maternity services and neonatal units were even greater than anticipated.

The first HFEA Code of Practice required that no more than three embryos should be transferred; then, in 2001 it was changed to a maximum of two embryos, with three only in exceptional circumstances. By this time although triplets were decreasing, twin births were continuing to rise, so the HFEA commissioned an independent multidisciplinary expert group to review the impact of multiple births, and to recommend how this could be addressed. The report One child at a Time: Reducing multiple births after IVF was published in 2006. Professor Peter Braude, Chair of the Expert Group stated: “Multiple birth is the single biggest risk to the health and wellbeing of children born after in vitro fertilization (IVF). It can be effectively reduced by transferring one embryo to those women most at risk if having twins. The time has come to make this change to IVF practice in the UK.”

In response to the recommendations the HFEA established the Multiple Births Stakeholder Group (with multidisciplinary membership including patient representatives) and launched the One at a Time campaign.

There were two fundamental concerns with implementing the elective single embryo transfer policy. Firstly, how the live birth rates could be maintained while reducing the number of embryos transferred - and secondly, how we engaged with patients to inform them why elective single embryo transfers were being recommended.

Probably the most important outcome is that birth rates have continued to rise while the multiple birth rates has fallen

I have no doubt that the collaboration between the HFEA, professional bodies and organisations, and most essentially the patient representatives, was the main factor in achieving our goal. Workshops were held with staff from HFEA licensed centres, in which they shared their multiple births minimisation strategies, their difficulties and successes.

Crucially, we listened to patients to understand their views and any concerns they had. Workshops, led by Fertility Network UK, were held for patients, to give us the opportunity to learn how they perceived the elective single embryo transfer policy, and the information they needed to be reassured that the aim was to give them the best chance of a healthy live baby.

Probably the most important outcome is that birth rates have continued to rise while the multiple birth rates has fallen. This is detailed in the recent Multiple births in fertility treatment 2019 report, which also summarises the next steps to be taken. These include working with clinics who have still have a higher multiple birth rate than 10% and reviewing whether there should be a reduction of the 10% multiple birth rate target.

Continuing to work closely with patients is critical. We now need to learn from patients who have had treatment while the policy to reduce multiple births has been in place - and understand the most effective way to convey the risks of multiple pregnancy and why single embryo transfer is recommended.

There will always be some multiple births following IVF, and of course spontaneous conception of twins and triplets. For those who do conceive twins after treatment, this is usually a shock. It is essential that we continue to support parents who are preparing to care for two or more babies, and that we work towards improving outcomes from multiple pregnancies. At the Royal College of Nursing (RCN), a project is underway with fertility nurses, midwives and patient representatives to prepare guidance on the transition from fertility to maternity services, so all women and their partners who conceive after IVF have appropriate care in their individual circumstances.

Finally, the multiple births policy has demonstrated the effectiveness of collaboration across the sector, and the HFEA’s commitment to put patients at the heart of safe treatment, care and emotional support.

Jane’s background is nursing and midwifery with a specialist interest in infertility and genetics. Jane led the development of the nursing team in one of the first IVF programmes in the UK. As the implications of multiple births arising from infertility treatments began to emerge in the late 1980s, she moved to the MBF to address the problems and became Director in 1998. She has written and lectured extensively on all aspects of multiple births and has contributed to substantial change in public and professional attitudes towards them. She us a founder and co – lead of the Eliizabeth Bryan Multiple Births Centre.

Jane was sub-editor for nursing, counselling and ethics for ‘Human Fertility’, the official journal of the British Fertility Society (BFS) from 1998 until 2020.

A former member and deputy chair of the HFEA Authority and a founder member of the Royal College of Nursing Fertility Nursing Forum, Jane has wide experience of the clinical, scientific and ethical challenges presented by the advances in reproductive technologies.

Jane was made a Fellow of the RCN in 2006, an Honorary Fellow of the BFS in 2008 was awarded a CBE in the Queen’s Birthday Honours in 2007 for services to nursing and healthcare. She was President of the BFS from 2018 to 2021.