Multiple child birth: developmental dilemmas

From the XVII European Congress on Perinatal Medicine

Hugo C. Verhoeven MD interviews Elizabeth Bryan MD, President of the International Society for Twin Studies

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Dr. Hugo Verhoeven:  “Good afternoon, my name is Hugo Verhoeven and I'm from the Center for Reproductive Medicine in Dusseldorf, Germany.  I'm reporting from the 17^th European Congress on Perinatal Medicine in Porto, Portugal.  I am on the Editorial Board of OBGYN.net, and it is an exceptional honor for me to talk today to Elizabeth Bryan who is a Pediatrician and President of the International Society for Twin Studies.  This society is an international, non-political, multidisciplinary, scientific organization and its purpose is to further research and public education in all fields related to twins and twin studies for the mutual benefit of twins and their families and of scientific research in general.  Elizabeth, we haven't known each other that long but long enough to give me the absolute feeling that I need to do an interview with you because I think in this field of research in twins you are a very important person.  Yesterday, I heard your lecture.  We know that the rate of multiple pregnancies is exploding worldwide and we know that one of the major reasons for that is the new techniques in artificial reproduction.  As discussed here at this meeting, we realize that we should educate the doctors performing reproductive medicine to take more responsibility for what's happening after their treatment.  We have the impression that many doctors say the pregnancy is there, that's it, and they're giving the problems to the obstetricians and to the neonatologists, and we heard here that they have considerable problems.  During your very important lecture yesterday, you were talking about some dilemmas that will certainly interest our readers and listeners.  Please repeat what you said yesterday to the audience of doctors here - do it for our listeners.”

Dr. Elizabeth Bryan:  “I think the important thing to remember is how difficult it is for a couple who are having difficulties with fertility to realize what it would mean to have three or more babies at the same time.  I think it is very difficult for them to imagine not only the pregnancy and the newborn period of their babies but also what life would be like for them as a family and for the children.  We know that if a mother conceives triplets, she is more likely to have a difficult pregnancy with complications, the babies are likely to be very premature, and we know that premature and low birth weight babies are much more likely to have long term complications such as cerebral palsy, and they are much more likely to die in the newborn period.  But what many parents do not realize is that even if they have three healthy children, those children may have difficulties in life, which they would never have had if they had been a single child.”

Dr. Hugo Verhoeven:  “That is a very important statement.”

Dr. Elizabeth Bryan:  “There are many children that find it difficult to be a triplet.  They are more likely to have difficulty in communication and language development but perhaps more importantly they have difficulty in relating to their mother and having to share that relationship with two brothers and sisters of the same age.  It's very difficult and the competition can be very intense and sometimes even aggressive.  Sometimes one twin will be left out completely and this will not only be unhappy for the child but also retard their development because they do not receive the attention and the stimulation that a normal single child would get.”

Dr. Hugo Verhoeven:  “But you also mentioned yesterday that there are a lot of dilemmas during pregnancy that you sometimes say - I have to do something with one baby but this has consequences for the other baby.  I do not want to go in detail, would you do that for me?”

Dr. Elizabeth Bryan:  “I think the dilemma that any couple face if they find they are having three or more babies is should they continue with the pregnancy or should they, in fact, reduce the number of fetuses down perhaps to twins.  It is particularly difficult for a mother with triplets to decide because on medical grounds alone it is a difficult balance because we know that the obstetric treatment and neonatal treatment will usually produce healthy children but not always.  So I think this is a very difficult dilemma for the parents when they have to consider the medical, social, and the psychosocial aspects.  I have spoken to many couples that are trying to make the decision as to whether they should have a fetal reduction or continue with their three or four babies.  One of the problems is that very often the mother and the father are not in agreement and this can be a very serious cause of concern and upset for the couple making this very difficult decision of which there is no right or wrong and there is no black or white decision.  Whatever you do, the outcome may or may not be happy, and it can never be ideal because even if you have two healthy babies at the end, you have the constant sadness that you have had to sacrifice one of more babies in order to have your two healthy babies.”

Dr. Hugo Verhoeven:  “What about the survivors?  Certainly you talked about this problem with your patients.  Do you tell them it's better to inform the survivors that they had one or two brothers or sisters who had to be sacrificed, and what are the survivors reaction of that?”

Dr. Elizabeth Bryan:  “This is a question that nearly all couples ask me - do we tell the children, and if we tell them, what shall we tell them?  At the moment, we do not know the answer to this question because there are no surviving children who have been followed long enough to know what their feelings would be.  I have met many couples that say they are not going to tell the children but if they do not tell the children, they must not tell anyone else at all because secrets come out.  On the whole, secrets are not a good thing in the family and so my own feeling is that it's probably best to tell the children but I have no evidence to say that that is correct advice and what you tell them is, again, a very difficult question.  We don't know the best nor do we know how these children may react.  They may be angry, they may feel guilty that they are the survivors, or they may just be grateful that the outcome for them has been good.  So it's a very difficult to know what they will feel about it.  I think probably the children should be honestly told that the parents felt that for their sake, the surviving children, that this was the best decision they could make although it was a very difficult decision.”

Dr. Hugo Verhoeven:  “We have the same problem in our specialty, should we inform children about the fact that they exist only after artificial insemination or after ovum donation - it's the same problem.  Shall we inform the kids - yes or no, certainly they find out sometimes.  Of course, it's a different emotional aspect.  I would like to go back now if possible to the morbidity of multiple pregnancies, you as a pediatrician know what is probably going on with twins and triplets from the medical side after they are born.  Could you tell us a little bit about the most common problems you have as a doctor with the newborns and with the parents?”

Dr. Elizabeth Bryan:  “I think the most common problems are back when the babies are born prematurely and are of low birth weight and must spend sometimes many weeks in our neonatal intensive care unit.  All mothers, be it with single babies or two or three babies, find that time very stressful and the fathers do too.  But if you have multiple births it is even more stressful because of the difficulty in relating to several babies at the same time.  We know from many studies that mothers who have a baby in intensive care find it more difficult to relate even to one baby and that this can have long term difficulties in their relationship but with two or three, you can imagine it is all the more difficult.  It is particularly difficult if one baby is much sicker than the other and maybe the mother will give more attention to one baby than the other.  It is very difficult if one baby dies, she needs to grieve and many mothers tell me how difficult it is to grieve for one baby and to celebrate the life of the other, and this continues to be a problem for many years.”

Dr. Hugo Verhoeven:  “From what you told us, many of the patients who are desiring artificial reproduction and many of the doctors who are performing those techniques have no idea, and I think one of the most important reasons for that is the lack of information.  So I think it's very important to stress once again that you are the President of a society that is not only doing research but also tries to inform patients, give them brochures and information material so that they know what they are talking about and that they know about the risks of that treatment.  Maybe you should give some more information on how you came up with this idea and how your society is functioning.”

Dr. Elizabeth Bryan:  “I'd like to say first that my main work for the last twelve years has been with the Multiple Birth Foundation in London, and the Multiple Birth Foundation's main aim is to educate those caring for these families and from the infertility treatment onwards, in fact, before the infertility treatment.  We have now published guidelines and leaflets, which are available not only to the professionals but to the couples before their treatment for infertility and later if they become parents of twins or triplets.  We also offer a telephone advisory service and a counseling service for couples before they start their treatment because the difficulty is that they can understand what the chances of having twins or triplets are but they often do not understand what the implications of that are.  It's no good just being told that you may have perhaps a 20% chance of having twins, you want to know what it means if you are pregnant with twins.  With the International Society for Twin Studies we want to do the same to spread the message, and we are very keen that infertility specialists should join our society because we know that there are many who are very responsible and who are trying hard to reduce the number of multiple births.  If they join us, then we can become a much stronger body to spread the message and influence our colleagues and we shall get this message across because the infertility specialists are causing great joy by producing many healthy babies but they are also causing great distress by creating these higher multiple births.  In a great majority these, it could have been avoided and that is what I think we must all learn and strive for.”

Dr. Hugo Verhoeven:  “My last question it is always the same, what do you expect in the future, what are your dreams as a pediatrician and as the President of the International Society for Twin Studies?

Dr. Elizabeth Bryan:  “My dream is that all infertile couples should have the baby they wish but a healthy baby and that they should not be faced with these dilemmas that can arise with multiple pregnancies.  Of course, some will have twins and for those who do have twins then my hope is that all those caring for them can be prepared for the difficulties that can arise so that these families can be supported, educated, and many of the problems will then be avoided.”

Dr. Hugo Verhoeven:  “Do you have some practical advise?”

Dr. Elizabeth Bryan:  “For the parents?”

Dr. Hugo Verhoeven:  “For the parents and for the doctors.”

Dr. Elizabeth Bryan:  “For the doctors, the best thing you can do is to introduce potential or expectant parents to others who have had the experience.  We need to develop a network of organizations for parents of twins and triplets, and this is something that we are very actively doing within the International Society for Twin Studies so that we work not only with the scientists and the clinicians but also with the parents themselves.”

Dr. Hugo Verhoeven:  “What you said is quite interesting because we have the impression, maybe not that much in the case of multiples, but bringing patients together with other patients who already had the experience in case of ovum donation or in vitro insemination, it's not that easy.  The patients don't want to talk about the past, and it surprised me that you say that's so very important.”

Dr. Elizabeth Bryan:  “It is completely different if you have twins or triplets because on the one hand you are very proud of your multiple birth children but on the other hand you are having great stress.  To get together to share, many parents find it difficult to admit to other people that they are finding it difficult because they want to be proud of their children and they don't want to say that it's very difficult.  But at the same time, they very badly need the support and they can support each other and be honest to each other.”

Dr. Hugo Verhoeven:  “My final remark is if we are counseling our infertile patients, most of the time I do it together with my andrologist and sometimes the boss of my endocrinology laboratory or somebody in the genetic department is coming with me.  Don't you think it should be a must of also having a neonatologist?”

Dr. Elizabeth Bryan:  “Absolutely.”

Dr. Hugo Verhoeven:  “It's part of the game.”

Dr. Elizabeth Bryan:  “Perhaps it's not a neonatologist but a pediatrician, somebody who is going to see the children on through their childhood.  That I think is very important, a neonatologist is excellent too but I think you need the pediatrician who works with the family for many years.”

Dr. Hugo Verhoeven:  “Elizabeth, thank you very much for this interview.”

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Reprinted with permission from OBGYN.net