Hum. Reprod. Advance Access originally published online on March 11, 2008
Human Reproduction 2008 23(5):1232-1233; doi:10.1093/humrep/den076
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LETTERS TO THE EDITOR |
Patient attitudes towards twin pregnancies and SET: a questionnaire study
1 INSERM, UMR S149, IFR 69, Epidemiological Research Unit on Perinatal and Women's Health, 16 Avenue P Vaillant-Couturier, Villejuif F-94807 France 2 Université Pierre et Marie Curie-Paris6, Paris F-75012, France 3 Hôpital Antoine Béclère, 157 rue de la Porte de Trivaux, 92141 Clamart Cedex, BP 405, France 4 Hôpital Saint Vincent-de-Paul, 74 Avenue Denfert Rochereau, 75014 Paris, France 5 15 rue Faraday, Centre de FIV Eylau La Muette, 75017 Paris, France
6 Correspondence address. E-mail: garel{at}vjf.inserm.fr
We read with great interest the article by Hojgaard et al., ‘Patient attitudes towards twin pregnancies and single embryo transfer—a questionnaire study’, in Hum Reprod 2007;22:2673–2678. The authors showed that most patients treated for infertility preferred to have twins (58%) rather than one child at a time (37.9%). The most frequent reasons given were ‘a desire for siblings, a positive attitude towards twins and a wish to have as few IVF treatments as possible’. They concluded that ‘an obligatory single embryo policy would conflict with patient interests and wishes’. These findings are consistent with most other studies showing an overall preference for twins rather than singletons; however, they deserve some discussion.
It is possible that the opinions expressed by these couples are above all a reflection of what is proposed to them. We know that couples being treated for infertility are prepared to do anything to be parents. They prefer to have twins than to be childless (Gleicher et al., 2006
). They do not tend to take into account the risks associated with twin births (Murray et al., 2004) and are more concerned about a high risk of failure than other factors such as the risk of severe handicap (Scotland et al., 2007). Their attitudes are affected by regulations governing the number of attempts allowed, by the management of costs in the patients' country (Gleicher et al., 2006) and their knowledge of the current results with ART (Blennborn et al., 2005).
The methods used to collect couples' preferences may mask more complex opinions. Virtually, all studies, including that of Hojgaard et al. (2007), explored couples' preferences using questionnaires. Structured self-completion questionnaires are unlikely to pick up detailed information about patients' feelings, specific experiences, concerns and contradictions (Pope and Mays, 1995). In a preliminary study of the reactions of women undergoing Friendly IVF (Olivennes and Frydman, 1998) and Standard IVF, we conducted semi-directed interviews with 20 patients (11 Friendly IVF and nine Standard IVF) 3 weeks after their first or second attempt in an ART centre at a Parisian hospital. At the end of the interview, we asked them to fill in a questionnaire. One question was used in both investigation methods: ‘Would you favor a twin pregnancy?’ In the questionnaires, the possible responses were ‘favorable’, ‘neutral’, ‘opposed to’ a twin pregnancy, and most patients (16/20) ticked ‘favorable’. In contrast, in the interviews, four patients replied without hesitating ‘favorable’ to a twin pregnancy. The other patients gave ambivalent responses and the preference for one child was apparent: ‘I would ideally prefer a singleton pregnancy but we would accept twins,’ or ‘One would be easier to handle but we are also prepared for twins’. During these interviews, the question about twin pregnancy aroused uneasiness. Patients were afraid to seem too demanding or excessively hard to please: ‘It does not matter. We'll take what we get’, ‘Ideally, I prefer one, but I'll accept twins’. It seemed to them paradoxical to consider that two is less desirable than one: ‘If we want a child, we should be happy to have two, but it scares me a little’. They avoided expressing what they considered unrealistic demands. The risk of a twin pregnancy was part of the treatment and they adapted their answers to the current possibilities of infertility treatment: ‘We prepared ourselves for a multiple pregnancy when we learnt that we needed IVF treatment, but one would be great’. This attitude sometimes existed well before attempting IVF treatment: ‘We accepted it at the beginning with Clomid: we have been taking the risk for six years!’
The consideration of couples' preferences for the choice of ART methods may be limited by only taking into account couples receiving treatment. To have a broader understanding of the wishes of couples who have difficulties conceiving, we should perhaps also observe those who decided not to undergo ART treatment. Some people may choose not to have these treatments because they do not want multiple pregnancies. It is also important to note that, in the absence of infertility problems, when a woman wants to become a mother she generally dreams of one baby; the possibility of having twins only generates positive reactions among a minority of women (Leiblum et al., 1990).
The study by Hojgaard et al. (2007), like all studies on couples' opinions about multiple pregnancies, reflects a certain reality. These studies may nevertheless underestimate the complexities involved in the wish to have a child for couples who have difficulties conceiving. Several years ago Gleicher et al. (1995) reported that a substantial number of couples receiving treatment would accept triplets. This attitude changed (Ryan et al., 2004) partly because progress in ART techniques meant that patients no longer feel that they reduce their chance of pregnancy by expressing a wish to have twins.
Using only currently available studies to develop a detailed understanding of couples' wishes and to justify procedures with a high risk of twin pregnancy may, to some extent, be approaching the problem from the wrong angle. If results with single embryo transfer improve, couples' attitudes will probably change and it is likely that more will be able to express their preference for singleton pregnancies.
References
Blennborn M, Nilsson S, Hillervik C, Hellberg D. The couple's decision-making in IVF: one or two embryos at transfer? Hum Reprod (2005) 20:1292–1297.
Gleicher N, Campbell DP, Chan CL, Karande V, Rao R, Balin M. The desire for multiple births in couples with infertility problems contradicts present practice patterns. Hum Reprod (1995) 10:1079–1084.
Gleicher N, Weghofer A, Barad D. A formal comparison of the practice of assisted reproductive technologies between Europe and the USA. Hum Reprod (2006) 21:1945–1950.
Hojgaard A, Ottosen LDM, Kesmodel U, Ingerslev HJ. Patient attitudes towards twin pregnancies and single embryo transfer—a questionnaire study. Hum Reprod (2007) 22:2673–2678.
Leiblum SR, Kemmann E, Taska L. Attitudes toward multiple births and pregnancy concerns in infertile and non-infertile women. J Psychosom Obstet Gynaecol (1990) 11:197–210.[CrossRef]
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Pope C, Mays N. Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. BMJ (1995) 311:42–45.
Ryan GL, Zhang HS, Dokras A, Syrop CH, van Voorhis BJ. The desire of infertile patients for multiple births. Fertil Steril (2004) 81:500–504.[CrossRef][Web of Science][Medline]
Scotland GT, McNamee P, Peddie VL, Bhattacharaya S. Safety versus success in elective single embryo transfer: women's preferences for outcomes of in vitro fertilisation. BJOG (2007) 114:977–983.[CrossRef][Web of Science][Medline]
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