The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Monday, October 23, 2006

The Allure of Multiples

I don't get it. Right now in the NICU we have 18 babies. Of these, only 4 are singleton births. And one probably shouldn't count as a singleton because she started off as a twin but her sister died at 23 weeks gestation.

We have two sets of triplets, and all the rest are twins. I can't tell you the number of times I've heard women express the desire for twins. I'm not sure where the romanticized idea originated from, but I guess the idea of getting two children with one pregnancy or the attention that moms get when they walk down the street with a double stroller plays a part. Honestly, though... I just don't get it.

A normal pregnancy is one baby. That's what the human body was built for. A multiple pregnancy is a complication. Call it what you want... a miracle, a double blessing, whatever. I just feel that people don't understand the risks of what they're wishing for.

For starters, the most immediate risk involved with multiple births is pre-term labour. A typical, single pregnancy lasts about 40 weeks, but a twin pregnancy often lasts between 35 to 37 weeks-- and that's if they're lucky and stay put. Nearly half of all twins are born prematurely (before 37 weeks), and the risk of having a premature delivery increases with higher-order multiples. Prematurity carries an enormous amount of risks unto itself, the most common complications being feeding difficulties, sepsis and apnea (episodes where the amount of oxygen in the baby's blood falls to dangerous levels, usually due to immature respiratory drive). Then there is the risk of various twin-to-twin transfusion syndromes, where one baby essentially 'steals' blood and nutrients from the other, putting the smaller twin in danger of intrauterine demise. Now I'm no neonatologist (clearly) but why would anyone wish for a condition that would put their baby's health at risk?

And the risks aren't just to the babies. Women are not built to breed large numbers of offspring at once. Imagine all of the ways that pregnancy is hard on a woman's body. Now imagine them doubled. Preeclampsia, gestational diabetes, and placental problems are all more likely to happen in the case of a multiple pregnancy, and can be much more serious as well. The labour is also riskier, as regardless of the initial presentation of the multiples (even if they're vertex-vertex as opposed to one or more babies being breech) as soon as one baby is born the other frequently changes position. This often requires an emergency c-section, which is significantly riskier for both mother and baby than vaginal delivery.

I know... not my most lighthearted post. But it drives me crazy to hear another misguided mom express how much she's always wanted a multiple birth. Particularly when I've spent the last month caring for the complications of just this kind of 'miracle'.

An interesting article was published in the journal 'Fertility and Sterility' in 2004, examining the desire of infertile couples for multiple births.* They reported that 20% of infertile couples expressed a strong desire for a multiple pregnancy. In one way, it makes sense-- if these couples have had significant difficulties in conceiving, they probably figure that having more than one baby with a single pregnancy gives them more 'bang for their buck' so to speak. They end up with more children without having to go through the stress and financial strain of additional fertility treatments. Also not surprisingly, this desire was correlated with a lack of knowledge regarding the risks of twin gestations. The study concluded that patients need to be educated about these risks before attempting fertility treatments that put them at higher risk of conceiving multiple fetuses. No kidding.

I need to get out of the NICU. I have babies on the brain. Thank God I start full-time family medicine next week.

And before you ask, yes... all of the babies but one set of triplets and one set of twins were conceived on Clomid. So these are man-made multiples, not naturally occurring multiples. But I'm not getting into fertility treatments and their repercussions. That's a post for another day.

* Ryan, G.L., Zhang, S.H., Dokras, A., Syrop, C.H., Van Voorhis, B.J. The Desire of Infertile Patients for Multiple Births. Fertility and Sterility: 81(3), 500-504.

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Anonymous Anonymous said...

I totally understand, Pediatrics can become a totally trying discipline at times.
Nice blog, totally gripping. keep up the good ok if i add ur blog to my link list?

1:52 AM

Blogger Fat Doctor said...

I can't imagine having more than one at a time. One is a lot. Especially when they poop and cry and spit up all the time. It would take a woman more tolerant than I am to mother two or three or four of the same age.

9:10 PM

Anonymous Anonymous said...

The cost and frenzy and heartache of infertility can drive you to make decisions you would have never thought to make before you started the process. I remember saying very specifically that IVF/ICSI was my "line in the sand" and that I would not even go there. Well, when your Dh has very few motile sperm and you desperately want to be pregnant with his child, you WILL cross that line. I would have been blissfully happy with daughter would have a playmate and a sibling and we could avoid having to dredge up the courage, the hope, the sadness, the pain and the $$$ that is the process called infertility.

OTOH, NICU babies are their own can of courage, hope, sadness, pain and $$. You are right in your concerns that Reproductive Endocrinologists do not address these concerns at ALL...or at least they didn't when we went through the process. Actually, the chances of higher order multiples with IVF are less than with just plain Clomid alone. IVF is more controlled, more precise. Clomid is not so much.

This is a very hard road to judge unless you walked down that path.

9:46 PM

Blogger Couz said...

I'm not judging anyone for wanting a baby. I know enough couples that have struggled with infertility to be extremely sympathetic to their pain. Wishing for a baby is understandable.

Wishing for multiples is what I believe is naive and misinformed.

10:21 PM

Anonymous wealthandtaste said...


i've recently come across your blog and i am now a regular reader. i'm an undergrad doubling in math/ems, and at the moment i'm in paramedic school learning about the wonders of vec and roc. i just wanted to say thanks for the humorous and educational posts, they help me keep my eyes on the prize in terms of that vaunted goal of med school.

take care,

12:06 AM

Blogger Sarah said...

Well, luckily wishing for something won't make it happen. Hoping for multiples is harmless. You either have them or you don't, it's not like women have a choice. Don't let something so harmless drive you crazy.

8:42 PM

Anonymous Anonymous said...

I was once of the the naive ones who is a fog of baby delight thought multiples would just be dreamy. Until I had one child. One is lots and lots. Then I met moms of multiples (the ones you can spot with bags under their eyes permanently until the multiples hit about 3 years of age), and I honestly don't know how they do it.
Worse yet (IMO) would be to have multiples after a singleton birth- then you KNOW how good you had it :)

8:09 PM

Blogger Irishdoc said...

When i was on OB I was constantly shocked at the number of people who thought that a multiple gestation was no big deal. They figure they will just go on bedrest at the end. They have no idea what there in for

3:10 PM

Blogger Ex Utero said...


do you mind if I use this post in this weeks ped.s grand rounds?

3:37 PM

Blogger Couz said...

Sure you can. I'd submit to grand rounds (the general ones, anyway-- I assumed the peds one were just for peds bloggers!) myself but I haven't had the time to figure out how the process works!

4:13 PM

Anonymous Anonymous said...

I'm a "natural" (non-clomid) twin, and I couldn't understand how so many people could be routing for me to have my own set of twins when I got pregnant. Even people who knew that my mom's twin pregnancy involved months of bedrest, delivery at 35 weeks, and a complicated c section with extreme blood loss from a badly lacerated bladder still thought it would be fabulous for me to pop out my own set!

As blase as people are about the difficulties that come with twin pregnancies, people are even more clueless about what it means to *parent* twins once they come home from the hospital. Me, I thanked God I just had one baby at a time. And my twin feels the same way.

10:34 PM

Blogger Flea said...

You can't fight anectdote with anectdote, Couz, but I'll try.

As a pediatric generalist I can say I have never met a mom who claims to have wanted the multiples she got. In almost every case the folks were happy but enormously stressed by the experience.

I'm sure my parents were stressed when my sister and I were born, especially as they did not know that my mother was pregnant with twins until my sister was delivered. They scrambled and acquired extra everything.

I have 4 sets of triplets in my practice, two of which were "accidents", the other two were the results of assistive technologies. In one case, the stress generated is doing some damage right now.



7:20 AM

Anonymous Brooklyn Girl said...

Interesting post. I'm an infertile woman who finally had a son via IVF. I never wanted multiples, but I was willing to have them if that was the only way that presented itself.

When I did IVF, I transferred 3 embryos with the knowledge that all 3 could implant and grow. I told myself that I would consider selective reduction if it came to that, but when all was said and done, after everything we went to to get pregnant, I don't know if I actually could have done that.

I do think I was adequately counseled on the risks of multiple births by my RE, but I can totally understand how other parents might not let this information sink in. When it's so hard to get pregnant with one baby, it's hard to imagine the possibility that you could ever be pregnant with more.

7:45 PM

Blogger Dream Mom said...

My father was a twin and twins run in our family. I wanted twins too. Early on in my pregnancy, the obstetrician informed me that I may be having "multiple" births. My husband was relieved when the ultrasound showed only one. I joke now that I have one Dear Son who is the work of three.

8:09 PM

Anonymous David Harmon said...

Flea: Two sets of spontaneous triplets in the same practice??? Yow! When my sister had spontaneous twins (fraternal), and she tells me she was a "nine days wonder" at the hospital!

8:27 PM

Blogger JSmith5780 said...

I am the mom of a singleton and then a set of spontaneous fraternal twins. The pregnancy was actually pretty easy...until 32 weeks when my singleton began having severe seizures. The stress did me in and the twins were born at 35.4 weeks. The first was an easily vaginal but the second had a prolapsed cord requiring immediate c-section with me going under general. Not my idea of a good delivery. Once I finally woke up I was miserable. I made two decisions...1)I would find a way not to have another set of multiples if I had more kids and 2)if I did have more kids, no c-section would be involved.

Although they were born very healthy at 5lbs 15 ox and 6lbs, the first six months of their lives I felt I ignored them because of the older one's severe seizure disorder.

Makes me wonder why someone would want to have multiples and also why some women would CHOOSE c-sections??

10:40 AM

Anonymous Anonymous said...

I'm a mother of two-month-old twins conceived via injectible gonadotropins/IUI, born healthy at 36 weeks. I was as well-informed of the risks as I think it's possible to be. My mother is my reproductive endo's nurse, with 20 years' experience in infertility treatment, and she's seen all the horror stories and told me about all of them. Still, I hoped for twins, and proceeded with a treatment that had a very good chance of giving me twins or more -- I'm lucky to have just twins, rather than triplets or quads.

As I've said on my own blog recently, I don't really think it's possible for an infertility patient to adequately absorb information about the risks of twins. High order multiples, sure, everyone understands that those are bad, and you don't find very many women at all who wish for those. It's very hard to understand emotionally how risky and scary a twin pregnancy can be, though, until you've been there. I didn't get it myself until 14 weeks in -- before that, my fears were all about miscarriage and vanishing twin. Before I actually got pregnant, I was secretly absolutely convinced that I'd never get pregnant at all. The risks of a twin pregnancy seemed about as far-fetched to me as the risks of getting run over by one of Santa's reindeer; sure, I suppose it could happen, but you've got to bring yourself to believe in Santa Claus first before you can worry about it.

On the other hand, the benefits of twins are so easy to imagine. Pre-infertility, I'd wanted a big family, but I had (and have) serious doubts about whether I'd manage to get pregnant at all. With twins, your children are guaranteed to have a sibling, without your having to go through infertility treatment again. Now that my children are here, I know we'll want a third in a couple years, but I'd be okay, I think, if the third doesn't happen. I won't feel like I *have* to go through the whole infertility misery again, the way I think I would if I only had one child. And I'm young enough, and our infertility wasn't serious enough, to have the possibility of a second pregnancy. Older women, or those who are already having to turn to donor egg, know they get one shot at it, and the size of their family is the number of babies.

When "normal" people tell me they wished for twins, I take that about as seriously as saying you wish you'd had really curly hair, and there's no point explaining the negatives to them. However, I think it's a bit more understandable when infertility patients wish for twins, and pursue paths which can lead to multiples.

11:06 AM

Anonymous Anonymous said...

OK, I'm odd. My family has unbelievable twinning rates - mom, both grandmothers are twins. Mom's cousing had 2 sets of twins. Her side has ONE set of IVF/Medically induced twins. Grandma and Great-Grandma always said her twins were the easiest. (Kept one another occupied even as infants. Didn't make sense to me, either.) There is an odd reason for this. We have incredibly large babies in our families - average weight at birth is 9 to 14 lbs for singletons and 5 to 8 lbs. for twins. We, obviously, are not normal.

Dad's family has real familial identical twinning. (Grandfather, mother, and cousin's twin girls I know about.) And my husband's father is a fraternal twin.

I always assumed I would have twins. I was shocked to find myself dealing with infertility. I hope for a singleton or twin pregnancy out of fear of higher order multiples. (It's the identical twinning rate that scares me most for that.)

Lucky for me, the second RE I saw took those fears seriously - and understood that my particular medical history was not average. (Certain hormone levels would not run the same - and there is no non-medically induced early menopause in my family - average age of menopause being 60 for us.) He is being conservative.

I know it shouldn't, but it really bugs me that people go on and on about the epidemic of twins. Well, for some folks, it was always a risk due to genetic factors. And the human female is quite capable of carrying twins. HOMs are a different story. You hit triplets, quads, etc., and that is a much graver concern.

But, for some women twinning is already a familial trait, and with the increase in maternal age, there is a chance that particular subset of women would have had natural twins earlier if circumstances were different.



12:57 PM

Anonymous Vally said...

Strangely, I grew up in a small town where there were THREE sets of triplets (my sisters included) born in the same year -- all naturally conceived. Why anybody would wish this on herself is completely mystifying. You are, as usual, completely and utterly right.

11:26 PM

Blogger Psyche said...

I guess I'm an exception to the rule. I love having twins. I'm very happy with the multiples I got. And I refuse to play good mom - bad mom by telling everyone how my twins were conceived. It shouldn't matter. It shouldn't be anyone's business. I was shocked at the number of people (strangers!) who asked us how they were conceived.

In any case, having twins now is considerably less risky than it used to be. Not all of the twinning rate is due to infertility treatments, anyway. Women are much healthier than they used to be. Most aren't worn out with being pregnant most of their adult lives. Nutrition is better. Treatments for preterm labor exist. And good people like Flea exist who can care for premature babies. I think it likely that more twins survive with better outcomes than in any other time period.

Are twin pregnancies really so dangerous that we should expect women to forego childbearing entirely instead of accepting the risks? I frankly don't think so.

6:33 PM

Blogger Couz said...

Whoa, psyche! Putting words in my mouth much?

Please point out where on earth I suggested that people should forgo childbearing rather than risk a multiple gestation. Are you sure you read the post in question?

6:47 PM

Anonymous Anonymous said...

Careful Doc- TTTS (twin to twin transfusion) can only happen as the result of a monozygotic (identical) twin pregnancy.

Don't blame the victims.

2:45 PM

Anonymous Anonymous said...

My identical twin died in utero shortly before my premature birth. I spent my childhood in awe of the sister I would never know, and resentful of my older sister because she wouldn't dress like me and didn't want to have anything to do with me.

I have a hard time even saying the word "twin." It's painful. And while one part of me would like to have twins of my own, another part of me knows that it would be extremely difficult. I'm jealous enough of strangers I see who are twins: I think I'd resent my own children.

It's definitely a complicated issue for everyone involved.

8:47 PM

Anonymous Anonymous said...

I just came across this site and read the blogs. I had twins naturally 2yrs ago and I do love it! I will say that people who say they want twins are weird! I mean this in a nice way. My husband has twins on both sides of his family and I on my mom's so we kept asking what our chances were. We were told that I was only carrying one because of my size and they only heard one heartbeat. We found out we were having twins at my first ultrsound at 22 weeks! We were floored! We had to make it work. And we have so far. Money is tighter than if there was only one and one of had to quit our job to take care of them since daycare is so expensive and we didn't see having one of our incomes going just to pay for someone else to raise our children. People are blinded by seeing other people's children being cute so they miss the "behind the scenes". You don't get a break on your medical bills or food or diapers! I'm saying all of this with kindness so maybe someone who wants a multiple birth will think about the pros and cons of that. I do have to say that after writing all this, I am blessed in the aspect that now that they are older, I can get housework done or other things done with them since they do entertain each other! Sometimes that can be bad though. Anyone who has more than one child- multiple or not, knows what I'm talking about! Now, I do have a friend that had a miscarriage and is now undergoing IVF. She always wanted twins, until I had twins. Now she is a little nervous about IVF due to the chance of multiple births but she is willing to do it if it means having a child for her husband. I wish anyone who has multiples well, it is a road that will be bumpy and paved... just how you do it is what counts the most.

1:16 PM

Blogger carlajeanne said...

This comment has been removed by the author.

6:40 PM

Anonymous Anonymous said...

I'm 37 and carrying monozgotic (identical) twins. I'm sick of people asking how they were conceived. No, I was not taking fertility drugs. I had no problem conceiving. Despite popular belief, a woman's ovaries do not shrivel up on her 35th birthday. (This is my second pregnancy. The first ended in a miscarriage. Both times, I conceived right away.) Plus, the occurrence of identical twins is in no way, shape or form caused by fertility drugs, genetics or age. They're just one of the inexplicable things that happen in nature. To speak to your post, twins that share a placenta are the only ones in danger of TTTS, and identical twins are usually the only type of twin that shares a placenta; therefore, identical twins most commonly are the ones in danger of TTTS. So, following what I said earlier, that danger has nothing to do with fertility drugs.

By the way, I have no issue with your post. I just wanted to make the lack of connection between fertility drugs and identical twins, and the presense of a connection between identical twins and TTTS, very clear.

Nor do I have an issue with women who do take fertility drugs. I have many friends who have. I thank God we live in a day when women who desperately want to be mothers, and who would be wonderful mothers, but who may not be able to conceive naturally have ways of making their dreams come true. I wish them all the best with every fiber of my being.

I do, however, take umbrage at the people who ask such a personal question re: fertility drugs and who assume that if you are over 35, you're going to have to take them in order to conceive.

And being pregnant with twins myself, I am thrilled that I live in a day and age when twin pregnancies are not nearly as risky as they used to be. Yes, most definitely risky indeed, but much less so today than in former years.

Okay, now I'm done blathering on. :)

6:54 PM

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