Having children via surrogacy is an expensive endeavor. In an effort to grow their family quickly and to save cost, Intended Parents often seek to explore a twin pregnancy (double embryo transfer) versus having to repeat the process twice with singleton pregnancies (single embryo transfers). Additionally, Intended Parents are often attracted to the minimally higher success rate (pregnancy rate but not necessarily birth rate) per cycle for two embryos versus one embryo transfers. This article intends to lay out the risk/cost analysis of double embryo transfers and subsequent twin pregnancies versus two journeys with single embryo transfers and singleton pregnancies in an effort to inform and educate both Intended Parents and Gestational Carriers.
IVF has been around for 4 decades, recently celebrating the first IVF baby, Louise Joy Brown’s 40th birthday. Then and now, the majority of patients utilizing IVF were couples in their mid to late 30's. Statistical Data regarding same sex couples utilizing IVF only started to be collected by SART (The Society for Assisted Reproductive Technology) in 2017 and is not yet available. Ten to fifteen years ago it was standard practice within the industry to transfer multiple embryos (more than two) because the success rate was dismal; 10-20 percent successful pregnancies per transfer. That being said, there still was success and those successes often ended with high order multiples. In the last five years, IVF has made incredible strides in practice and technology and success rates have significantly increased to ~60% per transfer(https://www.ncbi.nlm.nih.gov/pubmed/26174052). Recognizing that there were an abundance of triplets and quad births that are highly dangerous for both babies and carriers, doctors stopped the practice of transferring 3 or more embryos unless the embryos are of poor quality. Fortunately for everyone including parents, children, carriers and their Maternal-fetal Medicine specialists, the rate of high order multiples significantly decreased. That being said, while the risks of twin pregnancies are less than that of triplet or quad pregnancies, there are still significant risks in twin pregnancies that need to be considered.
Babies: The main risk of twins remains prematurity. Unfortunately, obstetricians have not found a way to prevent preterm delivery in twins. Nothing has conclusively worked to prolong the twin pregnancy; in the end 50% twins are born premature/preterm (before 37 weeks) compared to 13% of singletons. Additionally, the risk is not limited to “late prematurity”( births between 34-37 weeks) but also “moderate prematurity” (gestational age 32-34 weeks) , “very premature” (gestational age 28-32 weeks) and “extremely premature” (gestational age <28 weeks) (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4438860/) Depending on the gestational age of the twins at birth, twins are 3-5 times more likely to develop severe disabilities, cerebral palsy, lower IQ (average lower by 5 points) and death. While “late premature babies (gestational age 34-37 weeks) have less risk of death and often spend less time in the NICU, “late premature” babies are more likely to have cognitive problems that develop later on: learning difficulties, behavioral problems, speech delays, ADHD and Autism Spectrum Disorder (https://source.wustl.edu/2015/07/preemies-at-high-risk-of-autism-dont-show-typical-signs-of-disorder-in-early-infancy). ACOG (The American College of Obstetricians and Gynecologists) went so far as to, in 2013, modify their recommendation for elective induction from 38 weeks to 39 weeks stating “deliveries before 39 completed weeks of gestation can pose both short-term and long-term health risks for the newborn. “(https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Definition-of-Term-Pregnancy)
Gestational Carrier: In addition to the risk posed to the twins themselves, there are additional risks to the Gestational Carrier. A carrier/mother pregnant with twins is at increased risk for C-section (over 75% twins in the USA are born via cesarean), high blood pressure, diabetes, hemorrhage and death (although rare). With the increased health risks, the carrier is also at greater risk for hospital admission and short- and long-term bed rest; both of which can significantly increase the overall cost of the surrogacy process and can create additional stress in carriers.
Intended Parents: While becoming a parent poses a unique set of hurdles for every family, parents of twins are faced with additional challenges, both social and financial. As discussed above, with the increased risk of NICU time and long and short term developmental short comings, one parent often needs an extended leave of absence from work and ultimately may need to leave their career altogether. Additionally, there is a greater risk for divorce in parents of multiples. An article first published in The Journal of Obstetrics and Gynecology sums up the risk of twin parents succinctly “Multiple births also reduce labor force participation by mothers, reduce educational spending towards siblings of children born in multiple births, and are associated with higher rates of divorce” (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3069855/)
Often times parents are attracted to a DET (double embryo transfer) and subsequent twin birth because of the extensive costs associated with the surrogacy process. Parents assume that by opting for two single embryo transfers, the cost is then doubled. This assumption is false as it does not account for the increased cost of multiples and the reduced costs in secondary journeys.
For reasons stated above, twin pregnancies can cost upwards of double the amount of singleton journeys when you factor in bed rest/lost wages for your gestational carrier, childcare for your GC’s children while on bed rest, additional compensation for the GC who is carrying a twin pregnancy, additional cost of a cesarean section both in medical bills and compensation to the surrogate for the procedure, NICU time for two children, lost wages for one or both parents who need a leave of absence from work either short or long term and additional child care costs once the babies return home.
In second journeys, there are reductions in cost in various areas. Often, agencies will give discounts for second journeys. Embryos have already been created and likely PGS/PGD tested. There is no need for an additional egg donor if one was needed originally. Additionally, the second journey is often significantly less stressful as the Intended Parents are educated, have reasonable expectations about the process and are more confident in their decision to pursue this avenue of family formation.
In summary, twin pregnancies provide elevated risks to Intended Parents, the children and the Carrier. Risks range from short- and long-term disabilities for twin babies to financial risks for parents and health risks for the carrier. While it is understandable to want to increase the rate of success in pregnancy, the success rate of double embryo transfers resulting in pregnancy is only a slight elevation from that of single embryo transfers. More significantly, double embryo transfers are 50% more likely to produce a twin pregnancy as opposed to 4-5% chance with a single embryo transfer. In short, in the risk -cost analysis of double embryo transfers and subsequent twin pregnancies, the risks are far higher in twin pregnancies with a minimal amount of cost savings vs. two single embryo transfers.
This blog was co-authored by Brooke Kimbrough, co-founder of Roots Surrogacy and Georges Sylvestre, M.D., Division Chief Maternal Fetal Medicine at NYC H&H/Elmhurt Hospital. Mrs. Kimbrough is a former Gestational Carrier and Dr. Sylvestre is a parent through surrogacy.