As found in Belgium in 2003, the cost of multiple pregnancies continues to present a strong argument in favour of elective single embryo transfer.
Multiple pregnancies have long been recognised as the cause of added perinatal risk for both the mother and the baby; the mother is at risk of such maternal complications as pre-eclampsia, gestational diabetes and preterm labour, while the fetus is at greater risk of morbidity and mortality. In ART these added risks have been confirmed in registry studies from Denmark, which show that on average IVF twins are born three weeks before IVF singletons and have a mean birth weight 1000g lower.(1) IVF twins have a perinatal mortality rate twice as high as IVF singletons, and substantially more are admitted to neonatal intensive care units.
There is also recent evidence - from analysis of the HFEA database in the UK - that even singleton deliveries following a vanishing twin are also associated with increased risk of preterm birth and low birth weight.(2)
It is equally well recognised that, compared with singletons, multiple-pregnancy infants consume significantly more hospital resources, particularly during the neonatal period and first year of life. A retrospective population study from Australia of more than 230,000 ART pregnancies found mean hospital costs of a singleton, twin, and higher-order child up to the age of five were $2730, $8993, and $24,411 (respectively in 2009-2010 US dollars), with cost differences concentrated in the neonatal period and during the first year of life.(3)
A similar real-life cost analysis based on actual hospital invoices in Belgium showed a significantly higher total cost (ART, pregnancy follow-up, delivery, child cost until the age of two) per multiple birth (mean €43,397) than per singleton (mean €17,866). A 50% reduction in multiple LBR resulted in a hospital cost reduction of 13%.(4)
Now, a new report from the HFEA and other UK institutions (including the RCOG) confirms that twin births are indeed almost three times as costly as singletons, with most of those added costs preventable with a SET policy.(5) Thus, based on several detailed (and complex) costing models used for the report, the mean cost of a singleton pregnancy in the UK over the period of pregnancy, birth, neonatal care and long-term disability is estimated to be £4,892; the costs of a twin pregnancy over the same period is £13,959.
The report adds that much of this difference in costs comes from the need for emergency Caesarean section, post-neonatal death, admissions to neo-natal intensive care, and a range of other conditions like cerebral palsy. Like all such reports, the UK analysis specifically attributes much of the increase in multiple pregnancies to ART, noting that ' multiple pregnancy is widely recognised as associated with IVF'.
In what is likely to be one of the most thorough and comprehensive health economic assessments of the subject yet, the report adds that most of the health problems of twins can be explained by prematurity and low gestational weight: 'About half of twins are born under 37 weeks gestation and 10% before 32 weeks, compared with 1% of singletons; and, as a rough estimate, IVF twins are born with a mean birth weight ranging between 800g and 1000g less.'
Belgian legislation, introduced in 2003 to provide up to six cycles of fully reimbursed IVF treatment to all women under 43, was based largely on a similar cost analysis of multiple pregnancies. Thus, a fully reimbursed strategy was only affordable if the number of embryos transferred was limited (to one initially), which only then would lead to a decrease in perinatal costs associated with multiple pregnancy.
While the UK has no obvious plans to introduce fully subsidised IVF, it is now clear that the financial cost of multiples nevertheless presents a strong argument in the case for elective SET alongside that of the health risks. The multiple rate in the UK had dropped to 11% by 2016 from just over 25% in 2008. Presently, says the HFEA, many clinics are achieving a target of less than 10% set by the HFEA.
However, ESHRE's own monitoring data continue to show that the highest target standards are set by Sweden. Provisional European data calculated for 2015 show that Sweden achieved a cumulative delivery rate (fresh + FER per aspiration) of 39%. with a multiple rate of just 3.8%.
1. Pinborg A. IVF/ICSI twin pregnancies – risks and prevention. Hum Reprod Update 2005; 11: 575-593.
2. Kamath MS, Antonisamy B, Selliah HY, Sunkara SK. Perinatal outcomes of singleton live births with and without vanishing twin following transfer of multiple embryos: analysis of 113 784 singleton live births. Hum Reprod 2018; doi.org/10.1093/humrep/dey284.
3. Chambers GM, Hoang VP, Lee E, et al. Hospital costs of multiple-birth and singleton-birth children during the first 5 years of life and the role of assisted reproductive technology. JAMA Pediatr 2014; 168: 1045-1053.
4. Peeraer K, D'Hooghe TM, Vandoren C, et al. A 50% reduction in multiple live birth rate is associated with a 13% cost saving: a real-life retrospective cost analysis. Reprod Biomed Online 2017; 36: 279-286.
5. A report by the National Guideline Alliance about twin pregnancy costing. https://www.hfea.gov.uk/media/2650/nga-twin-pregnancy-costing-final.pdf