There is a recent and strong trend in western countries to advocate single embryo transfer (eSET). The rational behind this trend is to avoid complications of multiple pregnancy after IVF. However, we would urgue that twin pregnancy is totally different from high order multiple pregnancy and the long term economic analysis of twin pregnancy has never been explored before. We tried to calculate the risks and benefits of twin pregnancy from a society perspectives. Based on our model, it seems that double embryo transfer (DET) is still a valid option.

1. TWINS AFTER IVF:
REVISTED
kasr al ainy school of Medicine
Cairo University
ِ ‫ه‬‫اَّلل‬ ِ‫م‬ْ‫س‬ِ‫ب‬ِ‫ن‬ َٰ‫م‬ْ‫ح‬‫ه‬‫الر‬ِ‫يم‬ ِ‫ح‬‫ه‬‫الر‬

2. WHAT IS THE PROLEM?
 Current era is to advocate SET
 Still in our region we adopt TET

3. WHY THIS PROBLEM?
 It is widely perceived that twin pregnancy is a
complication of ART
 Due to increased neonatal and maternal morbidity ,
hence increased cost on society
 We would argue that this is not true

4. HOW TO PROVE THAT ?
 First : to distinguish between outcome of twins vs as
high order multiple (HOM) pregnancy
 Second : Economics are life related not only related to
neonatal period (Long term economics)
2/5/20164

5. FIRST: TWINS ARE NOT HOM
 Rate of complications in twins are much less than
HOM if we compare both to singleton pregnancy
(Van Wely, 2006)

6. PRETERM BIRTH
 Twins vs HOMs were 18.7 and 525.1 times,
respectively, more likely to be preterm
18.7 vs 525.1 X
CHAMBERS ET AL, 2014

7. PERINATAL DEATH
 Compared with singletons, twins and HOMs were
6.4 and 36.7 times, respectively, more likely to die
during the neonatal period.
6.4 vs 36.7 X
CHAMBERS ET AL, 2014

8. LONG TERM SEAUELAE
 Pinborg et al. 2004 reported that twins between two
and seven years of age have a similar risk of
neurological sequelae and cerebral palsy compared
to singletons of the same age.

9. WE AGREE
 Short term health service costs associated with twin
pregnancies are much higher than for singletons as
was shown in several publications

10. THEY ALWAYS TALK ABOUT THIS

11. BUT THEY NEVER TALKED ABOUT THIS

12. AND THOSE

13. GAP IN EVIDENCE
 the long term benefits of having a twin was never
compared to having a singleton
 This is important for developed countries that are
demonstrating negative population growth and are
actively seeking ways to reverse low birth rates.
 Long term benefit means production during his/her
life (between 18-59)

14. PRODUCTION PER PERSON
 In 2014, the average employed human capital
stock per head of working age population was
£448,358 (Mallett and Monahan, august 2015)

15. OBJECTIVE
 to evaluate from a community based view how
lifetime revenues from twins compare to singletons

16. METHODOLGY
 comparing capital stock per head of working age
(Connolly et al, 2008) from 1000 singletons birth
following IVF/ICSI to 1000 twin birth (2000 infants)
following IVF/ICSI.

17. METHODOLOGY
 We adopted the worst case scenario :
 Singlton won’t have any neonatal morbidity or
maternal mortality
 All twin pregnancy will deliver prematurely

18. FEMALE & MALE
 Female capital stock per head of working age
population is almost 64% of male = 286949
 Taking into consideration female to male ratio :
51:49

19. CAPITAL STOCK PER 1000 SINGLTON
 490 male x 449,358 =220,185,420
+
 510 female x 286949 = 146,343,990
 Total : 366,529,410

20. CAPITAL STOCK FOR 1000 TWIN PREGNANCY
 It is not as simple as we imagine
366,529,410 x 2 = 733,058,820
Cost of neonatal and maternal morbidity should be
calculated

21. ESTIMATING PROBABILITIES

22. COST CALCULATION
Procedure Unit cost
Hospital admission £629
Gestational hypertension £3000
Pre-eclampsia £4300
Gestational diabetes £3000
Term twins £1882
Preterm birth at 36 weeks £6552
Preterm birth at 32 weeks £65,716
Preterm birth at 30 weeks £85,372

23. COST OF NEONATAL & MATERNAL MORBIDITY
 We used the worst case scenario:- all babies will
deliver before 30 ws
 cost per baby staying for 9 weeks in a special baby
unit + 2 weeks in Neonatal Intensive Care level 2
 Plus assuming that all mothers will develop both
Preeclampsia and Diabetis
 Total: 85,372 + 4300 + 3000 + 629 + 172 = 93,472

24. COST SOURCE
Cost effectiveness analyses
Multiple Pregnancy: The Management of Twin and Triplet Pregnancies in the Antenata
NICE Clinical Guidelines, No. 129.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2011 Sep.

25. SO IN THE WORST CASE SCENARIO
 Neonatal & maternal morbidity will almost cost
93472 X 2000 = 186,944,000
 The difference = 733,058,820 - 186944000
= 546,114,820
~ 22% higher than singleton capital stock

26. PLS NOTE
 We did not calculate any neonatal or maternal
morbidity for singleton pregnancy
 We did not calculate Cost of IVF to get second baby
for women with singleton pregnancy
 If we calculate both, then the difference would be
much greater

27. MOST IMPORTANT
 infants conceived with ART contributed to ~ 6% of
all low birthweight (<2,500 grams) infants in
population, and to 6% of all very low birthweight
(<1,500 grams) infants (CDC 2012)
 Only 15.4% of twins in the population were
conceived following ART (Berg et al, 2014).

28. CDC, 2016
Multiple-birth
infants
among ART
infants§
Multipl
e-birth
infants
among
all
infants
¶
Proportion
of ART
multiple-birth
infants
among all
multiple-birth
infants (%)
Twin
infants
among ART
infants§
Twin
infants
among all
infants¶
Propor
tion of
ART
twin
infants
among
all
twin
infants
(%)
Triplet (plus)
infants
among ART
infants§
Triplet (plus)
infants
among all
infants¶
Propor
tion of
ART
triplet
(plus)
infants
among
all
triplet
(plus)
infants
(%)
No. % No. % % No. % No. % % No. % No. % %
Total 26,804 43.6
136,75
5
3.4 19.6 25,337 41.2
131,80
2
3.3 19.2 1,467 2.4 4,953 0.1 29.6

29. THIS MEANS THAT
 even reducing incidence of twins by SET will not
affect 80% of cost burden on society

30. QUESTIONING SET
 Fiddelers et al.2013 in an economic evaluations of
SET versus DET concluded that, from a cost-
effectiveness point of view, SET is only preferred in
good prognosis patients and when frozen-and-
thawed cycles are included

31. IN ANOTHER STUDY
 DET was found to be more cost effective than SET,
with an Incremental Cost-Effectiveness Ratio
(ICER) around €20,000 (Evers et al, 2006).

32. CONCLUSION
 We should always look at the whole picture

33. THANK YOU
Dr. Hesham Al-Inany MD, PhD
e-mail : kaainih@yahoo.com