FIGO COMMITTEE REPORT
Ethical recommendations on multiple pregnancy
and multifetal reduction
FIGO Committee for the Ethical Aspects of Human Reproduction
and Women’s Health
0020-7292/$ - see front matter D 2005 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd.
All rights reserved.
The FIGO Committee for the Ethi-
cal Aspects of Human Reproduction
and Women’s Health considers the
ethical aspects of issues that im-
pact the discipline of Obstetrics,
Gynecology and Women’s Health.
The following document represents
the result of that carefully re-
searched and considered discus-
sion. This material is not intended
to reflect an official position of
FIGO, but to provide material for
consideration and debate about
these ethical aspects of our disci-
pline for member organizations
and their constituent membership.
G.I. Serour, Chair
FIGO Committee for the Ethical
Aspects of Human Reproduction and
Gamal I. Serour
40 Talaat Harb Street, Cairo, Egypt
Tel.: +20 2 512 2406
fax: +20 2 575 4271
In recent years there has been a dramatic increase in multiple
pregnancies throughout the world. For example, some countries
reported a doubling of twin pregnancies and the quadrupling of triplets
over the last twenty years. The relative increase in higher order
pregnancy has been even greater.
Undoubtedly, the main factor has been the use of ovulation-inducing
drugs and of multiple embryo transfer in the treatment of infertility.
The increase in twin pregnancies may also be attributed in part to
trends towards increased maternal age at conception.
The need for infertility treatment has also been rising sharply due to
factors which include the impact of sexually transmitted diseases and
the trend towards pregnancy at later age.
Multiple pregnancy has very serious implications for the mother and
her offspring, for the family and the community, and for health service
resources, particularly where neonatal care services are limited or
International Journal of Gynecology and Obstetrics (2006) 92, 331—332
Recommendations regarding multiple
1. Every effort should be made to prevent infertil-
ity through further research. Timely education
and information about the risks and prevention
of infertility are necessary. In addition, research
and education are urgently required to improve
the outcome of technologies for assisted repro-
2. The clinicians should take professional responsi-
bility for optimizing their own practices in the
interest of avoiding multiple births.
3. Obstetrician—gynecologists have an important
responsibility to make both the public as well
as their patients aware of the many hazards
associated with multiple pregnancy, especially
with triplets and higher order pregnancies. In
addition, they must make them aware that the
high risk nature of multiple pregnancies requires
an expertise that may not be available in some
rural or smaller town areas.
4. Couples seeking treatment for infertility must be
fully informed, in writing, of the numerous, com-
plex and potentially far-reaching risks of multiple
progeny. Counselling should also be available
from experienced members of perinatal teams.
5. The misuse of drugs for the induction of ovula-
tion is responsible for a great many iatrogenic
multiple pregnancies. Therefore, those using
these drugs should be familiar with the indica-
tions for their use, their adverse side effects and
the methods of monitoring and preventing
iatrogenic multiple pregnancy.
6. Obstetrician—gynecologists using assisted repro-
ductive technologies, whether by the induction
of ovulation or the transfer of embryos, should
aim to achieve singleton pregnancies. Under
optimal conditions, single embryo transfer
should be performed and good cryopreservation
programs should be available. International and
national professional bodies have a responsibility
to issue recommendations for good practice with
a view to reducing the incidence of iatrogenic
multiple pregnancies. Centers should be certi-
fied or accredited in order to ensure a uniformly
7. In order to monitor and regulate professional
practice, audit of the use of these technologies
should include not only the fertility success rate
but also statistics on singleton live births as well
as the incidence of multiple pregnancy, the
maternal and perinatal mortality and morbidity,
the incidence of preterm delivery, and low birth
weight, the occurrence of long-term disabilities
among offspring, and the use of fetal reduction.
Couples should have access to reliable and
standardized local center statistics as well as
national and international statistics.
8. The risks for both mothers and the resulting
children from triplet higher-order pregnancies
must be disclosed to and discussed with the
couple. This discussion should include informa-
tion about the availability, use and implications
of fetal reduction.
9. Clinics and clinicians when discussing their
results in public must avoid describing multiple
pregnancies as a success rather than a compli-
cation of treatment. The media should be
aware that best professional opinion is to
regard multiple pregnancies as a complication.
Recommendations regarding multifetal
1. Multiple pregnancy of an order of magnitude
higher than twins involves great danger for the
woman’s health and also for her fetuses, which
are likely to be delivered prematurely with a
high risk of either dying or suffering damage.
2. Clinical priority should be by way of careful
planning and monitoring of infertility treatment
for the reduction or avoidance of multiple
pregnancies. However, where such pregnancies
reduce the number of fetuses rather than to do
3. Multifetal reduction is not medically considered
as terminating that pregnancy but rather as a
procedure to secure its best outcome.
4. Information provided must include the risks to
mothers and fetuses with and without fetal
reduction, including miscarriage. Whether the
couple decide to maintain or to reduce high-
order multiple pregnancies, they should be
assured that they will receive the best available
London, March 2005
FIGO Committee Report332