Howard Carp, MD

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       "I'm sitting now with Dr. Dan Farine, who's the Director of Fetal       Maternal Medicine at Mount Sinai Hospital in Toronto, Canada. He was the       chairman of the session on twin pregnancy this morning. Dr. Farine?"
       
       

 "Thank       you, Howard. It was actually a very pleasant session. The controversy was       not that much in terms of arguing between the speakers about their       approaches, it was more comprehensive in the sense that we had a few       speakers that touched on different aspects of twinning. The first talk was       actually quite provocative. It was given by Lewis Keith, who was the head       of the Institution for Twin Studies in Chicago. Lewis presented his own       personal experience with him and his twin brother that were labeled as       monozygotic and dizygotic in four different ways over the years. What he       brought up was the issue of zygosity from a different prospective, and the       fact that the genetics of twinning could be different after conception so       twins may be quite similar, but not perfectly similar, and there could be       some delayed variability which is introduced after conception. This led us       to into the discussion on how to diagnose monozygosity using new DNA       technology. It was pretty clear that, number one, there is no gross       standard and, number two, the more testing you're going to use, the more       you're going to find twins that are not exactly identical."
       
       

 "I       found this very interesting because what you were saying is, rather than       assuming that monozygotic twins were exactly the same genetically,       psychologically, etc., as we assumed before, he was now talking about a       new classification of monozygotic twins who were discordant for various       other features."
       
       

       "Absolutely, and those features could be specifically genetic,       diseases, or other conditions, so this is a new concept that kind of takes       us from the dichotomy of monozygotic--dizygotic."
       
       

       "And I understand there was also a lot of discussion on the ways to       diagnose twins early on in pregnancy rather than diagnosing monozygotic       and dizygotic twins at the time of delivery. That comes up with early       ultrasound, about the ultrasonic signs of monozygosity, isn't that       right?"
       
       

 "This       was discussed by Israel Meizner, and what he did was actually lump       together the data about ultrasound scanning and zygosity, which is       actually crucial for the management of the pregnancy. He did a very nice       summary of the early ultrasound data and the late ultrasound data leading       obstetricians to the best diagnosis of zygosity. He also touched on other       issues, like monoamniotic twins and conjoined twins, but the major issue       was actually trying to determine zygosity using ultrasound scanning. What       came out very, very clearly was that you need to scan those patients more       than once, and preferably somewhere before the eighth week mark, then       after the eighth week mark and at the second trimester, to get the optimal       ultrasound data which allows you to determine zygosity."
       
       

       "Yes. Could you also comment on the multiple pregnancy work and the       iatrogenic causes of multiple pregnancy? There was some discussions on       IVF, I understand - how many eggs were replaced in the uterus and, of       course, did this influence the multiple pregnancy rate."
       
       

 "This       actually came up several different times. It came up in the presentation       of Lewis Keith. It came up again in the presentation of Issac Blickstein       that actually made this as one of the determinants of how to deliver       twins, and the fact that many of these patients are infertile. He used       different technologies to get pregnant, and this modifies their perception       and the obstetrician's perception. This culminated in a very heated       discussion at the very end in terms of how many embryos should actually be       implanted back into the uterus and whether it would be re-suited to two or       to three. It was actually quite interesting to see Nick Fisk and Chervenak       disagreeing, very politely but very firmly, and then hear the input from       everybody else around the table and in the audience. It was also       interesting to see the difference between people with reproductive       endocrinology backgrounds. Dr. Insler discussed it in terms of the       perspective of the endocrinologist infertility specialist, and he       confronted those with the views of the maternal fetal medicine people on       the panel that felt that having triplets carries major risks. Lewis Keith       discussed the psycho-social issues, and he quoted the data from France       that showed that many of the families of triplets are devastated by major       social effects within the three years from the time of delivery. So it's       not only just a pure medical issue, but also it also has psychological       aspects."
       
       

       "Was the place of reduction of triplets down to twin pregnancies       discussed?"
       
       

 "I       think that in a way we tried not to discuss it too extensively since there       was another session devoted to that, but it certainly came up. I think       that the most interesting way it came up was Nick's provocative statement       that what you should do is either put back two eggs or put twenty back in       and then have a reduction. So the issue of reduction also became quite       extensive and served as a function of the next ethical issue in terms of       how to approach each reduction from ethical perspectives, and he gave a       very elegant overview of that issue."
       
       

       "Yes, I understand from there that you went on to the more       straightforward obstetric issues about twin-to-twin transfusion syndrome,       and how you should, in fact, deliver twins in the labor ward. Do you have       some comments on that?"
       
       

 "I       think Nick has given an excellent overview of the issue of the       twin-to-twin transfusion, and it was very provocative. I think that the       first point that he made was the fact that we have seven different therapy       modalities indicated, and none of them are perfect. He then looked at our       ability to diagnose the twin-to-twin transfusion as well, and he compared       his own data and other centers' data in terms of laser versus amnio-reduction,       and what would be the right indication to intervene. I think he gave a       very well balanced overview of the issues. We are still pretty far away       from where we should be, and the maternal fetal medicine community is       trying to overcome some of those hurdles by having conjoint efforts as       multi-center studies looking at specific modalities of therapy like       fenestration of the membranes."
       
       

       "Thank you very much, Dr. Farine."
       
       

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OBGYN.net Conference CoverageFrom First Congress on Controversies in Obstetrics, Gynecology & Infertility Prague CZECH REPUBLIC - October, 1999

Twins and Multiple Births

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       "I'm here with Dr. Louis Keith, who is the Professor of Obstetrics       and Gynecology at Northwestern University in Chicago, and the Director for       the Center for the Study of Multiple Births, also in Chicago. Dr. Keith       presented this morning, but I understand that he is also a 'professional'       twin who has described some of the problems that come up with twins. Dr.       Keith, could you give us a summary of some of the things that you were       speaking about this morning concerning twins and, particularly,       monozygotic twins?"
       
       

       "First let me clarify, if I may, the issue of being a 'professional       twin.' By this I mean that my brother and I speak frequently to the       public, the media, and the medical profession in general on behalf of       twins. In my case, I speak as an obstetrician and president of the Center       for the Study of Multiple Births. My brother and I both view the picture       on a broad canvas; we see many of the problems, as well as the joys. I'm       not aware of too many of my obstetric colleagues who are twins, or if they       are, who might address these issues in public-that's what I meant.
       
       Now, in terms of the issues that were addressed this morning, it was a       rather basic discussion that pointed out some of the medical problems that       accompany multifetal pregnancy reduction and deal with iatrogenic multiple       pregnancy. In this regard, the birth of the seven sextuplets in Iowa was       cited as an example, whether the public found this a joyous event or not.       In one way or the other, the public pays for this and for the cost of       other iatrogenic multiples. This is the point that I stressed-that the       public is paying for this epidemic of multiples."
       
       
       

       "One of the points that came up this morning was iatrogenic multiple       births that result from assisted reproductive technology. There is a very       real question being addresses as to how many embryos should be replaced,       whether reduction should be performed, or whether fewer embryos should be       replaced in the first place. Do you have any views on this, Dr.       Keith?"
       
       

 "l       think you summarized it very, very eloquently. This is a world-wide       debate, and this debate is becoming more and more acrimonious, if I may       use that term, as people begin to look at costs in terms of dollars,       pounds, Deutsch marks, French francs, Swiss francs, or in terms of the use       of the resources of entire nurseries that are often given over to the care       of iatrogenic multiples. Now, resource drain should be factored into the       equation whether one is for or against the production of iatrogenic       multiples and whether one is for or against the use of reductive       techniques. You can't very well discuss these two major issues without       bringing society into the discussion, noting that society is concerned       with the cost. From the point of view of the family, all too often there's       an enormous cost in terms of disruption of what is considered normal       family life to give three or four young babies the care that they need in       the first year. We know from the Iowa experience that this often requires       a tag team of helpers."
       
       

       "You also spoke this morning about a different concept regarding       monozygous twins, about the differences between monozygous and dizygous,       and how sometimes it will be very, very difficult to reach a diagnosis       about zygosity. Could you elaborate on this, please?"
       
       

       "Yes. That, of course, was my assigned topic. I spoke about the fact       that it's too simplistic to continue to say that a pair of twins is merely       monozygotic, meaning derived from one fertilized ovum, or a dizygotic       derived from two fertilized ova. This approach does not take into account       the possibility that there will be some differences, although minor, and       something as simple as the placement of a mole or as simple as the       presence or absence of a derelict hair that's coming out of the right       eyebrow. My brother has the same derelict hair coming out of his left       eyebrow. Thus, one might say we're not just the same, but that we're       mirror-image twins, in that regard. But there are other pairs of twins       where one will have cancer and the other won't, or where one has a       paralytic disease and the other doesn't. In the last couple of years, many       researchers have been trying to explain this phenomenon, and this is what       I threw out in this morning's discussion."
       
       

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OBGYN.net Conference CoverageFIGO 2000 INTERNATIONAL FEDERATION of GYNECOLOGY & OBSTETRICS: Washington DC, USA

Howard Carp, MD

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Twins and Multiple Births

Twins

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