Ms N, 35 years old primigravida, underwent IVF overseas. Five embryos were transferred and Ms N became pregnant with septuplets. She had an early dating scan that noted presence of six viable fetuses and one fetal demise. Upon return to Australia, she and her partner were counselled regarding risks of higher order pregnancy and they opted for fetal reduction at 12 weeks of pregnancy. After a detailed scan in a tertiary centre, she underwent reduction of four fetuses to continue with twin (DCDA) gestation.

In view of twin pregnancy, she was managed in a high-risk clinic. Ms N developed diabetes at 28 weeks and discordant growth of twins was noted at 31 weeks, further increasing the fetal surveillance. Her pregnancy was further complicated by onset of preeclampsia at 33–34 weeks.

Ms N was admitted for management of hypertension and, during her inpatient stay, her membranes spontaneously ruptured at 34 weeks. Two days later, she went into spontaneous labour and proceeded to have a vaginal birth of twin boys, weighing 2230 g and 1730 g.

The delivery was complicated by a postpartum haemorrhage of 800 mL that was managed medically; however, she continued to have ongoing moderate vaginal bleed over the next 12 hours, losing a further 400 mL. In view of the ongoing vaginal bleed, it was decided to take her for an examination under anaesthesia.

Initially, multiple fragments of adherent placenta were removed manually. Surprisingly, a fetus of 50 mm crown-rump length was also retrieved. This unusual find gobsmacked not just the mother, but also the obstetric team, despite their years of experience.

Post the evacuation, the bleeding settled. The total blood loss was 1200 mL. Ms N recovered well and was discharged home on day 4 while the babies remained in the nursery.

Discussion

A direct consequence of increase in the popularity of assisted reproductive technology (ART) is the increase in the incidence of multiple birth rates.

Our patient, unfortunately, ended up having all the major complications associated with multiple pregnancies, which included gestational diabetes, preeclampsia, preterm rupture of membranes, preterm labour, discordant growth of twins and postpartum haemorrhage. She also brought to our attention the risks of cross-border reproductive care (CBRC).

Women are increasingly accessing ART overseas, known as CBRC, for various reasons that include gender selection, avoiding long waiting lists, cheaper treatments, multiple embryo transfer and perceived increased success rates.^{1 2}

Australia has strict laws for gamete selection, commercial surrogacy, multiple embryo transfer and restriction for IVF, in case of disabilities and diseases. Implementation of polices such as single embryo transfer has resulted in significantly reducing the incidence of higher order pregnancies, secondary to ART, thereby greatly mitigating the complications associated with these pregnancies. However, adherence to these policies has also resulted in countries like Australia facing problems associated with CBRC

The explosion of CBRC has raised not only legal and ethical questions, but has also raised concerns in terms of ‘commodification‘ of ART.

Growth of CBRC has been exponential and resulted in development of commercial hubs for CBRC in countries such as India and Thailand. It is estimated that surrogacy in India is a $2.5bn industry.³ There are CBRC ‘brokers’ that facilitate the CBRC interaction, ranging from hotels to maternity waiting homes for the reproductive travellers.

When access to fertility treatment at home is restricted legally or ethically, couples look at accessing services in countries that do not have the same restrictions. When compared with Australia, countries such as India have highly permissive laws governing reproductive treatments.⁴ There are concerns about the nature of informed consent for gestational surrogates and commercial exploitation of surrogates and donors.

The wide variation in law between countries that leads to fertility tourism has resulted in children being stateless and questioning their parentage. There have been cases where it has taken almost two years for children to be united with their IVF parents.⁵

CBRC also has economic implications. In Western Australia, a study of the effects of CBRC on the local healthcare system found that one third of multiple pregnancies was a result of fertility treatment overseas. The study estimated that the healthcare cost exceeded $1m AUD and added significantly to the economic burden of the local healthcare system.⁶

RANZCOG has a guideline in place for management of CBRC.⁷ Clinicians in Australia are obligated to optimise the woman’s health prior to her accessing ART services. When the patients make use of fertility services overseas, they are not necessarily given the same education and counselling in order to minimise the morbidity associated with any coexisting medical conditions. So, women who seek ART overseas may be further exposed to risks secondary to their pre-existing diabetes, obesity, hypertension or other medical conditions, further adding to the disease burden.⁸

Lessons learned

Fertility treatment effects a woman’s health both physically and psychologically. Our case highlights complications of CBRC, multi embryo transfer, feticide and multiple pregnancies. Several strategies have been suggested to reduce the complications of multiple pregnancies associated with multi-follicular development seen in ART cycles. These include selection of high-quality embryos, single embryo transfer, patient selection, preimplantation genetic screening and patient education.

With CBRC, there are the added burdens of cost, travel and language that the woman and her family may have to face. Fertility societies like ESHRE have stressed that the ideal scenario is fair access to fertility treatment at home for all patients.⁹

It is an ideal that healthcare providers all over the world should aim for. The onus of responsibility rests with the fertility physicians and obstetric care providers to keep the risk associated with CBRC and multiple pregnancies to a minimum by educating and counselling the woman appropriately.

1. RANZCOG. Cross-border reproductive care. Available from: www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women’s%20Health/Statement%20and%20guidelines/Clinical%20-%20Gynaecology/Cross-Border-Reproductive-Care-(C-Gyn-36)-New-March-2016.pdf?ext=.pdf
2. MC Inhorn, P Patrizio. The global landscape of cross-border reproductive care: twenty key findings for the new millennium. Current Opinion in Obstetrics & Gynecology. 2012;24(3):158-63.
3. SL Crockin. Growing families in a shrinking world: legal and ethical challenges in cross-border surrogacy. Reproductive BioMedicine Online. 2013;27(6):733-741.
4. A Whittaker. Cross-border assisted reproduction care in Asia: implications for access, equity and regulations. Reproductive Health Matters. 2011;19(37):107-16.
5. SL Crockin. Growing families in a shrinking world: legal and ethical challenges in cross-border surrogacy. Reproductive BioMedicine Online. 2013;27(6):733-741.
6. KA Waller, JE Dickinson, RJ Hart. The contribution of multiple pregnancies from overseas fertility treatment to obstetric services in a Western Australian tertiary obstetric hospital. ANZJOG. 2017;57(4):400-4
7. RANZCOG. Cross-border reproductive care. Available from: www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women’s%20Health/Statement%20and%20guidelines/Clinical%20-%20Gynaecology/Cross-Border-Reproductive-Care-(C-Gyn-36)-New-March-2016.pdf?ext=.pdf
8. KA Waller, JE Dickinson, RJ Hart. The contribution of multiple pregnancies from overseas fertility treatment to obstetric services in a Western Australian tertiary obstetric hospital. ANZJOG. 2017;57(4):400-4
9. Cross-border reproductive care: a committee opinion. Fertil Steril. 2013;100(3):645-50.