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Identical twins occur when a single embryo, created by the union of a sperm and an egg, divides into two embryos. Ultrasound examinations performed early in the 5th week of pregnancy occasionally may fail to identify all fetuses. Naturally, twins occur in about one in 250 pregnancies, triplets in about one in 10,000 pregnancies, and quadruplets in about one in 700,000 pregnancies.
Your race, age, heredity, or history of prior pregnancy does not increase your chance of having identical twins but does increase your chance of having fraternal twins.
Assisted reproductive technology (ART) procedures such as in vitro fertilization (IVF) also contribute to the increase in the multiple birth rate. The duration of a normal singleton pregnancy ranges from 37 weeks to 42 weeks from the time of the last menstrual period. Complications increase with each additional fetus in a multiple pregnancy and include many medical issues that will be discussed below.
Since preterm labor and birth present such serious risks, the pregnant mother must understand the warning signs of early labor. The placenta is attached to the wall of the uterus, and the fetus is attached to the placenta by the umbilical cord. Another placental problem is twin-twin transfusion, a life-threatening condition in identical twins. Preeclampsia, also known as toxemia, occurs 2 to 5 times more often in multiple pregnancies. Women with multiple pregnancies are more likely to develop gestational diabetes during pregnancy. Although uncommon in twin deliveries, about 20% of triplet pregnancies will result in the delivery of at least one child with a major long-term handicap.
Of the premature babies who die, 50% succumb to respiratory distress syndrome, caused by immature lungs. Despite these numbers, it is important to note that the vast majority of multiple-birth infants do survive.
Prevention during infertility treatment is the best approach to avoiding a multiple pregnancy. The ultimate goal of ART is to achieve a high pregnancy rate while transferring a single embryo. When a triplet or high-order multiple pregnancy occurs, multifetal pregnancy reduction may be considered to improve the chance for survival of the fetuses. In order to achieve the best outcome with a multiple pregnancy, the expectant mother must work as part of the health care team.
Many physicians who manage multiple pregnancies believe that a reduction in activities and increased rest prolongs these pregnancies and improves outcomes.
Since preterm birth and growth disturbances are the major contributors to newborn death and disability in multiples, frequent obstetric visits and close monitoring of the pregnancy are needed. Prenatal diagnosis using a variety of new techniques can be done near the end of the first trimester to screen for Down syndrome and other genetic abnormalities. Many physicians perform cervical examinations every week or two beginning early in pregnancy to determine if the cervix is thinning or opening prematurely. Every multiple pregnancy should be considered at high risk, and obstetricians experienced with the management of multiple gestations should provide care. Although the majority of women with a multiple pregnancy do very well, their families may experience significant stress. Even when medical problems are overcome and the infants survive without disability, the effect of multiple births on family life is substantial.
Psychological counseling and support groups may provide a lifeline for the parents of multiples, who may feel isolated or depressed.
Published by the American Society for Reproductive Medicine under the direction of the Patient Education Committee and the Publications Committee. Thousands of doctors, nurses, and other professionals in the field of reproductive medicine are advancing their careers with the latest news, continuing education, discounts, and networking opportunities. According to the US Department of Health and Human Services, the twin birth rate has increased by over 75% since 1980, and triplet, quadruplet, and high-order multiple births have increased at an even higher rate.
The two embryos that result are dizygotic, not genetically identical, and can be the same or different sex. An “appearing twin” may be found after the 5th week in nearly 10% of non-identical twin or multiple pregnancies and in over 80% of cases of identical twins.
The overall rate of twins for all races in the United Statees is around 33 per 1,000 live births. Multiple pregnancy is more common in women who utilize fertility medications to undergo ovulation induction or superovulation. While most of these pregnancies are twins, up to 5% are triplets or greater due to the release of more eggs than expected.
In addition to these, there is a higher incidence of severe nausea and vomiting, cesarean section, or forceps delivery. Sixty percent of multiples are born prematurely (<37 weeks) compared to about 10% of singleton pregnancies.
Pelvic pressure, low back pain, increased vaginal discharge, or a change in the frequency of “false labor” pains should be reported to the physician.
The placenta provides blood, oxygen, and nutrition to the fetus through the umbilical cord. If the placenta is unable to provide adequate oxygen or nutrients to the fetus, the fetus cannot grow properly. This transfusion occurs when blood flows from one fetus to the other through a connection in a shared placenta. Fifteen percent to 20% of women with twin pregnancies will experience preeclampsia, and an even higher percentage is preeclamptic in triplet or high-order pregnancies.
Babies of diabetic mothers are more likely to experience respiratory distress and other newborn complications. Preterm delivery places an infant at increased risk for severe complications or early death. While physicians can transfer two embryos and still maintain acceptable pregnancy rates, the transfer of one embryo is associated with good pregnancy rates in certain patient groups, thereby resolving the problem of multiple pregnancies caused by multiple embryo transfer. While multifetal pregnancy reduction carries some risk of a complete miscarriage, it also reduces the chances of extreme premature birth.

A nearly total change in lifestyle can be expected, especially after about 20 weeks into the pregnancy. An expectant mother needs to gain more weight in a multiple pregnancy, especially if she begins the pregnancy underweight.
However, routine hospitalization for bed rest in multiple pregnancy has not been shown to prevent preterm birth. If an exam or ultrasound shows that the cervix is thinning or beginning to dilate prematurely, a cerclage, or suture placed in the cervix, may prevent or delay premature dilatation. These medications are given in hospital “emergency” settings in an attempt to stop premature labor.
A neonatal intensive care unit nursery should be available to provide immediate and comprehensive support to premature newborns. If prolonged hospitalization is needed, arrangements must be made for work, home, and family care. The impact of a multiple birth clearly affects the parents, but also the babies, other siblings, and the extended family. Most physicians can provide appropriate referrals to a mental health professional or a support group. In a small percentage of patients, treatment results in multiple pregnancy that may place the mother and the babies at increased risk for an unhealthy outcome.
A procedure in which a small amount of amniotic fluid is removed through a needle from the fetal sac at about 16 weeks into a pregnancy. Placement of a nonabsorbable suture around an incompetent (weak) cervical opening in an attempt to keep it closed and thus prevent miscarriage. A condition due to abnormal production of insulin resulting in abnormally elevated blood glucose (sugar) levels.
The female sex cell produced by the ovaries, which, when fertilized by a male’s sperm, produce embryos. The earliest stage of human development arising after the union of the sperm and egg (fertilization). A fluid-filled sac located just beneath the surface of the ovary containing an egg (oocyte) and cells that produce hormones. Substances secreted from organs of the body, such as the pituitary gland, adrenal gland, or ovaries, which are carried by a bodily fluid such as blood to other organs or tissues where the substances exert a specific action. Infertility is the result of a disease of the male or female reproductive tract that prevents the conception of a child or the ability to carry a pregnancy to delivery. A method of assisted reproduction that involves combining an egg with sperm in a laboratory dish. The naturally occurring expulsion of a nonviable fetus and placenta from the uterus; also known as spontaneous abortion or pregnancy loss. The administration of hormone medications (ovulation drugs) that stimulate the ovaries to develop a follicle and ovulate. A disk-shaped vascular organ attached to the wall of the uterus and to the fetus by the umbilical cord. A lung disease that affects premature infants and causes increasing difficulty in breathing. The administration of fertility medications in a manner intended to achieve development and ovulation of multiple ovarian follicles. The hollow, muscular organ in the pelvis where an embryo implants and grows during pregnancy. Neither the service provider nor the domain owner maintain any relationship with the advertisers. There are more multiple births today in part because more women are receiving infertility treatment, which carries a risk of multiple pregnancy. Depending on when the division occurs, identical twins may have separate placentas and gestational sacs, or they may share a single placenta but have separate sacs. Most of the time, this is the type of twinning that occurs from assisted reproduction procedures.
After 6 to 8 weeks, ultrasound should provide an accurate assessment of the number of fetuses. Black and non-Hispanic white women have similar rates of twinning, while Hispanic women are less likely. Women between 35 to 40 years of age with 4 or more children are 3 times more likely to have twins than a woman under 20 without children. Of women who achieve pregnancy with clomiphene citrate, approximately 5% to 12% bear twins, and less than 1% bear triplets or more.
If you are pregnant with twins or more, or if you are at risk for a multiple pregnancy, you should be aware of these and other potential problems you might experience.
Feasibility of a vaginal delivery depends on the size, position, and health of the infants, as well as the size and shape of the mother’s pelvic bones. The placenta ages prematurely and may slow fetal growth, especially late in the third trimester. Poor growth occurs in the “donor” twin, and excessive fluid develops in the “recipient” twin. Preeclampsia is diagnosed when the mother’s blood pressure becomes elevated and protein is detected in the urine.
However, gestational diabetes is common even in singleton pregnancies, and treatment is well established and effective. A baby’s lungs, brain, circulatory system, intestinal system, and eyes may be not fully developed. Furthermore, compared to singleton pregnancies of the same birth weight, there is no significant increase in the incidence of chronic lung disease or brain, eye, or gastrointestinal problems in multiple-birth infants. Consult the ASRM Practice Committee Report titled Guidelines on Number of Embryos Transferred for recommendations regarding the optimal number of embryos to transfer based on patient age, embryo quality, and other criteria. Approximately 10% of embryo transfers in the United States are now performed using elective single embryo transfer. A woman with a large number of ovarian follicles or high hormone levels has an increased risk of a multiple pregnancy, and the cycle may be canceled to avoid the risk.
Women with high-order multiple pregnancies usually are advised to avoid strenuous activity and employment at some time between 20 and 24 weeks. Amniocentesis may be complicated and difficult to perform in twins and triplets and may not be possible in high-order multiple pregnancies.

However, preventative cerclage has not been shown to prevent preterm birth in twins or triplets. Financial stresses are common, due to the additional costs of feeding, clothing, housing, and caring for multiple children. For more information, see the ASRM Patient Fact Sheet titled Challenges of Parenting Multiples. Since multiple pregnancies and their complications are an inevitable risk of fertility therapies, education about these risks is crucial prior to treatment. Some examples of ART are in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), pronuclear stage tubal transfer (PROST), tubal embryo transfer (TET), and zygote intrafallopian transfer (ZIFT). Cerebral palsy is characterized by an inability to fully control motor function, particularly muscle control and coordination.
The sac increases in size and volume during the first half of the menstrual cycle and at ovulation the follicle matures and ruptures, releasing the egg. The duration of unprotected intercourse with failure to conceive should be about 12 months or more before an investigation is undertaken, unless medical history, age, and physical findings dictate earlier evaluation and treatment. If the egg fertilizes and begins cell division, the resulting embryo is transferred into the woman’s uterus where it can implant in the uterine lining and further develop. Preeclampsia is characterized by high blood pressure, swelling, and protein found in the urine.
Superovulation is often combined with intrauterine insemination as an infertility treatment. A picture of internal organs produced by high frequency sound waves viewed as an image on a video screen; used to monitor growth of ovarian follicles, to retrieve eggs, and to monitor a fetus or pregnancy. The lining of the uterus, called the endometrium, produces the monthly menstrual blood flow when there is no pregnancy.
This booklet is in no way intended to replace, dictate or fully define evaluation and treatment by a qualified physician. In case of trademark issues please contact the domain owner directly (contact information can be found in whois). However, since the first publication in 1998 of the American Society for Reproductive Medicine’s (ASRM’s) Guidelines on Number of Embryos Transferred, the number of treatment-related pregnancies with triplets or more has decreased dramatically.
When a fetus is lost in the first trimester, the remaining fetus or fetuses generally continue to develop normally, although vaginal bleeding may occur.
During World War II, the incidence of non-identical twinning decreased in Europe when food was not readily available. The average duration is 35 weeks for twins, 33 weeks for triplets, and 30 weeks for quadruplets. Cesarean section is often needed for twin pregnancies and is expected for delivery of triplets.
Twins and high-order multiples that are more than 30% “underweight” by ultrasound measurements are at increased risk of complications and have death rates of nearly 25%. Therapeutic amniocentesis and laser coagulation of blood vessels that link circulation to the twins in the placenta(s) may reduce complications of twin-twin transfusion. Birth defects and stillbirths account for about 30% of the deaths in twins and multiple pregnancies. No proven way of reducing multiple pregnancies with superovulation has been identified, although preventing fertilization with development of more than three follicles is helpful in reducing high-order multiples.
However, reasonable data exist for the use of serum screening in the setting of multiple pregnancies and can be a helpful tool to assess risk of these and other conditions. Appropriate anesthesia and neonatal support are essential, whether delivery is performed vaginally or requires cesarean section. Postpartum depression also is more common after delivery of multiple pregnancies in both the mother and the father and may be long-term. Other problems that may arise are difficulties in feeding, bladder and bowel control, problems with breathing, skin disorders, and learning disabilities.
With a multiple pregnancy, more of these hormones are produced and lead to a rise in the mother’s blood sugar.
IVF is generally performed in conjunction with medications that stimulate the ovaries to produce multiple eggs in order to increase the chances of successful fertilization and implantation. As the risk of miscarriage (spontaneous abortion) and other problems increases with the number of fetuses present, this procedure may be performed in an attempt to prevent the entire pregnancy from aborting or delivering very prematurely. Also, more women are waiting until later in life to attempt pregnancy, and older women are more likely than younger women to get pregnant with multiples, especially with fertility treatment. When severe, the mother may have seizures, and stroke or other life-threatening complications are possible. Neonatal intensive care unit admission is required for one-fourth of twin and three-fourths of triplet deliveries.
As a result of prematurity, the risk for cerebral palsy is 4 times more likely to occur in twins. Assessment of fetal growth by ultrasound every 3 to 4 weeks during the second half of pregnancy is commonly performed. Delivery of multiples requires planning by the entire medical team and availability of full intensive-care support following birth.
IVF bypasses the fallopian tubes and is often the treatment choice for women who have badly damaged or absent tubes. Although major medical advances have improved the outcomes of multiple births, multiple births still are associated with significant medical risks and complications for the mother and children.
Healthy birth weights are most likely achieved when the mother gains nearly one pound per week in the first 20 weeks.
If you are at risk for a multiple pregnancy, this booklet will help you learn how and why multiple pregnancies occur and the unique issues associated with carrying and delivering a multiple pregnancy.
This delay, when possible, allows for continued growth in the protective environment of the uterus. The increase in fetal growth with appropriate nutrition and weight gain may greatly improve pregnancy outcome at a minimum of cost.
Birth weight also corresponds closely to the severity of disability throughout the childhood years.

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