The greatest risks are associated with multiple pregnancy and this is largely dependent on the use of ovulation induction agents (4). A common reason for anovulation is PCOS (Q7.2) and ovulation induction agents have frequently been employed. The arrival of metformin as an effective treatment that reverses the underlying cause of PCOS may reduce the need for ovulation induction.

IVF is associated with increased incidence of multiple pregnancy. The success of IVF has given it an element of glamour. Ultimately it is a matter of patient choice but it is my own view that there is a place for fully exhausting lower-tech treatments before resorting to IVF. Fertility units are compared by their pregnancy rates and 'take-home' baby rates. There is an understandable temptation to put back as many embryos as possible to achieve positive results (Figure 11.1). Those of us who are involved in the care of the resultant pregnancies see the joys of successful outcomes but our views are chastened when we see things go wrong (see 8). In the UK, the number of embryos that can be transferred into the uterus has been limited to three and there is current debate suggesting that we should further reduce to two. This is a move that many of us obstetricians would favour.

There is an advantage in pregnancies following infertility treatment being cared for by a team with a special interest in this area. Whilst I have no doubt that even greater vigilance is given in the care provided for pregnancies resulting from infertility treatment, there is evidence that successful outcomes occur slightly less frequently when compared with pregnancies achieved naturally. Doctors in general, and obstetricians in particular, are better placed than most to contemplate the miracles of nature. We do not intervene unless we believe that there is a definite advantage. When a pregnancy reaches term, there is no advantage for the baby to await events or to experience passage through the birth canal. An increasing proportion of women who have experienced infertility elect to be delivered by caesarean section.

There is a perceptible pressure to reduce obstetric intervention albeit mainly from those who have not experienced the occasional downside of natural childbirth. For those women who have experienced prolonged infertility and successful treatment, natural childbirth may seem less important than for others. There is an element of risk in every aspect of our lives and sadly there are times when even particularly precious pregnancies go wrong at the last moment. Usually, although not always, it is an unavoidable event of nature.

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