Conjoined twins (also known as Siamese twins) are identical twins whose bodies are joined in utero.

A rare phenomenon, the occurrence is estimated to range from 1 in 50,000 births to 1 in 100,000 births, with a somewhat higher incidence in Southwest Asia and Africa.[1] Approximately half are stillborn, and a smaller fraction of pairs born alive have abnormalities incompatible with life. The overall survival rate for conjoined twins is approximately 25%.[2] The condition is more frequently found among females, with a ratio of 3:1.[1] Two contradicting theories exist to explain the origins of conjoined twins. The older and most generally accepted theory is fission, in which the fertilized egg splits partially. The second theory is fusion, in which a fertilized egg completely separates, but stem cells (which search for similar cells) find like-stem cells on the other twin and fuse the twins together. Conjoined twins share a single common chorion, placenta, and amniotic sac, although these characteristics are not exclusive to conjoined twins as there are some monozygotic but non-conjoined twins that also share these structures in utero.[3]

Types of conjoined twins

Conjoined twins are typically classified by the point at which their bodies are joined. The most common types of conjoined twins are:

Thoraco-omphalopagus (28% of cases):[6] Two bodies fused from the upper chest to the lower chest. These twins usually share a heart, and may also share the liver or part of the digestive system.[7] Thoracopagus (18.5%):[6] Two bodies fused from the upper thorax to lower belly. The heart is always involved in these cases.[7] Omphalopagus (10%):[6] Two bodies fused at the lower chest. Unlike thoracopagus, the heart is never involved in these cases; however, the twins often share a liver, digestive system, diaphragm and other organs.[7] Parasitic twins (10%):[6] Twins that are asymmetrically conjoined, resulting in one twin that is small, less formed, and dependent on the larger twin for survival.

Other less-common types of conjoined twins include:

Cephalothoracopagus: Bodies fused in the head and thorax. In this type of twins, there are two faces facing in opposite directions, or sometimes a single face and an enlarged skull.[7][8] Xiphopagus: Two bodies fused in the xiphoid cartilage, which is approximately from the navel to the lower breastbone. These twins almost never share any vital organs, with the exception of the liver.[7] A famous example is Chang and Eng Bunker.
Ischiopagus: Fused lower half of the two bodies, with spines conjoined end-to-end at a 180 angle. These twins have four arms; two, three or four legs; and typically one external set of genitalia and anus.[7]

Separation
Surgery to separate conjoined twins may range from relatively simple to extremely complex, depending on the point of attachment and the internal parts that are shared. Most cases of separation are extremely risky and life-threatening. In many cases, the surgery results in the death of one or both of the twins, particularly if they are joined at the head. This makes the ethics of surgical separation, where the twins can survive if not separated, contentious. A case of particular interest was that of Mary and Jodie, two conjoined twins from Malta who were separated by court order in Great Britain over the religious objections of their parents, Michaelangelo and Rina Attard. The surgery took place in November, 2000, at St Mary's Hospital in Manchester. The operation was controversial because it was certain that the weaker twin, Mary, would die as a result of the procedure. (The twins were attached at the lower abdomen and spine; Jodie's heart and lungs supplied both of their bodies.) However, if the operation had not taken place, it was certain that both twins would die.[10][11]
Mary and Eliza Chulkhurst (or Chalkhurst), commonly known as the Biddenden Maids, were a pair of conjoined twins supposedly born in Biddenden, Kent, in the year 1100. They are said to have been joined at both the shoulder and the hip, and to have lived for 34 years. Lakshmi Tatama is an Indian girl born in 2005 in a village in Araria district, Bihar, having "4 arms and 4 legs." She was actually one of a pair of ischiopagus conjoined twins where one twin was headless due to its head atrophying and chest underdeveloping in the womb. The result looked like one child with four arms and four legs.

Conjoined Twins FAQ: How Does it Happen? Answer: Monozygotic-- also known as identical -- twins form when a single fertilized egg splits into two embryos. This split can happen anytime after fertilization; as more time passes, the twins are more likely to share commonalities. If the split occurs more than twelve days post conception, the embryos may not fully divide and may form with a connection. Or, the "fusion" theory of conjoined twinning suggests that stem cells from one twin adhere to like stem cells from the other twin, fusing together and developing conjoinedly. Like all monozygotic twins, conjoined twins are always same sex (either both boys or both girls). It is estimated that seventy percent of conjoined twins are female.

Amber Dhara - The story revolves around the life of two conjoined twins: Amber and Dhara, who share the vital organ, 'liver' and are conjoined at the hip. The 20% of the liver is a part of Amber's body and the remaining 80% is a part of Dhara's body,

In some cases, conjoined twins have one healthy twin, and one very unhealthy, called parasitic. In these cases, separation is necessary to protect the healthy child. It is frequently tragic and difficult for parents to make such decisions, since agreeing to separation surgery is essentially agreeing to allow one child to die. On the other hand, the choice not to separate parasitic twins tends to mean both twins will die. When conjoined twins cannot be separated they frequently are able to manage through living a very different lifestyle. Difficulties occur when the twins share the same reproductive system, or excretory pathways. Others suffer from postural difficulties if they are joined at the head. Life expectancy for conjoined twins who cannot be separated frequently depends on how many organs are shared. If heart, lungs, liver, or kidneys are shared, providing the work for two bodies may be very difficult. In some cases, the conjoining is almost always fatal during the first few days of life. Conjoined twins who share a heart have a low rate of survival. Twins who share a heart and brain tend to be considered non-viable. In other cases, called inclusion twinning, one twin absorbs the body of a dying twin while still in utero. Sometimes the surviving twin must undergo surgery to removed skeletal portions of the other twins body.