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The advance of IVF has led to an increase in high-risk multifetal pregnancies. Selective reduction aims to reduce those risks by reducing the number of fetuses. What do people about to undergo IVF need to know about the practice of selective reduction?

Fertility treatments, primarily IVF, have offered many people who could not have conceived naturally the chance to become parents. Alongside the immense hope and happiness fertility treatments give to so many couples also come new challenges. IVF, a costly procedure, is often not covered by insurance policies — and costs rise with every treatment cycle. By placing multiple embryos in a patient's uterus, the chances of pregnancy are increased. 

Where fertility treatments result in high-risk, multifetal pregnancies, the pregnant woman and her partner will be presented with the option to selectively reduce the pregnancy, that is to remove one or more of the fetuses in order to create the best chance of a healthy, complication-free pregnancy. 

Why Selective Reduction Is Performed

With the advance of assisted reproductive technology, or ART, we’ve seen a huge increase in the number of multifetal pregnancies. While twin and higher-order multiple pregnancies have always been considered risky, they simply affect many more families now. The twin pregnancy rate has gone up by as much as 76 percent between 1980 and 2009 alone, while the rate of multifetal pregnancies involving triplets or more went up 400 percent between 1980 and 1998, at which point the numbers peaked.

Multifetal pregnancies place a much greater strain on a pregnant woman’s body than do singleton pregnancies. The risks of miscarriage, high blood pressure, pre-eclampsia, gestational diabetes, iron-deficiency anemia, folate-deficiency anemia, and polyhydramnios (too much amniotic fluid) all rise. 

In addition, mothers pregnant with multiples are more likely to be placed on bed rest, to suffer uterine and vaginal hemorrhage after delivery, to have a cesarean section, and to have to stay in hospital for longer.

Those, of course, are just the medical risks. Families who welcome multiple babies at once have to take care of more babies who are likely to have more medical problems than average. Health care costs and childcare costs are higher, parents are more likely to endure enormous quantities of stress, and the possibility that working outside of the home is a viable option for both parents is reduced.

And what risks do multiple pregnancies pose to babies? Research has shown that infants who had multiple siblings in utero are far more likely to be born prematurely, to suffer from cerebral palsy, to have chronic lung disease, and to be faced with learning disabilities, behavioral problems, and developmental delays. Babies who were part of multifetal pregnancies are more likely to die, not just during pregnancy and birth but also in the first year of life. The risks increase with every fetus.

Why, you may ask, did the rate of high-order multiple births peak in 1998? The numbers can be explained by a combination of single embryo IVF and selective reduction. 

Selective reduction, the practice of reducing the number of fetuses, has negative ethical connotations to many. Its goal, however, is to maximize the health and safety of the mother and to reduce the chance of babies being born with debilitating brain damage and other devastating long-term health issues. One mother who went through a selective reduction told me that the decision to go ahead was hard, but the alternative would have been "cruel", the alternative would have constituted knowingly engaging in a pregnancy that could lead to brain damaged children with a poor quality of life. As quadruplet pregnancies pose health risks to mothers too, not reducing the pregnancy could even have left this woman's older son without a mother. 

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