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.
READ IVF And Twins: Stronger Embryo Helps A Weaker One Survive
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.
What Do You Need To Know About Selective Reduction If You Are Undergoing IVF?
Selective Reduction: The Procedure
Selective reduction is also referred to as multifetal pregnancy reduction or MFPR. The procedure is most often carried out in pregnancies in which quadruplets or beyond are present, and the pregnancy is usually reduced to twins. When carried out for reasons related to the risks of multifetal pregnancies in general, it is typically performed between nine and 12 weeks gestation. When carried out due to severe birth defects in one of the fetuses, or because the baby is at risk of dying or has already passed away, it is termed "selective termination" and can be done later on during a pregnancy.
Selective reductions are usually carried out trans abdominally: using ultrasound technology, a potassium chloride injection is guided into the uterus and delivered to the selected fetus or fetuses. The injection stops the fetal heart. When done during the first trimester, the selected fetuses can be expected to be reabsorbed by the body, though some vaginal bleeding usually occurs.
Though MFPR increases the chances that the remaining fetus(es) will develop normally and healthily and reduces the odds of pregnancy complications, the procedure does come with risks.
In some cases, selective reduction results in a miscarriage of the remaining fetus(es), in preterm labor, or in infection. Alongside the ethical considerations, this is something affected families will want to consider before deciding in favor of or against selective reduction. Discussing the risks and benefits as well as the emotional aspects of the decision with your doctor and with a spiritual leader or a therapist can help those faced with this dilemma reach an ultimate decision.
Single Embryo IVF
Women who have high odds of becoming pregnant through IVF have been shown to have comparable rares of live deliveries when they undergo a single embryo transfer as opposed to a multiple embryo transfer. Though it is possible to become pregnant with twins as the result of a single embryo transfer, higher-order multiples — so triplets or beyond — are extremely unlikely to occur.
If you are under 35, have good quality eggs, and do not wish to be faced with the decision of selective reduction, you will want to discuss the possibility of single embryo IVF, formally called "elective single-embryo transfer", with your health care team.
What If You Don't Want Selective Reduction?
Your doctor will be informing you about the risks a higher-order multiple pregnancy poses to you and your babies, and will offer you the possibility of undergoing a selective reduction. Informed consent is key to your ability to make health care decisions appropriate to you and your situation, and therefore your doctor will present you with all the relevant facts to help you make a decision. However, the final choice is yours to make. As the American Congress of Obstetricians and Gynecologists put forth, it is important to acknowledge "a woman’s right to hold views, make choices, and take actions based on her personal values and beliefs".
Should you choose to proceed with your higher-order multiple pregnancy, your medical team will continue to inform you and provide the best care possible to maximize the chances that you and your babies will be healthy.