The Dilemma of Multifetal Reduction

How could I now be "too pregnant"? My husband and I had discussed our IVF plan ahead of time. We would not transfer back more than two embryos, maybe even just one. Reduction was never going to be a decision that we would be forced to make. But when we received the call from our nurse on day three after our retrieval telling us only three embryos had survived with no chances for a frozen cycle, we caved. Even the doctor who performed our transfer assured us that we would be lucky if we got pregnant with even one, and that the chances of triplets would be almost nonexistent. Yet, now at 10 weeks pregnant with triplets, we are faced
with whether to take the "chance" and reduce the pregnancy from three to two, maybe even one or "go for broke" with three, hope they are not born prematurely and that the resulting children will not suffer lifelong medical and cognitive complications?

Multifetal pregnancy reduction has been described as a "new moral problem" created by the advancement, but not perfection, of assisted reproductive technologies (ART) [Ann-Marie Begley, Nursing Ethics, 2007(2)]. It is a moral conflict for recipients (i.e., women, couples, partners, and gestational surrogates) who use ART to build their families or assist others in building theirs, and then find themselves at risk because of being "too pregnant" with too many embryos. Recipients are asked to make a decision between sacrificing one for the sake of the other(s) or continuing a pregnancy that will, more than likely, have lifelong consequences for the carrier, the children born, and the intended parents. For those with previous losses or failed fertility treatments this position of having too many seems like another cruel twist to their already painful childless life. For surrogates who believe that they can carry any pregnancy to a healthy conclusion, the decision by the intended parents is often difficult to comprehend and accept.

While advances in reproductive medicine have enabled physicians to develop better treatment tools with IVF cycles and pregnancy predictions, there is still an element of "guessing". Even in the best of situations, taking into account all possible medical measurements, the decision about how many embryos should be transferred is, at best, a game of probabilities, not absolutes. Yet, none of these individuals would describe themselves as gamblers.

The chances for high order multiples is even greater when recipients use fertility enhancing medication with an IUI cycle (intrauterine inseminations). While the odds for a pregnancy may appear low, the chances for multiples of twins and above greatly increase with this "low tech procedure". Yet, the idea of becoming "too" pregnant seems ludicrous. Studies appear to indicate that patients who believe or have been told that their chances for taking home a baby are low, will disregard the risks for twins or greater when transferring embryos. Many who have been told about the chances for multiples have forgotten or ignored what they have been told when faced with a less than favorable embryo quality on the day of transfer. Recipients are extremely vulnerable on the day of transfer or insemination and often need direction from the physician in making decisions. Many physicians will strongly urge a lower number of embryos for transfer, which is consistent with The American Society of Reproductive Medicine (ASRM) guidelines. Others have reported that it is not uncommon to be met with anger from their patients when they enforce their program policies. Patients desperate to become pregnant insist that more, not less, embryos have to be better. For this reason it is important that prior to transfer there be a discussion about the program policy on the number of embryos to be transferred, as well as a discussion of the recipients' moral and religious concerns and beliefs, and willingness to undergo a reduction. In fact, reduction is often talked about by both recipients and physicians as the easy solution to this unimaginable dilemma; "Then you will just reduce!".

Nadya Suleman, "Octomom", is a perfect example of this chance game. Take out the discussion about whether she should or should not have been allowed to transfer 6 frozen embryos and just look at the odds of her having octuplets at this particular clinic with its poor success rates. The chances were poor to none that she would have gotten pregnant at all. In fact, in 2008 this clinic reported no successful births for a woman of her age using frozen embryos. Reduction probably was not part of the conversation. Yet, 8 babies were born and the emotional and financial costs to the children, the mother, not to mention her entire family and society, continues to mount on a daily basis.

Many physicians, recipients and gestational carriers underestimate the negative consequences of a multiple pregnancy both medically and psychologically. In a study by Britt and Evans [Social Science and Medicine, 65 (2007)], they found that a woman's frame of reference, particularly her conceptual frame of reference in terms of when she considers life begins, greatly impacts her decision-making difficulty when considering multi-fetal reduction. In fact, being able to frame this decision medically, that a live, healthy birth and baby is better than none, eases the process. Studies have shown that a triplet pregnancy has a 9.7% chance of perinatal mortality and a 7-8% chance of one or more of the triplets developing cerebral palsy. There are further significant adverse obstetric, neonatal, financial, emotional and social consequences of multiple pregnancies (including twins). While triplet and above pregnancies are viewed as assisted reproductive technology (ART) failures, most iatrogenic (symptoms and possible death brought on unintentionally by the procedure, transferring more than one embryo) morbidity and mortality are the result of twin pregnancies. It has also been shown that women with multiples have a higher incidence of postpartum depression, again placing the woman, her
marriage and her newborn children at risk. [Antsaklis, Souka, Daskalakis, Papantoniou, Koutra, Kavakis, and Mesogitis, The Journal of Maternal-Fetal Neomnatal Medicine 2004: 16]

Few patients understand that the reduction procedure is not performed until a pregnancy reaches week 11 and should preferably not occur after 14 weeks. The reasons for waiting until week 11 are the following: first, the risk of spontaneous reduction or 'vanishing twin or triplet' has by then passed; second, a limited anomaly scan can be performed to detect gross structural anomalies and features of aneuploidy to guide selection of the fetus(es) for reduction; third, screening for aneuploidy using nuchal translucency (NT) can also be performed prior to MFPR, again to guide selection if the NT measurements are discordant; and finally, with data suggesting that the incidence of aneuploidy, as well as other anomalies being higher in pregnancies conceived by IVF and ICSI, some units now routinely offer karyotyping with chorionic villous sampling(CVS) before the MFPR is performed. According to studies, pregnancy outcome appears to be similar if invasive prenatal diagnosis by CVS is performed prior to fetal reduction. [Wimalasundra, Seminars in Fetal &Neonatal Medicine 15 (2010),]

In Europe, pressure has been put on IVF centers to transfer back single embryos. In fact, a survey in 2005 revealed that in Belgium and the Scandinavian countries, 70 percent of all transfers are single embryos. This is in contrast to the United States where, on average, only 5-7% of cycles are single embryo transfers(SET); mostly among women under the age of 36 with day 5 transfers. [] [Grifo, Fertility and Sterility, January 2010]. Unfortunately, the cost of most fertility treatments is not covered by insurance in the United States. For those individuals who do have coverage there is often a lifetime cap which has often been exhausted by the costs of the fertility work-up or other low-tech treatments; resulting in no money left for the IVF cycle or only enough coverage for one IVF cycle. As a result, with the present success rate for SET still below the success rate of a two embryo transfer, individuals often feel that they have no choice but to put back two embryos or more to increase their chances for success. Many have forgotten or ignored what they have been told about the reduction procedure.

A study out of Sweden in 2005 examined the decision making process and factors of IVF patients in choosing one versus two embryos for transfer. In this study of 274 IVF patients equally distributed between males and females, more than a quarter of this population felt that they did not have any information about embryo transfer. Males and females were interviewed
separately and viewed the risks differently, men being more concerned about the risks of a multiple pregnancy than their female counterpart. Physicians and embryologists played a role when patients were informed of the quality of their embryos, though patients still felt the decision was theirs to make. The biggest factors affecting the number of embryos to be transferred are: a woman's age; duration of treatment; number of previous failed cycles; and already having a child. While doctors and embryologists played a role, these other factors were more dominant. In the US, unlike Sweden where fertility treatment costs are covered, having no or limited health insurance coverage may also play a role in how many embryos a patient transfers. Women with repeated losses or failed cycles often see a pregnancy with twins as a "blessing". Facing the prospect of not being pregnant at all versus too many feels like a welcome relief for all the time lost, "a two for one deal". [M. Blennborn, Nilsson, Hillervik, and Helberg, Human Reproduction, Vol. 20 No. 5, 2005]

Upon first learning of their pregnancy, couples may come to the gradual realization that a multiple pregnancy has been created. With each subsequent blood test, the reality of their choice now becomes all too clear. Reduction may now be front and center. For many couples the decision to reduce their pregnancy is not an easy one. "Bittersweet" is the feeling that most couples use to describe the predicament that they are now facing. The emotions in this "new moral decision" often seem overwhelming; not to mention the medical, marital, social, religious and financial repercussions. Yet, the time is short and choices must be made with guidance from their doctor and their OB/GYN. Not only can they assess the psychological stability of the recipients as they confront this decision, but they can also provide a safe and nonjudgmental place for them to discuss their feelings, concerns and questions. It is not unusual to find partners disagreeing on what choice to make; even telling the pregnant partner that the decision is up to her. Considering the lifelong implications of this choice, the decision should always be made by both partners. For this reason, it is important that differences be discussed and worked through for the health and welfare of the marriage and the potential children. Yet, the time is short and choices must be made with guidance from their doctor. It is important that a trained mental health professional in reproductive medicine be part of this discussion.

Frequently, when recipients share these choices with family and friends, they receive opinions that are judgmental and critical. Again, this can prevent recipients from really having the chance to explore their true feelings on reduction and the risks of a multiple pregnancy. Inevitably, this is the reason why so many isolate themselves during this painful time; avoiding the disapproving discussions of others. There is no "right" choice. While many who have considered themselves pro-choice on a woman's right to choose whether to abort a pregnancy or not, find this decision (MFPR), where they have knowingly opted for more embryos to be transferred, or used medications to increase their egg numbers, a difficult one to make peace with themselves. For many, accepting that reducing is for the greater good can be a helpful, but still troubling approach, psychologically, particularly when the embryos being reduced are healthy. A trained mental health professional in reproductive medicine can be helpful as all parties involved express their concerns and explore the pros and cons of their

Whether the recipients decide to reduce or continue the multiple pregnancy, counseling can be helpful with whatever they may face for the duration of their pregnancy. Unforeseen concerns and losses will need to be addressed emotionally. For example, watching the development of the fetuses each week on ultrasounds in the first trimester, can make the decision to reduce even more difficult and confusing. It is not uncommon that when reduction is considered recipients opt to stop watching the ultrasounds. Once a decision has been made, recipients find themselves reconnecting to the pregnancy. Often, within a few weeks after the reduction, recipients feel that they can finally begin enjoying the pregnancy. They need to be encouraged to feel the joy of announcing it to family and friends. At the same time it is not unusual for many to have mixed feelings of joy and sadness as they continue on in their pregnancy; needing help to understand that all these reactions and emotions are normal. It is important that medical and mental health professionals leave the door open to any counseling needs in the future. It is not unusual for a follow-up counseling appointment to be made after the delivery of the baby/babies, in order to put closure on any unresolved feelings. At times, the birth may raise feelings about the reduction. Feelings will vary from person to person depending on their pregnancy experiences. Some may express a sense that the reduction was the right decision for them given their pregnancy experiences, though they may feel a sense of sadness and irony over having been placed in such a predicament. Again, there is no one
answer in this choice.

Patricia Mendell, LCSW, is a psychotherapist in private practice. She is Co-Chair of the Board of Directors of Path2Parenthood, and part of the Path2Parenthood Mental Health Advisory Council. She co-created and has facilitated a workshop entitled, "Families Created Through Donation and Surrogacy" and leads a monthly support group Family Building Network for families created through donation and surrogacy. She is a member of the Mental Health Professional Group (MHPG) of ASRM and is a MHPG Mentor. Patricia has written and spoken extensively at conferences throughout the United States on fertility, pregnancy loss, disclosure, family, and parenting issues including children with learning issues and ADHD/ADD. As a therapist, fertility survivor and parent, Patricia is well aware of the impact decision-making choices have on people's lives. She believes that with the right support system and practical educational tools one can feel confident in tackling any of life's challenges., 212-819-1778, 718-230-9383