Monday, August 15, 2011

Limitless Possibilities: Twin Selective Reduction

Being an infertility vet, you get to hear a lot of harrowing stories and meet some incredible women who have had to make difficult choices along the way in their quest to build their family. One that has come up a few times is selective reduction -- a process that reduces the number of fetuses in a high-order gestation, usually triplet and up. It is rare, however, to pursue selective reduction when carrying twins, as twin gestations have become much more common these days. While there are still risks involved with twins, doctors are far more knowledgeable about the necessary precautions to be taken in order to facilitate a healthy pregnancy and delivery. 

The process of selective reduction involves injecting potassium chloride into the heart of the fetus(es), leading it to stop. It is probably one of the hardest decisions one can make: how do you choose which one of your babies should die? In some instances, the results from a prenatal screening makes the choice more obvious (albeit, still as painful), while others leave that decision to the random selection by one's doctor (position and access to the babies). 

I have had friends who were faced with this heart breaking decision; all of whom opted to reduce from triplets to twins. So when I came across this article in the New York Times Magazine by Ruth Padawer -- "The Two-Minus-One Pregnancy" -- I was amazed to read that twin reductions are also common. Similarly to the silence we experience when going through infertility, there seems to be an even greater taboo when it comes to opting to reduce a twin pregnancy to a singleton.

I leave it to you, dear followers, to draw your own conclusions, judgements  and questions when it comes to this specific type of selective reduction, but here were some of my thoughts that I'd like to put out there:

  • Not everyone who chooses to reduce a twin pregnancy to a singleton pursued infertility treatments, but for those who did, is the stigma attached to the twin to single fetus reduction not a reminder for the REs to transfer fewer embryos -- ideally a single embryo -- rather than transferring 2,3,4 or more in order to ensure implantation?
  • While the final decision of how many embryos to transfer is left to the patient and her doctor, many infertility patients who are receiving either limited or no insurance coverage (i.e., paying out-of-pocket for each treatment) request that at least two or more embryos be transferred to increase the odds of success and not having to undergo any further treatments. If insurance companies covered IF treatments, would fewer women find themselves in this difficult position of having to terminate one or more of her fetuses?
  • As infertility patients, do we take the risks of high-order multiples too lightly seeing so many twins and triplets strolling down our neighborhoods or on TV? While each failed cycle leads to the next, are we too quick to want to "complete" our family in one shot and not taking the time to evaluate our physical, financial and emotional limitations? (I am not referring here to women who transfer a single embryo that then splits up.)
  • A lot of the language used by the women interviewed for this story refers to their desire to be the "the best mom possible" for their children. Some of these women already had children while others were simply overwhelmed with the idea of parenting twins. Either way, they deemed that having a singleton would allow them to "perform" at the highest standards. I wonder how much of our societal pressures to be "super moms" affected the decisions to pursue selective reduction? Is being an "imperfect" parent truly that horrible? Aren't' all generations brought up by so-called imperfect parents and somehow turn out okay? 
I leave you with a quote about the duality of choices by bioethicist Josephine Johnston from this riveting article that continues to stir in my mind as I put it in various contexts:

 “In an environment where you can have so many choices, you own the outcome in a way that you wouldn’t have, had the choices not existed. If reduction didn’t exist, women wouldn’t worry that by not reducing, they’re at fault for making life more difficult for their existing kids. In an odd way, having more choices actually places a much greater burden on women, because we become the creators of our circumstance, whereas, before, we were the recipients of them. I’m not saying we should have less choices; I’m saying choices are not always as liberating and empowering as we hope they will be.”

I look forward to reading your comments. 


    Anonymous said...

    due to my incompetent cervix, i have been counseled by my OB to reduce to 1 in the event of identical twinning as we will only transfer 1 embryo next time.
    the MFM who is performing my TAC says that i can transfer up to three and not reduce any that's how secure he is that it will work, but im tired of being somebody's statistic. im just trying to bring a baby home. twice i have added to the success rates of pregnancy at an ivf clinic. twice i have not brought babies home.
    knowing now what i didn't then, i am an advocate for SET for at least the first IVF. but you see not all people have the coverage that allows them to try more than once. our first IVF was OOP. it worked. we thought we were done. we still aren't, 5 years after starting ttc and 2 years after 1st IVF. thankfully we have coverage now, but there are many people hanging their hopes on that ONE cycle because that's all they will get. for a lot of people, it isn't money but a race against the biological clock. i worry at 33 because i only have one ovary. i feel like endometriosis could take my other one at any time.
    anyway im not real sure what i would do in the case of selective reduction of a twin. having lost two sets of twins it would be a huge decision and one i hope i don't have to face. my heart goes out to those who do.
    i hope you get a good discussion going here.

    The Infertility Doula said...

    Lis, thank you for commenting. I think your personal journey brings up a very interesting twist to the whole story. In your case, maybe you will have to reduce in order to ensure a live birth...(I also deeply hope you won't be faced with such a difficult decision). So are our feelings about SR ultimately affected by the circumstances leading up to the SR? Should you have to divulge your past losses in order to be "forgiven" for your ultimate decision? What about your privacy?

    You leave us with much to think about. Thank you.

    MoonNStarMommy said...

    I am a full believer ... that everyone has their own reasons for what they do, and people do things because they feel they have no choice. I don't judge people, eh... okay I do... but I *try* not to judge people and I try to always put myself in their shoes, with the question ... *What would I do?* ...

    With that said, my personal belief is I could never have an abortion, never choose for my child's life to end. It's a personal belief ...

    My first pregnancy, at 19 years old, I was carrying twins and lost one early on - believing I had lost the whole pregnancy - found out at 8 weeks, I was STILL pregnant. Somehow I managed to keep hold of that baby, even though I had another threatened miscarriage at 10 weeks. Then 5 years and 4 more miscarriages, I was hopeless and gave up, and it was then that I got pregnant with my 2nd miracle...

    at 18 weeks, I was told I had to make a choice. My son has a rare genetic disorder and I was told I should "interrupt the pregnancy" .. I was being told my child would die in utero and if he did survive birth, he'd die shortly after, and if by some MIRACLE he continued to live, he would have no quality of life - being so mentally and physically delayed "it wouldn't be worth it" ...

    All I could think in that moment was ... "Who are you to say you have all the answers?"

    I told him "That is not an option"

    My son made it to 33 weeks before it was necessary to get him out for both our sakes (he was having heart decelerations and I had pre-eclampsia) .... he came out at 1lb 12oz and was whisked away to the NICU with the word that "he will likely die with in 24 hours."

    I had made my OB/RE PROMISE me to get him out alive, all I wanted was to hold him in my arms alive at least once... I would take whatever time God would give us with him... he was my miracle, I fought 5 years for him and I felt there was a plan in motion from a higher power then I ...

    40 hours later, he was taken off the breathing machines, he was breathing on his own. Doctors and Nurses would go past his bed wondering why a 1lb - 2lb baby was not on a breathing machine. Pretty soon his Dr's would come in and tell me "there is no change, we're just waiting for him to gain weight" ...

    9 years later ... he is currently sleeping on the chair in the living room ... he just broke his little nose a week ago ... he has delays and he has medical issues, and he is really small for his age, but if you met him, you wouldn't initially think there was a thing wrong with him.

    Then my 3rd son came along and more medical issues, no one even SUGGEST that I end his life because they knew I wouldn't.

    And then my last pregnancy - perfectly healthy ...

    My heart breaks for any expecting Mother and Father who has to make that choice, it's not a choice that any parent should have to make, period.... :(

    MoonNStarMommy said...

    PS Happy ICLW from #86 :D

    Kristin said...

    I think it's a very personal and private decision and no one can presume to understand all the reasons (medical and personal) someone might make the decision to reduce to a singleton. And, I do think the pressure to be super parents may add to these decision.

    ICLW #19

    Sarah said...

    I agree with Kristen it is a very personal and private decision.

    I know for us we were told to transfer 3 embryos. For us we knew we could not do selective reduction. While the odds that all three would take, my husband and I decided to make the decision based on the idea that all three would take, were we prepared to raise triplets?

    Happy ICLW

    Kristen said...

    I'm only commenting on this because general I feel like it's none of my business what women choose to do with their bodies.
    But. My feeling is that if you don't think you'd be OK with twins, don't transfer two embryos. And personally I don't know how anybody could reduce from 2 to 1, especially after trying so hard to get pregnant. That decision would haunt me for the rest of my life.
    But it's weird, because I had an abortion in my teens, and don't feel bad about that. And is this any different?
    So I guess I don't know how I feel.
    Again I return to "Who am I to judge?"

    Hillary Berger said...

    I honestly try not to answer these types of questions. When contemplating "what I would do in that situation" I am automatically judging others. I have no way of knowing what I would do in a situation like "lis" described.
    My heart goes out to the women who have to make such a difficult decision.

    p.s I am an infertile professional Birth Doula...the name of your Blog peaked my interest :)

    Anand said...

    Oh my ! Sad post on infertility

    Anonymous said...

    Being a mother of 5 (which includes a set of natural fraternal twins) from a previous marriage, when my new husband wanted a baby, we decided on one more. We had to have IVF due to his poor quality sperm. I, 30, and him, 33. I guess I didn't educate myselk thoroughly on how effective transferring 2 embryos would be, but we are currently 8 weeks pregnant with twins and I am absolutely devistated. I don't know what to do. The whole IVF process has put our marriage in a dark place and I don't know if we will make it to delivery married. I've been researching selective reduction but I don't know if this situation would be appropriate for the procedure.

    The Infertility Doula said...

    Anonymous, I'm sorry to hear about your situation. While I don't know all the details, I would ask that you think if your marital problems are solely due to your expecting twins or whether the issues would have arisen regardless. Either way, I hope you find a resolution that gives you peace of mind.

    Catherine Tucker said...

    "I guess I didn't educate myselk thoroughly on how effective transferring 2 embryos would be"

    Please don't blame yourself. It's your RE's job to educate you; it's not your job to educate yourself.

    Anonymous said...

    This blog is a year or so old...but I stumbbled upon it. I am now facing a do I, or do I not, reduce situation. We have 2 boys at home already (born by FET). We transferred 4 embryos our first time and got b/g twins born at 33 weeks. Our daughter passed away 6 hours later. A year later we transferred 3 embryos resulting in our 2nd son. We decided, based on age, to try one more time. One more child. Again we transferred 3....this time all 3 took! I am 6 weeks along, and contimplating reduction. Not because I don't want these children, but because I cannot have 3 children. Physically (since my twins were 33 weeks how early would these be) emotionally and financially. We do not have family that can help us on an ongoing basis if I end up on bedrest...especially if I end up in the hospital. It's not fair to my other 2 children at home (ages 2 and 4) if I'm not well enough to take care of them. My husband works out of town 3-5 nights a week-so I'd be alone. People want to say "oh it will work out..just think of all the joys etc" but at the end of the night they are not paying the bills x5! They are not the ones getting up every 2 hours...x3! Not to mention, the health issues that could be with premature babies. I already went through that with my oldest, and thankfully we got lucky. I already watched a child die...if born too early I cannot watch that again to another...let alone 3. It is a tough decision...

    The Infertility Doula said...

    Dear Anonymous, thank you for sharing your story. I am very sorry to hear about the predicament you're in. There is no doubt that selective reduction decisions are never as clear cut as we might believe them to be. I am going to post an article I recently read about premature babies. It is a sobering read. I hope you make the right decision for you and your family.

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