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.