More than 20 years ago, I got a phone call from a distressed colleague. One of his patients, a woman only 4 feet 10, was pregnant with quadruplets. He felt, and I agreed, that she had virtually no chance of having a healthy pregnancy. He recommended that she consider terminating and trying again. But she had spent seven years trying to get pregnant. She asked him if anyone could do "half an abortion." He said he didn't know, but he called me. I am an obstetrician and medical geneticist who specializes in developing new prenatal screening and diagnostic tests. I told my friend that as far as I knew, "half an abortion" had never been done in the U.S. But with the woman's life at stake—and all four babies—we had nothing to lose. I did the procedure, which we called selective reduction. Today, her twins are young adults. (Article continued below...)
When I first heard that a California woman had given birth to octuplets after undergoing in vitro fertilization, I couldn't believe it. As the details of Nadia Suleman's story emerged, it became only more incredible. As it turned out, a clinic transferred six embryos (two of which later split into identical twins) to Suleman, who had six children already, meaning she was extremely fertile. I have nothing against IVF. More than 2 million women worldwide have children because of it. But with the increase in fertility treatments, the U.S. birthrate of twins has more than doubled in the past 30 years. Overlooked in the happy news, though, are the troubling surges in neonatal deaths, developmental disabilities and other long-term problems.
For those reasons, doctors prefer to avoid multiple births. But with each cycle of IVF costing more than $10,000, there's enormous pressure to get patients pregnant—fast. Guidelines of the American Society of Reproductive Medicine and the Society of Assisted Reproductive Technologies say that in women under 35, usually only one or two embryos should be transferred to the uterus in any cycle. The U.S. average is 2.4. A third of such pregnancies result in twins, and 4.3 percent yield triplets or more. In women over 35, the overall pregnancy rate falls dramatically, and the proportion of multiples goes up.
In some countries there are strict laws regulating how many embryos can be transferred. In the U.S., reproductive medicine has mostly been a political exercise hijacked by conservatives to promote a "right to life" agenda and not patient welfare. But if fertility doctors don't want government to step in, they've got to find ways to enforce their own guidelines and crack down on egregious behavior, such as the conduct that gave us the octuplets.
In the meantime, my services will continue to be in demand. I'm one of a small cadre of experienced, high-risk obstetricians who now offer selective reduction for higher-order multiples. This is accomplished—usually at about three months of gestation—by reducing the number of fetuses down to a manageable number, usually two. I am often asked how we decide which fetus to reduce. I perform genetic testing on most patients the day before, so we get back significant information about the pregnancy. The first priority is if there is a confirmed abnormality; the second is if I am suspicious about other findings (such as a thickness at the back of the neck, which can signify an anomaly like Down syndrome). Finally, if nothing else matters, we can take into account gender preferences if the couple has them.
Of course, selective reduction can be an agonizing decision for a parent, but most of the couples who come to me have had a longstanding infertility problem. For them, selective reduction is just one more hurdle to deal with. But they are better able to cope when they know the facts: a woman with a quadruple pregnancy has about a 25 percent chance of losing all four babies, but she can decrease the loss rate to about 5 percent by reducing to twins. The risks of prematurity, cerebral palsy and genetic abnormalities (if tested) are all reduced, too.
Reduction will always be controversial. A woman has an abortion because she wants—for whatever reason—to not have a child. But women who have reductions are often desperate to have children. In high-risk situations, reduction may be the best way—sometimes the only way—for that to happen. I realize that in the minds of pro-lifers, this reasoning is flawed. But if performing this procedure means that couples who have suffered years of anguish can have their own healthy children, I'll take all the criticism I get.