Selective Reduction: A Painful ChoiceMeredith O'Brien
The Most Difficult Choice
Patrice Sullivan said she never felt as though she had an option. “It was a horrible choice,” said the Boston area mother of six-year-old twin girls. After undergoing an intrauterine insemination—where the ovaries are stimulated to produce eggs, and semen is introduced directly into the uterus—Sullivan was shocked to learn she was pregnant with quadruplets. Soon after the ultrasound revealed four beating hearts, Sullivan’s doctor told her, “This won’t work.” She was urged, for the sake of her own life and to attempt to have healthy babies with good birth weights, to reduce her pregnancy at least to triplets. “I trusted them,” Sullivan said of the doctors.
Sullivan, who had been trying for years to get pregnant, was now faced with a procedure which she described as “like an abortion.” After a great deal of agonizing—without emotional support from her doctor or the medical staff—she and her husband decided, at 11 weeks into the pregnancy, to reduce it to triplets. “It was very emotional,” she recalled, saying that she was awake during the “horrible process.” Five weeks later, Sullivan lost one of the remaining three fetuses in a miscarriage.
Losing one of the triplets was “such a shock and overwhelming loss” on top of the grief over the reduction, she said. Sullivan didn’t tell people she’d initially been carrying quadruplets but did share the triplet news with them. To her surprise, friends provided no comfort. “Many people, including the doctors, told us that it was probably better that the baby died before ‘it’ was born because it probably wouldn’t have been healthy anyway,” Sullivan said. “The usual response was, ‘Well, at least you still have twins.’ We really were not allowed to publicly grieve. People just didn’t want to hear it.”
People in Sullivan’s position are often urged to reduce not just to triplets, but to twins because of the risks involved. Whatever choice they make, they often find themselves alone, without support and afraid to talk about it because people don’t understand the complexity of their decision.
As the number of triplet and higher order births has increased dramatically, more and more physicians are urging parents to avoid them. Between 1980 and 1997, the number of births for a triplet or more pregnancy spiked by over 400 percent from 1,377 to 6,737, according to a 1999 federal Centers for Disease Control (CDC) report. The average gestational age for triplets is almost 34 weeks (40 weeks is considered normal for a singleton), according to Mothers of Supertwins (MOST). Quads average about 31 weeks while quintuplets are usually born at 28.5 weeks, the group said. “Among triplet pregnancies, the rate of premature labor before 37 weeks is 68 percent,” MOST reported, adding that premature births for more than three babies is a near certainty.
However, these babies are almost all premature and have low birth weights. “Rates of low birth weight, very low birth weight, and infant mortality were four to 33 times higher for twins and triplets and higher births” than for singleton births, said the CDC report. According to MOST statistics, 88 percent of triplet births involve babies weighing less than 5.5 pounds while 100 percent of quads and quints are smaller than 5.5 pounds.
The selective reduction procedure recommended for many women who find themselves pregnant with higher order multiples involves the doctor inserting a needle into a fetus’ heart and injecting air into the umbilical vein, according to the book, Having Twins. An ultrasound is then performed to make sure that that particular fetus’ heart has stopped beating. The reduction is typically done as early as possible in the pregnancy.
From Six to Three
Denise Foltz of Michigan knew the risks. She was pregnant with six after taking infertility medication, in maternity clothes at five weeks and was very sick during the first trimester. “I was scared to death and totally in love,” she said. “I loved all of those babies.” She already had one successful pregnancy following infertility treatment and was shocked when the doctor told her she was having so many.
Unlike Sullivan’s physician, Foltz’s doctor suggested that they wait and see how her body tolerated the pregnancy and whether all of the fetuses continued to thrive before deciding on a reduction. “I knew it had to be an informed decision, not an emotional decision,” she said. So Foltz and her husband threw themselves into medical journals and reports, analyzed the statistics, interviewed perinatalogists, visited neonatal intensive care units, and consulted with clergy. The decision was made. Reduce to triplets. “The night before [the reduction], we called the doctor at home and asked if we could go for quads, but my doctor recommended against it,” Foltz said. The next day, she cried all the way there, all the way home, and for weeks afterward, she said.
“I had little bouts of depression over the years,” Foltz said, adding that she can’t bear to watch specials about families with quads or more. “I wanted all of those babies. I still think about them . . . But I know I made the right choice.” Today she has healthy 10-year-old triplets whose weight ranged from 5 pounds 6 ounces, to 6 pounds 2 ounces when they were born at 34-1/2 weeks.
No Options Discussed
After trying to have a baby for five years, Los Angeles’ Patty Shier found herself in a similar situation but made the opposite choice. Shier was told she was pregnant with five fetuses following the last of four in vitro fertilization attempts. A devout Christian, Shier said she told her doctor from the beginning that no matter what happened, there was no way she was going to reduce a pregnancy. Nonetheless, the doctor transferred seven embryos into her uterus telling her the chances of a higher order multiple pregnancy “were not good.”
Following her first ultrasound, Shier said her doctor was insistent that she’d never make it through the pregnancy and would never have any babies if she didn’t reduce. “There was no objective discussion of the options,” Shier said, adding that she was never presented with mortality or birth defect statistics, phone numbers for organizations specializing in higher order multiples, or any offers of counseling. She and her husband pored over the studies, spoke with doctors, and consulted the MOST organization on their own. The only word she kept hearing over and over again from her doctor was “reduce.” “It’s just a very hard thing to hear,” Shier said of her doctor’s warning.
Despite the risks of a loss of all the babies or of having sick children, Shier went ahead with the pregnancy. She was bed rested at 18 weeks, moved to the hospital at 27 weeks and gave birth to what she called “the healthiest quints in the country” at 33 weeks. They ranged in weight from 3 pounds 5 ounces, to 4 pounds 5 ounces. Within four weeks, they were all sent home from the hospital. “I didn’t have to live with the question of whether I should or shouldn’t have,” Shier said.
Michigan’s Sue Treber, mother of three-year-old quads, echoed Shier’s sentiments. A series of doctors doggedly tried to persuade her to reduce her quadruplet pregnancy, after years of infertility treatment, including one specialist in pregnancy reduction whom she called “overbearing” and who “made me feel foolish,” she said. Then Treber tracked down perinatalogists who had success with quad pregnancies, consulted some multiples support groups, and decided to go for it. “If we had listened to what the majority of the doctors say, we wouldn’t have them,” she said of her quads. “I don’t think enough doctors give women the feeling that they have a choice.”
That’s exactly what makes Nancy Eaton of Maine look back on her decision to reduce her pregnancy from four to three fetuses with reservation. “We went from that [ultrasound] room so excited, ‘Oh wow’ . . . and then the doctor says, ‘This is not a good thing,'” Eaton said. Her doctor ran through the risks for the quads and put pressure on her to reduce to twins. “That was a total shock to us,” said Eaton, who had used an infertility treatment to get pregnant. “We didn’t know what to do.”
The perinatalogist she spoke with, who specializes in high risk pregnancies, said some quads can do well but added that she’d likely be on bed rest at 16 weeks. “We talked back and forth,” she said of herself and her husband. “We did not have the heart to go down to two.” It was particularly hard, she said, because her mother was not supportive of reduction. “She was one of the ones saying, ‘You just can’t do this,'” she said. Because she was so uncertain, she wishes she had had a support network or some counseling to get through the ordeal. “You felt like you were on an island and no one else had gone through this before you,” Eaton recalled.
Going into the reduction procedure, Eaton was still weighing the decision in her head. “I still felt that I wasn’t sure,” she said. While she cried a great deal about the procedure during the pregnancy, the reality of the reduction didn’t really hit home until she saw her triplets in the hospital after being born at 31 weeks—all healthy—at around three pounds each. Eaton said she looked at them and thought, “What did I do?” It’s particularly hard, she said, when she sees three of her friends who have quadruplets. Though one mother has two children with cerebral palsy, the rest are healthy. “It was so hard on me emotionally,” she said of the reduction. “I don’t think I could do it again.”
Maureen Doolan Boyle, the executive director of MOST, said would-be parents need to make sure they consult the right people and do what’s right for their pregnancy in the middle of such emotional upheaval. “These are not unplanned pregnancies,” Doolan Boyle said, noting that nearly 90 percent of the people pregnant with more than two had infertility treatment. “There has been a tremendous heartache that has brought them here. The decision is made out of love.”
Many of the women who call her are bullied by infertility specialists into reducing their pregnancies to twins, Doolan Boyle said, but those women need to make sure that they’re getting their advice from people like perinatologists who are trained and experienced at dealing with high risk pregnancies. Patients should scrutinize the statistics they are given, she said. For example, Doolan Boyle said,”In the vast majority of triplet pregnancies, it isn’t necessary to reduce . . . because the outcome isn’t statistically significant.” In other words, there’s no statistical difference between twin and triplet pregnancies when it comes to positive outcomes, she said. Connie Agnew in the book Twins! concurred, saying, “[T]his is a gray area because the data shows the risk of a triplet compared to a twin pregnancy is not much greater.”
For women pregnant with higher order multiples, these are some of the recommendations made by Doolan Boyle and moms who have faced reduction:
- Ask your doctor for objective statistics on the ranges of gestational ages, weights, and health of any higher order multiples that he or she has dealt with.
- Consult at least two or three perinatalogists to assess the likelihood of a successful pregnancy.
- Get an assessment of how healthy the fetuses are and whether it’s likely one or more might not make it through the entire pregnancy.
- Call support groups like MOST, The Triplet Connection or Keeping Pace with Multiple Miracles. They will put you in touch with other moms who’ve been in the same situation.
- Seek counseling through your clergy and mental health professionals. Consult the Center for Loss in Multiple Birth if you believe you need specialized counseling.