Would/ Should you selectively reduce a multiple pregnancy
Women and couples facing a multiple pregnancy often feel very alone when faced with the decision of whether to selectively reduce the pregnancy.

Selective fetal reduction is the seldom-discussed darker side of infertility treatment. This reluctance to discuss leaves the women and couples who face this decision feeling very alone. You can sometimes find articles discussing the concept in abstract, but seldom find someone who writes about it personally.

I ran across this first person article in Elle magazine by Bettina Paige about her decision on whether to reduce her twin pregnancy to a singleton – Fertility Treatments: Would You Get Selective Reduction.  It`s not a new article, but I somehow missed it when it first came out, and since there are so very few resources for people facing this decision it is worth a discussion.

Selective Fetal Reduction of Multiples

When fertility treatments result in three or more fetuses, most women will be advised by their doctor to reduce the pregnancy to twins for the safety of the remaining fetuses (multifetal pregnancy reduction). The risk of losing the pregnancy completely is significant with triplets and more, plus the risk to the babies in triplet, quadruplet, and quintuplet pregnancies is high. The health justification is murkier when this issue is reducing a twin pregnancy.

Paige in the Elle article was 43 and trying to have a second child. She was very clear at the beginning that they could financially and emotionally handle only one more child. Before moving to the safer option of IVF, her insurance required that she first try several rounds of IUI (artificial insemination). Her doctor started her off with injectable ovulatory stimulation drugs. At the time of the insemination, there were four mature eggs. She conceived twins. Contrary to what most people think, the vast majority of higher order multiples (3+) are the result of IUI with injectable ovulatory stimulating drugs, not IVF.

Sophie’s Choice

Paige writes poignantly of trying to decide whether to reduce the pregnancy to one single baby.

[I realized] that people viewed selective reduction in its own category: You weren’t terminating an unwanted accidental pregnancy; you were making a “Sophie’s Choice” between siblings, something a good mother would do only with a gun to her head.

I also worried that the surviving child would be scarred by the loss. Perhaps the fetus would register the cessation of the heartbeat in the neighboring sac, the stilling of the fluttery movements. Could the proximity of decaying fetal tissue infuse my womb with the specter of death? If the chosen one ended up with mental illness or autism, would I always blame myself for having a reduction? All this may seem melodramatic, but I’ve heard about identical twins holding hands in utero; I’ve seen the secret language and private reality shared between even fraternal twins.

Perversely, I held out hope that the CVS would show that one of the fetuses had an abnormality.

Not Part of God’s Plan

Paige commented in the article that on some level it was easier to think of these twins as not a part of God’s plan since they were conceived through fertility treatment. Once medical technology is involved, it is easier for many to keep it involved. As it was succinctly put in a 2011 New York Times article The Two-Minus-One Pregnancy:

If I had conceived these twins naturally, I wouldn’t have reduced this pregnancy, because you feel like if there’s a natural order, then you don’t want to disturb it. But we created this child in such an artificial manner – in a test tube, choosing an egg donor, having the embryo placed in me – and somehow, making a decision about how many to carry seemed to be just another choice. The pregnancy was all so consumerish to begin with, and this became yet another thing we could control.

Why Talk About This Dirty Little Secret?

Selective reduction is an uncomfortable topic for many many people, and I suspect that some would wish I would just keep quiet and let it remain in the dark. They think it reflects badly on infertility medicine and don’t want attention raised. While it may well reflect badly, I disagree that we shouldn’t talk about it for two reasons.

Our mission at Creating a Family is to provide unbiased accurate information and support to those struggling to create their family. People facing this decision are just as deserving of our education and support. There are few places they can turn for help.

You are Not Alone

If you are facing this decision, you are unfortunately not alone. Resources are not readily available, but there are some. One of the best was a Creating a Family show on Fetal Reduction with Dr. Mark Evans, who was one of the first doctors in the country to successfully perform this procedure.



Here are some other resources to check out:

  • Creating a Family show about multiples: So Your Expecting Multiples, Now What? We don`t talk about fetal reduction a great deal, but focus on risks and management of multiple pregnancies.
  • The Two-Minus-One Pregnancy by Ruth Padawer. Well-researched 2011 article in the New York Times on the ethics of reducing twins to a singleton.
  • Why I Decided To Have A Selective Reduction by Koa Beck. Not a first person account, but this 2012 article was based on an interview with a 43 year old single woman who reduced a triplet pregnancy to twins.
  • Washington Post Magazine ran a very thorough article by Liza Mundy in 2007 titled “Too Much to Carry?: Women pregnant with multiple fetuses face one of the toughest choices imaginable: Risk the health of all, or take the lives of some.” Much of the information is still very relevant, plus Mundy is such a darn good writer.
  • Selective Reduction: A Painful Choice by Meredith O’Brien. Well-researched undated article about the pressure to selectively reduce a multiple pregnancy many women face from their fertility doctors.

Think Before You Transfer or Inseminate

The second reason I talk about selective reduction is as warning. There is not much other than support we can offer for people actually facing this heart wrenching decision, but we CAN make a real difference by educating women before they go in for their embryo transfer or artificial insemination of the real dangers of multiple pregnancy. Paige knew she didn’t want more than one, and on some level understood the risks of the procedures. Yet, when caught up in the intensity of treatment and the overwhelming pull of wanting and fear of not getting, she forgot and now must live with the consequences.

I entertained dark daydreams of miscarrying both children as a way out of this intractable situation. I was furious at myself for closing my eyes to the risks of multiples – I felt as irresponsible as someone who kept getting “accidentally” pregnant because she forgot to insert her diaphragm.

It is worth talking about selective fetal reduction if this discussion influences one person towards caution.

So, what do you think? Did you think about this possibility when you went in for a transfer or when you had an IUI with more than two mature eggs?


Image credit: The New York Times Magazine article The Two-Minus-One Pregnancy. Well worth the read.