Selective
We were discussing a mother pregnant with quintuplets at our weekly perinatal conference. This was many years ago, when five to six fertilized eggs at a time were routinely placed in a woman during in vitro fertilization, and we were grappling with the ethics of that and ways to prevent such high order multiple pregnancies.
"In my opinion," said one of my partners, "A woman should have to agree to have selective termination if more than three embryos result before we agree to have that many fertilized eggs placed." One of the perinatologists agreed. Hmmm, I thought. So much for the non-judgmental approach.
The subject of selective termination came up, not surprisingly, in the comments section of my previous post about sextuplets. Selective termination means reducing the number of embryos in a multiple pregnancy, by terminating them, until there are two or three embryos remaining - a number that is much less likely to result in extremely preterm delivery. Since it involves abortion, it is not surprising that it can lead to heated, emotional discussions. Although in this post I don't really want to get into the whole abortion debate, I do want to say why I think that selective termination will never be the best answer for multiple pregnancies caused by infertility treatments.
For one thing, whether you are pro-abortion or anti-abortion (or pro-choice or anti-choice), we can all agree that there are many people who, because of their anti-abortion beliefs, will simply never consent to selective termination, and this is probably a sizable proportion of the population. Are we to deny some infertility treatments to that many people because they do not agree to selective termination?
The thing that bothers me the most, though, when people talk about selective termination as a solution for these pregnancies is that it's like closing the barn door after the horse got out. Selective termination after we've caused a pregnancy with, say, five embryos? Wouldn't it be much better to be more careful and do a better job of not making a woman pregnant with quints in the first place? If this requires changes in insurance reimbursement for infertility treatments, then so be it. If this requires better education of couples to assure that they don't have sex when the woman's ovaries are releasing six eggs due to infertility treatment, then lets do that.
But acting as if selective termination of a multiple pregnancy that we have iatrogenically caused is a fine way of dealing with the problem - regardless of your abortion beliefs -is just bass ackwards.
"In my opinion," said one of my partners, "A woman should have to agree to have selective termination if more than three embryos result before we agree to have that many fertilized eggs placed." One of the perinatologists agreed. Hmmm, I thought. So much for the non-judgmental approach.
The subject of selective termination came up, not surprisingly, in the comments section of my previous post about sextuplets. Selective termination means reducing the number of embryos in a multiple pregnancy, by terminating them, until there are two or three embryos remaining - a number that is much less likely to result in extremely preterm delivery. Since it involves abortion, it is not surprising that it can lead to heated, emotional discussions. Although in this post I don't really want to get into the whole abortion debate, I do want to say why I think that selective termination will never be the best answer for multiple pregnancies caused by infertility treatments.
For one thing, whether you are pro-abortion or anti-abortion (or pro-choice or anti-choice), we can all agree that there are many people who, because of their anti-abortion beliefs, will simply never consent to selective termination, and this is probably a sizable proportion of the population. Are we to deny some infertility treatments to that many people because they do not agree to selective termination?
The thing that bothers me the most, though, when people talk about selective termination as a solution for these pregnancies is that it's like closing the barn door after the horse got out. Selective termination after we've caused a pregnancy with, say, five embryos? Wouldn't it be much better to be more careful and do a better job of not making a woman pregnant with quints in the first place? If this requires changes in insurance reimbursement for infertility treatments, then so be it. If this requires better education of couples to assure that they don't have sex when the woman's ovaries are releasing six eggs due to infertility treatment, then lets do that.
But acting as if selective termination of a multiple pregnancy that we have iatrogenically caused is a fine way of dealing with the problem - regardless of your abortion beliefs -is just bass ackwards.
posted by neonataldoc at 7:42 PM
17 Comments:
I am hesitant to comment, simply because I personally have never undergone infertility treatments. Despite this, my heart goes out to those who have to work so hard and spend so much in order to have a family. In the cases of the recent sextuplets, I cannot imagine enduring what these families are having to endure--the idea of that complicated of a pregnancy alone scares me off.
The particular hospital I stayed in only took on patients with three or less babies. What I am wondering, is what happens when a woman becomes pregnant with quads or more and then EVERYONE involved has to scramble because no one is sure how to treat such a pregnancy? I mean, how many doctors have delivered sextuplets? Higher-order multiples (as I understand it) are rarely, if ever, allowed to go even remotely full-term, so already these families are dealing with NICU stays and then care after the babies come home must be very overwhelming.
Does it all boil down to money? Another mom of twins who happened to be my roomate during bedrest, commented that she didn't like one of the doctors because he told her that before she underwent infertility treatments, she needed to lose weight. Yet, somehow this same doctor's office continued IVF anyway. How does that happen?
I agree with nearly everything you said on this subject. Just a little quibble with the idea that most people who talk about selective reduction as a required possibility before multiple embryo transfer consider it a "solution" to high-order multiples. Solution is too simple a word, I think. It's more of a frustrated trade: If people want to have the choice of high-embryo transfers, then the medical personnel involved want some sort of "out" available when things go terribly wrong. It is an imperfect balance between maintaining patient choice before pregnancy and the doctor being able to preserve some possibility that the pregnancy they help create might end in a healthy, happy way for at least one child, even if too many embryos implant.
To me, selective reduction is like the emergency brake on a car. It is crude. It is difficult to use. But in the event that the regular brakes fail, that emergency brake can still keep you from slamming into a wall. So there it sits in every car, just in case.
IMO, health insurance should pay for at least basic fertility treatments so the whole "this is my one $15K shot at a baby, load me up wi!" issue goes away. That alone would likely result in a huge reduction of selective reductions.
Several thoughts on this issue.
First, I agree entirely that prevention of multiple pregnancies is better than treatment, be it selective abortion or carrying multiples to probably not term and trying to save neonates that are too small. Some IVF specialists are now advocating single embryo transfer for best results. This, obviously, has a lower chance of multiples than a multi-embryo transfer, although identical twins are always possible.
I also agree that insisting that a woman who has a high order multiple pregnancy have selective abortion is a bad idea. Whatever her reasons, the decision to have a selective termination needs to be hers.
However, if I were an infertility specialist, I would certainly discuss the possiblity of multiples (and the level of risk for any given procedure) before performing any fertility enhancing procedure and make sure that the couple involved understood their options. If the potential mother or parents find the possibility of being faced with either having to try to raise 6 very sick children or having a selective abortion to avoid that situation impossible to cope with then maybe fertility treatment isn't the best option for them. Or at least, treatments with higher risk of multiples should be avoided.
Furthermore, I would strongly recommend selective abortion in the case of high order multiples, for the very reasons you outline in your post below: better chance of survival and health for the embryos that are retained, it is much easier to raise one, two, or even three children than 6, etc. However, if she refuses, then she refuses and we focus on trying to make the pregnancy go as close to term as possible and have the babies be born as healthy as they possibly can be.
I agree with what you wrote. When me and my husband went through IVF, it wasn't even a thought of having the doctor transfer any more than 2, because of my age. But me and my husband spent a lot of time talking about what if both took and could we handle twins, etc. We decided we could. So we went forward with two, and both took, and we now have beautiful twins that I wouldn't trade for anything in the world!
But I was honest with myself and me and my husband both agreed that we couldn't handle or afford triplets, so if by some miracle one of the embryos had split, we probably would have done selective reduction. That being said, I'm thankful every day of my life that that was a decision I never had to make.
To put it in emotional perspective, nothing is sadder than wanting children and feeling like you may not be able to have them. I know many people who said they would have the doctor put 10 embryos in just to increase their odds (not that their docs would!), especially after countless rounds of IVF and hundreds of thousands of dollars spent. Sometimes people want something so badly, they don't think about what might happen if they get it. Especially if financially you can't afford it, and you are down to your last cycle.
It's just such a tough pill to swallow, and sometimes the thought of 5 kids is better than the thought of none. But I have a feeling that people are imagine 5 HEALTHY kids, not thinking about the real possibilities of what could happen and what risks are involved in carrying 5 kids.
just my 2 cents.
One other thing to be aware of is that selective reduction doesn't reduce the risk proportionately. In studies of triplets reduced to twins, the outcomes are better than unreduced triplets, but still worse on average than twins conceived as such.
You talked in this post and the last about being more careful and not causing the high-order multiples in the first place. Well, I ran the numbers yesterday (details on my blog), and the odds of conceiving sextuplets are roughly only 0.00114%, even when six mature follicles are present. Those odds are really very low already, despite what all the press coverage would lead you to believe. It would be nice if they were zero, but do you really think it's feasible to get them much lower?
The Washington Post had a fascinating story in their Sunday magazine on May 20th, 2007. The author is Liza Mundy - if you do a search on the post website you'll find it. You might first find the "chat" she did about irt, and that will provide a link that works (the post might have archived the story itself). The title of the story was "Too Much to Carry?" and I think it was draw from her most recent book. She interviewed a doctor who does a lot of reductions, and also interviewed a few patients. Well worth the read (sorry I am not providing the link). I've just recently found this site and am riveted. Thanks for this window on the world.
Weighing in with another comment regarding "insisting" women have selective reductions:
Saying you theoretically agree to selective reduction in order to qualify for a certain fertility treatments is NOT the same as thing as forcing a reduction. Thankfully in the US, nobody can force a woman to have an abortion against her will.
As good as free will is, the irony is that it lessens the effectiveness of what might otherwise be a good system to cut down on the number of HOMs. Why? Because people can lie about their intentions to reduce (or even just change their minds later on) and a HOM pregnancy would still be created and progress under certain circumstances.
Of course that just brings us back to Neonatal Doc's main point again -- that preventing these things from occurring, rather than dealing with them later, seems like the most logical way to proceed.
I worry that people reading this post won't realize that transferring 5-6 embryos is no longer the standard of care. Now it's between 1-2 for the majority of couples. Some couples depending on their circumstances and history, may have more transferred, but it's directly related to the circumstances of their cycle, not a blind 'let's throw 'em all in and see what sticks' approach.
I also wanted to point out, for anyone who bothers to read through all the comments, that adoption is incredibly expensive. No one is giving away babies for free except God. Everyone else wants their cut.
For us, adoption was a much more expensive option than IVF. Adoption routinely costs $20k and up. Want to go to Russia? You'll pony up $40k and deal with bureaucratic rep tape for up to two years. The tax breaks for IVF were better too. For adoption, the tax credit is limited to $10k but is unlimited for medical expenses. Adoption can really get expensive.
Nor is adoption psychologically benign for the child. My family has adopted members and, despite what society thinks, a loving family is not always enough to overcome the psychosocial baggage of a poor start in life. Building a family via adoption requires a different set of finances, emotional readiness, and committment than getting pregnant.
And for all those who suggest infertile couples adopt, have you? No? Well, why not?
M
My brief history so that you'll know where I'm coming from is that my living daughter was conceived via IVF. We did 3 year's worth progressing up the chain of fertility treatments until she was conceived. We transferred 3 fresh embryos with failure. Then, transferred 3 that were frozen and thawed (frozen embryo transfer) and she came from that batch. In addition, I have also lost a daughter born at 25 weeks. She lived 2 very short weeks.
I'm unsure and have not followed the sextuplet story too closely. Where they IVF or IUI (interuterine insemination) babies. Most RE's do not transfer large number of embryos these days and most high order multiples are a result of IUIs. Regardless, due diligence MUST be made to prevent HOM's from occurring. I know the pain, the desperation, the fear of never having a biological child.
I overstimmed on an IUI cycle. I had 6 possibly 7 mature follicles and cancelled the cycle. I just was not prepared to face the possibility of HOM. Couples going through fertility treatments must be made aware of the possibility.
Also having lost a child due to extreme premturity, I say that it's just not worth it. Do not inseminate, do not transfer, do not take this risk!!
"Some couples depending on their circumstances and history, may have more transferred, but it's directly related to the circumstances of their cycle, not a blind 'let's throw 'em all in and see what sticks' approach."
One blog I read, Barely Tenured, is written by a woman who had four transferred, at Cornell. But...infertility treatments had failed for her before, her husband has CF and thus they're working with a VERY limited amount of sperm, and she told the doctor (truthfully) that she was willing to do SR. She got pregnant with one healthy baby, who is currently more than a year old. Sometimes the risk is worth taking even if all of the policy issues aren't there - her concern wasn't money, it was that she and her husband had reached their end as far as unsuccessful infertility treatments were concerned, and had a low risk of success to begin with.
So, sometimes the risk is worth taking...but I hasten to note that her doctor was reluctant to transfer more than three before she outright said that she'd do SR.
But, in general, I agree with your point. It's valuable to remember that the human reproduction system can be very unpredictable - the McCaughey septuplets were conceived on a lower dose of fertility drugs than the level on which the parents had previously conceived just a singleton. However...
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We went through an IUI cycle and now have quadruplets growing. It bothers us a LOT as we have to go through reduction. We worry not just about the two that we have to reduce, but also about the safety of the other two. We were so happy until yesterday when we found out this.
We had two mature follices and two smaller ones that the doctor said didn't have a chance. Unfortunately for us, all four matured and implanted.
Hi, I am the husband. My wife went through IUI. That's it. Neither one of us have kids, this is the first try at infertility treatment. We are carrying six embryos. We thought there might be just five, but one that was smaller than the rest has caught up, and there are six heartbeats at 10 weeks. We are reducing. This has been an awfully hard decision to make. Keep in mind that we had to wait until 10-11 weeks in order to increase the chances of survival for our twins. I am trying to convey the reality that, no matter your beliefs, it is a choice for your children. There is no selfishness in this decision. People think of abortion as such, but this is a different reality, one in which not only the mother's health is at stake, but also all the children. I want my children to have a good life. It's a catch-22 of a situation, one that nobody should have to go through. I want everybody to know that there is no shame in this. I want healthy children, not for my sake, but for theirs. I know there are others out there struggling with this. Wish us luck. We reduce 9/18/07.
JW at tchefunkte@gmail.com
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