When a woman is carrying three or more children, a medical argument can be made in favor of selective reduction. STORY HIGHLIGHTS
- For women carrying multiple fetuses, a medical argument for selective reduction is clear
- The risks of selective reduction have declined since it was introduced 26 years ago
- After a reduction, pregnancies tend to proceed normally
“They’re my grandkids,” he explained, then laughed. “But everyone always says the same thing” — he held up his hands, like someone appealing to a higher power, and shook them dramatically — ” ‘We don’t want twins!’ “
Hilarious, I thought. Dr. H.’s reaction suggested that anyone desperate enough to visit him would take a kid any way she could get one.
“But I really don’t want twins,” I said. “I already have a 3-year-old, and money is tight. One more is all we can handle.”
“Welllll,” Dr. H. replied, “given your age, we need to be aggressive. So I’d recommend going right to IVF. But if you want, we can transfer only one embryo.”
For that privilege, I had my insurer to thank, surprisingly enough: Since my policy covered three rounds of IVF, Dr. H. said, we could be conservative with the number of embryos we implanted each time.
“Great,” I replied, with a sigh of relief. “Then let’s get started.”
I left the consultation feeling excited and optimistic. Here was a science so precise that Dr. H. could choose among outcomes — you don’t want twins? Fine. I’ll just implant one embryo.
I was in control, finally. I’d spent months taking my temperature, monitoring my cervical mucus, and visiting an acupuncturist, wondering all the while if these efforts were any more effective than chanting a spell: Bibbity, bobbity, boo!
as opposed to the one generated naturally — it was “highly unlikely” that more than one of the eggs would be fertilized. (Later, I’d realize that the ovulation-induction drug Dr. H. suggested I take, Gonal-f, comes with a higher chance of multiples than the more common Clomid. He’d breathed not a word of this to me.)
“We won’t know anything for sure until we do a sonogram,” Dr. H. tried to reassure me. “And a third of the time, one of the twins vanishes anyway. So it’s too early to tell. But you’re pregnant — that’s the important thing…. Congratulations.” It came out sounding like an admonition.
Or perhaps he was opposed to abortion and trying to steer me away from the procedure known as “selective reduction,” in which one or more fetuses in a multiple pregnancy is terminated. I had no way of knowing.
funny, smart, a source of regular joy. As he got older, our lives got easier.
We took trips and found time for exercise and going to movies; we even had space in our two-bedroom apartment for guests. But at that moment, I didn’t want to hear any of that. I’d always wanted two children, and I countered with my best argument: Preserving our lifestyle seemed like a self-centered reason to deprive our son of a sibling.
Selective reduction had been my contingency plan, yet I’d never thought — or felt — through actually using it. I didn’t even know how the procedure was done. Now I was horrified at the idea of terminating one of the fetuses growing inside me by injecting potassium chloride into his or her heart.
With my son, I’d witnessed the step-by-step progress from blip to eight-pound, two-ounce boy, marveling at the increasingly recognizable sonogram images, poring over the weekly e-mail announcements from a pregnancy website: Your baby now has fingernails, your baby is now the size of a lemon, a banana, a melon. … And while I strongly believed in women’s right to have an abortion, the unlucky fetus destined for elimination wasn’t merely an abstract potential life, or an accident.
He or she was the product of my love for my husband, a life we’d made together on purpose. This fetus had an identity, not least as someone’s twin. “Selective reduction” was Orwellian; I knew I was ending what could be a life.
and a chorionic villus sampling (CVS) was recommended beforehand to ensure that the fetus retained had the best chance of being healthy.
I had to make these appointments while deciding what to do. On the Web, I found a small, controversial message board on which veterans of reductions offered guidance. I searched among the threads for a local doctor willing to perform a two-to-one reduction — many won’t — feeling as if I were searching for a back-alley abortion.
“But neither of us even likes our brothers and sisters that much,” my husband persisted. In fact, if it weren’t for the affection between our son and his cousins, he went on, we’d rarely see our siblings.
Eventually, though, it was the sweetness of the cousins’ connection that persuaded my husband to agree to a second. Then, when he had one foot onboard, I dragged the rest of him into the world of assisted reproduction — about which he knew just enough to issue the dictum against twins. Don’t worry about it, I’d bluffly assured him. If we end up with more than one, there’s a way to take care of it. But I was certain that wasn’t going to happen.
During my weekly visits to Dr. H.’s office over the next month, I watched the two little sacs on the sonogram darken and grow, develop heartbeats and vaguely human outlines. “Can you turn the screen away, please?” I asked, tears pooling in the corners of my eyes. “I don’t want to get attached.”
Dr. H. turned it toward me and said sternly: “Start getting attached.”
I’d already asked him about selective reduction. A colleague of his had told me that many women do it, and that it was no more dangerous than amniocentesis. But Dr. H. contradicted her: The odds of losing the entire pregnancy were about 10 percent, he said, and he didn’t do reductions himself.
I kept telling myself I should be happy to be pregnant at all: After wanting another child for the better part of two years and trying and failing for 12 months to have one on my own, I’d conceived! But I grew increasingly despondent as the deadline for terminating one of the pregnancies loomed.
My husband was convinced that twins would radically change our lives for the worse. We’d have to leave our beloved neighborhood for a place with cheaper rents and better public schools — there was no way we could afford private education for three kids.
We’d kiss goodbye any hope of career advancement, at least for the foreseeable future. To his list, I added the loss of my income, necessary to meet our expenses. I couldn’t see how I’d be able to resume working after the birth since we could never afford full-time help, and — no matter how well they napped — two infants wouldn’t leave much time for anything else.
But, but, but…Wasn’t sacrifice part of what being a parent was all about? Was it more accurate to say that we didn’t want to handle twins, rather than we couldn’t? Perhaps the answer to that question would’ve been yes, had my husband and I been two totally different people.
Because beyond the practical concerns, I knew that we didn’t have the energy, the patience, or the fortitude to juggle two infants in addition to our son. As it was, I sometimes felt like a superhero, and my husband and I fought over sharing the responsibilities of one child.
Even in the best of times we struggled not to bark out demands and to keep from seeing the other as the enemy. But struggle we did, because the life we’d made — our marriage, our community of friends, and especially our son — seemed worth the effort. I seriously doubted that this fragile equilibrium could withstand the stress of three young children.
And as much as I wished the situation were different, it wasn’t. I know it sounds selfish, but I wanted to protect the well-being of the people already in my life — my son, my husband, and, yes, myself.
my tightening waistband, my tender breasts, my queasiness — felt like punishment for my baby lust and an indictment of my failings as a mother. Since I was certain I couldn’t manage two babies, how could I be sure I wouldn’t be overwhelmed by one?
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.
When a woman is carrying three or more fetuses, the medical argument in favor of selective reduction is clear. A 1999 study compared the outcomes of 143 cases of triplets reduced to twins with 12 sets of triplets and 812 sets of twins. A quarter of the women carrying triplets lost the entire pregnancy, versus 6.2 percent of those who reduced triplets to twins, which was in line with the miscarriage rates for the nonreduced twins.
Further, a quarter of the triplets were severely premature (and all had attendant complications), compared with 5 percent of the triplets reduced to twins.
Beyond the improved medical outcomes, the daunting financial, emotional, and practical challenges of raising triplets — and the potential psychic toll of being one of three (from the developmental delays connected to prematurity to a deficit of parental attention at a young age) — makes reducing triplets pretty uncontroversial.
Not so twins. Plenty of people have twins and manage to care for them. And there has been no real medical rationale for going from two to one, although recently that has changed somewhat.
The risks of selective reduction have declined since it was pioneered by New York obstetrician Mark Evans 26 years ago, when the odds of losing the entire pregnancy were roughly 10 percent (as Dr. H. told me). But now the figure for two-to-one reductions is roughly 3 percent, according to Evans.
Studies have shown that after a reduction, pregnancies tend to proceed as if a woman had begun with whatever number of fetuses she ends up with. So given the roughly 8 percent chance of miscarrying twins, compared with 4 percent for a single baby, a woman who has a reduction cuts in half her odds of losing her pregnancy.
Moreover, national health data show that twins are more than five times as likely to be born premature before 37 weeks, seven times more likely to be born prior to 32 weeks, and nine times more likely to have a low birth weight. In a paper examining these risks in the journal Obstetrics & Gynecology, Evans and his coauthors concluded: “Our data suggest that the likelihood of taking home a baby is higher after reduction than remaining with twins.”
But the medical benefits didn’t drive our decision — which was true among posters on the selective reduction message board: Even if they said they hoped to maximize their chances of “taking home a baby,” they didn’t think friends and family would buy it.
“Don’t tell anyone,” they advised. “If you already mentioned that you were pregnant with twins, say that the other one vanished.” I’d told a few friends that my hormone levels might indicate two fetuses, but now I lied, saying my doctor had been mistaken.
“Thank God,” my sister-in-law exclaimed. She told me about a single friend who got pregnant with artificial insemination and was considering aborting one of the fetuses. “Can you imagine? It’s like there will always be this secret from the remaining one.”
“Well, can you blame her?” I snapped. “It’d be hard enough to have one on your own, but two?” What I wanted to add but didn’t was that despite working part-time and having a full-time nanny and a relatively helpful husband, my sister-in-law complained incessantly about how exhausted she was caring for two kids, two kids who were three years apart.
I was taken aback by the ferocity of her judgment – particularly since I’d heard her argue just as fervently for a woman’s right to choose. But I’d begun to realize 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.
the same dimples, slender back, and full lips. I felt a rush of nausea, as if I was eliminating a bit of him, too — or at least his DNA.
What I couldn’t foresee, lying there on the table, was how guilty I’d feel watching my son struggle with having to share his mother with only one sibling: the girl I’d give birth to seven months later. Nor could I anticipate the number of times that I’d think to myself — as I stumbled out of bed to breast-feed in the middle of the night, or yelled “No!” to my son as he threw a ball too close to the baby, or harangued my husband with the tally of how many diapers each of us had changed – thank God we didn’t have twins. We’d made the right decision, for us.
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Tags: Reduction, Selective Reduction