HOW MANY IS TOO MANY?

Keywords

Over the last twenty years, advanced infertility treatments have allowed literally millions of women to achieve pregnancies. One unfortunate side effect has been the generation of large numbers of multiple pregnancies whose risks of pregnancy loss, prematurity, resultant perinatal mortality and morbidity are enormously increased. Prenancy loss rates for singletons that are known early in gestation is about 3%, for twins 8%, triplets 15%, quads 25%, quintuplets 50%, and sextuplets + approaching 99%. As documented by the United States Centers for Disease Control, the risk of cerebral palsy in singletons is 1/700, for twins 1/100, and for triplets 1/25. Over the past twenty years a small cadre of physicians has performed fetal reductions that have been shown to dramatically reduce the risks of pregnancy loss, prematurity, and its resultant sequelae. In most cases higher order gestations have been reduced to twins with significant lowering of pregnancy loss rates, perinatal mortality, and morbidity. For patients starting with triplets, loss rates by reduction are reduced from about 15% to 5% going to twins and to 7% going to a singleton. While the loss rate is higher going to a singleton, morbidity rates for a singleton are lower, thus making the counseling for triplet reductions more complex. Many patients with multiples are also of advanced maternal age. In my program more than half of patients having reductions also have chorionic villus sampling for FISH analysis before reduction to maximize the chance of healthy newborns. The ethical issues surrounding fetal reduction will never have complete agreement. Our approach has been to try to achieve the most benefit for the least harms in the attempt to have couples achieve the goal of taking home healthy children.

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