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Abortion in America: terminating one twin

It began as an intervention for extreme circumstances. So how did pregnancy reduction become an option for women carrying twins?

by Ruth Padawer
Friday 23 September 2011

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'When considering which foetus to eliminate, doctors aim for whichever one is easiest to reach.' Photograph: Getty Images. Digital manipulation: Guardian Imaging

As Jenny lay on the obstetrician's examination table, she was grateful that the ultrasound technician had turned off the overhead screen. She didn't want to see the two shadows floating inside her. Since making her decision, she had tried hard not to think about them, though she could often think of little else. She was 45 and pregnant after six years of fertility bills, ovulation injections, donor eggs and disappointment – and yet here she was, 14 weeks into her pregnancy, choosing to extinguish one of two healthy foetuses, almost as if having half an abortion. As the doctor inserted the needle into Jenny's abdomen, aiming at one of the foetuses, Jenny tried not to flinch, caught between intense relief and intense guilt.

"Things would have been different if we were 15 years younger or if we hadn't had children already or if we were more financially secure," she said later. "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."

Reproductive medicine, for all its successes, has produced a paradox: in creating life where none seemed possible, doctors often generate more foetuses than they intend. In the mid-1980s, they devised an escape hatch to deal with these mega-pregnancies, terminating all but two or three foetuses to lower the risks to women and the babies they took home. But what began as an intervention for extreme medical circumstances has quietly become an option for women carrying twins. With that, pregnancy reduction shifted from a medical decision to an ethical dilemma.

Jenny's decision to reduce twins to a single foetus was never really in doubt. She and her husband already had primary school-age children. She felt that twins would soak up everything she had to give, leaving nothing for her older children. Even the twins would be robbed because, at best, she could give each one only half of her attention and, she feared, only half of her love. Jenny desperately wanted another child, but not at the risk of becoming a second-rate parent. "This is bad, but it's not anywhere near as bad as neglecting your child or not giving everything you can to the children you have," she said, referring to the reduction. She and her husband intend never to tell anyone about it. Jenny is certain that no one, not even her closest friends, would understand.

This secrecy is common among women undergoing reduction to a singleton. Doctors who perform the procedure, aware of the stigma, tell patients to be cautious about revealing their decision. (All but one of the patients I spoke to insisted on anonymity.) Some patients are so afraid of being treated with disdain that they withhold this information from the obstetrician who will deliver their child.

What is it about terminating half a twin pregnancy that seems more controversial than reducing triplets to twins or aborting a single foetus. Perhaps it's because twin reduction (unlike abortion) involves selecting one foetus over another, when either one is equally wanted. Perhaps it's our culture's idealised notion of twins as lifelong soul mates, two halves of one whole. Or perhaps it's because the desire for more choices conflicts with our discomfort about meddling with ever more aspects of reproduction.

Plenty of infertility patients who conceive twins are ecstatic from the start about getting a two-for-one deal; some studies indicate that most IVF patients prefer twins. Fertility drugs and in vitro fertilisation both markedly increase the chance of multiples. About 5-20% of pregnancies from fertility drugs turn out to be twins or higher, according to the American Society for Reproductive Medicine (ASRM), and half of babies conceived through IVF are part of a multiple pregnancy. Perinatologists and obstetricians have lobbied fertility specialists to use ovulation-inducing drugs more judiciously and to transfer fewer embryos into their patients. Over the past few years, the campaign has resulted in fewer pregnancies of triplets and up, but the number of twin pregnancies continues to climb. In the UK, since 2004, a maximum of two embryos can be transferred to women under the age of 40, and a maximum of three can be transferred to those aged 40 and over so the chances of multiple births has been greatly reduced. In the US, the number of embryos to transfer is made jointly by the physician and patient. There is no official limit.

No agency tracks how many reductions occur in the US, but those who offer the procedure report that demand for reduction to a singleton, while still fairly rare, is rising. Mount Sinai Medical Centre in New York, one of the largest providers of the procedure, said that by 1997 15% of reductions were to a singleton. Last year, by comparison, 61 of its 101 reductions were to a singleton, and 38 of those pregnancies started as twins.

That shift has made some doctors in the field uneasy, and many who perform pregnancy reductions refuse to go below twins. Dr Mark Evans, an obstetrician and geneticist, was among the first to reduce a pregnancy. He soon became one of the procedure's most visible and busiest practitioners, as well as a prolific author on the topic. Early on, Evans decided the industry needed guidelines, and in 1988 he and an ethicist with the National Institutes of Health issued them. One of their central tenets was that most reductions below twins violated ethical principles.

The justification for eliminating some foetuses in a multiple pregnancy was always to increase a woman's chance of bringing home a healthy baby, because medical risks rise with every foetus she carries. The procedure, which is usually performed around week 12 of a pregnancy, involves a fatal injection of potassium chloride into the foetal chest. The dead foetus shrivels over time and remains in the womb until delivery. Some physicians found reduction unnerving, particularly because the procedure is viewed under ultrasound, making it visually explicit, which is not the case with abortion. Still, even some doctors who opposed abortion agreed it was better to save some foetuses than to risk them all.

Through the early 90s, the medical consensus was that reducing pregnancies of quadruplets or quintuplets clearly improved the health of the woman and her offspring. Doctors disagreed about whether to reduce those to triplets or twins and about whether to reduce triplet gestations at all. But as ultrasound equipment improved and doctors gained technical expertise, the procedure triggered fewer miscarriages, and many doctors concluded that reducing a triplet gestation to twins was safer than a triplet birth. Going below twins, though, was usually out of the question.

In 2004, however, Evans publicly reversed his stance, announcing in a major obstetrics journal that he endorsed twin reductions. For one thing, as more women in their 40s and 50s became pregnant (often thanks to donor eggs), they pushed for two-to-one reductions for social reasons. Evans understood why these women didn't want to be in their 60s worrying about two tempestuous teenagers or two college-tuition bills. He noted that many were in second marriages, and while they wanted to create a child with their new spouse, they did not want two, especially if they had children from a previous marriage. Others had deferred child-rearing for careers or education, or were single women tired of waiting for the right partner. Whatever the particulars, these patients concluded that they lacked the resources to deal with raising twins.

Evans's new position wasn't only a reaction to changing demographics. The calculus of risks had also changed. For one thing, he argued, in experienced hands such as his, the procedure rarely prompted a miscarriage. For another, recent studies had revealed that the risks of twin pregnancies were greater than previously thought. They carried an increased chance of prematurity, low birth weight and cerebral palsy in the babies and gestational diabetes and pre-eclampsia in the mother. Evans concluded that "parents who choose to reduce twins to a singleton may have a higher likelihood of taking home a baby than pregnancies remaining with twins". He became convinced that everyone carrying twins, through reproductive technology or not, should at least know that reduction was an option.

Many doctors, including some who do reduction to a singleton, dispute Evans's conclusions, pointing out that while twin pregnancies carry more risks than singleton pregnancies, most twins (especially fraternal) are fine. Dr Richard Berkowitz, a perinatologist at Columbia University Medical Centre and an early practitioner of pregnancy reduction, says: "The overwhelming majority of women carrying twins are going to be able to deliver two healthy babies." Though Berkowitz insists there is no clear medical benefit to reducing below twins, he will do it at a patient's request. "In a society where women can terminate a single pregnancy for any reason – financial, social, emotional – if we have a way to reduce a twin pregnancy with very little risk, isn't it legitimate to offer that service to women with twins who want to reduce to a singleton?"

Other doctors refuse to reduce below twins unless the pregnancy presents unusual medical concerns. Among them is Dr Ronald Wapner, director of reproductive genetics at Columbia and another reduction pioneer. Sometime in the late 90s, when Wapner practised in Philadelphia, he received his first two-to-one request. "She said, 'Either reduce me to a singleton, or I'll end the pregnancy.'" He consulted his staff, all women, and they concluded that if a woman can choose to end a pregnancy, she can reduce from two to one. Besides, in this case, the team would be saving a foetus that would otherwise be aborted.

As word spread, a stream of patients called Wapner's office, scheduling reductions to a singleton. A few months later, the sonographer who had worked with Wapner for nearly 20 years stopped at his office. She says: "I told him I just wasn't comfortable doing a termination of a healthy baby for social reasons, and that if we were going to do a lot of these elective reductions, I thought he should bring in someone else who was more comfortable."

Wapner immediately called a meeting with his staff. Every one of them – the sonographer, the genetic counsellors, the schedulers – supported abortion rights, but all confessed their growing unease with reductions to a singleton. "There's no medical justification in a normal twin pregnancy to reduce to one," Wapner said, "so we decided to allocate our resources to those who would get the most benefit. We were in the business to improve pregnancy outcomes, and those reductions didn't fit the criteria." He hasn't done an elective two-to-one reduction since.

Evans estimates that most doctors who perform reductions will not go below twins. Shelby Van Voris was pregnant with triplets when she discovered this. After she and her husband tried for three years to get pregnant, they went to a fertility doctor near their home in Savannah, Georgia. He put Shelby, then 30, on fertility drugs and, when that didn't work, injections. By then, her husband, a 33-year-old army officer, had been deployed to Iraq. He left behind three vials of sperm and she was artificially inseminated. She soon found out she was carrying triplets. Frantic, she yelled at the doctor, "This is not an option for us! I want only one!"

Her fertility specialist referred her to a doctor in Atlanta who did reductions. But when Shelby called, the office manager told her that she would have to pay extra for temporary staff to assist with the procedure, because the regular staff refused to reduce pregnancies below twins. She contacted three more doctors and in each case was told: not below two. "It was horrible," she says. "I felt like the pregnancy was a monster, and I just wanted it out, but because we tried for so long, abortion wasn't an option. My number one priority was to be the best mum I could, but how was I supposed to juggle two newborns or two screaming infants while my husband was away being shot at? We don't have family just sitting around waiting to get called to help me with a baby."

Eventually, she heard about Evans and flew to New York for the procedure. "I said, 'You choose whoever is going to be safe and healthy,'" she says. "I didn't give him any other criteria. I didn't choose gender. I had to make it as ethically OK for me as I could. But I wanted only one."

She paid $6,500 [£4,000] for the reduction and left Evans's office incredibly relieved.

Today, her daughter is two and a half years old. Shelby intends to tell her about the reduction one day, to teach her that women have choices, even if they're sometimes difficult. "I am the mother of a very demanding toddler," she says. "I can't imagine this times two, and not ever knowing if I'd have another person here to help me."

When considering the choice of which foetus to eliminate, doctors aim for whichever one is easier to reach, if both appear healthy (which is typical with twins). To the relief of patients, it's the doctor who chooses – with one exception. If the foetuses are different sexes, some doctors ask the parents which one they want to keep.

Until the last decade, most doctors refused even to broach that question, but that ethical demarcation has eroded, as ever more patients lobby for that option and doctors discover that plenty opt for girls. Some patients, like Shelby Van Voris, want no part in the decision. Others say that as much as they hate the idea of choosing based on sex, if there's a choice to be made, they want to be the ones to make it.

Society judges reproductive choices based on the motives behind them. Think about the common reaction to a woman who aborts because contraception failed versus a woman (and her partner) who took no precautions at all. "It changes our judgment of the moral character of the individual making the abortion decision," says Bonnie Steinbock, a philosophy professor who is on the ethics committee of the ASRM. "In the first case, it wasn't her 'fault'; in the second, it was. It doesn't mean the careless person shouldn't have the right to an abortion, but it does mean we're going to have a very different reaction to that choice." Likewise, people may judge two-to-one reductions more harshly because the fertility treatment that yielded the pregnancy significantly increased the chance of multiples. "People may think, 'You brought this about yourself, so you should be willing to take some of the risk,'" Steinbock says.

Women who reduce to singletons sometimes think the same thing. "Most of the two-to-one patients have gone to incredible lengths to get pregnant," says Donna Steinberg, a clinical psychologist in Manhattan who specialises in counselling infertility patients. "They've paid a lot of money and put their bodies through tremendous stress, and they've got what they wanted – and now they're going to reduce? Outsiders think, 'How is that possible?' And that's also where the patients' guilt comes from."

It's not only the parents who may feel guilty. Even if parents work hard to conceal it, the child may discover the full story of his or her origins, and we don't know what feelings of guilt or vulnerability or loss this discovery might summon.

The doctors who do reductions sometimes sense their patients' unease, and they work to assuage it. "I do spend quite a bit of time going through the medical risks of twins with them, because it takes away a little bit of the guilt they feel," says Dr Joanne Stone, the head of Mount Sinai's maternal foetal medicine unit. Sometimes, she says, couples disagree about whether to reduce a twin pregnancy, and she encourages them to see a therapist so they can be at peace with whatever they decide.

One of Stone's patients, a New York woman, was certain that she wanted to reduce from twins to a singleton. Her husband yielded because she would be the one carrying the pregnancy and would stay at home to raise the child. They came up with a compromise. "I asked not to see any of the ultrasounds," he said. "I didn't want to have that image, the image of two. I didn't want to torture myself. And I didn't go in for the procedure either, because less is more for me." His wife was relieved that her husband remained in the waiting room; she, too, didn't want to deal with his feelings.

In some ways, the reasons for reducing to a singleton are not so different from the decision to abort a pregnancy because prenatal tests reveal anomalies. In both cases, the pregnancies are wanted, but not when they entail unwanted complications – complications for the parents as much as for the child. Many studies show the vast majority of patients abort foetuses after prenatal tests reveal genetic conditions such as Down's syndrome that are not life-threatening. What drives that decision is not only concern over the quality of life for the future child, but also the emotional, financial or social difficulty for parents of having a child with extra needs. As with reducing two healthy foetuses to one, the underlying premise is the same: this is not what I want for my life.

That was the thinking of Dr Naomi Bloomfield, an obstetrician near Albany who found out she was pregnant with twins when her first child was not quite a year old. "I couldn't have imagined reducing twins for non-medical reasons," she said, "but I had an amnio and would have had an abortion if I found out that one of the babies had an anomaly, even if it wasn't life-threatening. I didn't want to raise a handicapped child. Some people would call that selfish, but I wouldn't. Parents who abort for an anomaly just don't want that life for themselves, and it's their prerogative to fashion their lives how they want. Is terminating two to one really any different morally?"

I was nine weeks pregnant when my husband and I learned we were having twins. My terror was instantaneous, and for the next few days I could not seem to grab enough oxygen to breathe. Aborting half the pregnancy didn't occur to us – who knew it would even be doable? – but for a few panicky hours, we wondered if it was possible to give one up for adoption. I was right to be afraid. Studies report enormous disruption in families with multiples, and higher levels of social isolation, exhaustion and depression in mothers of twins. The incessant demands of caring for two same-aged babies eclipse the needs of other children and the marriage. It certainly did for us. And yet the thought of not having any one of them is unbearable now, because they are no longer shadowy foetuses but fully-fledged human beings whom I love.

A and her partner had been together 15 years when they decided to get serious about having children. Because both women were 45, they tried to double their already slim chances by both being inseminated. They each tried it three times; nothing took. At their doctor's suggestion, they chose an egg donor in her mid-20s. Both women went through IVF, each with two embryos transferred. Both women got pregnant, but A quickly miscarried. Her partner gave birth to a healthy boy, whom they adore. When their boy was nearly a year old, both women underwent IVF again.

On their son's first birthday, they found out they were pregnant, both with twins. "We did it exactly the same way as last time, so we never expected this," A said.

Because A had already miscarried once, her doctor worried she might not carry two to term; if she reduced, the doctor said, she had a better chance of taking a baby home. The women were tempted to reduce both pregnancies, so each woman would carry one, in part to ensure that even if one miscarried, they would have at least one baby. "But we discovered that the reality of having two pregnant mums when you have a 14-month-old is insane. We've both been very ill from the pregnancies, and it's been hard to give him what he needs. At 14 months, they're inquisitive and energetic, and it was becoming harder and harder to chase him and get him up and down the slide. There were days I'd be in the bathroom throwing up, she'd be on all fours with him, and then we'd switch."

For the sake of the boy they already had, they decided to reduce A's pregnancy to one, and right after that A's partner miscarried. "I don't wish this on anyone," A says. "I'm very grateful that we had this option at our disposal, that it can be done safely and in a legal way, but it was very difficult for both of us. I still wonder, 'Did we choose the right one?' – even though I wasn't the one who chose. That idea, that one's gone and one's here, it's almost like playing God. I mean, who are we to choose? Even as it was happening, I wondered what the future would have been if the doctor had put the needle into the other one."

The women have told no one in their families, no colleagues and only one friend. I ask A what would happen if she wound up losing the pregnancy after all. "We've talked a lot about it," she says after a bit. "I've come to realise there's only so much we can control. There's a point where you just have to let nature take its course."

Source: Guardian UK.

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