Targeting “Excess” Children: Risks of Multifetal Pregnancy Reduction

Elizabeth Ring-Cassidy and Ian Gentles

Just as reproductive technologies have changed obstetrical practice, so too have they led to a type of abortion which affects a different population of pregnant women from those who do not want to be pregnant. These women have waited and planned to have a child, and it is ironic that they and their partners who are suffering the problems of infertility must often come face-to-face with abortion.

There is a large literature detailing the psychological distress experienced by couples who wish to have children but who cannot conceive naturally. The following quotation captures the feeling poignantly:

You can’t have a baby — a numbness beyond desperation. Baby lust — do you know how it feels to want a baby so much that every other activity in life, everything you’ve worked for and planned for — jobs, friends, family, marriage — seem hollow as a tin can? To be in emotional pain so extreme that when you see a pregnant woman’s stomach or a newborn baby the pain becomes physical?(1)

An Emotional Roller Coaster

Laffont and Edelmann concluded that long-term infertility that is treated by in vitro fertilization (IVF) superimposes cycles of hope and disappointment on the already depressed and vulnerable psyche of couples who are having difficulty conceiving.(2) The process can take up to nine cycles of treatment because few couples conceive on the first attempt.

Indeed, the overall success rate of IVF is a matter of continuing controversy. Oddens and colleagues found that for women involved in this treatment psychological well-being may deteriorate after unsuccessful treatment cycles.(3)

Both partners experience psychological swings during treatment, and Boivin and colleagues observed that “[s]pouses appeared equally . . . to respond . . . with ambivalent feelings involving emotional distress and positive feelings of hope and intimacy.”(4) But the literature suggests that women report greater negative reactions to IVF failures than men. The coping mechanisms utilized by some women to face the cycles of failure,(5) are the same denial and desensitization often seen in post-abortion psychopathology.

Following this cyclical emotional roller coaster, the fortunate couple may find themselves pregnant. In increasing numbers, however, these pregnancies are “higher order” with three or more implanted fetuses. “The international rates of triplet or higher order pregnancies after assisted reproduction are 7.3 percent at conception.”(6) In order to deal with such pregnancies, women must put themselves in the care of high-risk obstetrical experts who know the latest research on the new technologies used in the management of multiple pregnancies.

One of these new approaches is known as Multifetal Pregnancy Reduction (MFPR)-a form of abortion in which the most accessible fetuses are terminated by a needle stab through the heart and the overall pregnancy number is reduced to twins or a singleton. The dead fetuses remain in utero until the delivery of the living ones. This approach was developed by genetic researchers, some of whom are active participants in the prenatal diagnostics aspects of the Human Genome Project.

While many researchers end their studies with a call for curbs on the number of embryos that are implanted (which would reduce the likelihood of higher order multiple births to near-natural levels),(7) many other continuing studies are committed to the improvement of the techniques for MFPR.

What is interesting about the studies in this area is the high degree of overlap between researchers. The twelve most prolific writers in this field all cite each other and often collaborate on research.(8) This self-referral or “incestuous citation”(9) is similar to that found in the general abortion literature. As in the other abortion areas, the majority of these researchers are themselves practitioners of the MFPR procedure and some have the distinction of being not only practitioners but also advocates for and cited as experts on the probity of the procedure.

The procedure for aborting some of the fetuses in multiple pregnancies has been improved and expanded to the point that all major teaching hospitals in North America and Western Europe now routinely offer couples MFPR as an option for management of multiple pregnancies. One problem, however, is that the couple who never imagined themselves actually having a single child, and who have succeeded thanks to advanced IVF techniques, may feel themselves to be faced with what auto dealers call a “mandatory option” in dealing with their unexpected bounty.

For many couples their new situation is very uncomfortable, not least because the gestational age at which these abortions are occurring has steadily increased to the point where Evans and colleagues are supporting the use of the technique into the third trimester (or after 26 weeks of pregnancy).(10)

The use of this technique is often a logical outcome of the psychology of desperation of infertile couples, and itself produces a logic described by Berkowitz and colleagues:

The medical justification for performing multifetal pregnancy reduction is philosophically similar to the “lifeboat analogy” . . . it is justifiable to sacrifice some “innocent” fetal lives to increase the chances of survival or decrease the risk of serious morbidity in the survivors of the procedure.(11)

MFPR Compared to Genetic Abortions

In an attempt to make the use of MFPR a more readily-accepted part of obstetrical practice, the literature links the procedure to the already well-tolerated practice of abortion for genetic or fetal abnormality. The proponents of this technique believe the linkage addresses two important concerns.

First, they conclude that patients will not tolerate multiple births, so the use of MFPR will avoid the “trauma”(12) of the abortion of a wanted pregnancy on the grounds that if reduction is not offered, the patient will choose to abort all the embryos. Second, MFPR will lead to the ultimate goal of having their own child. This principle of Ethical Justification has also been articulated in terms of three goals:

1. Achieving a pregnancy that results in a live birth of one or more infants with minimal neonatal morbidity and mortality;

2. Achieving a pregnancy that results in the birth of one or more infants without antenatally detected anomalies;

3. Achieving a pregnancy that results in a singleton live birth.(13)

The research literature assumes that parents faced with the potential birth of three to seven children at once are “free” to choose to abort most of them to achieve a family size of their choice. Individuals acting out of desperation, however, are not “free,” and without freedom there is no true choice.

The psychological impact of coercive choice is well documented in the decision-making literature. Miller delineated several models that apply to the decision to abort(14) and Cassidy expanded upon these in relation to decision-making in abortions for fetal abnormality.(15) The consensus among psychologists is that major life decisions based on perceived or overt coercion result in significant psychological distress.

In North America, the prevailing model for making medical decisions is based on the concept of “personal autonomy” and informed consent which have become cornerstones for the ethical acceptability for all medical procedures.(16) Often, however, the decisions taken by couples to reduce the number of fetuses can be seen as lacking true personal autonomy because of parental desperation, medical coercion, and a lack of informed consent.

Restricting Choice and the Lack of Informed Consent

A couple’s capacity to give full assent is badly compromised due to the pre-existing psychological trauma brought on by long-term infertility and the IVF process itself. As the number of these multifetal abortions grows, the families involved are now coming forward to discuss pursuant issues which are only just beginning to be dealt with in the clinical therapy and post-abortion healing literature. Kluger-Bell describes a family of triplets whose IVF resulted in a quad pregnancy. As her client notes:

. . . I really didn’t feel like I had a whole lot of choice about reducing it. And I was pretty much told by the doctors, ‘Oh, well, you’re not going to carry that many babies.’ And most likely it would have to be reduced to two. And not knowing anything about it, we thought that was just the way it was.

It was only when this family firmly expressed their desire to have all four babies that the doctors agreed to leave three. The MFPR was successful, but the client paid an emotional price:

. . .emotionally there’s still an ache that will probably always be there. We had been trying for so many years to create life, it was very contradictory and painful . . . no one ever said we could consider keeping all four . . . why wasn’t that an option?(17)

Ninety-nine per cent of the women who go through fetal reduction had achieved pregnancy through infertility treatment. Therefore, they represent a group which Tabsh describes as “highly motivated to have a successful pregnancy outcome. They tend to be compliant with the medical plan for their care,”(18) and will therefore, as Macones and Wapner imply, assent to whatever approach will most likely assure them of a healthy child. In general, women seeking such an outcome will do anything the medical experts deem necessary.(19)

Ironically, until 1995, the attitude of infertility patients towards multiple births had never been investigated. Gleicher and colleagues found that the medical profession’s implementation of MFPR was made without input from patient populations:

It can therefore be no surprise that the survey reported here about patient attitudes is in strong conflict with the rather universally accepted practice patterns of minimizing multiple pregnancy rates . . . [infertile patients] express a considerable desire for multiple births . . . The medical profession so far has assumed that the decision to minimize multiple births . . . was reflective of patient desires. This study suggests otherwise.(20)

The ethical justification for MFPR is the desperate desire of parents to have a healthy baby. But what is the psychological price?

To desperate people, the avenue that promises the greatest hope may appear to be the morally best option, especially if pregnancy reduction is presented as the medically appropriate decision–the decision that will guarantee them one live baby.

To refuse such an option requires freedom from coercion and access to other management approaches that provide alternatives. It is clear that these couples do not meet the criterion for free choice and, indeed, the actual level of coercion in this procedure is striking in the recent literature on surrogacy.

Medical Outcomes of MFPR

The main rationale for MFPR is clearly the birth of at least one healthy child. Does MFPR guarantee this? This seems to be a matter of debate. Groutz and colleagues found that “Contrary to previous studies we found a higher incidence of pregnancy complications after MFPR compared with spontaneous twins. . . .”(21)

Souter and Goodwin did a meta-analysis of all 83 of the articles published on the procedure since 1989 and found that:

[T]here is a general consensus that reducing triplets to twins results in significant secondary benefits: lower cost and fewer days in hospital and a decrease in a variety of moderate morbidities associated with prolonged hospitalizations and preterm delivery for mother and baby. However, it is not clear that couples are more likely to take home a healthy baby, if they undergo multifetal pregnancy reduction.(22)

A recent Swedish study also identified the presence of post-procedure full miscarriage in 21 percent of the cases undertaken in that country; a further 18 percent died in the womb or shortly after birth, or were born with defects.(23)

Likewise, Elliott has suggested that studies of properly managed triplet pregnancies “show an equal or better outcome with nonreduced triplets compared with selective reduction.”(24)

Psychological Outcomes of MFPR

Given the difficulties inherent in the MFPR procedure, it is not surprising that even following the achievement of the goal of parenting a child, couples who have participated in MFPR decisions experience the grief and emotional distress associated with the loss of a child. Some researchers have claimed that these families do not experience significant psychiatric disturbance because “the birth of healthy children helps reduce the traumatic impact of fetal reduction.”(25) What is not stressed in the literature, however, are the following observations:

1. There are significant attrition and refusal rates in study samples.

2. Couples who miscarried the whole pregnancy following the procedure are unwilling to participate in follow up.

3. There is no study of the full psychological impact on the children who are described by practitioners as “the surviving fetuses.”

Given these limitations, the studies that do address the psychological outcomes find that a significant proportion of their sample experience psychological distress following the procedure. The affective reactions are immediate, and intense grief reactions are characterized by repetitive and intrusive thoughts and images of the terminated fetus(es).

Schreiner-Engel and colleagues report that twenty per cent of those willing to participate in follow up experienced long-term dysphoria. “Their continued feelings of guilt appeared due to a wishful belief that some better solution should have been found.” The characteristics of the most disturbed group were those who were young, religious, came from larger families, wanted more than two children, and viewed the ultrasound of the pregnancy more frequently. The authors conclude that “seeing multiple viable fetuses on repetitive sonograms may interfere with the ability of women to maintain an intellectualized or emotionally detached stance toward the multifetal pregnancy.”(26)

Interestingly, the researchers assume that women who have undergone the stress and emotional impact of infertility and subsequent treatment can–and somehow should be able to–be detached from the one thing that has been a driving force in their lives, having children. This expectation goes against all that is known about maternal-infant attachment and psychosocial understanding of the nature of pregnancy.(27)

Garel and colleagues had a 44 percent interview refusal rate among reduction patients. Of those who agreed to be seen at one and two years post-procedure, one-third reported “persistent depressive symptoms related to the reduction, mainly sadness and guilt. The others made medical and rational comments expressing no emotion.”(28) In these latter cases, apparent lack of emotion following MFPR is similar to the repressed range of emotion found among those women having elective abortions.

Another issue of concern is the psychological impact this will have on parenting interactions with surviving children. About such parents, McKinney and colleagues noted: “Conscious and unconscious responses to the procedure included ambivalence, guilt, and a sense of narcissistic injury, increasing the complexity of their attachment to the remaining babies.”(29)

No research has been done on the long-term implications of parental distress on the psychological development of these children, nor have any studies addressed the dynamics of post-abortion survivor syndrome.

Conclusion

The psychological effects of multifetal pregnancy reduction on parents and surviving children appear to be similar to those associated with other induced abortions, namely, feelings of grief and loss, minimized somewhat by the carrying to term of at least some of the fetuses.

Serious concerns exist about the quality of disclosure and counseling couples receive when MFPR is being recommended. The highly stressed psychological state of couples who have been struggling to become pregnant may predispose them to submitting to medical recommendations that violate their conscience. The possibility of emotional coercion by medical personnel exists.

MFPR does not guarantee that the remaining fetuses will remain healthy. It may instead precipitate complications and even the loss of all pregnancies. More research needs to be done into the effects of MFPR on couples and on their future family life with the surviving babies.

~~~

This article is excerpted from Women’s Health After Abortion: The Medical and Psychological Evidence, by Elizabeth Ring-Cassidy and Ian Gentles. Copyright 2002, Elizabeth Ring-Cassidy and Ian Gentles. Reprinted with permission.

The book is available online here. It can also be ordered through the de Veber Institute.

Learn More: Read the article “IVF, Mass Production and Coercion”

Citations

1. K. Blomain, Customer Review of An Empty Lap: One Couple’s Journey to Parenthood, by Jill Smolowe, Oct. 31, 1997.

2. I. Laffont, R.J. Edelmann, “Psychological aspects of in vitro fertilization: a gender comparison,” Journal of Psychosomatic Obstetrics and Gynecology 15(2):85-92, June 1994.

3. B.J. Oddens, et. al., “Psychosocial experiences in women facing fertility problems–a comparative survey,” Human Reproduction 14(1):255-61, Jan. 1999.

4. J. Boivin, et. al., “Psychological reactions during in-vitro fertilization: Similar response pattern in husbands and wives,” Human Reproduction 13(11):3262-3267, Nov. 1998.

5. M.P. Lukse and N.A. Vacc, “Grief, depression, and coping in women undergoing infertility treatment,” Obstetrics & Gynecology 93(2):245-51, Feb. 1999.

6. J. Cohen, “How to avoid multiple pregnancies in assisted reproduction,” Human Reproduction 13(Supplement 3):197-218, June 1998.

7. Ibid.

8. E. Cassidy, “Multifetal Pregnancy Reduction (MFPR): The psychology of desperation and the ethics of justification,” in J. Koterski, ed., Life and Learning IX: Proceedings of Ninth Annual Meeting, University Faculty for Life, in Deerfield, Illinois 1999 (Washington, DC: University Faculty for Life, 2000).

9. M. Crutcher, Lime 5: Exploited by Choice (Denton, TX: Life Dynamics, 1996).

10. M.I. Evans, et. al., “Selective termination for structural, chromosomal, and Mendelian anomalies: international experience,” American Journal of Obstetrics and Gynecology 181(4):893-7, Oct. 1999.

11. R.L. Berkowitz, et. al., “The current status of multifetal pregnancy reduction,” American Journal of Obstetrics and Gynecology 174(4):1265-1272, April 1996.

12. M.I. Evans, “Ethical issues surrounding multifetal pregnancy reduction and selective termination,” Clinical Perinatology 23(3):437-451, Sept. 1996.

13. F.A. Chervenak, “Three ethically justified indications for selective termination in multifetal pregnancy: A practical and comprehensive management strategy,” Journal of Assisted Reproduction and Genetics 12(8):531-536, Sept. 1995.

14. W.B. Miller, “An empirical study of the psychological antecedents and consequences of induced abortion,” Journal of Social Issues 48(3):67-93, Fall 1992.

15. E. Cassidy, “Psychological Decision-Making Models: An Extension of Miller’s Abortion Decision Models to Miscarriage and Genetic Abortion in Light of the Human Genome Project,” University Faculty for Life, June 1997 (unpublished conference paper).

16. F.J. Beckwith, “Absolute autonomy and physician-assisted suicide: Putting a bad idea out of its misery,” in J. Koterski, ed., Life and Learning VII. Seventh University Faculty for Life Conference; 1997; Loyola College, Baltimore (Washington, DC: University Faculty for Life, 1998).

17. K. Kluger-Bell, “Unspeakable Losses: Understanding the Experience of Pregnancy Loss, Miscarriage, and Abortion,” (New York: W.W. Norton, 1998).

18. K.M. Tabsh, “A report of 131 cases of multifetal pregnancy reduction,” Obstetrics & Gynecology 82(1):57-60, July 1993

19. G.A. Macones, et. al., “Multifetal reduction of triplets to twins improves perinatal outcome,” American Journal of Obstetrics and Gynecology 169(4):982-986, Oct. 1993.

20. N. Gleicher, et. al., “The desire for multiple births in couples with infertility problems contradicts present practice patterns,” Human Reproduction 10(5):1079-1084, May 1995.

21. A. Groutz, “Pregnancy outcome after multifetal pregnancy reduction to twins compared with spontaneously conceived twins,” Human Reproduction 11(6):1334-1336, June 1996.

22. I. Souter and T.M. Goodwin, “Decision making in multifetal pregnancy reduction for triplets,” American Journal of Perinatology 15(1):63-71, Jan. 1998.

23. A. Radestad, et. al., “The utilization rate and pregnancy outcome of multifetal pregnancy reduction in the Nordic countries,” Acta Obstetricia et Gynecologica Scandanavica 75(7):651-653, Aug. 1996.

24. J.P. Elliott, “Multifetal reduction of triplets to twins improves perinatal outcome,” American Journal of Obstetrics and Gynecology 171(1):278, July 1994.

25. M. McKinney, et. al., “The psychological effects of multifetal pregnancy reduction,” Fertility and Sterility 64(1):51-61, July 1995.

26. P. Schreiner-Engel, “First-trimester multifetal pregnancy reduction: acute and persistent psychologic reactions,” American Journal of Obstetrics and Gynecology 172(2 Pt 1):541-547, Feb. 1995.

27. B. Campion, “An argument for continuing a pregnancy where the fetus is discovered to be anencephalic,” in J. Koterski, ed., Life and Learning IX: Proceedings of Ninth Annual Meeting, University Faculty for Life in Trinity In-ternational University 1999 (Washington, DC: University Faculty for Life; 2000).

28. M. Garel, “Psychological reactions after multifetal pregnancy reduction: A 2-year follow-up study,” Human Reproduction 12(3):617-622, March 1997.

29. M.K. McKinney, “Multifetal pregnancy reduction: psychodynamic implications,” Psychiatry 59(4):393-407, Winter 1996.

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