When fertility treatments become frightening
Carrying multiple fetuses can increase risks for both mother and babies
 | “As the number of fetuses rises, the threat of complications goes up, too,” says Harish Sehdev, M.D., a doctor at Pennsylvania Hospital in Philadelphia. |
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“I count ... six babies in there,” the ultrasound technician said slowly. “And they all have strong heartbeats.”
Kristina stared at the monitor, following the technician’s pointer as he showed her the little black blurs on screen. Her joy turned to shock, then panic. Six babies? How could she possibly carry, let alone care for, six babies? She burst into tears as her husband, Michael, in disbelief, counted the embryos once again.
After three years of trying to conceive a second baby, Kristina had been thrilled in July 2005 when she learned she was pregnant — even when her doctor revealed she was having triplets, the result of fertility drugs and artificial insemination. “We knew the chances of multiples were high with fertility treatments, but we were cool with the idea of twins,” says the stay-at-home mom, 33, who lives in Phoenix. “One more seemed fine. We were excited.”
So, despite knowing the added risks of complications with twins, Kristina was positively giddy over the news by the time of her eight-week ultrasound at a high-risk obstetrician’s office near her home. As she lay down on the table, she joked with the technician. “I’m having triplets!” she said. “Just don’t tell me I’m having any more!” A few moments later, the technician blanched and turned the screen around so Kristina could see it as he pointed out the six sacs. “All I could think was that I couldn’t do that to my daughter,” Kristina recalls. “What kind of life would she have? Would we have? I knew we wouldn’t be able to handle it.”
The alternative offered by her doctor a few minutes later wasn’t much better: a multifetal reduction, in which the doctor would stop the heart of three or four of Kristina’s fetuses, leaving behind triplets or twins to grow to full term. A fairly simple procedure, reduction poses few risks to the mother and is usually recommended by high-risk obstetricians to avoid the dangers of multiples: potentially deadly blood pressure swings and a higher chance of gestational diabetes, anemia and kidney infections for the mom; prematurity, cerebral palsy or death shortly after birth for the babies. But it wasn’t that simple to Kristina. The daughter of devout Catholics, she had always been pro-life, determined, if she ever got pregnant, to see it through. “Abortion was never an option,” she says. “If I accidentally got pregnant, that was it. I’d be the one who put myself in that position, and I’d have to go through with it.”
Yet here she was, pregnant by choice and contemplating what, in her mind, amounted to the same thing: getting rid of her babies because they were a health risk and a life unimagined. “It felt like it was my fault because I wanted a baby so badly that I took medicine and forced my body to conceive,” she says. “Now this is what I got, but I didn’t want it. It seemed so hypocritical. I was devastated.”
Greater risk of complications
Kristina didn’t actually know the full extent of the problems she might face until she read the brochures about the risks of carrying multiples that her doctor sent home with her. Then she learned what high-risk obstetricians tell their patients: It’s not a matter of mere inconvenience but of life and death. “As the number of fetuses rises, the threat of complications goes up, too,” says Harish Sehdev, M.D., a doctor at Pennsylvania Hospital in Philadelphia. “Part of our job is to help women deliver healthy babies. And sometimes that means offering a reduction.”
Carrying multiples, even twins, can be a dangerous proposition. With each additional fetus, the odds of spontaneous miscarriage increases from 1 percent for women carrying one fetus to 9 percent for triplets. (There are no stats on higher numbers of multiples because they are so rare.) Women pregnant with multiples also have a greater chance of preeclampsia, a short-term blood pressure disorder that, if not controlled, can lead to seizures or liver or kidney damage and is a leading cause of maternal mortality around the world. (For triplets, the chances are at least 40 percent.) Plus, just about every multiples delivery is a cesarean section, which is usually safe but on occasion can lead to infection, bowel and bladder injury or the need for blood transfusion.
Once born, the babies themselves may face a host of issues that often land them in the hospital’s neonatal intensive care unit for months. For any baby, the biggest complication comes from preterm delivery, considered to be anything before 37 weeks. Women pregnant with one baby deliver at 39 weeks, on average. From there, the average gestational age goes down: 36 weeks for twins, 33 weeks for triplets, 31 weeks for quadruplets. (There are no available numbers for sextuplets because they are so rare, but Dr. Sehdev says the averages keep getting lower with more babies.) Some newborns, especially those arriving before 24 weeks, never make it home. Many of the rest — sometimes several multiples in one family — leave with lifelong ailments. Cerebral palsy, one of the most severe, is up to 10 times more likely in multiple births than among singletons, according to a review of studies published in Clinics in Perinatology. “We can never tell in advance how far along a woman will go or what problems she’ll have,” Dr. Sehdev says. “All we know is that the hazards are pretty high when you’re talking about multiples. For a lot of people, they’re too high.”
Multifetal reductions developed in the mid-1980s, alongside the rise of in vitro fertilization (IVF) and artificial, or intrauterine, insemination (IUI), which brought scores of women pregnant with multiples to high-risk ob/gyns. Already, doctors had a method to reduce a baby in utero if they detected a condition such as Down syndrome in one of a pair of twins. They now utilize the same technology to reduce multiple fetuses — but not without controversy. Like Kristina, many equate multifetal reduction with abortion and insist it’s wrong to sacrifice one fetus for the sake of another. Women facing the prospect often hide it from loved ones, instead sharing their anxieties via Internet support groups.
Jill, a woman from California whose name has been changed to protect her identity because her family doesn’t know she had a reduction in 2006, says her parents are so religious, she couldn’t tell them she’d gotten pregnant through IVF, which the Catholic church forbids. After discovering she had conceived triplets, she had a double burden: hiding her pregnancy and deciding in secret whether to reduce to twins. In the end, she decided the risks of having triplets outweighed her guilt over the reduction. But it was a lonely process. “My parents have picketed at abortion clinics,” Jill says. “They’d never understand. To this day, only my husband and my doctor know what I went through. I felt completely alone.”
Doctors who perform the procedure are wary of discussing it. “It’s a bit like inviting someone with a shotgun onto your front lawn,” says Sean Tipton, spokesman in Washington, D.C., for the American Society for Reproductive Medicine (ASRM). Jeffrey Keenan, M.D., medical director of the National Embryo Donation Center in Knoxville, Tennessee, admits that reductions can protect the life of the mother or babies, but he’s skeptical that everyone who opts for a reduction actually needs one — especially those carrying triplets. “Like abortion, it’s a matter of convenience because parents say they can’t handle three or don’t have room or won’t get sleep,” says Dr. Keenan, a member of the Christian Medical Association in Bristol, Tennessee. “Do we want a utopian society, where every pregnancy is exactly what you want, with no complications? Life’s not like that. If you want that, don’t get pregnant.”
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