Selective Reduction: Making An Impossible Choice
I know much more about infertility that I ever thought possible for somebody without an MD. I’ve been in the game six years, and while the reproductive endocrinologists can point to my perfect four-year-old twin daughters and count me among their success stories, I had barely begun my education when they were conceived on my very first IVF attempt. A most important lesson would take years to be fully taught and, even then, at great cost. My girls were born in March, 1995 after a fairly uneventful pregnancy. I was on light bedrest, but never suffered preterm labor. In fact, I barely contracted until the day they were born at 35+ weeks. As anybody whose suffered infertility knows, even an uneventful pregnancy isn’t carefree, but as I passed the 32-week mark, I was finally able to relax. Once my girls were here, I put away any thoughts about what could have happened with this pregnancy because they didn’t. Looking back, I’m grateful for that naivete, so long-gone now. In the spring of 1997, we decided to start trying again. We had frozen embryos left from our first IVF and ever-so-cautious in our second attempt, we put back only two. It didn’t work. On our third attempt, we put back four. I got pregnant, but the result was a blighted ovum and I had a D&C in June. We waited three months and tried again, with a fresh cycle. We debated long and hard on whether to put back three embryos or four. The doctor said he didn’t have an ethical problem putting back four; the chances were so slim of all four taking. Finally, my husband said something I wish we’d remembered later: “We know the one thing we don’t want is quads, and the only way to avoid that is to put back three.” So we did. I got pregnant, but soon realized it was an ectopic pregnancy and had surgery to remove my tubes in November. Tubes gone, my doctors were certain my bad luck was behind me, and we put back three frozen embryos the following January. For the third time, I got pregnant with just one baby. Two consecutive appointments showed a healthy heartbeat and I was released to my regular Ob/Gyn. At my very first appointment, I learned that the heartbeat was no more and the baby had died. I felt defeated, but couldn’t give up. We waited five months before trying again. We wanted to be sure to have the best chance at a healthy pregnancy. The cycle was routine by now, and when it came time for transfer, the doctor recommended replacing three embryos. Desperate for success, we asked for four. She didn’t really argue, or even show much concern. We felt confident that this cycle would be the one, and were validated when 10 days later, we got a positive pregnancy test – and a 450 beta. The nurse who left the message gave a chuckle and made a comment about “however many are in there.” I was terrified. My husband told me I was overreacting, but I knew 450 was big trouble. At my first ultrasound, we saw two sacs. Relief flooded in. Twins were exactly what we’d wanted. On the next ultrasound, we saw four sacs, though one was completely empty and our doctor told us his hunch was three, maybe four. Full of anxiety, we left for a week’s vacation and came home to four strong and steady heartbeats. We were crushed. Infertile friends couldn’t understand why – after all, we were pregnant! That was the beginning, the start of realizing that nobody understands the reality of multiple pregnancy. That the Iowa septuplets were nothing short of a miracle, that quadruplets aren’t just about four identically-outfitted babies in a mega-stroller, that faith isn’t enough to make humans fit to carry litters, that plenty of women with faith spend hours each week at doctors with their children. Selective reduction. As an infertile couple, we certainly didn’t miss the irony in perhaps choosing to abort children we’d so desperately sought to conceive. But we owed to ourselves and our babies to make the best choice we could. As we gathered our wits and made appointments with specialists for consultations, I combed the web in search of information and prayed for a spontaneous reduction that never came. I called a supertwins organization and talked for an hour about what a quad pregnancy might entail – an idealized and minimized view, but one that gave me hope for what I might accomplish. Then I talked to a respected doctor at a respected medical center in Manhattan and she gave me a completely opposite view. I talked to families who had reduced and families who hadn’t. Whatever I wanted to decide, there were more than enough people out there to support that decision. I researched and read and questioned until I realized that there was no right answer. And then my husband and I questioned ourselves. With no guarantee no matter what we chose, it was time to accept responsibility for this decision and make it according to our beliefs, needs, and desires. Our decision-making process lasted six weeks and in the course of it, these are the issues we explored, the questions we asked ourselves again and again until we knew the answers revealed our truest feelings and were leading us to the right decision. I hope they can do the same for you. I’ve divided them into two, equally important, categories. Before you read them, I must emphasize how important it is to get your medical facts first, so you know what the realities of multiple birth are and what your odds of carrying a pregnancy – reduced or not – to term.
PERSONAL These first four questions are the most important and the hardest to answer, but will lead you closer to a true decision than any other. –How would you feel if you reduced and lost the entire pregnancy? (Reduction is not a cure-all; and it carries its own risks.) –How would you feel if you didn’t reduce and lost the entire pregnancy? –How would you feel if you reduced and had healthy babies, most likely at the expense of the reduced ones? –How would you feel if you didn’t reduce and one, two or more babies with birth defects or ongoing handicaps from prematurity? –How would you feel if you reduced and then lost one of the remaining babies, with a premature survivor?
All of these scenarios are both possible and probable; the problem is, you can’t choose which will be yours. Instead, you have to look at these four questions and decide which leaves you with the worst feelings, which you just couldn’t live with. Go with your gut here because this is probably the best indicator of what you really want to do, even if you’re afraid to face the decision in reality. Take the worst case scenario in keeping them against the worst case scenario in reducing and you’ll know what you can live with, even if they’re both painful choices. The rest of the questions should help to reaffirm this gut feeling or help you move closer to a choice if you’re wavering.
– What is your most desired outcome in this pregnancy? (e.g. healthy babies, or any babies, perhaps if you’ve been trying for a long time) –If you were to lose this pregnancy, what are the chances that you could become pregnant again? –How do you feel about “heroic measures” being used to save your babies, or seeing them hooked up to invasive IVs, monitors and ventilators for their first weeks/months of life? Would it bother you or would you think it was helping them? Neonatal ICU is very touch-and-go; can you handle that? –How do you feel about giving birth and not being able to hold your babies? How important do you feel early maternal bonding is? –How do you feel about surrendering your pregnancy to doctors, medications and anxiety? Many women who’ve waited a long time to get pregnant want to experience all the joys of pregnancy they’ve been waiting for so long. A multiple pregnancy does not allow for that. –Do you have other children? How do you feel they would handle extended hospitalization, perhaps caregiver roulette, during your pregnancy? How would they handle the births (i.e. constant hospital visits) and the homecomings? Only you know your child’s personalities and can’t assume that all children are “adaptable.” –Could you be the kind of parent you want to be to four or more children at once? –How do you think the stress of multiples would affect your marriage? Your life? Your goals?
PRACTICAL –If you have other children, do you have a way to take care of them during the pregnancy, which will most certainly include early bedrest and perhaps months of hospitalization? –Do you work? If yes, is it necessary for you to continue to work once the babies are born? If yes, will working provide enough income to pay for the kind of childcare necessary to enable you to continue working (perhaps up to two people to care for the children so you can be completely free to work)? A full-time nanny (30-50 hours) can run up to $700 weekly, depending on where you live. –If you won’t work, can your husband’s income provide for your current expenses, plus the additional expenses multiples will bring, including some kind of at least part-time assistance, diapers, formula, perhaps a larger car or house payment? Would your husband have to take a second job? Is it possible for him to work a second job in addition to his primary job? Don’t assume that society takes care of multiples; this might be true for the first living septuplets, but not for quads. Bottom line: Can you afford to have multiples? –Do you have family and friends locally who can be counted on to help? This is absolutely crucial. –If yes, what kind of help will they give? E.g., they may offer to take your older kids off your hands and that’s not what you will need. –How important is it for you to have your children go to college (or, to a lesser degree, dance lessons, summer camp, whatever luxuries/opportunities you might consider important for yourself or your children)? Many quad families are barely making ends meet and not saving at all for the future.
It’s a lot to think about, and not a decision to be taken lightly. I can tell you that once you make a decision with your heart and your mind, you will feel better. You will still be anxious, worried and scared, but you will know that you have made a decision that you can live with, no matter what happens. If you’ve made your decision this way, it should never be a decision you second-guess because you will know exactly why you made it. I wish I didn’t know this, but I do.
We made our decision and still, with all of our forethought, we lost the entire pregnancy at 25 weeks, one day, with the premature births of our son and daughter and their deaths several days later. It was the hardest thing we have ever been through and while we doubted ourselves for putting back four embryos, we never doubted the decision we made once we learned of our quadruplet pregnancy.
For you, it doesn’t matter what I decided. I know enough people who decided the opposite and suffered the same sad outcome to know that there are no guarantees. If you’re looking for promises, you won’t make the decision you need to make for you. And in this position of having to decide between Hell and Hades, that is the best you can do. It’s important that, if you know nothing else right now, you know that no matter what happens, you did the best you possibly could do. –Donna
Donna, after a number of tries, conceived twins again who were born near term a year and a half after the loss of her babies.