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decision pointShould I consider a multifetal pregnancy reduction?

When considering in vitro fertilization, your doctor will help you decide how many embryos to transfer, with the goal of having a healthy pregnancy with one fetus. You will likely discuss this decision before your treatment cycle begins and again before embryo transfer. If more than two embryos implant and grow in your uterus, you will probably be counseled about multifetal pregnancy reduction to increase the chances of a healthy pregnancy and infant survival.

Embryo transfer success versus the risk of multiple pregnancy

Women older than 35 may have more embryos transferred than a younger woman would. More embryos maximize a woman's chances of conceiving and carrying a healthy pregnancy. But it also increases the risk of multiple pregnancy.

The American Society for Reproductive Medicine recommends that women younger than 35 have no more than two embryos transferred, women ages 35 to 37 have no more than three embryos transferred, and women who are older than 40 have no more than four embryos transferred. Women who have a good chance of becoming pregnant on the first IVF cycle should have fewer embryos transferred, while women who have had several unsuccessful IVF cycles may have more.1 These recommendations are set to limit the number of multiple pregnancies occurring from infertility procedures.

Women older than 40 have a high rate of embryo loss when they use their own eggs. As an alternative, older women can choose to use more viable donor eggs.

If you are considering assisted reproductive technology (ART), fertility drugs, or both, talk to your doctor about how you can avoid a triplet-or-more pregnancy. The decision to have a multifetal pregnancy reduction can be difficult and traumatic.

Multiple pregnancy is a common complication of infertility treatment. It increases risks for both the mother and the fetuses, such as preeclampsia, miscarriage, premature birth, and long-term disability for the babies. The greater the number of fetuses, the greater the chance of a bad outcome. Multifetal pregnancy reduction (MFPR) is a procedure that can be done during the first trimester to reduce the number of fetuses in a multiple pregnancy-usually from three, four, or five fetuses to two. This is done to help the remaining fetuses have a better chance of healthy survival.

The decision to eliminate one or more fetuses from a pregnancy may be emotional and complex. For some people, this issue raises ethical and spiritual concerns. Consider the following facts when thinking about MFPR.

  • With each additional fetus in the uterus, the risks of illness, death, and disability increase.
  • A successful MFPR lowers all risks, making it more likely that you will have a healthy pregnancy and healthy newborn(s).
  • MFPR can cause miscarriage of other fetuses. About 6 in 100 triplet-to-twin procedures lead to miscarriage.2 (This is about the same risk of miscarriage for any twin pregnancy.3)
  • Not all triplet-or-more pregnancies are successful. About 25 in 100 triplet pregnancies end in miscarriage.3 Another 19 in 100 infants from these pregnancies die in the first year of life, often from complications of premature birth.
  • Early genetic testing (chorionic villus sampling) and fetal ultrasound can help identify if one fetus has a genetic disorder and the other does not. This information may help you decide whether to have a selective MFPR.

What is multifetal pregnancy reduction?

Multifetal pregnancy reduction (MFPR) is a procedure that reduces the number of fetuses in a multiple pregnancy-usually from three, four, or five fetuses to two so that the remaining fetuses have a better chance of survival. The goal of MFPR is to increase the chance of a successful, healthy pregnancy.

An MFPR is usually done early in a pregnancy, between the 9th and 12th weeks, sometimes after having genetic testing for fetal problems. The most common method of fetal reduction is transabdominal MFPR. For this procedure, the doctor uses ultrasound as a guide and inserts a needle through the woman's abdomen and into the uterus to the selected fetus. The doctor injects the fetus with a potassium chloride solution, which stops the fetal heart from beating. Sometimes, vaginal bleeding happens after the procedure; this is normal.

The dead embryo or fetus is absorbed by the mother's body. This absorption process is normal and similar to vanishing twin syndrome.

What are the benefits of a multifetal pregnancy reduction?

Family life. In interviews done 2 years after their pregnancies, parents who reduced their pregnancies to twins report less anxiety and depression and more satisfaction with their parent-child relationships than parents of triplets.4

Mother risk. Multiple pregnancy also increases the mother's risk of pregnancy complications such as gestational diabetes, preeclampsia, or anemia. These risks increase with each additional fetus in the uterus.

Infant risk. In a pregnancy with triplets or more, there is a high risk of miscarriage, stillbirth, premature birth, and disability. Only half of families with triplets are not affected by death or a disabled child. Only about one-third of families with quadruplets are not affected by death or a disability.5 To lower these high risks, many doctors offer multifetal pregnancy reduction (MFPR).

A multifetal pregnancy reduction improves your chances of avoiding miscarriage, carrying your pregnancy longer, and delivering one or more healthy babies.2

How does a triplet-reduced-to-twin pregnancy compare with a triplet pregnancy? 2
  Births and losses of twins after MFPR Births and losses of triplets (no MFPR)
Percent of planned babies born, taken home

93.0%

78.6%

Premature birth before 32 weeks

10.1%

20.3%

Premature birth before 28 weeks

2.9%

8.4%

Miscarriage before 24 weeks

5.6%

11.5%

One or more fetal deaths during the pregnancy

27 out of 1,000 live births

92 out of 1,000 live births

What are the risks of multifetal pregnancy reduction?

The risks of multifetal pregnancy reduction include:

  • Miscarriage of the remaining fetuses. When reducing a triplet to a twin pregnancy, the miscarriage rate is about the same as in normal twin pregnancies.3 The miscarriage rate seems to be about the same when reducing from 3, 4, or 5 fetuses, but is higher when reducing from 6 or more.6
  • Emotional risks for you, especially if the pregnancy miscarries. Some parents who go on to have a healthy pregnancy view the pregnancy reduction as sad but medically needed. Others who have had an MFPR followed by a healthy pregnancy first report feeling grief, guilt, and depression about their decision, though this typically lessens with time.4
  • Infection of the abdomen or uterus (rare).

Some couples choose to implant fewer embryos to reduce the chances of a pregnancy of triplets or more, rather than consider multifetal pregnancy reduction.

If you need more information, see the topics Multiple Pregnancy: Twins or More, Miscarriage, and Premature Infant.

Your choices are to:

  • Carry a multiple pregnancy of three, four, or five fetuses along with being informed about your risks associated with that choice.
  • Have multifetal pregnancy reduction along with being informed about your risks associated with the procedure.

The decision about whether to have a multifetal pregnancy reduction takes into account your personal feelings and the medical facts.

Deciding about multifetal pregnancy reduction
Reasons to have a multifetal pregnancy reduction Reasons not to have a multifetal pregnancy reduction
  • You have learned from genetic testing or other tests that you are carrying one or more fetuses with a birth defect.
  • You do not know of specific fetal problems, but you are carrying three or more fetuses, which puts them at higher risk.
  • You want to ensure that you have at least one healthy baby. MFPR will increase the chances of this.
  • You are concerned about the pregnancy risks to you, such as preeclampsia, gestational diabetes, or placenta abruptio.
  • You cannot financially or emotionally afford to have three, four, or five babies to care for.

Are there other reasons that you might want to have a multifetal pregnancy reduction?

 

 

  • Your religion prohibits multifetal pregnancy reduction.
  • You have personal, moral, or ethical concerns about reduction.
  • You are concerned that the procedure may cause a complete miscarriage. This is most likely when fetuses share the same amniotic sac and placenta.
  • You are financially and emotionally prepared to raise three or more children, possibly with special needs.

 

 

Are there other reasons that you might not want to have a multifetal pregnancy reduction?

 

 

These personal stories may help you make your decision.

Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about having a multifetal pregnancy reduction. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

The emotional distress of aborting a fetus would be hard for me to deal with for the rest of my life. Yes No Unsure
Raising three or more children, one or more possibly disabled, would be hard for me to deal with for the rest of my life. Yes No Unsure
We have the financial resources to raise three or more children of the same age with one or more possibly disabled. Yes No Unsure
I am at high risk for pregnancy problems. Yes No Unsure
Genetic testing has found one or more fetal problems. Yes No Unsure
My religion or personal morality is against the practice of multifetal pregnancy reduction. Yes No Unsure
Miscarrying after a multifetal pregnancy reduction would be different for me than miscarrying because of other risks that I can't control. Yes No Unsure
I realize that the miscarriage risk is lower after a multifetal pregnancy reduction than it is for carrying triplets or more. Yes No Unsure

Use the following space to list any other important concerns you have about this decision.

 

 

 

 

 

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to use or not use multifetal pregnancy reduction.

Check the box below that represents your overall impression about your decision.

Leaning toward having multifetal pregnancy reduction

 

Leaning toward NOT having multifetal pregnancy reduction

         
  • Fertility Problems
  • Multiple Pregnancy: Twins or More

Citations

  1. American Society for Reproductive Medicine (2006). Guidelines on number of embryos transferred. Fertility and Sterility, 86(4): S51-S52.

  2. Wimalasundera R, et al. (2003). Reducing the incidence of twins and triplets. Best Practice and Research Clinical Obstetrics and Gynaecology, 17(2): 309-329.

  3. Yaron Y, et al. (1999). Multifetal pregnancy reductions of triplets to twins: Comparison with nonreduced triplets and twins. American Journal of Obstetrics and Gynecology, 180(5): 1268-1271.

  4. Garel M, et al. (1997). Psychological reactions after multifetal pregnancy reduction: A 2-year follow-up study. Human Reproduction, 12(3): 617-622.

  5. Strauss A, et al. (2002). Multifetal gestation-Maternal and perinatal outcome of 112 pregnancies. Fetal Diagnosis and Therapy, 17(4): 209-217.

  6. Stone J, et al. (2002). A single center experience with 1,000 consecutive cases of multifetal pregnancy reduction. American Journal of Obstetrics and Gynecology, 187(5): 1163-1167.

Author Bets Davis, MFA
Author Sandy Jocoy, RN
Editor Kathleen M. Ariss, MS
Associate Editor Pat Truman, MATC
Primary Medical Reviewer Sarah Marshall, MD - Family Medicine
Specialist Medical Reviewer Kirtly Jones, MD - Obstetrics and Gynecology
Last Updated March 21, 2008

WebMD Medical Reference from Healthwise

Last Updated: March 21, 2008
This information is not intended to replace the advice of a doctor. Healthwise disclaims any liability for the decisions you make based on this information.

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