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DIFFICULT DECISIONS: MULTIPLE PREGNANCIES AND REDUCTION
Tuesday February 24th, 2009 11:22 AM

Patricia Mendell, LCSW, Reprinted with permission from The American Fertility Association Infocus Magazine Spring 2002-revised October 2008

“USER BEWARE”, these fertility enhancing
Medications may lead to unwanted
Pregnancies with multiples.

If fertility medications carried this label, about the risks of multiple births and multi-fetal reduction, would couples heed the warning? Or, would an even greater number of infertile couples flock to these medications in the hopes of ending their misery sooner? Yet, in an individual’s/couple’s quest to become pregnant, little attention is paid to the medical, emotional and financial risks with multiple pregnancies and/or reduction concerns when fertility enhancing medications are used in their treatments. Recipients know little about the complications of a multiple pregnancy for the recipient mother and the lifelong risks to the development of babies in utero, and beyond. Most know even less about the reduction procedure (not performed until pregnancy weeks 10-12), the risks of a reduction and pregnancy loss, and the potential repercussions it may cause to the rest of the pregnancy.

Often, battle weary individuals/couples cannot imagine that they could finally become pregnant or potentially “too pregnant”. When faced with having too many babies or none at all, they will jump at the opportunity for more in order to have this nightmare over with forever. In the absence of knowledge, reduction is often talked about by recipients as an easy solution to an unimaginable dilemma. Repeated disappointments with multiple eggs, from costly IUI cycles, stimulated with gonadotropins, are frequently seen by the recipient as examples that more eggs cannot ever be harmful. Considering that most are told that their chances for pregnancy are below 25% with these treatments, the idea of becoming pregnant at all seems elusive. For those who do become pregnant with multiples on these cycles, there comes a startling awareness that this “low tech treatment” can produce such unwanted results. In fact, it is often these low tech treatments that are the culprits for most of the multiple pregnancies with triplets or more. Some individuals, when counseled on the possibility of a multiple pregnancy, will select to do IVF in order to reduce their chances for multiples; even putting just one embryo back. In Europe pressure has been put on IVF centers to transfer back single embryos. In fact, a survey in 2005 revealed that in Belgium and the Scandinavian countries 70 percent of all transfers are single embryos. This is in contrast to the United States where, on average, only two percent of the cycles are single embryo transfers. Unfortunately, in the United States the cost of most fertility treatments are not covered by insurance. And, for those individuals who do have coverage there is often a lifetime cap which has often been exhausted by the costs of the fertility work-up or other low-tech treatments; resulting in no money left for the IVF cycle or only enough coverage for one IVF cycle. As a result, with the present success rate for a single embryo transfer still below the success rate of a two embryo transfer, individuals often feel that they have no choice but to put back two embryos or more for their limited chances.

In-vitro fertilization cycles with one’s own/donor eggs pose another dilemma for couples. Many couples feel invested both emotionally and financially in their cycles. Many times they are not prepared for the realities of the cycle. The day of retrieval is often filled with great hope and excitement as they await their fate as to the number of eggs harvested. The following day they are called and told the number of eggs that have become fertilized. Often, this number is half or two thirds of the number of eggs initially retrieved. As they prepare for the three or five day transfer with the beginning of their progesterone shots, they are hoping for a large number of embryos for both transfer and cryopreservation. Most couples are not called until the day of transfer when they are given a time to come in for the procedure. Many describe the day of transfer as extremely emotional and upsetting. Couples are asked to come just prior to the procedure to speak with the doctor in charge to discuss the disposition of their embryos (i.e. what is their status both in quality and quantity). Few are prepared for the results. Most are surprised and disappointed when they learn of the drop in viable embryos. Many expected that the fertilization number would be the same on the day of transfer as it was on day 2. Frequently there are few, if any, suitable for cryopreservation. The recommended number of embryos for transfer may change according to the age of the eggs, the quality of the embryos and the number of previous failed cycles. With this reduced number, couples often feel very unsure and vulnerable when asked about how many embryos are being suggested for transfer. With the fear that the IVF could fail, the concern for not getting pregnant outweighs the threat of reduction. Many have forgotten or ignored what they have been told about the reduction procedure. Few comprehend what it would mean to be pregnant with more than one baby at a time. Couples are extremely vulnerable at this time and often need direction from the physician in making this decision. Many physicians will strongly urge a lower number of embryos for transfer which is consistent with ASRM guidelines. It is not uncommon for this suggestion to be met with angry resistance by the couple who again feel desperate to conceive and believe more has to be better. At this time, it is extremely important that previous questions about the moral and religious concerns of the couple are readdressed. Included in this is a need for discussion of the timing of the possibility of reduction and the dangers of a multiple pregnancy. Still, when patients have had repeated failures in the past, none can imagine that this time will be any different for them, even with more.

Upon first learning of their pregnancy, couples may come to the gradual realization that a multiple pregnancy has been created. With each subsequent blood test the reality of their choice now becomes all too clear. Reduction may now be front and center. For many couples the decision to reduce their pregnancy is not an easy one. “Bittersweet” is the feeling that most couples use to describe the predicament that they are now facing. Often, this pregnancy comes after a hard fought battle with infertility. Many have experienced the sadness of living month after month with no pregnancy. Some have gone through multiple pregnancy losses. None could have imagined that having too many embryos would ever be their problem. The emotions in this difficult decision often seem overwhelming, not to mention the medical, marital, social, religious and financial repercussions. Yet, the time is short and choices must be made with guidance from their doctor. It is important that a trained mental health professional in reproductive medicine be part of this discussion. Not only can they assess the psychological stability of the couple as they confront this decision but they can also provide a safe and non-judgmental place for couples to discuss their feelings, concerns and questions. It is not unusual to find partners disagreeing on what choice to make; even telling the pregnant partner that the decision is up to her. Considering the lifelong implications of this choice, the decision should always be made by both partners. For this reason it is important that differences be discussed and worked through for the health and welfare of the marriage and the potential children.

Frequently, when couples share these choices with family and friends, they receive opinions that are judgmental and critical. Again, this can prevent couples from really having the chance to explore their true feelings on reduction and the risks of a multiple pregnancy. Inevitably, this is the reason why so many couples isolate themselves during this painful time; avoiding the judgmental discussions of others. Again, counseling can provide a safe haven for exploring feelings and making realistic plans for the future. There is no “right” choice. For many couples brief counseling can enable them to feel better about their decision to reduce or go forward with the multiple pregnancy.

Some couples may choose to continue in counseling for support after their decision for the duration of their pregnancy. For others who decide to go forward with the multiple pregnancy, counseling may continue to be helpful as they go through the more difficult times with the end of the second trimester and the concerns of the third trimester. Unforeseen concerns and losses will need to be addressed emotionally, if they arise. If one spouse pressured the other to reduce there may be a resurrection of those resentments and angry feelings. Others feel the crisis has past once the reduction has been performed and the pregnancy seems secure. Often, within a few weeks after the reduction, couples feel that they can finally begin enjoying the pregnancy. They need to be encouraged to feel the joy of announcing it to family and friends. It is important that medical and mental health professionals leave the door open to any counseling needs in the future. It is not unusual for a follow-up counseling appointment to be made after the delivery of the baby/babies, in order to put closure on any unresolved feelings. At times, the birth may raise feelings about the reduction. Feelings will vary from couple to couple depending on their pregnancy experiences. Some may express a sense that the reduction was the right decision for them given their pregnancy experiences, though they may feel a sense of sadness and irony over having been placed in such a predicament. Again, there is no one answer in this choice.

I have counseled too many patients, who on the day of embryo transfer are told about multi-fetal reduction as they are ready for their transfer. Many facilities transfer back more embryos than they had thought they would, in the hopes of beating the odds. While transferring more appears to increase the likelihood of success, it also increases the likelihood for multiples. An educated patient needs help in understanding that more is not necessarily better. Unfortunately, many patients find out, all too soon, that they have had “too good” an outcome and now must face the agonizing decision of whether to reduce or continue on with a high risk pregnancy.

Research indicates that multiples tend to result in more pregnancy complications, lower birth rates and a higher incidence of depression and marital discord in families. For this reason, it is imperative that each time patients consider a new treatment plan, they revisit with their doctor the reduction question; addressing what it would mean for them if they were confronted with the emotional and moral dilemma of a multiple pregnancy.