Too Much to Carry?

By Liza Mundy
Sunday, May 20, 2007

THE MEDICAL PRACTICE OF MARK EVANS IS LOCATED ON THE GROUND FLOOR OF A MANHATTAN TOWNHOUSE, nestled discreetly among the restaurants and nail salons of the Upper East Side. To be admitted, patients must ring a buzzer and wait for the door to open before taking a seat inside the crowded waiting room.

Down the hall in a tiny examining room one morning, a sonographer named Rachel Greenbaum was sitting on a high stool next to an ultrasound machine. "Do you want to see the screen?" she asked one of Evans's patients, who was lying unhappily on an examining table. The woman, pale-skinned, fine-featured, tall, in her 30s, was wearing a hospital gown. Beside the woman was her husband, sitting in a chair, holding his wife's hand. He too was pale, and, like his wife, he looked miserable. "Yes, I'd like to see them," the woman on the table said firmly.

"I'll just take a few pictures, and I'll show them to you," Greenbaum said.

"Them" referred to the three fetuses in the woman's belly, a long sought pregnancy achieved by in vitro fertilization. The woman and her husband were about to turn their triplets into twins in a procedure known as selective reduction.

Selective reduction is one of the most unpleasant facts of fertility medicine, which has helped hundreds of thousands of couples have children but has also produced a sharp rise in high-risk multiple pregnancies. There is no way to know how many pregnancies achieved by fertility treatment start out as triplets or quadruplets and are quietly reduced to something more manageable. The U.S. Centers for Disease Control and Prevention, which publishes an annual report on fertility clinic outcomes, does not include selective-reduction figures because of the reluctance to report them.

The industry doesn't publish them, either. "This is a very sensitive topic," says David Grainger, president of the Society for Assisted Reproductive Technology, the membership group for IVF clinics. It's sensitive, personally, for patients, but also politically, for doctors.

Mark Evans is one of the few doctors in the country who not only performs reductions but also is willing to discuss all qualms, ethics, issues, outcomes. Evans, who describes himself as an obstetrician-geneticist, is a pioneer in fetal therapy. Using stem-cell transplants, he developed the first in-utero correction of SCID, a genetic disorder that severely compromises the immune system. He has also pioneered fetal surgeries, including bladder shunts for fetuses with urological obstructions. The goal of his practice is the delivery of a healthy baby. In some cases, this can be achieved by treating a fetus in utero. In some cases, it is achieved by sacrificing a fetus in utero.

In 2005, I spent two days with Evans, where the first reduction patient was the distressed woman who had become pregnant with triplets. Triplets pregnancies are far riskier than most people realize: Carrying three babies to term would more than double the woman's risk of developing the most severe diseases of pregnancy, such as preeclampsia. The average triplet is born two months premature, significantly raising the risk of disabilities such as cerebral palsy and of lifelong damage to the infant's lungs, eyes, brain and other organs. By reducing the pregnancy to twins, the woman and her husband would decrease the risk of severe prematurity. And the risk of losing her entire pregnancy would fall from 15 percent to 4 percent.

As she was having her sonogram, the patient told Greenbaum how she'd ended up there. After suffering a series of miscarriages, she and her husband had IVF performed, producing three embryos. To maximize the chances of a successful pregnancy, all three embryos were put into her uterus. All three took.

"Triplets," Greenbaum said.

"So they tell me," the woman said, her voice hollow.

And, sure enough, on Greenbaum's screen were three little honeycombed chambers with three fetuses growing in them. The fetuses were moving and waving their limbs; even at this point, approaching 12 weeks of gestation, they were clearly human, at that big-headed-could-be-an-alien-but-definitely-not-a-kitten stage of development. Evans has found this to be the best window of time in which to perform a reduction. Waiting that long provides time to see whether the pregnancy might reduce itself naturally through miscarriage, and lets the fetuses develop to the point where genetic testing can be done to see which are chromosomally normal.

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