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Too Much to Carry?

Greenbaum periodically magnified one fetus and brought it into focus. She would then freeze the frame and do two things: measure the fetuses to assess their growth and see if any one is lagging; and take a "nuchal translucency," measuring the fluid behind each fetus's neck. An excess of nuchal fluid suggests a possible problem: Down syndrome, for example. They are all measuring at 11 weeks and 6 days," Greenbaum said.

"That's right," the woman said, wonderingly. "It is 12 weeks tomorrow."

So far, there was nothing anomalous about any of the fetuses. Greenbaum turned the screen toward the patient. "That's the little heartbeat," she said, pointing to the area where a tiny organ was clearly pulsing. "And there are the little hands. There's the head. The body."

"Oh, my God, I can really see it!" the patient cried. "Oh, my God! I can see the fingers!"

"Okay!" she said, abruptly, gesturing for the screen to be turned away. She began sobbing. There were no tissues in the room, so her husband gave her a paper towel, which she crumpled to her face. The patient spent the rest of the procedure with her hospital gown over her face, so she would not see any more of what was happening.

WHAT WAS HAPPENING WAS DAY ONE OF A TWO-DAY PROCESS, in which one of the woman's three fetuses would be eliminated through an injection of potassium chloride, which stops the fetal heart. This process was developed by a select group of doctors including Evans, a large man with the occasional impatience of someone smarter than most of the people around him.

Evans, now 54, was in high school when he became interested in genetics, and he soon realized that the action, genetic therapy-wise, was going to be in prenatal. He became known as an adept practitioner of fetal therapy -- somebody with the know-how and the nerve to treat a tiny creature growing deep and invisible to the naked eye, within a vulnerable womb.

In 1984, Evans says, he was contacted by an ob-gyn who had a patient pregnant with quadruplets from fertility treatment. The patient, not even 5 feet tall, was too small to carry four babies to term. The doctor saw no solution but to abort them. The woman, unwilling to sacrifice a pregnancy she had worked so hard for, asked whether it might be possible to do a "half-abortion." The way abortion is normally performed, through vacuum suction, this would not be possible, but the doctor called Evans to see if there might be another way.

"I don't know if it's possible, but I know how I would do it," Evans replied. The woman was sent to Evans, who, as he puts it, stabbed two of the fetuses with a needle. "Not an elegant technique," he acknowledges. But it worked. "I reduced four to two," he says, "and the two are in college right now."

The technique has been refined. Today, Evans performs CVS, chorionic villus sampling, on his reduction patients. In CVS, a small portion of the placenta, which shares the chromosomes of the fetus, is drawn into a hollow needle. The tissue is shipped to a lab for an overnight test for genetic birth defects. The same test can also determine the gender of each fetus. Evans also studies the position of each fetus. The point is to seek a rationale for which one, or ones, to eliminate.

Most of Evans's practice does not involve reduction. He does genetic counseling and testing of pregnant women, and in most cases gets to deliver the news that their baby is blessedly normal. The days I spent with him, Evans had three sets of patients coming in for reduction. The first was the unhappy couple, who left the office so shaken that they would not allow me to watch their reduction the following day. The second was a woman who had flown in from Puerto Rico and who arrived for her ultrasound alone, clearly terrified and needle-shy. She shrieked throughout the CVS procedure, making the tense and difficult process of aspirating three incipient placentas even more tense and difficult.

His third couple was two women. One was a physician whose practice involves young children with severe birth defects. The other had a job that also brought her into contact with children in difficulty. Like the other patients seeing Evans for reductions, the women were gracious enough to let me sit in, but asked that identifying details not be revealed. For the purposes of this story, I'll call them Jane and Emma.

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