Too Much to Carry?

Emma was the one who was pregnant, via a sperm donor. She had suffered a miscarriage after her first artificial insemination. But the next time, she got pregnant with quadruplets. "We went from famine to feast," said Jane, explaining that they felt that carrying four babies to term would be far too risky. These women knew all too well what serious disability does to a child and to a family. Evans outlined what would happen and reviewed the criteria for deciding which to reduce: chromosomal abnormalities, fetal position, professional instincts. "And then, if absolutely nothing else matters, and if everything else is equal . . ."

"Selection for sex," finished Jane.

"If there's a gender difference, we'll talk about that," he acknowledged.

"I used to be totally not willing to talk about gender," elaborated Evans, who has pieced together his own ethics during more than 20 years of practice. At the outset, he worked with a bioethicist to develop guiding principles. For years, he says, the majority of sex-selection requests came from Asian and Indian parents, who tended to want to keep the boys. That he would not do. Increasingly, however, what people want is the Holy Grail of the modern two-child family: one boy and one girl. He finds that morally acceptable.

Emma positioned herself on the table for her sonogram, while Jane scrutinized the four fetuses on the screen. "They are all tucked in really nicely into their little nests," she said, fascinated. "The most I've ever looked at in utero is two."

Greenbaum took the measurements. The growth of all four babies was fine. The nuchal folds were fine. Evans studied the way the fetuses -- labeled A, B, C and D -- were positioned and quickly made one decision. "I want to test C," he says, "because I'm trying to keep it." Located in the most interior spot, C would be the hardest to get at. To eliminate C, he would almost certainly have to go through B, cutting off any other options. But to justify keeping it, he needed to make sure C was normal.

The women were planning to eliminate two of the fetuses and keep two, which would decrease their chances of losing the entire pregnancy from 25 percent if they did nothing to 7 percent if they reduced to twins. And if they fell into the 7 percent who miscarry, this would be "despite the reduction, not because of it," Evans said. There may be some risk from the procedure itself. In 20-odd years, he estimates, a "handful" of pregnancies have miscarried shortly after his performing the reduction, and with a less experienced practitioner, the risk of procedure-caused miscarriage is higher, probably just under 1 percent. But based on the statistics, he argues, "it's almost always safer to do this than not to do it."

Jane wanted to safeguard Emma's pregnancy but was feeling some ethical qualms. "It's killing me that we're going to do this," Jane said. "I never thought I would feel that. I'm the most pro-choice person. I'm vehemently pro-choice."

When Evans was finished, Emma got up from the table, and the women left for the day. Tomorrow they would be called, like the others, once their test results were back.

MIDMORNING THE NEXT DAY, THE WOMAN FROM PUERTO RICO ENTERED THE DOCTOR'S COUNSELING ROOM, this time accompanied by her mother. Evans told the patient that all three of her fetuses were normal. The patient let out an elated squeal. This, said Evans later, is unusual: Often couples are relieved if there is something wrong with one fetus, since this makes the decision to reduce easier to bear. "We can leave you with two," he said.

"Do you know the sex?" the patient's mother asked.

"All are girls," Evans said, in front of him a sheet on which he had written the sex chromosomes. A: XX, B: XX, C: XX. "Two girls! That's what she wanted!" the mother said.