Too Much to Carry?

"Dos niñas!" said the patient, who ran out of the counseling room and into the waiting room, where she summoned her grandmother and another elderly woman, and suddenly there were four women in the room looking ecstatically at Evans, who explained what would happen next. Because there were no abnormalities and no sex differences, he said, he would go to the "next level of subtlety" in determining which to reduce.

"It's up to you," the mother of the patient said.

"It can't be three?" said the patient, wistfully.

Evans reviewed the loss rates for triplets. The patient's mother was clearly in favor of reduction. They had been over this before, she said, with the IVF doctor in Puerto Rico. "The risk would be too great," she said. "Sometimes you have to do unpleasant things to have a family."

"Very unpleasant," said the patient, who went into the examining room. Evans opened a pack of instruments; a square napkin with a hole in the center went over the patient's belly, which he swabbed with antiseptic.

"I'm a coward," the patient said, bracing herself. Evans and Greenbaum, wearing surgical gloves, inspected the ultrasound. Evans decided, based on location, to go for fetus C, which was the most accessible.

Selective reduction is actually quicker than CVS. It takes a smaller needle to inject a chemical down than it does to draw a placenta piece up. Even so, the procedure demanded great skill, dexterity and resolve from Evans and Greenbaum. Destroying a fetus requires three hands: one to hold the ultrasound transducer on the patient's belly; one to inject the needle and maneuver it into a position near the fetal heart; another to draw out the metal rod at the core of the needle and replace it with the vial of potassium chloride. Evans, who is left-handed, did all these things at various times, tools close together as he worked over the patient's belly. At points, Greenbaum assisted by holding the vial until he needed it; holding the transducer; and coaching him into position, watching on the screen and issuing directions. Evans worked for a while trying to get the needle into the right spot.

"I'm not in," he said at one point, tensely. Then he pinned C with the needle, and pushed the plunger to release the chemical. The fetus, which had been undulating and waving, went still. It would remain in the womb, while the other fetuses grew and developed.

"Let's check the other two," Evans said, and they moved the transducer to see the other two fetuses, still there, still waving, two hearts beating, unaware of what had just happened to the sibling they would never have. "Do you want to see your twins?" he asked the patient.

"I don't want to see the other one," the woman said quickly.

"I chose my words carefully," Evans told her. "Do you want to see your two daughters?"

And so he showed her the two daughters, babies so important to this family that three generations of women had made the flight from San Juan to New York to ensure the safety of the pregnancy. Contemplating her two living fetuses, the woman's face displayed an explosion of emotion. Her face went intensely red. Then Greenbaum adjusted the machine so that it showed, suddenly, a vivid 3-D image of the twin fetuses, an ultrasound image so rich and detailed that it looked like a digital photograph taken from deep within the belly. There were the two faces, the two fontanels, the two nasal ridges, the eight limbs, everything.