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Too Much to Carry?
"That's the heartbeat, the hands," said Evans to the patient, who was gazing, rapt, at the ultrasound.
"They're beautiful!" said the woman's mother, who had been summoned into the room.
"You can see the arm going up and down," Greenbaum said, pointing to one. "This one is a busy baby!"
"A busy baby!" joyfully repeated the patient's mother.
AFTER THE PROCEDURE, I ASKED EVANS IF WHAT HE HAD JUST DONE WAS AN ABORTION. "Technically, this is not an abortion, a procedure that kills the fetus and empties the uterus," he said. "The bottom line is, abortion ends the pregnancy. We don't end the pregnancy. We very specifically don't end the pregnancy."
It's not a distinction antiabortion groups necessarily make. "We're opposed to any taking of life of the human person after they're conceived," said Wanda Franz, president of the National Right to Life Committee, which opposes selective reduction, as it does abortion, unless the life of the mother is clearly at risk. Franz argues that most multiple pregnancies, including high-order ones, should be carried to term, with the fetuses treated as patients. "Occasionally, you have tragedies, and the babies don't survive, but those are the kind of tragedies that can't be prevented."
While Evans and I chatted, the sonographer, Rachel Greenbaum, was eating a salad. A new mother herself, she was pumping breast milk between procedures. She had been recently hired by Evans and, just back from maternity leave, was trying to get used to this part of her job.
"I don't particularly like doing the reductions," she said. "I find it very stressful. With every patient, I think, If it was me, what would I do? Some of these people tried to get pregnant for the past five years and prayed to God. And now that they are pregnant, they are telling God: You gave me too many. I sometimes feel like we are playing God, and that is very emotionally stressful."
Greenbaum, who is Jewish, takes seriously her religion's admonition not to take a life. What sustains her, she said, is the knowledge that the reductions she has been involved with were done for sound medical reasons. She would never, she said, work at an abortion clinic. "This is as close as I would get," she said. "Here, it is completely different. You are helping people have healthy babies."
Still, she says: "It's a very hard procedure, because the baby is moving, and you are chasing it. That is what is very emotional -- when the baby is moving and you are chasing it.
"Do you still feel emotional?" she asked Evans.
"I've come to look at it as: The finished product has a much better chance of surviving," replied Evans, who had been following the conversation intently. "Look, you never want to dehumanize it, because then you get cavalier. You have to keep the big picture in mind. We're not losing one. We're saving some."
When he began performing reductions 20 years ago, about 75 percent of his patients had gotten pregnant using fertility drugs alone, which often cause a woman to ovulate many eggs at once, and can result in extremely high-order multiples. Back then, he estimates, about 40 to 45 percent were pregnant with quads or higher; the same percentage were carrying triplets; and 10 percent were twin pregnancies in which one fetus had a serious problem. But things have changed. Now, 75 percent of his patients have gotten pregnant through IVF, a more controlled form of fertility treatment, and the size of the pregnancies has gone down. Now it's 5 to 10 percent very high-order multiples, 20 percent quads, 60 percent triplets, and about 10 to 15 percent twins.
When he was working to establish bioethical principles, Evans decided that he would not reduce a normal twin pregnancy. He would take somebody from three to two, but he would not take somebody from two to one. "The rationale we used was: One, every OB knows how to take care of twins, and two, the outcome is not as good as with singletons, but good enough. And number three, all these were fertility patients, and if we could get them to twins, that was that much closer to their family ideal. And four, we didn't know what the risk might be of damaging one of the fetuses by the procedure. Because of all of the above, it didn't feel ethical to go ahead and do that."
But Evans's thinking has changed. He is willing now to reduce two to one, and he does so. Not often, but the incidence is increasing. There are now data showing that reducing one twin does not affect the physical well-being of the twin who remains. Plus, many of his patients are women in their late 30s and early 40s, some married for the second time. Both partners may already have children, and what they want is one child together. And for a woman reducing a twin to a singleton, the pregnancy loss rate drops from 8 percent to 4 percent.
Evans has written articles arguing that it is ethical to reduce a twin pregnancy. After all, he said, if it's okay to reduce from one to none -- that is, if you support abortion rights -- then two to one should be okay, too. The idea is still controversial. "Twenty years ago, the ethical debate was with triplets. But now, as far as I'm concerned, there is no doubt about triplets, and the ethical debate has moved to twins."
And it is a debate. At the same time that Evans and others have been publicizing the data about the risks of gestating twins, other specialists have been showing women how they can take care of themselves to enhance their chances of carrying a multiple pregnancy to term or close to term. Among these is the nutritionist Barbara Luke, who has published books on successful gestation of multiple pregnancies, pointing out, among other things, that eating lots of protein helps the babies grow. Luke also published a 2004 article in the journal Fertility and Sterility showing that babies who started out as high-order multiples and were reduced to twins did not do as well as babies who started out as twins. The implication was that reduction may be bad for a pregnancy. This argument drives Evans -- and some of his colleagues -- nuts. They believe it's not fair to compare reduced twins to twins who started out as twins.
"Reduction is not bad for you," Evans says. "Starting out as quints is bad for you."
The long-term psychological consequences of reduction are still little understood. According to Isaac Blickstein, one of the world's experts on multifetal pregnancies, the studies that have been done suggest that the aftereffects of selective reduction are different from those of abortion. In general, parents feel better after the reduction is over. But grief can return, postpartum, as parents contemplate the babies they have, and think about the one, or ones, they lost. One study found that one-third of women who underwent selective reduction reported persistent depression a year later. At two years, most were feeling better. But, Blickstein notes, "psychoanalytic interviews with women who underwent [selective reduction] describe severe bereavement reactions including ambivalence, guilt, and a sense of narcissistic injury, all of which increased the complexity of their attachment to the remaining babies."
"Complexity of their attachment to the remaining babies" seems an apt way to put it. I encountered this one day when I was interviewing a mother who had reduced triplets to twins. "In some ways, the selective reduction becomes harder to deal with after the babies are born," the mother said. "They are babies with personalities, and you become attached to them, and you think: I could have ended up with one of these being gone, and the one that is gone could have been one of these."
"Now that I know my two daughters, looking at them, I think: It could have been you," she continued. "You terminated an embryo that could have turned into a baby you would love as much as the ones that you have, and that's hard."
THE TEST RESULTS FOR JANE AND EMMA STACKED UP LIKE THIS: A: XX, B: not tested, C: XY, D: XX. Two girls, one boy, one unknown. The known ones all normal. And so, for this last reduction procedure of the day, one decision had been made. Evans would reduce B, which was most accessible. As for the other one, he told the women they could have two girls -- that is, he could keep A and D -- or they could have a boy and a girl, in which case he would keep C and one of the girls. "If you want one of each, I'll keep one of each," Evans told them.
They wanted one of each. "I have mixed feelings about it, but I think boys and their mother have a very special relationship," said Jane, who alluded to what she perceived as the difficulty of raising adolescent girls. And with that, she and Emma had done it: They had selected for sex. They had made their choice not on the now unacceptable idea that boys are superior to girls but according to the notion that boys and their mothers may have easier, less tempestuous relationships.
Now Emma was on the table, and everybody was looking at four fetuses on the sonogram. The screen had been turned so that even Emma could see it. Evans decided that in addition to B, he would eliminate D, because of its position, farthest from the cervix, and most accessible after B. Just now, on the sonogram, D happened to be visible, moving and waving. "D is really active. That's what I hate to see," said Jane, who had woken up in the middle of the night worried about the "karma of what we are doing."
Evans prepared two syringes, swabbed Emma with antiseptic, put the square-holed napkin on her stomach. Then he plunged one of the needles into Emma's belly and began to work his way into position. He injected the potassium chloride, and B, the first fetus to go, went still.
"There's no activity there," he said, scrutinizing the screen. B was lying lengthwise in its little honeycomb chamber, no longer there and yet still there. It was impossible not to find the sight affecting. Here was a life that one minute was going to happen and now, because of its location, wasn't. One minute, B was a fetus with a future stretching out before it: childhood, college, children, grandchildren, maybe. The next minute, that future had been deleted.
Evans plunged the second needle into Emma's belly. "See the tip?" he said, showing the women where the tip of the needle was visible on the ultrasound screen. Even I could see it: a white spot hovering near the heart. D was moving. Evans started injecting. He went very slowly. "If you inject too fast, you blow the kid off your needle," he explained.
After Evans was finished injecting, D moved for a few seconds, then went still. Now, as we watched, there was something called the effusion: a little puff. "When I see that effusion, I know it's done," Evans said, taking "one last look at D before I come out," to make sure D was gone.
"Want to see your twins?" he asked the women, who did. On the ultrasound, he showed them the living fetuses, moving vigorously in their sacs. The women thanked him profusely. "Thank God there are people like you," Jane said.
"I'm sorry we had to meet under these conditions," Evans said.
Six months later -- I learned, from an e-mail the women sent -- Emma went into labor. The boy and girl were born vaginally, both healthy, both immediately and deeply cherished. The women e-mailed photos of both of them, nestled together on a blanket. "We could not be happier," they wrote.
During the course of the pregnancy, they had been able to see traces of the two reduced fetuses in the ultrasounds; Jane said that she felt it was important to own up to what they had done. After the birth, Jane inspected the placenta for the remains of the reduced two, which were visible in the placental tissue. She said "goodbye to the two that we were unable to carry," Emma wrote me in an e-mail, "which I know was very helpful to her."
Liza Mundy is a staff writer for the Magazine. This is excerpted from her new book, Everything Conceivable: How Assisted Reproduction Is Changing Men, Women, and the World, published by Alfred A. Knopf. She can be reached at firstname.lastname@example.org. She will be fielding questions and comments about this article Monday at 1 p.m.