Post Magazine: Selective Reduction

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Liza Mundy
Washington Post Magazine Staff Writer
Monday, May 21, 2007; 1:00 PM

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.

Washington Post Magazine staff writer Liza Mundy was online Monday, May 21, at 1 p.m. ET to discuss her article, Too Much to Carry?, taken from her book, "Everything Conceivable: How Assisted Reproduction is Changing Men, Women, and the World."

Submit your questions and comments before or during today's discussion.

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Liza Mundy: Hello everyone and thanks for writing in. There are many very, very thoughtful questions that have been posted in advance, and I am starting to draft some answers. My answers will begin appearing in just a few moments. Thanks, Liza Mundy

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Arlington, Va.: To what extent, do you think, have financial issues contributed to the increasing number of multiple pregnancies? For example -- if I were to decide to undergo an infertility treatment such as IVF, my insurance would pay for half. So I have an incentive to ask the doctor to implant a whole bunch of embryos, because it's costing me a lot of money out of pocket. But I get pregnant with quadruplets and decide to carry them all, my insurance would pay 100 percent for that (even if I have 4 preemies who need 5 months in the NICU and the bill tops $1 million.)

But what if more insurance companies paid for the whole cost of IVF -- as long as you don't implant more than 2 embryos? Would that help resolve the multiple pregnancy problem (and prevent couples from making the very difficult choice to reduce the number of fetuses the woman is carrying?)

Liza Mundy: That's a great question. I do think that money plays a large role in fueling multiple births. Just as you say: many insurance plans currently do not cover IVF (and, I learned during an appearance on the Diane Rehm show, lots of people seem to be hotly opposed to paying for other peoples' fertility treatments, which surprised me). The upshot is that often, patients are paying for IVF themselves, which runs anywhere from $ 8,000 to 12,000, though sometimes more. THere is, therefore, a very strong incentive, for patients, to ask that more than two embryos be transferred into the mother, with the hope that one at least will take. The idea of going through treatment, and paying $10,000, and getting no pregnancy, is very daunting. Patients sometimes talk about not wanting to "waste" an embryo by not transferring it. And often, patients are okay with the idea of a multiple pregancy, unaware of the difficulty of the decisions that may be set in motion.

Then, just as you say, the insurance company ends up paying for the costs associated with multiple births.

As an example of a shining light in this area, I would hold up the state of Connecticut, which does require insurance coverage for IVF, AND at the same time, limits the number of embryos that may be transfered. Patients are assured another round if the first one doesn't work. This seems to me a very sane and sensible policy, and one worthy of emulation.

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Arlington, Va.: In your article, you discuss the health risks to mother and babies of carrying higher-order multiples, but don't mention much about the enormormous strain on parents/families of caring for and raising triplets/quads. I believe this is also an argument for allowing parents the option of selective reduction. Do you agree?

Liza Mundy: I agree. I have three chapters in my book on multiple births, and I talk a lot--a lot--about the stress and strain of raising high-order multiples. Not everything could be put in the excerpt, but I can assure you, it's all in the book. For me, this was one of the most important revelations of my book reporting.

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Charlottesville, Va.: Thank you for an insightful and balanced article. Very few people outside of those who "have their butts in the chair" facing the decisions and statistics the women in your article had to face and their doctors and counselors have any idea what an intensly complex and difficult decision they face. Thank you for making your article true reporting with an adequate representation of multiple views. I'm guessing you're going to take some heat for it from radicals who don't see any view other than their own as valid, but take it in stride, because you did great work.

Liza Mundy: Thanks very much for your comments.

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Houston: Several years ago, our reproductive endocrinologist told us that ART doctors were beginning to move away from implanting more than three embryos and from doing intrauterine insemination with more than three egg folicles present. The goal was to avoid the problems of high order multiples and the issues surrounding selective reduction. Has this trend actually happened?

Liza Mundy: Yes, this trend is happenign: the question is whether it's happening fast enough. Severals years ago, the American Society for Reproductive Medicine published embryo-transfer guidelines for doctors to follow; the aim was to reduce the number of embryos being transferred. Since then, the average number of embryos transferred per cycle has gone down, to somewhere between two and three. The thing is; these are entirely voluntary guidelines. Some practices have done a great job of reducing the number of embryos transferred, but others have not. If you look at the annual surveillance report issued by the Centers for Disease Control, you'll see that some clinics have almost eliminated triplets; but at other clinics, the rate is still startlingly higher.

The number of embryos transferred is still much lower in some European countries, which are trying when possible to move to soemthign called Single Embryo Transfer. Of course, in most of those countries, IVF is paid for by a national health system, so patients will get another try.

As for intrauterine insemination (that is, straightforward insemination, often performed in tandem with fertility drugs that cuase a woman to ovulate more egg than one--a much less controlled situation than IVF)--I would hope that doctors are showing restraint here and I am sure tha many are. But there is no entity tracking this, that I know of.

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Out here: No, insurance shouldn't be paying for implantation -- and maybe rather than requiring them to pay for IVF then having more IVF, how about insurance companies not pay for babies born using IVF?

I know, it's impossible to do, it's just another point ...

That perhaps this whole IVF thing is something we shouldn't be doing -- or don't implant more than 2 embryos if you don't want to live with the consequences.

I was crying as I read the piece -- and I am the staunchest supporter of choice there is.

Our society is trying to give everyone everything they want -- if you can't get pregnant without modern science, perhaps you shouldn't be getting pregnant -- perhaps you should adopt the millions of kids out there without parents who you could help.

Liza Mundy: Well, I happen to think that insurance companies should pay for IVF, because infertility, after all, is a disease: a medical condition like any other. And the consequences of insurance not covering it include, among other things, more multiple births. And it has never been quite clear to me why it is the infertile, alone of all people, who are assigned the responsibility of adopting all the needy children in the world. Why shouldn't we all be held responsible for these childrens' welfare? Adoption is a wonderful route, clearly, for so many reasons, but I think that people suffering from infertility are often asked "why don't you just adopt," as if adoption is an easy process. Anyway--that's a whole 'nother topic.

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North Carolina: Thank you for a fascinating article. As a pediatrician in the NICU, I've seen many multiples with health problems (some mild, some severe, some fatal). I believe that the family who choose reduction are sometimes the bravest parents there are. Ideally, reduction would be unnecessary. But I'm glad that there are those who are willing to provide this treatment that is technically, emotionally, and ethically difficult.

Liza Mundy: Thank you for your comments.

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Davis, Calif.: Thank you for your article. My wife and I used IVF to conceive but unfortunately after months and months of trying suddenly had four fetuses. When we went through the counseling on selective reduction we were told by the doctor that the procedure carried with it a greater risk of premature delivery for the remaining children. However, if I understand your article correctly, the dctor you interviewed disagrees with that theory. What is the latest thinking on that subject? I ask because after a great deal of anguish my wife and I did decide to reduce to twins but when my wife was just past 20 weeks she went into labor and delivered two beautiful girls who did not survive. Now we wonder if the difficult decision we made to protect them didn't ultimately contribute to their death. I should mention that like the women you interviewed in your article, my wife and I are strongly pro-choice. Although we later had a healthy and normal pregnancy using IVF producing another beautiful and wonderful little girl who we cherish, we continue to struggle with the decision we made nearly 5 years ago. Any insight on the latest research would be appreciated.

Liza Mundy: Thank you for writing in, and first of all, I am so sorry for your experience and for your grief. I know that these procedures do often involve very powerful subsequent emotions and second-guessing. I would uge you to try not to feel guilt about this; clearly, you made the best, most responsible choice that you could. Perhaps Mark Evans, if he is reading this chat, could write in and fill us in on the research. I do know that it is his view that reduction reduces the risk of later miscarriage, but of course, that risk is never taken to zero. It's his view that if miscarriage does occur, it is DESPITE the reduction procedure, rather than becuase of it. There are twins who start as twins that also miscarry.

As with so many aspects of science and medicine, there may be no final, definitive answer to this question. After all, with miscarriage, it is often impossible to say why exactly it occurred. Miscarriage is the least well understood, but most common, complication of pregnancy. So please, don't blame yourself. I wish I could be of more help.

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Rockville, Md.: Wow -- what a difficult-to-read article, but it was amazingly well-written, if that makes any sense. Very complex issues. I must say I was surprised/shocked/saddened to hear Dr. Evans refer to "blowing the kid off the needle." And in front of the patient, while it's being done! I thought the whole point of his work was that he justified the reductions and, presumably in doing so, did not think of them as "kids" he was killing?! Seems at best like a highly insensitive remark.

Liza Mundy: It is his way of talking. What can I say. He was talking doctor-to-doctor in that case. I think he was pitching his comment to this particular patient, who he felt could handle it. But yeah, it's a blunt way of putting it.

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Washington, D.C.: Thank you for this article on a seldom-discussed topic.

A few years ago, just days after discovering that I was pregnant with twins, we found out that one of the fetuses had Down syndrome and significant growth impairment. Previous pregnancy complications made it very unlikely that I would have carried even the healthiest twin fetuses to term, so my husband and I, with the support of our families, decided to try for one healthy full-term baby rather than risk the grim likelihood of early delivery of both babies, at least one of whom would have serious medical and developmental issues.

Thankfully, the high-risk OB who had performed the testing was also able to handle the reduction, allowing me to continue to carry the healthy fetus almost to term.

My experience opened my eyes to the frailty of reproductive rights. I was nervous that my husband and I might encounter protestors in the parking lot of my practitioner's building. I also felt vaguely like a criminal during preparations for the procedure: I was asked to pay in cash, and was told not to submit for reimbursement from my insurance company.

I feel lucky, though, to have been pregnant in this country. In many countries, I would have been required to carry both fetuses to term -- their health and mine be damned. I am heartsick that so many people in this country would condemn my choice and attempt to prevent other women and families from exercising a similar one.

Liza Mundy: A very eloquent testimony to the difficulty of these decisions. I will post your comment for others to read.

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Washington, D.C.: Some health insurance plans require patients to undergo less expensive procedures with a higher risk of high-order multiples (such as intrauterine insemination) before they will cover more controlled procedures like IVF. Have you found in your research that health plans are starting to move away from this policy, which can result in multiple babies needing NICU and possibly longer-term medical care?

Liza Mundy: I am no expert on the vagaries of insurance coverage--it varies wildly from state to state and health plan to health plan--but I think your point is excellent. Some insurance plans will only cover the lower-level treatments, which, as you say, can carry a much higher risk of multiples. Seems counterproductive, to me.

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Upstate New York: I'm highly offended by "Out here"'s comment. Does this person have children? And can they imagine what life would be without their children? We just had our transfer of two embryos in our IVF cycle on Friday. It sickens me that if my disease were in the hands of "Out here," I'd die a barron woman.

Liza Mundy: Yes, I was surprised by the number of people who don't view infertility as a legitimate medical condition, worthy of coverage. It is. It is a medical condition. That's just a fact. But people suffering from infertility have to deal with this stigma all the time, particularly for some reason in this country. In the UK and many northern Europeans, there is state coverage for IVF and people just consider it a medical treatment that everyone deserves to have access to.

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Washington, D.C.: Thank you for the article. As someone who made the decision to reduce from triplets to twins 18 months ago, I know the pain that those profiled in your piece went through. Our "higher order" pregnancy was the result of very conservative fertility treatment -- we were given a 1-2 percnet chance of having multiples. We realized that we were not financially, emotionally or logistically able to care for three children. It was the hardest decision we ever have had (or will have to) make. We chose not to tell anyone of our "secret" in fear of the comments we would receive. I still think about the sibling my twin boys would have, had we not made the fateful decision and wonder about him/her.

Thank you for bringing this sensitive subject to light.

Liza Mundy: Thank you for your comments. There are so many comments on the board, right now, that in some cases I am simply going to post them without much gloss from me. They are all very moving testimonials, I believe, about how deeply patients think about their decisions.

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Omaha, Neb.: Excellent, thought-provoking article. When couples are trying to get pregnant through IVF, how often does their doctor explain the potential impacts of multiple embryos? How often do transfered embryos "not take"? I felt great sympathy for the couples faced with eliminating of the embryos and wondered how many couples elected to have only one or two implanted in order to avoid this kind of situation. Also, I am frankly surprised that any couple would be willing to speak with a journalist/author during such a personal and tragic moment. How many couples did you initially request to interview and did the couples you did interview give you any insight as to why they felt comfortable sharing their stories with a virtual stranger?

Liza Mundy: There is a huge amount of uncertainty with every IVF embryo transfer. About one-third of IVF "cycles' or rounds success and result in a pregnancy; two-thirds don't.

In part becuase of the lack of federal funding for human embryo research--there has been an effective 30-year ban--fertility labs still have no good way to diagnose a viable embryo. They can't study embryos; all they can do, really, is look at them. They don't have a very reliable grading scale. SO often, doctors will transfer two, or three, or even four, or (decreasingly) more. Sometimes one will take; sometimes all will take. It's extremely difficult to predict the outcome.

As for the patients who permitted me to witness the procedure: Yes, it was extremely kind of them to let me observe the proccdure. I did not actually interview them while it was going on, but simply was there as an observer. Permission was always secured prior to the procedure. I strongly suspect that they agreed because they wanted to educate the public about how difficult these decisions can be, and to provide solidarity to others going through the procedure. I tried hard to be sensitive and unobtrusive. In some cases, I think they were glad to have somebody else in the room with them. The mother of one of the patients very much wanted people to understand what patients go through.

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Fairfax, Va.: That was a very difficult article to read. I guess although I'm pro-choice I was struck by how difficult it must be to want a child or children so, so badly to go through fertility treatment and then to have to purposely "reduce" your pregnancy. I can't imagine having to make that choice. Did you feel at all emotional when you were in the room with the mothers? I'm sure you're equipped as a journalist to deal with such emotions, but did you find the experience at all emotionally draining or difficult?

Liza Mundy: Yes. Of all the reporting I did for my book, this was among the saddest. I felt terribly sad afterward. The situation seemed, to me, very stark. I don't know quite else what to say about it.

I have to say, as well, however, that of all the reporting I did for this book, the truly saddest was listening to the narrative of a woman who was pregnant with triplets, and lost them all at 21 weeks. And that possible outcome is the reason why peopel undergo reduction. There is no clear-cut choice that is the right one to make. In my book there is a whole chapter on triplets, and the uncertainty surrounding these pregnancies, which can be go poretty well, all things considered, or can be disastrous. And it's impossible to know in advance how they will turn out.

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Alexandria, Va.: Provocative article!

I have two process questions ... if you visited with Dr. Evans two years ago, why is this being run by the magazine now? And, was it a conscious decision -- that is, were your editors concerned it was TOO provocative -- to run the politics story on the cover? In my opinion, your article was the "lead" story in this week's magazine.

Liza Mundy: This is a book excerpt. I did the reporting two years ago; the book is just out now (there is link to it in the intro, I think; it's called Everything Conceivable: How Assisted Reproduction is Changing Men, Women, and the World) and the Post ran this as an excerpt from it. I don't think there was any fear of running it on the cover. In for a dime, in for a dollar.

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Alexandria, Va.: At the risk of straying too "off topic," just want to add to the very good response you gave regarding the question,

"Why not just adopt?"

As you pointed out in the Diane Riehm show segment, adoption is becoming increasingly difficult. I am glad that women have the option for abortion and don't face the same stigma they used to a single mothers, but it means there are far fewer babies available for adoption. Also, people do not realize that adoption, even domestic adoption, is a very, very expensive process. With some IVF clinics offering "money-back guarantees" it makes sense for a couple to try IVF, and if it doesn't work, then pursue the adoption option. My desire to have my own pregnancy had less to do with a need to carry on my DNA, than a desire to offer my children the best prenatal care and nine months in the womb of someone who I knew was taking good care of herself. Certainly no guarantee of a healthy baby, but it meant I gave my kids the start in life I could.

Liza Mundy: I'm just going to post this; I'm going to try to post as many comments as possible, since there is a big backlog.

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Washington, D.C: I'm currently pregnant with triplets (I didn't use IVF), and I was stunned reading your article. I was particularly horrified by the seeming pressure on the one woman who traveled there with her mother who asked if she could keep all three.

There are increased risks to higher order multiples, but if you have a reduction there is a 100 percent chance of losing one of the babies. I just can't imagine how people can look at the same ultrasound images that I look at and want to get rid of one of these babies.

Liza Mundy: Thanks for your opinion, and congratulations. I did also think that one woman was being pressured, a little bit, by her mother.

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Alexandria, Va.: Did you find that television shows like "Jon and Kate plus 8" on Discovery Health are skewing people's perceptions of multiple pregnancies, since these shows only seem to highlight cases in which there is only a positive outcome, i.e., sextuplets that all survive with no apparent medical challenges? It seems to me that these shows are perpetuating a mindset that carrying multiples is really no big deal, which certainly isn't the case.

Liza Mundy: I can't comment on that particular show, but I do think that in general, the media presents multiple pregnancies in a warm and fuzzy light, as "miracle babies." The McCaughey septuplets are on the cover of Ladies Home Jouranl every Christmas. You'll see newspaper headlines like; "Three sets of triplets born in one hospital in one day! What a miracle!" In my book I tried hard to correct that impression. This was one of the chief revelations, for me, of reporting a book about the impact of assisted reproduction: just how very difficult these multiple pregnancies can be. Starting out, I have to say, I had no idea.

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Rockville, Md.: Europe has been ahead, but more and more clincs in the U.S. are transferring fewer and fewer embryos in IVF cycles often including SINGLE embryo transfer -- and using IVF more and more rather than stimulated IUI cycles -- to reduce the risk of triplets -- down 69 percent in IVF since 1996 (Stillman JAMA Feb 2007)-- and thereby try to eliminate even a consideration of selective reduction. How have you found that insurance coverage for infertiltiy or shared risk refund programs help cpouples avoid the risks of needing selective reduction?

Liza Mundy: I do think that both insurance coverage, and "Shared risk" reduce the likelihood of multiples. For readers who don't know what this is, "shared risk" is a situation where a couple pays a rather large up front fee--I don't know what the exact figure tends to be these days, possible as high as $40,000--but for this, gets a set number of guaranteed IVF cycles. That way, patients are more likely to make the choice of having fewer embryos transferred, knowing they will get more tries if treatment fails. And if all rounds faile, they get a large portion of their money back. Of course, to avail oneself of this option, you have to be able to afford that up-front fee.

In this as so many areas of fertiity treatment, the people most likely to end up with multiples are those with less money.

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Rockville, Md.: Your article was extremely interesting. Has Dr. Evans ever been picketed by anti-choice protestors and/or receiving any threatening messages from such groups? Did he share his concerns for his safety after this article was released?

(I ask because these groups target physicians who provide both regular GYN care and also abortions).

Thanks!

Liza Mundy: He and I talked about that. He has, occasionally, been targeted by protesters. At one point, he said, when his children were ounger, they had some sort of evacuation plan. But he is, as you can tell, quite outspoken about what he does.

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Still Trying: Thank you for the sensitive, thoughtful article. Experiencing infertility is anguishing, without having this decision to make. Those of us with fertility issues wouldn't wish this medical problem on our worst enemy and never want to be faced with having to make such a decision.

Liza Mundy: Excellent comment. (I have to say something in order to post these comments--otherwise they won't post.)

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Falls Church, Va.: I did wonder about one thing, which is the option of gender selection in reduction. The cultural preference for one boy/one girl seems, if not as sexist as the desire for male children, still unfair. (Maybe I say this as a girl with two sisters and no brothers.) What is the BIG difference between a boy and girl anyway? I understand that if you're going to reduce anyway, it seems to make sense, but it's still biased. It still seems to make a practice which should be (and for the most part is) about health and well-being into different territory.

What if, for instance, they could do a test of sexual orientation in utero? Could they test things like height, eye color? You know what I'm getting at -- I'm sure you deal with these issues in your book, which is on my summer reading list!

Liza Mundy: There is a similar comment in the queue; I'm going to post yours, and then post the other one, and then try to answer.

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Odenton, Md.: What are your thoughts on allowing the expecting parents to make the decision of which fetus to eliminate based on the sex of the fetus? It makes sense to me that fetuses would first be eliminated if they did not test normal. After that, I think it makes sense to base it on location. I just don't see why anyone should get to choose based on the sex.

I was also wondering if you spoke to anyone who went through reduction a few years ago. It would be interesting to hear what they think about the procedure after living a couple of years with the surviving children.

Liza Mundy: Really hard question: the one about gender. Dr. Evans and I talked about this. If you read the piece, you'll know that for many years he refused to use gender as a criterion, becuase in some cultures, what peopel wanted was boys. Now what most American couples are after is "family balancing." If they have a girl they want a boy; if they have a boy, they want a girl. He's willing to accommodate that.

THis is also an issue in other aspects of fertility treatment; couples can use genetic testing, before the fact, to select a male or female embryo, and an increasing number of patients are doing so.

This is a terribly difficult issue for reproductive rights. They are of course in favor of reproductive liberty, but since sex-selection is traditioanlly associated with culling females, and since it's almost always based on gender stereotype, some reproductive rights advocates are not convinced that reproductive liberty should apply to gender selection.

Personally, I feel very uncomfortable with gender selection. I would be very comfortable with saying, simply: No, you can do that. This part, you don't get to choose. I say that in the book. Sex selection is not permitted in the UK, incidentally.

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Washington, D.C.: Liza, You've often written about fertility and pregnancy issues. You do it very well. Where did your interest in this topic develop?

Liza Mundy: Well, I came of age in the 1980s, when reproductive rights issues were very much in the minds of most college women, and I've lived through so many changes in women's lives, women's work issues, etc; it's just a live issue, for so many people I know. I have two children of my own, who are old enough, now, to also find all this very interesting.

Several years ago I did an article for the Post on infertility as experienced by the poor; after that piece ran, I was having lunch with a woman who sent some money to the people in the article. She herself was pregnant with IVF twins, and she and her husband were now having a great deal of trouble knowing what the right thing was to do with thei excess frozen embryos. During that conversation, I became aware of how the menu of "choice" had expanded since the 1980s, when of course, "choice" had only one real meaning. Part of my goal in writing the book I've just written was to deeply explore many of the choices--including, most agonizingly, reduction--that are now offered, and in some cases, imposed by new technologies.

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Silver Spring, Md.: Thank you for highlighting the absolute horror of what abortion truly is. There is no difference. Even though your intention was to shed light on what you and the doctor refer to as "reductions," your story showed readers in a graphic manner how a baby's instinct to fight for his or her own life is present at merely 12 weeks gestation. A baby is fighting for his or her life by trying to escape a needle which will take his or her life. These people are playing God -- the parents, the so-called doctors. There is no justification for this. Getting rid of the Down's babies, if there is one, randomly choosing A, B or C if none are "defective." Yes, this "doctor" is taking a life that will never grow up, go to college, get married, just like all the other abortions in this country.

Liza Mundy: Just going to post this one. We are over time; I'll do a few more.

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College Park, Md.: What about genetics? Do people using fertility treatments to conceive ever worry about passing on the infertility to their children?

Liza Mundy: Well, thanks to infertility treatment, it's known that men with very low sperm counts can pass--and are passing--their infertility on to their sons. As I say in my book, nobody seems to worry much about this, becuase when it comes to infertility, everybody always focuses on women.

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washingtonpost.com: "Everything Conceivable: How Assisted Reproduction is Changing Men, Women, and the World."

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Bethesda, Md.: Did any of the women who chose the reduction intend to tell the living siblings about the "reduced" one? Why or why not?

Liza Mundy: Great question. I don't know. In answer to one other question about the psychological aftereffects, I did talk to couples who, several years after the fact, continued to think about the reduction and the fact that one of their living children could have been one the one that was reduced, and vice-versa. And they continued to experience some sadness. But that doesn't mean they thought it was the wrong decision. They still thought it was the right one. A very complicated situation, obviously. Thanks to everyone who wrote in with thoughtful comments that, I thought, did justice to how difficult the dilemma is.

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USA: I had selective reduction done more than 10 years ago, from triplets to twins, which were conceived via much fertility intervention. I feel it was the right decision as during the pregnancy doctors were concerned about one of the twins not growing properly. They were born healthy at nealr 38 weeks, approx 6 lbs each.

I didn't feel a lot of guilt or conflict about the decision. I guess my thinking is, there are a lot of babies I didn't have through birth control in order to provide a better life for the family that we do have, and that was another of them. My partner and I did have a little ceremony to bid farewell to the one that wasn't going to join us.

However, I have not told the twins or their sibling born a few years later as I am not sure what they would think about it. The doctors said one of the 3 was smaller and that was the one they eliminated, but had they not been able to access that one safely, it would have been one of the others. So it could have been one of the twins who were born and are our precious children.

Liza Mundy: I'm going to post this last one, and maybe a few more.

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Columbia, Md.: What an impossible decision to have to make for families if in fact the other babies will not survive without the reduction. Don't reduce and possibly have no children, reduce and have one or two. I cannot see how people who have been through this reduction cannot wonder what could have been when they look at their surviving children, not wonder about the missing one or two. Science has given women better methods to conceive children but along with it harder life decisions. I could not conceive so have no children (am too old now) and I cried while reading this story. I wondered what decision I would have made. I cannot say.

Liza Mundy: And this one...

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Washington, D.C.: My family had to face this choice. After two years of infertility treatments and an early miscarriage, I found myself pregnant with triplets (this was NOT through IVF). I decided not to terminate any of them because after all we had gone through to conceive, the pregnancy seemed like a miracle and I couldn't bear to choose which of the three would live and which would die. But in the end, I ended up losing all of them at the 17th week of pregnancy. Seven years later, I still look back and wonder whether or not I should have gone through selective reduction to give at least some of them the chance to grow up, but I know at the time I could not have done so. I have instead, refused to go through that level of fertility treatment again even though I know it would guarantee ovulation and probably a pregnancy because I am afraid to conceive multiples again and be faced with the same situation.

Liza Mundy: And that one. Many thanks to all who wrote in.

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washingtonpost.com: This concludes our discussion with Liza Mundy. Thank you for joining it.

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