“I count ... six babies in there,” the ultrasound technician said slowly. “And they all have strong heartbeats.”
Kristina stared at the monitor, following the technician’s pointer as he showed her the little black blurs on screen. Her joy turned to shock, then panic. Six babies? How could she possibly carry, let alone care for, six babies? She burst into tears as her husband, Michael, in disbelief, counted the embryos once again.
After three years of trying to conceive a second baby, Kristina had been thrilled in July 2005 when she learned she was pregnant — even when her doctor revealed she was having triplets, the result of fertility drugs and artificial insemination. “We knew the chances of multiples were high with fertility treatments, but we were cool with the idea of twins,” says the stay-at-home mom, 33, who lives in Phoenix. “One more seemed fine. We were excited.”
So, despite knowing the added risks of complications with twins, Kristina was positively giddy over the news by the time of her eight-week ultrasound at a high-risk obstetrician’s office near her home. As she lay down on the table, she joked with the technician. “I’m having triplets!” she said. “Just don’t tell me I’m having any more!” A few moments later, the technician blanched and turned the screen around so Kristina could see it as he pointed out the six sacs. “All I could think was that I couldn’t do that to my daughter,” Kristina recalls. “What kind of life would she have? Would we have? I knew we wouldn’t be able to handle it.”
The alternative offered by her doctor a few minutes later wasn’t much better: a multifetal reduction, in which the doctor would stop the heart of three or four of Kristina’s fetuses, leaving behind triplets or twins to grow to full term. A fairly simple procedure, reduction poses few risks to the mother and is usually recommended by high-risk obstetricians to avoid the dangers of multiples: potentially deadly blood pressure swings and a higher chance of gestational diabetes, anemia and kidney infections for the mom; prematurity, cerebral palsy or death shortly after birth for the babies. But it wasn’t that simple to Kristina. The daughter of devout Catholics, she had always been pro-life, determined, if she ever got pregnant, to see it through. “Abortion was never an option,” she says. “If I accidentally got pregnant, that was it. I’d be the one who put myself in that position, and I’d have to go through with it.”
Yet here she was, pregnant by choice and contemplating what, in her mind, amounted to the same thing: getting rid of her babies because they were a health risk and a life unimagined. “It felt like it was my fault because I wanted a baby so badly that I took medicine and forced my body to conceive,” she says. “Now this is what I got, but I didn’t want it. It seemed so hypocritical. I was devastated.”
Greater risk of complications
Kristina didn’t actually know the full extent of the problems she might face until she read the brochures about the risks of carrying multiples that her doctor sent home with her. Then she learned what high-risk obstetricians tell their patients: It’s not a matter of mere inconvenience but of life and death. “As the number of fetuses rises, the threat of complications goes up, too,” says Harish Sehdev, M.D., a doctor at Pennsylvania Hospital in Philadelphia. “Part of our job is to help women deliver healthy babies. And sometimes that means offering a reduction.”
Carrying multiples, even twins, can be a dangerous proposition. With each additional fetus, the odds of spontaneous miscarriage increases from 1 percent for women carrying one fetus to 9 percent for triplets. (There are no stats on higher numbers of multiples because they are so rare.) Women pregnant with multiples also have a greater chance of preeclampsia, a short-term blood pressure disorder that, if not controlled, can lead to seizures or liver or kidney damage and is a leading cause of maternal mortality around the world. (For triplets, the chances are at least 40 percent.) Plus, just about every multiples delivery is a cesarean section, which is usually safe but on occasion can lead to infection, bowel and bladder injury or the need for blood transfusion.
Once born, the babies themselves may face a host of issues that often land them in the hospital’s neonatal intensive care unit for months. For any baby, the biggest complication comes from preterm delivery, considered to be anything before 37 weeks. Women pregnant with one baby deliver at 39 weeks, on average. From there, the average gestational age goes down: 36 weeks for twins, 33 weeks for triplets, 31 weeks for quadruplets. (There are no available numbers for sextuplets because they are so rare, but Dr. Sehdev says the averages keep getting lower with more babies.) Some newborns, especially those arriving before 24 weeks, never make it home. Many of the rest — sometimes several multiples in one family — leave with lifelong ailments. Cerebral palsy, one of the most severe, is up to 10 times more likely in multiple births than among singletons, according to a review of studies published in Clinics in Perinatology. “We can never tell in advance how far along a woman will go or what problems she’ll have,” Dr. Sehdev says. “All we know is that the hazards are pretty high when you’re talking about multiples. For a lot of people, they’re too high.”
Multifetal reductions developed in the mid-1980s, alongside the rise of in vitro fertilization (IVF) and artificial, or intrauterine, insemination (IUI), which brought scores of women pregnant with multiples to high-risk ob/gyns. Already, doctors had a method to reduce a baby in utero if they detected a condition such as Down syndrome in one of a pair of twins. They now utilize the same technology to reduce multiple fetuses — but not without controversy. Like Kristina, many equate multifetal reduction with abortion and insist it’s wrong to sacrifice one fetus for the sake of another. Women facing the prospect often hide it from loved ones, instead sharing their anxieties via Internet support groups.
Jill, a woman from California whose name has been changed to protect her identity because her family doesn’t know she had a reduction in 2006, says her parents are so religious, she couldn’t tell them she’d gotten pregnant through IVF, which the Catholic church forbids. After discovering she had conceived triplets, she had a double burden: hiding her pregnancy and deciding in secret whether to reduce to twins. In the end, she decided the risks of having triplets outweighed her guilt over the reduction. But it was a lonely process. “My parents have picketed at abortion clinics,” Jill says. “They’d never understand. To this day, only my husband and my doctor know what I went through. I felt completely alone.”
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Doctors who perform the procedure are wary of discussing it. “It’s a bit like inviting someone with a shotgun onto your front lawn,” says Sean Tipton, spokesman in Washington, D.C., for the American Society for Reproductive Medicine (ASRM). Jeffrey Keenan, M.D., medical director of the National Embryo Donation Center in Knoxville, Tennessee, admits that reductions can protect the life of the mother or babies, but he’s skeptical that everyone who opts for a reduction actually needs one — especially those carrying triplets. “Like abortion, it’s a matter of convenience because parents say they can’t handle three or don’t have room or won’t get sleep,” says Dr. Keenan, a member of the Christian Medical Association in Bristol, Tennessee. “Do we want a utopian society, where every pregnancy is exactly what you want, with no complications? Life’s not like that. If you want that, don’t get pregnant.”
An imperfect science
There are no good statistics on how many reductions are done every year because physicians do not have to report them. Anecdotally, doctors say the number peaked in 2000 when, for example, Ilan Timor, M.D., director of the division of ob/gyn ultrasound at New York University in New York City, performed about 100. Now, Dr. Timor says, he generally does about 60 per year. Mostly, the drop is due to improved techniques, both for IUI (better ultrasound technology has made it easier for doctors to see how many eggs have been stimulated) and IVF (specialists are better able to determine in the lab which embryos are most likely to survive). Now ASRM’s IVF guidelines call for implanting one embryo in women under 30 and two in women between 30 and 35. Not all doctors abide, as evidenced in the case this past January of Nadya Suleman, the 33-year-old woman from Whittier, California, whose doctor implanted six embryos, which resulted in her giving birth after 30 weeks to eight babies after two embryos split. Needless to say, success rates for IVF have gone up. “The best embryos give the best chance of getting pregnant,” says Arthur Wisot, M.D., a fertility specialist with Reproductive Partners Medical Group in Los Angeles. “Adding embryos doesn’t boost the odds of conceiving, just the odds of having multiples.”
Success rates for IUI have climbed, too: Nowadays, most high-order multiple pregnancies are the result of fertility drugs, which stimulate ovulation so women conceive through insemination. This is an imperfect science: Despite higher-quality ultrasounds and blood tests, doctors can’t always be certain how many eggs will be released and fertilized. Still, many women choose IUI over IVF for financial reasons. Each IUI cycle costs between $500 to $2,000, depending on the fertility drug used, whereas IVF’s price tag can reach up to $12,000 per round. Only about 20 percent of health plans cover either, Dr. Wisot says, so for those who can’t afford IVF or won’t do it for religious reasons, IUI puts them at risk for conceiving a dangerously high number of babies — and facing the terrible choice that plagued Kristina. “If I’d known how many embryos I’d get, I never would have done the IUI,” she says. “I’d heard there was a chance, but I never imagined I’d end up with six. I mean, who does?”
Kristina, then an assistant at a car-financing group, was newly married when she got pregnant with her first daughter, Meghan. She was 23 at the time and figured it would be no problem to have one or two more babies before she turned 30. She was wrong. Soon after Meghan turned 2, the couple spent a year unsuccessfully trying to conceive on their own. Then they spent two years off and on with two different specialists who prescribed Clomid, a pill that stimulates ovulation — it made Kristina hyperemotional but didn’t get her pregnant. Her health plan didn’t cover IVF, so Kristina opted for injectable stimulants combined with IUI in her doctor’s office. Although the specialist warned Kristina the treatment carries a high chance of twins and possibly triplets, he said he’d only had one case of quadruplets in more than a decade of practice. And after the first round of treatment failed, Kristina was sure she’d be lucky to conceive. “He told me that if he sees more than four eggs, he won’t do the insemination,” she said. “So I wasn’t worried. Frankly, I was more worried that it wouldn’t work at all than that it would work too well.”
Ten days after her second IUI, Kristina took a pregnancy test. “It was positive,” she recalls. “Finally! I was so thrilled I never stopped to think about how many babies it might be.” At the doctor’s office a few days later, her hormone levels seemed high for a normal pregnancy, but it wasn’t until an ultrasound at seven weeks that the doctor first spotted three little heartbeats. Immediately, he referred her to a high-risk OB, who later brought up reduction — a heartbreaking discussion that may be most difficult for women carrying triplets. “The risk of four or more babies is so clear that it’s a relatively simple decision,” Dr. Sehdev says. “But there’s still debate about whether carrying triplets is that much worse than carrying twins. That’s the hardest for many women.”
Dr. Sehdev says counseling women pregnant with triplets can be more difficult than talking to those with four or more embryos, in part because moms-to-be often have stories about healthy triplets they’ve known. And in fact, as many triplets are born above the average gestational age of 33 weeks as below it — often leaving the hospital with no complications. “You never know which group you’ll be in,” Dr. Sehdev says. “Just because one couple had problems or didn’t, doesn’t mean another couple will or won’t.” Some patients come in recalling TV celebrations of high-order multiples soon after their births — which makes doctors cringe. “Couples ask why they can’t be like the family on TV,” Dr. Sehdev says. “But these shows never focus on outcomes for the babies. They never talk about the ones who won’t survive or who will have neurological issues for life.”
Still, there are women whose remorse after reduction is not easily forgotten. When Stacey Magliano, 37, a stay-at-home mom from Woodstock, New York, found out in 2004 she was carrying quintuplets, she says all she heard about was the worst-case scenario — disabilities, death and other complications. She says she reduced to twins despite her and her husband’s discomfort with abortion because she felt she had no other choice. Only afterward did she learn about the success stories — women with five embryos who made it past 30 weeks, families who happily raise multiples. Now, with a 6-year-old, 3-year-old twins and a 1-year-old, she says she regrets her decision to reduce. “I don’t think I made an informed decision,” says Magliano, whose babies were all conceived using infertility drugs. “A lot of people who go forward don’t have negative outcomes. I’d never do it again.”
Dr. Timor says most patients carrying triplets choose to reduce to twins, a procedure that makes up about 40 percent of the reductions he performs. But Kristina never considered it: “I told my doctor I didn’t need to think about it. We knew we’d keep three if that happened. A decision had been made.”
Everything changed when she found out she was carrying six. Through tears, she watched the tiny hearts pulsing on the ultrasound monitor, little black blobs inside six sacs, with no arms or legs yet. She carried the image in her mind for weeks as she struggled with what to do. Logically, she knew a reduction made sense, and the people she’d told — her husband, her parents and her best friend — all agreed. But in her heart, Kristina felt it was wrong, a betrayal of her beliefs and her babies. She spent hours scouring the Internet, occasionally finding the Web site of a family with quintuplets who seemed healthy and happy. At those moments, she’d think that she, too, could handle it. “I never let anything hold me back,” she says. “Why should I let this?” But the success stories were few and far between. Mostly, she came across heart-wrenching message boards on which women mourned the death of their multiples or traded stories about the struggles of handling ongoing disabilities in their surviving kids. All of it added to her torment. She’d waited so long to be pregnant, but now she couldn’t enjoy one minute of it. She didn’t bond with the babies, knowing some wouldn’t make it. Instead, she tried not to think about the six babies developing inside her — except to pray that some would spontaneously reduce. “Emotionally, that would have been better because it would have been out of my control,” Kristina says. “This way, I felt hopeless. I didn’t want to be making this choice. It was horrible.”
‘I was sad but relieved’
As she approached her 12-week mark — when her doctor had told her he needed to do the reduction — Kristina knew she couldn’t put off the decision any longer. Every ultrasound showed that her babies were still alive; every week that passed felt like torture. She scheduled an appointment for the reduction, tearfully conceding that she had no other choice: She couldn’t possibly carry six babies, risking her health just when she needed it most. They couldn’t possibly all be healthy. And she couldn’t possibly care for them. “I was in denial the whole time,” Kristina says. “But I realized it would be much worse to get halfway through and then lose all or some of the babies, or for that to happen after they were born. This was bad, but that was something I couldn’t face.”
Kristina was still hesitant when she and her husband arrived at her doctor’s office the September morning of the procedure. As she lay down on the table, the anxiety of the previous weeks flooded over her again. She started crying, softly at first, as the technician again swirled the ultrasound paddle over her belly to locate the embryos. Even now, Kristina hoped that one or more of the hearts would have stopped on its own. Instead, she gazed one last time at six pulsing blobs onscreen before the technician printed a picture — a bittersweet memento that would torment Kristina for months. As the technician turned the monitor away, she watched the doctor fill a syringe with potassium chloride, a clear metal chemical that stops the heart when inserted directly into it. He put his empty hand on Kristina’s belly and poised the 3-inch needle over her. Then he studied the ultrasound monitor, which served as a guide to where to insert the tip. Because Kristina’s age put her at lower risk, the couple had not had genetic testing, so she knew the doctor was deciding which babies to reduce based on size of the fetus and location in her uterus; if all fetuses appear equally well-developed with no abnormalities, doctors typically select ones easiest to reach, usually those highest in the uterus.
Kristina’s doctor took only a few moments to locate the first embryo he planned to reduce. But as he touched the needle to her skin, she suddenly started sobbing. Her uterus tightened, preventing the needle from going through. “I was freaking out, still questioning if we should do it,” she recalls. “It’s not that it hurt so much. I was just at my wit’s end by that point.” After a few minutes, Kristina calmed down enough for the doctor to insert the needle. He pushed it all the way into the first baby’s heart, then injected the potassium chloride, a process that took only a few seconds. By the time he’d removed the needle, Kristina was sobbing again. And again her uterus became so tense he wasn’t able to continue. As she tried to relax, the technician put the ultrasound paddle over the first baby, expecting to see its heart had stopped. But it hadn’t. Somehow, the fetus had survived the injection, a rare anomaly. Michael, who was facing the monitor, gasped. For Kristina, the news was too much. She leaped off the table, inconsolable.
“Stop!” she shouted, in hysterics. “I can’t do this! It’s not meant to be!”
Kristina rushed from the room and spent the rest of the day at home, in tears, avoiding talk about the morning’s events. But when she woke up the next day, nothing had changed. She felt a reduction was her only option, regardless of how excruciating. “By now, Michael and I were both so drained, we just needed to get on with it,” she says. So again, they drove to the doctor’s office, and she lay on the table. This time, she remained calm while the doctor inserted the needle, three separate times, injecting the potassium chloride into the three embryos easiest to reach. In total, the procedure took 20 minutes. When the technician checked, all three hearts had stopped. “I couldn’t look at them,” Kristina says. “And I couldn’t look at the other three, either. I was sad but relieved that it was behind me.”
Still, Kristina couldn’t completely relax yet. She knew that every reduction bears the risk of infection or premature labor, which can end the entire pregnancy — an added insult that she couldn’t bear to think about. Patients like her, who have the reduction between 12 and 14 weeks, have a 2 to 3 percent risk of losing the whole pregnancy if the body misreads the loss as miscarriage and tries to abort the remaining fetuses; after 15 to 20 weeks, the risk inches up to about 5 percent, Dr. Sehdev notes. The fear of losing everything meant Kristina wouldn’t let herself truly connect with the three small lives growing inside her. “Only when I felt them move at 18 weeks was I able to bond with my babies,” she recalls. “That’s when I finally thought it might be OK.”
Kristina delivered her triplets 10 weeks early, after ultrasounds determined one had stopped growing, which isn’t unusual for triplets or even twins. That baby, Nathan, was almost 2 pounds; siblings Evan and Makena each weighed more than 3 pounds. Nathan spent nearly four months in neonatal intensive care and the next year in and out of the hospital. He’s still slightly developmentally behind his siblings — who came home after seven weeks — but is expected to catch up and have no permanent disability.
Three years later, Kristina still wonders what could have been. She never knew if her other babies were girls or boys, never had the chance to name them. But the grueling months spent at the hospital with Nathan finally made one thing clear to her: She did the right thing. “To this day, if I knew I could have six healthy babies, I’d have carried them,” she says. “But seeing how sick Nathan was made me realize how tough it could be. I have no regrets.”
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