Multifetal pregnancy reduction – why would you do it?

By Gregory K Pike.

Multifetal Pregnancy Reduction (MFPR) was initially a response to the high incidence of multiples in Assisted Reproductive Technology. It has even been called “an integral fail-safe of infertility practice”. Its goal was, and mostly still is, to improve outcomes by terminating some fetuses in a multiple pregnancy, on the grounds that the more there are, the higher the risk of adverse outcomes for the mother and her children. MFPR effectively tries to convert a higher order pregnancy to a lower order one – quadruplets or triplets to twins or a singleton, or twins to a singleton.

Whatever way one looks at it, MFPR is ethically charged. For those who support protection of life in utero, MFPR may be seen as equivalent to, or worse than, abortion. Even for those who take a different view, there is something disturbing about the arbitrariness of choosing one or more to die to give those left behind a better chance of a healthy outcome. More disturbing still is the use of MFPR to reduce twins for socioeconomic or other lifestyle reasons.

Setting aside for the moment the moral status of the fetus, how does MFPR balance out on a purely cost-benefit analysis? In other words, does MFPR work, and even if it does, what are the costs? My paper goes into this in some detail.

On the side of benefit, MFPR does reduce prematurity – it provides more room and time for development for those chosen for survival. However, the research is mixed here. For example, for reduction of twins to a singleton, some studies found no difference, or even an increase in prematurity after MFPR. Another found that whereas prematurity after 32 weeks was reduced, prematurity before 32 weeks was increased by MFPR. It is also fair to ask whether the reduction in prematurity for twins to a singleton is meaningful given the generally favourable outcomes for twins in any case.

Reducing mortality is a benefit – but again, the evidence is mixed. This seems to be true for either perinatal mortality (fetal death after 24 weeks gestation and up to 7 days after birth), or neonatal mortality (death between birth and 28 days). But on a somewhat different measure, risk of there being no surviving child, most studies show an increase after MFPR. In other words, more couples go home after MFPR without any child at all.

On the cost side, the primary risk of MFPR is that it may cause loss of the whole pregnancy, a miscarriage. While risk of loss after MFPR was lower for quadruplets, it was higher for triplets and twins. Moreover, triplets reduced to a singleton led to higher loss compared with triplets reduced to twins.

Besides the moral questions, what tends to get lost in the pragmatism of MFPR is the psychological distress – both in the decision-making process and after. There’s scant research on this, but what does exist unsurprisingly reveals high levels of trauma in the lead up to surgery and, whilst the evidence is equivocal, after MFPR. And no one seems to have studied the obvious – what about the surviving children? Some may never be told, but for those who are, how will they perceive the fact that – on their parents choosing – they survived, and their sibling(s) didn’t?

Most couples will find it hard to predict what the psychological toll might be, so their decision may boil down to whether the chance of a better outcome is worth risking miscarriage or other mortality. In reality, it is more than likely that such a simple reckoning will not be made without at least some consideration of the moral status of the fetuses. Which is why some version of the ‘lifeboat dilemma’ has been argued to apply. The problem is, the analogy doesn’t work well, for classically the dilemma rests upon killing some (or evicting from the lifeboat) so that others may live. But MFPR is not like that. It involves eliminating some so that the chances of a better outcome for others are enhanced – but unlike in the ‘lifeboat dilemma’, with risks to others in the ‘lifeboat’. MFPR cannot be reduced to ‘a life for a life’ and trying to do so diminishes the moral debate.

MFPR is in some senses an ‘indecent proposal’, placing before couples an agonising choice that can be so finely balanced on risk and benefit that a new risk emerges – the temptation to choose for non-medical reasons. At the outset, abortion was made available for medical reasons but is now something else entirely. At the outset, MFPR was solely for medical reasons, but at least for one of the most active clinics it is increasingly for ‘quality of life’ ones.

Whatever the justification for MFPR, it does sharpen the question of fetal moral status. As has been argued, “ … the main problem with reduction is that it breaches a wall at the center of pro-choice psychology. It exposes the equality between the offspring we raise and the offspring we abort.”

 

Author: Gregory K Pike

Affiliations: Bios Centre, London, UK

Competing interests: None declared

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