Health Library Should I Consider a Multifetal Pregnancy Reduction?From Healthwise

This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.

When considering in vitro fertilization, your doctor will help you decide how many embryos to transfer, with the goal of having a healthy pregnancy with one fetus. You will likely discuss this decision before your treatment cycle begins and again before embryo transfer. If more than two embryos implant and grow in your uterus, you will probably be counseled about multifetal pregnancy reduction to increase the chances of a healthy pregnancy and infant survival.

Embryo transfer success versus the risk of multiple pregnancy

Women older than 35 may have more embryos transferred than a younger woman would. More embryos maximize a woman's chances of conceiving and carrying a healthy pregnancy. But it also increases the risk of multiple pregnancy.

The American Society for Reproductive Medicine recommends that women younger than 35 have no more than two embryos transferred, women ages 35 to 37 have no more than three embryos transferred, and women who are older than 40 have no more than four embryos transferred. Women who have a good chance of becoming pregnant on the first IVF cycle should have fewer embryos transferred, while women who have had several unsuccessful IVF cycles may have more.¹ These recommendations are set to limit the number of multiple pregnancies occurring from infertility procedures.

Women older than 40 have a high rate of embryo loss when they use their own eggs. As an alternative, older women can choose to use more viable donor eggs.

Key points in making your decision

If you are considering assisted reproductive technology (ART), fertility drugs, or both, talk to your doctor about how you can avoid a triplet-or-more pregnancy. The decision to have a multifetal pregnancy reduction can be difficult and traumatic.

Multiple pregnancy is a common complication of infertility treatment. It increases risks for both the mother and the fetuses, such as preeclampsia, miscarriage, premature birth, and long-term disability for the babies. The greater the number of fetuses, the greater the chance of a bad outcome. Multifetal pregnancy reduction (MFPR) is a procedure that can be done during the first trimester to reduce the number of fetuses in a multiple pregnancy—usually from three, four, or five fetuses to two. This is done to help the remaining fetuses have a better chance of healthy survival.

The decision to eliminate one or more fetuses from a pregnancy may be emotional and complex. For some people, this issue raises ethical and spiritual concerns. Consider the following facts when thinking about MFPR.

• With each additional fetus in the uterus, the risks of illness, death, and disability increase.
• A successful MFPR lowers all risks, making it more likely that you will have a healthy pregnancy and healthy newborn(s).
• MFPR can cause miscarriage of other fetuses. About 6 in 100 triplet-to-twin procedures lead to miscarriage.² (This is about the same risk of miscarriage for any twin pregnancy.³)
• Not all triplet-or-more pregnancies are successful. About 25 in 100 triplet pregnancies end in miscarriage.³ Another 19 in 100 infants from these pregnancies die in the first year of life, often from complications of premature birth.
• Early genetic testing (chorionic villus sampling) and fetal ultrasound can help identify if one fetus has a genetic disorder and the other does not. This information may help you decide whether to have a selective MFPR.

What is multifetal pregnancy reduction?

Multifetal pregnancy reduction (MFPR) is a procedure that reduces the number of fetuses in a multiple pregnancy—usually from three, four, or five fetuses to two so that the remaining fetuses have a better chance of survival. The goal of MFPR is to increase the chance of a successful, healthy pregnancy.

An MFPR is usually done early in a pregnancy, between the 9th and 12th weeks, sometimes after having genetic testing for fetal problems. The most common method of fetal reduction is transabdominal MFPR. For this procedure, the doctor uses ultrasound as a guide and inserts a needle through the woman's abdomen and into the uterus to the selected fetus. The doctor injects the fetus with a potassium chloride solution, which stops the fetal heart from beating. Sometimes, vaginal bleeding happens after the procedure; this is normal.

The dead embryo or fetus is absorbed by the mother's body. This absorption process is normal and similar to vanishing twin syndrome.

What are the benefits of a multifetal pregnancy reduction?

Family life. In interviews done 2 years after their pregnancies, parents who reduced their pregnancies to twins report less anxiety and depression and more satisfaction with their parent-child relationships than parents of triplets.⁴

Mother risk. Multiple pregnancy also increases the mother's risk of pregnancy complications such as gestational diabetes, preeclampsia, or anemia. These risks increase with each additional fetus in the uterus.

Infant risk. In a pregnancy with triplets or more, there is a high risk of miscarriage, stillbirth, premature birth, and disability. Only half of families with triplets are not affected by death or a disabled child. Only about one-third of families with quadruplets are not affected by death or a disability.⁵ To lower these high risks, many doctors offer multifetal pregnancy reduction (MFPR).

A multifetal pregnancy reduction improves your chances of avoiding miscarriage, carrying your pregnancy longer, and delivering one or more healthy babies.²

What are the risks of multifetal pregnancy reduction?

The risks of multifetal pregnancy reduction include:

• Miscarriage of the remaining fetuses. When reducing a triplet to a twin pregnancy, the miscarriage rate is about the same as in normal twin pregnancies.³ The miscarriage rate seems to be about the same when reducing from 3, 4, or 5 fetuses, but is higher when reducing from 6 or more.⁶
• Emotional risks for you, especially if the pregnancy miscarries. Some parents who go on to have a healthy pregnancy view the pregnancy reduction as sad but medically needed. Others who have had an MFPR followed by a healthy pregnancy first report feeling grief, guilt, and depression about their decision, though this typically lessens with time.⁴
• Infection of the abdomen or uterus (rare).

Some couples choose to implant fewer embryos to reduce the chances of a pregnancy of triplets or more, rather than consider multifetal pregnancy reduction.

If you need more information, see the topics Multiple Pregnancy: Twins or More, Miscarriage, and Premature Infant.

Your choices are to:

• Carry a multiple pregnancy of three, four, or five fetuses along with being informed about your risks associated with that choice.
• Have multifetal pregnancy reduction along with being informed about your risks associated with the procedure.

The decision about whether to have a multifetal pregnancy reduction takes into account your personal feelings and the medical facts.

These personal stories may help you make your decision.

Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about having a multifetal pregnancy reduction. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

Use the following space to list any other important concerns you have about this decision.

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to use or not use multifetal pregnancy reduction.

Check the box below that represents your overall impression about your decision.

Return to the topic:

• Fertility Problems
• Multiple Pregnancy: Twins or More

Citations

1. American Society for Reproductive Medicine (2006). Guidelines on number of embryos transferred. Fertility and Sterility, 86(4): S51–S52.

2. Wimalasundera R, et al. (2003). Reducing the incidence of twins and triplets. Best Practice and Research Clinical Obstetrics and Gynaecology, 17(2): 309–329.

3. Yaron Y, et al. (1999). Multifetal pregnancy reductions of triplets to twins: Comparison with nonreduced triplets and twins. American Journal of Obstetrics and Gynecology, 180(5): 1268–1271.

4. Garel M, et al. (1997). Psychological reactions after multifetal pregnancy reduction: A 2-year follow-up study. Human Reproduction, 12(3): 617–622.

5. Strauss A, et al. (2002). Multifetal gestation—Maternal and perinatal outcome of 112 pregnancies. Fetal Diagnosis and Therapy, 17(4): 209–217.

6. Stone J, et al. (2002). A single center experience with 1,000 consecutive cases of multifetal pregnancy reduction. American Journal of Obstetrics and Gynecology, 187(5): 1163–1167.

Author:	Bets Davis, MFA Sandy Jocoy, RN	Last Updated: March 21, 2008
Medical Review:	Sarah Marshall, MD - Family Medicine Kirtly Jones, MD - Obstetrics and Gynecology
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