Article statistics updated 2010

1. I am expecting quadruplets and am being asked to consider reducing to twins. I know it is possible to carry healthy triplets, what do we do?

You are correct in that many families have carried triplets to a healthy outcome. There are many considerations and only you, your partner, informed healthcare professionals, perhaps other multiple-birth parents and genetic counseling can help you reach a decision.

Some things you might consider:

Ascertain the health risk vis-à-vis the mother and all of the babies. If one (or more) fetuses have anomalies, you may feel that reduction is the decision to make, thereby giving the healthy fetuses a better chance at a healthy gestation and life.

Learn the survival statistics:
• 75% of quadruplets survive. Of that figure, 50% of them have disabilities ranging through a series of impairments such as blindness to cerebral palsy. The average gestation for quadruplets is 31 weeks. 

• 90% of triplets survive and 10% impairment rate can be expected, with an average gestation of 33.5 weeks. 

• 98% of twins survive with a 5% impairment rate and the average gestation is 35-38 weeks (NOTE: a singleton gestation rate is based on 40 weeks).*

*statistics quoted from research paper by V.M. (2000, statistics updated 2010)

2. Did we do the right thing?

This is such a difficult question and there are no easy answers. Even though the timeframe for the decision whether to have the procedure or not is so short (ideally between 10 and 12 weeks gestation), be sure and do your homework. Below are some Internet Sites to visit, talk to other families who have considered the procedure, learn as much as you can about the procedure and the possible ramifications. Knowledge is Power and permits you to make the best possible decision for your personal situation.

I must refer to one Mom’s (who reduced from 4 to 3) thoughts and wisdom. As she put it:

Someone once said to me "make the decision from your head, not your heart". I agree with the intent of that comment. An informed decision is the best decision. However, you can never really feel good about such a decision, and you will never be 100% certain of your choice. You can survive this and one day you will be at peace with it. Recently I was able to answer a question that had tormented me from the beginning. "How do I ask forgiveness or understanding from that lost child - the one I never gave a chance at life?" The answer - there is no need to ask for forgiveness for a child loves unconditionally. The love we have for that child was and is equally returned. It was through love that my husband and I conceived, and it was with love that we reduced. It is the love not the loss that I chose to hold onto. Somewhere between your head and your heart, what you know and what you feel, you will find the answer. Allow yourself to listen to both.

3. We have lost a child(ren). We hurt so much and we cannot share nor openly talk about our pain.

Even though a child(ren) has died through reduction, the child lives on.

Multifetal pregnancy reduction is one type of loss that is nearly impossible to 'share' with others let alone have them fully understand the anxiety and dilemma that has been faced. We conceived many babies and chose to reduce one (two, or three). It may be that the parents have tried to get pregnant for years and not they are forced to make a decision which interferes with their pregnancy dreams and kill one of their much-wanted babies. With the alteration of the dream it can be very difficult to openly discuss personal feelings, fears, anxieties and to have them acknowledged, or understood, by family or friends. A sense of isolation coupled with the grief of the new reality can combine to make the pain greater.

Some may equate a reduction to an abortion. I feel that a reduction is done for the love of all the children and to give them all the best chance to be healthy and not to lose the pregnancy. An abortion is done to lose the pregnancy.

It may not be unusual, like a miscarriage, for others to have difficulty in relating to your loss. "Well it wasn't a baby yet" or "you have others" may be expressed to you. Try and find a caring and understanding person to share your pain and grief. It might be a special friend, grief counselor, religious leader, family doctor or bereavement support group. Grief is personal and knows no timetable. Grief is a journey not a destination and may require some support at different stages of life. It is important to recognize the pain, possible feelings of guilt and grief and work with them, to address and acknowledge them. Only then can we move on, forever changed and with a new reality. Don't be afraid to cry or seek appropriate professional support, if need be.

4) How do we tell the survivors? Do we tell the survivors? When is the best time?

A very difficult series of questions. If the reduction was discussed with other family members or friends, there is a chance that at some time in the future, even inadvertently, your children will hear the news from someone else. In order to control the situation as best you can, it is helpful to let them know their beginnings. Parents know their children best and can assess when is the best time for them to hear the news. Use age-appropriate language for whatever age you feel is right. Beginning as early as possible may be an easier because if you don’t choose the right words at age 2 years, say, the results will be less damaging than if you didn’t choose the right words at 14 years old. Another point to keep in mind is that when a secret is made public, it loses impact and can no longer cause as much harm as it would when sprung upon someone at a later stage. The news later in life can rock their world and change who they are.

Be prepared for some very difficult rebuttal questions such as why wasn’t I killed? Did you kill my sister/brother? Was it a boy or girl who was killed? Will you kill me (and/or my sisters/brothers)? All of these and more are possible.

Bottom line, you know your kids best. If and when you decide to share their beginnings, the decision is up to both of the parents.

REDUCING TWINS TO ONE

In the last year (2009/10), there has been an increase in families looking to reduce twins to one. For those looking for such a reduction, please consider the following:

~98% of twins survive with a 5% impairment rate and the average gestation is 35-38 weeks.
~as the majority of twins pregnancies are without issue, there is little
or no risk for a mother and father who were healthy to begin with. There is also minimal risk for the babies.
~find out what type of twins you are carrying, i.e. monozygotic (identical) or dizygotic (fraternal). Monozygotics can share some aspects of their time in the womb such as one or two placentas, one or two amnions, one or two chorions. A small percentage of monozygotics share all three. Reduction will be more of a risk, the more the babies share and depending how many they do share, a reduction may negatively impact the whole pregnancy.
~it can be very difficult to find a doctor willing to reduce twins when the twins and Mom are healthy. There usually has to be extenuating circumstances to one, both or all, e.g. one baby has a serious anomaly, Mom has had previous difficult and high risk pregnancies, before a doctor will consider such a reduction.
~reducing twins to one may carry a higher risk than completing either a spontaneous or infertility assisted twin or singleton pregnancy.

ADDITONAL THOUGHTS FROM A PARENT WHO REDUCED 4 TO 3

~don’t be overly rushed with the decision, there is time, whatever you do;
~with time comes healing;
~if you have to ask then you already have the answer;
~walk a week as if you did [reduce]; and
~walk a week as if you did not [reduce].

Sources

Bereavement: Guidelines for Professionals, These guidelines focus on the particular issues raised by the loss of a twin, triplet or more by Elizabeth Bryan, MD, FRCP, FRCPCH and Faith Hallett, The Multiple Births Foundation, UK

Twins! Pregnancy, Birth and The First Year of Life by Connie L. Agnew, M.D., Alan H. Kein, M.D., and Jill Alison Ganon, 1997, Harper Perennial

Web Links

Selective Reduction Loss Support
Created in May, 2003, this Site is a message board for those families seeking connection with other families whom have used Selective Reduction (multifetal pregnancy reduction).

Additional Resources

Multifetal pregnancy reduction by Evans and Britt, at the Global Library of Women's Medicine site.
Evans, M, Britt, D, Glob. libr. women's med.,
(ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10214
http://www.glowm.com/?p=glowm.cml/section_view&articleid=214&SESSID=haaj72nm2tvd91b1f18m3chhk5