The woman, pale-skinned, fine-featured, tall, in her 30s, was wearing a hospital gown. Beside the woman was her husband, sitting in a chair, holding his wife's hand. He too was pale, and, like his wife, he looked miserable. "Yes, I'd like to see them," the woman on the table said firmly.
"I'll just take a few pictures, and I'll show them to you," Greenbaum said.
"Them" referred to the three fetuses in the woman's belly, a long sought pregnancy achieved by in vitro fertilization. The woman and her husband were about to turn their triplets into twins in a procedure known as selective reduction.
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. There is no way to know how many pregnancies achieved by fertility treatment start out as triplets or quadruplets and are quietly reduced to something more manageable. The U.S. Centers for Disease Control and Prevention, which publishes an annual report on fertility clinic outcomes, does not include selective-reduction figures because of the reluctance to report them.The industry doesn't publish them, either. "This is a very sensitive topic," says David Grainger, president of the Society for Assisted Reproductive Technology, the membership group for IVF clinics. It's sensitive, personally, for patients, but also politically, for doctors.
Mark Evans is one of the few doctors in the country who not only performs reductions but also is willing to discuss all qualms, ethics, issues, outcomes. Evans, who describes himself as an obstetrician-geneticist, is a pioneer in fetal therapy. Using stem-cell transplants, he developed the first in-utero correction of SCID, a genetic disorder that severely compromises the immune system. He has also pioneered fetal surgeries, including bladder shunts for fetuses with urological obstructions. The goal of his practice is the delivery of a healthy baby. In some cases, this can be achieved by treating a fetus in utero. In some cases, it is achieved by sacrificing a fetus in utero...."I used to be totally not willing to talk about gender," elaborated Evans, who has pieced together his own ethics during more than 20 years of practice. At the outset, he worked with a bioethicist to develop guiding principles. For years, he says, the majority of sex-selection requests came from Asian and Indian parents, who tended to want to keep the boys. That he would not do. Increasingly, however, what people want is the Holy Grail of the modern two-child family: one boy and one girl. He finds that morally acceptable.
...Evans reviewed the loss rates for triplets. The patient's mother was clearly in favor of reduction. They had been over this before, she said, with the IVF doctor in Puerto Rico. "The risk would be too great," she said. "Sometimes you have to do unpleasant things to have a family."
...When he was working to establish bioethical principles, Evans decided that he would not reduce a normal twin pregnancy. He would take somebody from three to two, but he would not take somebody from two to one. "The rationale we used was: One, every OB knows how to take care of twins, and two, the outcome is not as good as with singletons, but good enough. And number three, all these were fertility patients, and if we could get them to twins, that was that much closer to their family ideal. And four, we didn't know what the risk might be of damaging one of the fetuses by the procedure. Because of all of the above, it didn't feel ethical to go ahead and do that."
But Evans's thinking has changed. He is willing now to reduce two to one, and he does so. Not often, but the incidence is increasing. Please see "No Intention of Ever Saying No..."...Evans prepared two syringes, swabbed Emma with antiseptic, put the square-holed napkin on her stomach. Then he plunged one of the needles into Emma's belly and began to work his way into position. He injected the potassium chloride, and B, the first fetus to go, went still.
"There's no activity there," he said, scrutinizing the screen. B was lying lengthwise in its little honeycomb chamber, no longer there and yet still there. It was impossible not to find the sight affecting. Here was a life that one minute was going to happen and now, because of its location, wasn't. One minute, B was a fetus with a future stretching out before it: childhood, college, children, grandchildren, maybe. The next minute, that future had been deleted.
Evans plunged the second needle into Emma's belly. "See the tip?" he said, showing the women where the tip of the needle was visible on the ultrasound screen. Even I could see it: a white spot hovering near the heart. D was moving. Evans started injecting. He went very slowly. "If you inject too fast, you blow the kid off your needle," he explained.
After Evans was finished injecting, D moved for a few seconds, then went still. Now, as we watched, there was something called the effusion: a little puff. "When I see that effusion, I know it's done," Evans said, taking "one last look at D before I come out," to make sure D was gone.
"Want to see your twins?" he asked the women, who did. On the ultrasound, he showed them the living fetuses, moving vigorously in their sacs. The women thanked him profusely. "Thank God there are people like you," Jane said.
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