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The incidence of multifetal pregnancy has increased dramatically with the introduction of artificial reproductive techniques (ART). These pregnancies are at high risk for maternal, perinatal and long-term complications, and embryo reduction (ER) has been used for a number of years in an attempt to improve these outcomes. In high-order multifetal pregnancies ER is associated with a decrease in the background risk of miscarriage and perinatal death, but there are some questions regarding the benefits of reduction in triplet pregnancies. The importance of preventative ethics, by restricting the number of embryos transferred or careful monitoring of ovulation induction agents is generally agreed upon. Regulation of treatment regimes coupled with refinements to ART, have reduced the rate of triplet- and higher-order multifetal pregnancies in the last few years. In this article, the moral status of a fetus is discussed and biomedical ethical principles are examined in the context of ER. In addition, religious considerations and medical guidelines are discussed.
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Ethical considerations in embryo-reduction
Aris T. Papageorghiou
St. George’s University of London, Cranmer Terrace, London SW17 0RE, UK
Multifetal pregnancy;
Triplet pregnancy;
Embryo reduction;
Medical ethics
The incidence of multifetal pregnancy has increased dramatically with the introduction of
artificial reproductive techniques (ART). These pregnancies are at high risk for maternal,
perinatal and long-term complications, and embryo reduction (ER) has been used for a
number of years in an attempt to improve these outcomes. In high-order multifetal
pregnancies ER is associated with a decrease in the background risk of miscarriage and
perinatal death, but there are some questions regarding the benefits of reduction in triplet
pregnancies. The importance of preventative ethics, by restricting the number of embryos
transferred or careful monitoring of ovulation induction agents is generally agreed upon.
Regulation of treatment regimes coupled with refinements to ART, have reduced the rate
of triplet- and higher-order multifetal pregnancies in the last few years. In this article, the
moral status of a fetus is discussed and biomedical ethical principles are examined in the
context of ER. In addition, religious considerations and medical guidelines are discussed.
&2006 Elsevier Ltd. All rights reserved.
Over the last 25 years the incidence of multifetal pregnan-
cies has increased dramatically. For example, although the
incidence of twin births is commonly quoted as about 1 in
90, in the USA it has trebled to almost 1 in 30. For triplet-
and higher-order multiples the increase has been even more
pronounced: in the USA, the rate of triplet- and higher-order
multiple birth rates between 1980 and 1998, surged from 37
to 193 per 100,000 live births, an increase of more than
500%; while in the UK the rates increased from 15 to 48 per
100,000, respectively. Although many factors, including
maternal age, parity and racial background influence the
incidence of multifetal pregnancy, it is the use of assisted
reproductive techniques (ART) that are thought to have
caused the majority of this increase. The risk of multifetal
pregnancy from ART correlates with the number of embryos
Multifetal pregnancies are at higher risk for maternal,
perinatal and long-term complications when compared with
singletons or twins. Embryo reduction (ER) has been
advocated for a number of years in order to improve these
outcomes. The procedure is most commonly carried out
transabdominally, by ultrasound-guided fetal intracardiac
injection of potassium chloride, but the transvaginal route
has also been used to aspirate the gestational sac using
suction. The disadvantage of the latter is that it is
performed earlier in pregnancy (around 78 weeks) there-
fore precluding an 1113 week scan for examination for
fetal defects and measurement of fetal nuchal translucency;
in addition, the possibility of spontaneous loss of a
pregnancy is higher in early pregnancy.
There is good evidence that in high-order multifetal
pregnancies (i.e. quadruples and more) ER is associated with
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a decrease in the background risk of miscarriage and
perinatal death. However, there are some questions
regarding the benefits of reduction in triplet pregnancies.
Data suggest improvements in outcomes after ER with time
and increased operator experience; but there are concerns
regarding longer-term safety of ER. For example, observa-
tional data suggesting that death of a co-twin increases the
risk of cerebral palsy for the surviving twin by a factor of
eight when compared with the risk for twins when both
survive. Finally, there have also been improvements with
time in neonatal care and improved mortality statistics in
prematurity-related complications, meaning that for triplet
pregnancies there is some controversy concerning the
possible benefits of reduction. A recent Cochrane review
found no randomised, controlled trials comparing outcomes
after ER with expectant management, and concluded that
results and conclusions from non-randomised studies are
limited by potential bias and must be interpreted with
The aim of this article is to give some insights into the
ethical problems surrounding ER in multifetal pregnancy.
The problem
Couples faced with multifetal pregnancies have three
options of management: termination of the entire preg-
nancy; continuing with the entire pregnancy; or ER by
selective termination. The issues surrounding ER and the
complications arising from multifetal pregnancy create a
bitter irony for infertility patients; these difficult choices
affect mainly couples who have undergone long-standing
efforts to achieve pregnancies by ART. From the ethical
viewpoint, what parents chose will depend on their social
and religious background, but also on the medical evidence
that is presented to them. The difference between
termination of the whole pregnancy and ER is that in the
latter the intention is not to terminate the pregnancy but to
increase the chance of normal development of the remain-
ing fetuses, making the first priority the well-being of the
children that will be born. Although there is little doubt that
this is true for high-order multiples, in the case of triplet
pregnancy there is some debate regarding the medical
benefits of ER. So what ethical considerations are there
other than medical evidence?
Most authors start their discussion of ethical considerations
by emphasising the importance of preventative ethics. So, in
the case of ART, the incidence of multifetal pregnancy can
be reduced by restricting the number of embryos trans-
ferred, or by careful monitoring of ovulation induction
agents and avoidance of fertilisation. Such restrictions need
to follow careful discussion during the informed consent
process, including ethical reasoning and decision-making, as
well as consideration to the woman’s wishes regarding the
possibility of ER, in order to avoid conflicts between the
woman and her physician. Importantly, over the last few
years there has been both voluntary and statutory regulation
of treatment regimes. It is thought that implementation of
such regulations, coupled with refinements to ART, have
been responsible for the reduction in the rate of triplet- and
higher-order multifetal pregnancies that has been observed
since 1998.
Biomedical ethics
The moral foundation of modern biomedical ethics is based
upon four prima facie principles: respect of autonomy,
beneficence, non-maleficence, and justice. These can be
summarised as follows:
Autonomy: The patient has free will and accord, has the
right to information and self-determination. The patient
can chose to intentionally participate or decline treat-
Beneficence: The patient’s welfare is the first considera-
tion, so do what clinically benefits the patient.
Non-maleficence: First do no harmbut remember there
can be a balance between risk and benefit.
Justice: Do not discriminate (for example on the basis of
age, sex, and race), be consistent, accountable and
respect the law.
These principles obviously apply to the pregnant mother,
but do all of them also apply to the fetus? And in the case of
multifetal pregnancy, do they apply to each fetus, or to the
pregnancy as a whole? In order to answer this question we
must first consider the moral status of the fetus.
Moral status of a fetus
Persons have rights, for example the right to life, to thrive
and to be protected from harm. In considering the issue of
termination of pregnancy, Hope and colleagues discuss the
number of possible views on the moral status of the fetus:
(i) Identity as a human organism: According to this view
there are no good grounds for according a different
moral status to the human being at different stages in
its development. Most supporters of this position put
the moment at when the embryo attains full moral
status as conception. Before conception neither the egg
nor the sperm can be said to have the same identity as
the later child, but once conception has taken place the
organism that will be the child has come into existence.
(ii) The potential to be a person: This differs from the
argument of human identity (above) in that it does not
accord fetuses and embryos moral status for what they
are but because of what they have the potential to
become. According to the argument from human
identity, killing the fetus is wrong because you are
killing something that has the right to live. According to
the argument from potential, killing the fetus is wrong
because it involves carrying out an act that will have
the effect of preventing a future person from existing.
(iii) Identity as a person: This view is that a person is a
human being that has certain characteristics. An
embryo or fetus (or baby) is a moral entity only at the
point when it becomes a person. Most proponents of
this approach hold that being a person must involve
some degree of consciousness, and on most forms of this
A.T. Papageorghiou182
view, fetuses less than 24 weeks do not have moral
(iv) Conferred moral status: This states that moral status
need not be based only on intrinsic properties of the
entity (position 3 above), but that it can be conferred
by others. Thus, conferring moral status at birth can be
justified in terms of the consequences for others and in
terms of fostering concern, warmth and sympathy for
The authors go on to suggest that each of the four views
faces problems: while the first two positions appear to give
too much moral protection to very early embryos, the third
position may give too little protection to infants and people
with severe learning difficulties. The fourth position seems
to many to exaggerate the importance of others at the
expense of the individual.
McCullough and Chervernak argue that there are irrecon-
cilable differences among philosophic and theological
methods that have been deployed over the centuries of
debate about the independent moral status of the fetus.
Their suggested line of argument is that the moral status of
the fetus depends on whether it is reliably expected later to
achieve the moral status of becoming a child and later that
of being a person. There are two possible links between a
fetus and child (and then person). In the case of a
potentially viable fetus this is being presented to a physician
and involves medical interventions that can result in ex-
utero life. The viable fetus, when the pregnant woman
presents herself for medical care, is therefore a patient.
However, it is important to stress that obligations to the
fetus must be considered along with beneficence-based and
autonomy-based obligations to the pregnant woman. In the
case of the pre-viable fetus, technological factors cannot
result in the fetus becoming a child. The link is therefore
being presented to a physician and the decision of the
pregnant woman to continue a pre-viable pregnancy to
viability and, subsequently, to term. Thus, the pre-viable
fetus is a patient solely as a function of the pregnant
woman’s decision to confer the status on the fetus and
present herself for care, and the fetus has no claim to the
status of being a patient independently of the pregnant
woman’s autonomy: the pregnant woman can withhold,
confer and withdraw previously conferred moral status of
being a patient according to her own values and beliefs.
Ethics in ER
Using this background Chervernak and McCullough go on to
suggest that in high-order multifetal pregnancy, were the
pregnant mother to confer the same status on all fetuses
this would jeopardise the whole pregnancy. In fact, for some
of the fetuses to become patients she withholds conferring
this status on others, thus justifying fetal reduction.
Another argument that is commonly put forward is that
the medical justification for the procedure is philosophically
similar to the ‘lifeboat analogy’some drowning people can
legitimately be denied access to a dangerously full lifeboat
if bringing them aboard would cause it to sink and result in
the loss of additional lives. In the case of multifetal
pregnancy, this translates into the argument that it is
justifiable to sacrifice some normal fetuses in order to
increase the chances of survival, or decrease the risk
morbidity, in the remaining fetuses.
Religious considerations differ. In the catholic faith the
embryo is considered and treated as a human person from
the first moment of conception, having fundamental human
rights, including (and foremost) that of the right to life.
From this viewpoint,
‘‘ythe moral prohibition remains even in the case where
the continuation of the pregnancy involves a risk to the
life or to the health of the mother and of the other
Conversely in Judaism, fetuses have no independent
moral status, and most Rabbinic decisors agree that ER is
permitted in certain circumstances. Some permit this only in
situations where the continuation of the pregnancy threa-
tens the mother’s life; others allow it in multifetal
pregnancy as in this case the pregnancy itself is threatened.
Muslim law is relatively lenient with regard to the abortion
of disadvantaged fetuses. In the case of ER it is permitted
only if the prospect of carrying the pregnancy to viability is
very small, or if the mother’s health or life is threatened.
Medical guidelines
The European Society of Human Reproduction and Embryol-
ogy (ESHRE) Task Force on Ethics and Law Ethical published
guidance on issues related to multifetal pregnancies.
Regarding ER, they comment that ethical dilemmas are
closely connected to the problem of abortion, but with the
main difference being that that the intention not to
terminate the pregnancy but to increase the chance of
development of the remaining fetuses. They go on to
comment that, especially in higher-order pregnancies, not
performing a reduction will increase the risk of losing the
pregnancy and all the fetuses, and that in a sense the
reduction is medically indicated. Prevention of multifetal
pregnancies should be preferred because the decision to
reduce the number of embryos is psychologically and
morally demanding, as well as carrying detrimental effects
(higher incidence of prematurity) on the development of the
remaining fetuses. They conclude that reduction
‘‘yis morally acceptable if the physician has acted
according to the rules of good clinical practice and has
tried to minimise the risk of a multifetal pregnancy. The
benefits for the remaining embryos of reducing a higher-
order multifetal pregnancy exceed the disadvantages of
carrying the pregnancy to term or risking miscarriage.
With triplets, opinions vary according to personal
experience and access to neonatal care. The reduction
of twins to a singleton is acceptable in cases of maternal
disease, poor obstetric outcome and compelling social
and psychological reasons of the woman.’’
The Committee on Ethics of the American College of
Obstetrics and Gynecology also points out that there is a
distinction between ER reduction and selective termination
of an abnormal fetus and that therefore its ethical rationale
is different; that the first approach should be prevention;
and that there is a need for careful counselling beginning
Ethical considerations in embryo-reduction 183
before treatment for subfertility starts and continuing
throughout a patient’s care. They conclude that
‘‘yno physicians need participate in any activities that
they find morally unacceptable, [but that] all physicians
should be aware of the medical and ethical issues in these
complex situations and be prepared to respond in a
professional, ethical manner to patient requests for
information and procedures.’
These points are also highlighted by the French National
Consultative Ethics Committee for Health and Life Sciences.
In addition they advise that ‘Physicians using such techni-
ques must be adequately trained y’ and that ‘The
possibility of resorting to embryo or foetal reduction cannot
excuse or justify lack of caution in the use of these
The constant and dramatic rise in the incidence of multifetal
pregnancy has been slowed over the last few years, and this
is likely to be due to regulations as well as refinements to
ART. From a preventative ethics point of view, this is a
positive outcome as choosing ER is psychologically and
morally demanding and carries detrimental effects. High-
order multifetal pregnancy carries such high risks to the
mother and the pregnancy itself that ER can be ethically
justified on the consideration of beneficence (a balance of
greater clinical good over clinical harm). It can be argued
that the fetus can be considered not to have an independent
moral status, unless such a status is conferred upon it by the
mother. In view of this, ER can also be justified on the
principle of respect for the autonomy of the pregnant
mother (a balance of greater good over harm as defined by
the patient’s perspective). This justifies ER in cases where
the issue of beneficence is not as clearly documented, such
as in triplet pregnancy.
Further reading
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Births: final data for 2002. National vital statistics reports,
vol. 52(10). Hyattsville, Maryland: National Center for Health
Statistics; 2003.
2. Simmons R, Doyle P, Maconochie N. Dramatic reduction in
triplet and higher order births in England and Wales. BJOG
3. Dodd JM, Crowther CA. Reduction of the number of fetuses for
women with triplet and higher order multiple pregnancies.
Cochrane Database Syst Rev 2003;CD003932.
4. The ESHRE Capri Workshop Group. Multiple gestation pregnancy.
Hum Reprod 2000;15:185664.
5. Petterson B, Nelson KB, Watson L, Stanely F. Twins, triplets, and
cerebral palsy in births in Western Australia in the 1980s. BMJ
6. Evans MI, Berkowitz RL, Wapner RJ, Carpenter RJ, Goldberg JD,
Ayoub MA, Horenstein J, Dommergues M, Brambati B, Nicolaides
KH, Holzgreve W, Timor-Tritsch IE. Improvement in outcomes of
multifetal pregnancy reduction with increased experience. Am
J Obstet Gynecol 2001;184:97103.
7. Papageorghiou AT, Liao AW, Skentou C, Sebire NJ, Nicolaides KH.
Trichorionic triplet pregnancies at 1014 weeks: outcome after
embryo reduction compared to expectant management.
J Matern Fetal Neonatal Med 2002;11:30712.
8. Blickstein I. How and why are triplets disadvantaged compared
to twins? Best Pract Res Clin Obstet Gynaecol 2004;18:63144.
9. European Society of Human Reproduction and Embryology 6.
Ethical issues related to multiple pregnancies in medically
assisted procreation. The ESHRE Task Force on Ethics and
Law*Human Reproduction 2003;18:19769.
10. Part 8Use of gametes and embryos: code of practice. The
human fertilisation and embryology authority, 6th ed. UK:
HFEA; 2003.
11. American Society for Reproductive Medicine. Guidelines
on number of embryos transferred. A practice committee
reporta committee opinion (revised). American Society
for Reproductive Medicine; 1999.
12. Beauchamp TL, Childress J. Principles of biomedical ethics.
New York: Oxford University Press; 1979.
13. Hope T, Savulescu J, Hendrick J. Medical ethics and law: the
core curriculum. Edinburgh: Churchill Livingstone; 2003.
14. McCullough LB, Chervenak FA. Ethics in obstetrics and
gynecology. New York: Oxford University Press; 1994.
15. Chervenak FA, McCullough LB. The limits of viability. J Perinatol
Med 1997;25:41820.
16. Congregation for the doctrine of the Faith. Instruction on
respect for human life in its origin and on the dignity of
procreation: Replies to certain questions of the day. http://www.
A.T. Papageorghiou184
... This increase in multifoetal pregnancy has been from 1.25% in spontaneous pregnancies to 5-8% with clomiphene induced cycles 1,2 and is nearly 30% in patients using exogenous gonadotrophins for super ovulation for sub-fertility. [3][4][5][6] Various measures have been taken to reduce the incidence of multifoetal gestation by making single embryo transfer the norm. 7,8 Multiple pregnancies being high-risk pregnancies are frequently complicated by preterm delivery, low birth weight, preeclampsia and increased perinatal morbidity and mortality. ...
Background The transvaginal ultrasound-guided embryo reduction technique is a feasible option for the prevention and management of the medical and obstetric risks associated with high-order multiple pregnancy resulting from assisted reproductive treatment.Method Multifoetal pregnancy reduction was carried out in 51 in vitro fertilisation pregnancies (IVF) and one intrauterine quintuplet pregnancy resulting from intrauterine insemination (IUI) using transvaginal approach under ultrasonographic guidance.ResultsOf the 52 embryo reduction procedures, 48 (92%) were performed between the seventh and eighth weeks of gestation, three between eighth and ninth weeks and one in the 10th week of gestation. Forty-nine patients (94%) underwent reduction from triplets to twins, two from quadruplet to twins, and one from quintuplet to twin pregnancy. The average time required for the embryo reduction was 5.0±0.5 minutes per sac in early gestation (6th-9th weeks), increasing to 8.5 minutes per sac for later procedures, due to technical difficulties brought about by increased embryo size and mobility. All embryo reduction procedures were successfully performed in a single session.Conclusion Transvaginal ultrasound guided embryo reduction technique performed between seventh and eighth-weeks of gestation is an effective and safe procedure for embryo reduction.
The objective of this paper is to analyze the perceptions and practices of clinicians in relation to the management of embryos subjected to in vitro fertilization techniques. Methodology is Qualitative (subjectivist and phenomenological). A total of 15 semi-structured interviews were conducted using saturation sampling for clinical personnel who have participated in vitro fertilization procedures. The data is analyzed with the Atlas Ti 8.0® program. Results: Clinicians consider the embryo as a Human being or future human being, in addition, deserving of respect and consideration even proposing improvements in the processes of handling and storage. Conclusion. Embryos are not considered as entities susceptible of damage from not only technical but ethical arguments. From the principialist current, the need to promote attitudes of responsibility and prudence to avoid dogmatism (moral objectivism) is described, proposing a deliberative position.
Objective: The incidence of perinatal mortality and morbidity in triplet pregnancies according to chorionicity is yet to be established. The aim of this systematic review was to quantify perinatal mortality and morbidity in trichorionic triamniotic (TCTA), dichorionic triamniotic (DCTA) and monochorionic triamniotic (MCTA) triplets. Methods: MEDLINE, EMBASE and CINAHL databases were searched in December 2017 for literature published in English describing outcomes of DCTA, TCTA and/or MCTA triplet pregnancies. Primary outcomes were intrauterine death (IUD), neonatal death, perinatal death (PND) and gestational age at birth. Secondary outcomes comprised respiratory, neurological and infectious morbidity, as well as a composite score of neonatal morbidity. Data regarding outcomes were extracted from the included studies. Random-effects meta-analysis was used to estimate the risk of mortality and morbidity and to compute the difference in gestational age at birth between TCTA and DCTA triplet pregnancies. Results: Nine studies (1373 triplet pregnancies, of which 1062 were TCTA, 261 DCTA and 50 MCTA) were included in the analysis. The risk of PND was higher in DCTA than in TCTA triplet pregnancies (odds ratio (OR), 3.3 (95% CI, 1.3-8.0)), mainly owing to the higher risk of IUD in DCTA triplet pregnancies (OR, 4.6 (95% CI, 1.8-11.7)). There was no difference in gestational age at birth between TCTA and DCTA triplets (mean difference, 1.1 weeks (95% CI, -0.3 to 2.5 weeks); I2 = 85%; P = 0.12). Neurological morbidity occurred in 2.0% (95% CI, 1.1-3.3%) of TCTA and in 11.6% (95% CI, 1.1-40.0%) of DCTA triplets. Respiratory and infectious morbidity affected 28.3% (95% CI, 20.7-36.8%) and 4.2% (95% CI, 2.8-5.9%) of TCTA and 34.0% (95% CI, 21.5-47.7%) and 7.1% (95% CI, 2.7-13.3%) of DCTA triplets, respectively. The incidence of composite morbidity in TCTA and DCTA triplets was 29.6% (95% CI, 21.1-38.9%) and 34.0% (95% CI, 21.5-47.7%), respectively. When translating these figures into a risk analysis, the risk of neurological morbidity (OR, 5.4 (95% CI, 1.6-18.3)) was significantly higher in DCTA than in TCTA triplets, while there was no significant difference in the other morbidities explored. Only one study reported on outcomes of MCTA pregnancies, hence, no formal comparison with the other groups was performed. Conclusion: DCTA triplets are at higher risk of perinatal mortality and morbidity than are TCTA triplets. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
In her article, “Selective Reduction: ‘A Soft Cover for Hard Choices’ or Another Name for Abortion?,” Radhika Rao explores the dense thicket of contradictions and conflicts related to abortion and selective reduction. Selective reduction is one name for a procedure performed to terminate one or more fetuses in a multi-fetal pregnancy in order to increase the chances that the other fetuses and the pregnant woman will emerge from the pregnancy healthy. Though Rao, in keeping with some authorities, uses the terminology selective reduction in her piece, others prefer the term multi- fetal pregnancy reduction (MFPR) as more reflective of the procedure’s goals and practice. Competing monikers for the same procedure speaks to the importance of naming when discussing the termination of fetal life. It is also a sign of the array of legal, ethical, and medical conundrums surrounding practices that end or alter the course of a pregnancy.
Ureteral injury during pelvic laparoscopic surgery is a known complication and it had morbidty depending on the time of their recognition. The incidence of these injuries are 0.5-2 % and most of these complications happened with gynaecology , endourology and general surgery operations. The risk factors precipating more injuries. Diagnosis of these injuries determine the out come, if diagnosed intraoperative repair should be done immediately. Late detection had bad morbidty and loss of some of renal functions. Ureteral injury can be prevented and reduced by more training and learning for surgeons and meticulous laparoscopic techniques. Laparoscopic ureteric injuries repair became popular by experience laparoscopy surgeon. Remute ureteral injury due to over cooking with the diathermy close to the ureter should be avoided.
This article concerns the issue of multifetal reduction performed in some cases of higher order multiple gestation in order to decrease the possibility of adverse pregnancy outcomes and increase the chances of survival in the remaining fetuses. If multifetal pregnancy reduction is considered as a treatment option, it is usually performed in the first or early second trimester. The decision to reduce one or more fetuses is extremely complicated, and numerous factors must be considered, since the procedure has risks, such as loss of the entire pregnancy or preterm labor and birth of the remaining fetuses. In addition, there are also psychological risks for the mother. Typically women faced with this decision have struggled for years with infertility and now they are asked to consider terminating one or more of the fetuses to prevent morbidity and/or mortality in others. Nurses who work with infertile women may be able to assist in minimizing the need for multifetal pregnancy reduction by educating women about the risks associated with assisted reproductive technologies and higher order multifetal pregnancy before decisions are made about multiple embryo transfers or intrauterine insemination after ovulation induction.
Full-text available
To examine the rate of cerebral palsy in twins and triplets in births from 1980 to 1989 in Western Australia and to identify factors associated with increase in risk. Pluralities for all births in Western Australia were identified through the standardised midwives' notification system, and cases of cerebral palsy were identified from the Western Australian cerebral palsy register. Multiple births, cerebral palsy, excluding postneonatal cause. The prevalence of cerebral palsy in triplets, of 28 per 1000 survivors to 1 year (95% confidence interval 11 to 63) exceeded that in twins (7.3; 5.2 to 10) and singletons (1.6; 1.4 to 1.8). Although twins and triples were more likely than singletons to be low in birth weight, their risks of cerebral palsy if low in birth weight were similar. In contrast, in normal birthweight categories twins had a higher rate of cerebral palsy (4.2; 2.2 to 7.7) than singletons (1.1; 1.0 to 1.3). The prevalence of cerebral palsy was similar in twins of unlike sex pairs, all of whom are dizygotic, and in like sex pairs. A twin pair in which one member died in utero was at higher risk of cerebral palsy: 96 per 1000 twin pairs (36 to 218) compared with 12 (8.2 to 17) for twin pregnancies in which both survived. There was a similar but non-significant trend for death of one triplet to be associated with increased risk of cerebral palsy in the survivors of the set. Triplet pregnancies produced a child with cerebral palsy 47 times more often than singleton pregnancies did and twin pregnancies eight times more often. Eighty six per cent of cerebral palsy in multiple births was in twins. As multiple births are increasing mainly because of personal and medical decisions the increased risk of cerebral palsy in multiple births is of concern.
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To compare the outcome of trichorionic triplet pregnancies managed expectantly with those reduced to twins or singletons. This was a retrospective study of trichorionic triplet pregnancies with three live fetuses at 10-14 (median 12) weeks' gestation referred to our unit for consideration of embryo reduction. Women were counselled as to the available options of either expectant management or embryo reduction. In those choosing reduction, a needle was inserted into the uterus transabdominally and potassium chloride was injected into the fetal heart. Using data derived from this study and from a review of studies reporting on survival and handicap by gestational age in singletons, the effects of embryo reduction on survival and handicap rates were estimated. Main outcome measures were miscarriage before 24 weeks of gestation, preterm delivery before 32 weeks, perinatal death and handicap rates. In total, there were 280 trichorionic triplet pregnancies and 125 of these were managed expectantly, 133 were reduced to two fetuses and 22 were reduced to one fetus. The rates of miscarriage were 3.2% for those managed expectantly, 8.3% for those reduced to twins and 13.6% for those reduced to singletons. The rates of early preterm delivery in those pregnancies that did not miscarry were 23.1%, 9.8% and 5.3%, respectively. The percentages for pregnancies with at least one survivor were 95.2%, 91.0% and 81.8%, respectively, and the median gestation at delivery was 34 weeks for the non-reduced, 36 weeks for those reduced to twins and 38 weeks for those reduced to singletons. From the published series on early preterm delivery, it was estimated that survival increases from about 27% at 24 weeks to about 98% at 32 weeks, and handicap decreases from 28% at 24 weeks to less than 5% at 32 weeks. From these estimates and the data on triplet pregnancies, it was calculated that, in triplets reduced to twins, compared to those managed expectantly, the chance of survival is similar (90.3% compared to 93.3%), but the risk of handicap may be lower (0.6% compared to 1.5% per fetus). In trichorionic triplet pregnancies, embryo reduction to twins does not improve the chance of survival but may reduce the rate of handicap. Reduction from triplets to singletons may reduce both the survival rate and the handicap rate among survivors.
Multiple gestation pregnancy rates are high in assisted reproductive treatment cycles because of the perceived need to stimulate excess follicles and transfer excess embryos in order to achieve reasonable pregnancy rates. Perinatal mortality rates are, however, 4-fold higher for twins and 6-fold higher for triplets than for singletons. Since the goal of infertility therapy is a healthy child, and multiple gestation puts that goal at risk, multiple pregnancy must be regarded as a serious complication of assisted reproductive treatment cycles. The 1999 ESHRE Capri Workshop addressed the psychological, medical, social and financial implications of multiple pregnancy and discussed how it might be prevented. Multiple gestations are high risk pregnancies which may be complicated by prematurity, low birthweight, pre-eclampsia, anaemia, postpartum haemorrhage, intrauterine growth restriction, neonatal morbidity and high neonatal and infant mortality. Multiple gestation children may suffer long-term consequences of perinatal complications, including cerebral palsy and learning disabilities. Even when the babies are healthy they must share their parents' attention and may experience slow language development and behavioural problems. Current data indicate that the average hospital cost per multiple gestation delivery is greater than the average cost of in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) cycles. Prevention is the most important means of decreasing multiple gestation rates. Multiple gestation rates in ovulation induction and superovulation cycles can be reduced by using lower dosage gonadotrophin regimens. If there are more than three mature follicles, the cycle should be converted to an IVF cycle, or it should be cancelled and intercourse should be avoided. In IVF cycles two embryos can be transferred without reducing birth rates in most circumstances. Embryo reduction involves extremely difficult decisions for infertile couples and should be used only as a last resort. Assisted reproductive treatment centres and registries should express cycle results as the proportion of singleton live births; twin and triplet rates should be reported separately as complications of the procedures. Reducing the multiple gestation pregnancy rate should be a high priority for assisted reproductive treatment programmes, despite the pressure from some patients to transfer more embryos in order to improve success. If nothing is done, public concern may lead to legislation in many countries, a step that would be unnecessary if assisted reproductive treatment programmes and registries took suitable steps to reduce multiple pregnancy rates.
We provide an ethical analysis of the divergence of mortality and potential morbidity in very premature infants. Based on this ethical analysis we conclude that at this time viability should be at 24 weeks or greater and not at 23 weeks.
This paper provides an overview of ethical issues in obstetrics and gynecology. We first define two basic ethical principles, beneficence and respect for autonomy. We first apply these principles to gynecologic practice, emphasizing the role of informed consent. We then apply these principles to obstetric practice, utilizing the concept of the fetus as a patient and identifying its clinical implications for directive versus non-directive counseling for fetal benefit. (C) 1997 Elsevier Science ireland Ltd.
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This study was undertaken to evaluate a decade of data on multifetal pregnancy reductions at centers with extensive experiences. A total of 3513 completed cases from 11 centers in 5 countries were analyzed according to year (before 1990, 1991-1994, and 1995-1998), starting and finishing numbers of embryos or fetuses, and outcomes. With increasing experience there has been a considerable improvement in outcomes, with decreases in rates of both pregnancy loss and prematurity. Overall loss rates in the last few years were correlated strongly with starting and finishing numbers (starting number > or =6, 15.4%; starting number 5, 11.4%; starting number 4, 7.3%; starting number 3, 4.5%; starting number 2, 6.2%: finishing number 3, 18.4%; finishing number 2, 6.0%; finishing number 1, 6.7%). Birth weight discordance between surviving twins was increased with greater starting number. The proportion of cases with starting number > or =5 diminished from 23.4% to 15.9% to 12.2%. The proportion of patients >40 years old increased in the last 6 years to 9.3%. Gestational age at delivery did not vary with increasing maternal age but was inversely correlated with starting number. Multifetal pregnancy reduction outcomes at our centers for both losses and early prematurity have improved considerably with experience. Reductions from triplets to twins and now from quadruplets to twins carry outcomes as good as those of unreduced twin gestations. Patient demographic characteristics continues to change as more older women use assisted reproductive technologies. In terms of losses, prematurity, and growth, higher starting numbers carry worse outcomes.