Contemplating Selective Reduction
After learning that a local hospital does do selective reduction (SR), it has spurred a conversation with my husband about the possibility of choosing to transfer two embryos, to up our odds of getting pregnant on this final try, knowing that SR would be an option for us, if by some rare and fateful twist both of them stick, considering our first 3 donor egg embryos were failures.
I’ve read a lot of blogs and articles about SR, which I’d only heard of in the past few months on the infertility forums, and found the discussion very interesting…and laced with a lot of hypocrisy out there from some.
So yes, y’all know me. I’m going to sound off. Because every woman needs to be supported in doing what is best for her own family… even if that’s something you might not want to do yourself.
By the way I’m not even going to give any time to those who are against a woman’s right to choose in the first place. You can stop reading now if you’re from that world that thinks you should be able to dictate what I do with my body. I don’t have time for that disdain for women.
First of course there were the Bible-thumpers who claim that “God” is the one deciding if you get pregnant, not the embryo viability or your uterine receptivity (or both). A lot of people claiming they are pro-choice for X, Y, or Z but that somehow in the case of IVF you should be forced to stick with however many you get, because of the old nauseating adage about “Him” (oh do I truly detest the paternal nature of organized religion) and how “He” only “gives you what you can handle”.
Um yeah that’s why we’ve got thousands of foster kids in the system, kids who are neglected and/or abused, and parents in tremendously dire financial straits… because all of them are so obviously handling it so well.
And there were many who were not interlacing religion into the matter who said they were pro-choice… yet somehow this was wrong, and most hypocritically saying that “of course” it was okay for triplets and above, but to reduce from twins to a singleton was somehow a huge ethical problem.
To me this is the ultimate hypocrisy.
Here’s the deal: from a health perspective, twin pregnancies automatically are deemed high risk. Automatically. Gestational diabetes, preeclampsia, increased potential for miscarriage, preterm birth, placental abruption, and low birth weight are all part of the high risk of carrying multiples. Not something that’s questioned by doctors. So, combining a twin or greater pregnancy with being overweight (an “appropriate” BMI for me based on weight/height lands me at under a size 10…so any thing 10-18 which I’ve fluctuated around since I divorced my ex 11 years ago labels me “obese”, btw) and of “advanced maternal age” (I am 42)? Your risk is amplified exponentially.
Along with that, those with multiples are forced to have a hospital birth, as midwives want nothing to do with you because of the risks. And in our C-section-happy society today, vaginal births are so often out of the question for twins (with half of overweight women, no matter how great their and the baby’s health is, being told they are “too high risk to deliver” and mandated to have a C-section).
And we’re not even talking yet about the quality of life for the family involved. From the massive financial implications, including potentially bankrupting hospital bills ( due to premature labor and health complications), loss of income, and of course overall costs of raising two babies at the same time, to the emotional and mental toll of caring for two infants at the same time, there is a shit-ton for women to think about.
A few things we’ve already heard in our own circle about multiples…
- Our naturopath who specializes in fertility said that the cost of having twins forced she and her wife into bankruptcy.
- My primary care physician said that after she adopted, she got pregnant with twins, and this tripled amount of time and energy ended up “setting her back in her career at least 10 years”.
- I don’t know any working mothers who have twin babies. (Did I mention I’m our primary breadwinner, self employed for 4 years in an industry where if you disappear even for a short while, you’re forgotten…and replaced…while my husband’s job provides our health benefits? Oh and that daycare for twins and our area would run and that day care for twins and our area would run about $3,000/ month minimum ?)
Once again I’m not implying that it’s a bad thing to have twins or higher – just that it is a choice that needs to be thought out , and one that is not right for everyone. Some prospective parents WANT twins..or as many they can have. The “two and done” mindset. Which I can totally empathize with in their situations – and hey, if you can handle it, and the other risks are outweighed by this desire, good for you. Amen to that. But it doesn’t take away from those who cannot or do not want to go that route. And we’ve GOT to start respecting that – no matter what their reasoning.
So what about those of us who just want to have one baby? Or those like my husband and I who want to birth one baby because we are in the long “gestation” period called international adoption? Why is the choice to selectively reduce creating such moral outrage among so many who otherwise consider themselves pro-choice? Why the fuck is it “controversial” (as many news stories like to describe it) to make a thoughtful, legal choice that will be best for both you as parents as well as the future of the child(ren) you bring into the world?
Back in 2010, a year before my future husband even discovered my blog which led to our romance and eventual marriage, Bettina Paige published an incredible article, Would You Get Selective Reduction?, talking about her choice to reduce from twins to a singleton, when they found out they were pregnant following her IUI.
Paige had done her homework, both formally and informally, and as she said,
“According to research I’d done before seeing him, I knew that the live birth rate for in vitro fertilization for a 43-year-old like me was less than one in 20, and that was when the average number of embryos implanted was three. So going with only one had to worsen the already poor odds, didn’t it?…A few friends my age had implanted as many as five embryos at once, with no baby to show for it. I was crazy, not to mention arrogant, they said, to think I could get pregnant with one.“
So she was highly doubtful, and had every right to be. Hell, I’m using DONOR eggs which were supposed to knock out the age factor out of the game and give me a rockin’ 60% chance (50% if you include the 10% chance of miscarriage) of getting knocked up and yet, three IVFs later I’m as empty as a pocket with nothing to lose. (Thanks, Mr. Simon, for those words.)
Here’s the thing: SR is also not as rare as we might think. Selective reduction, like infertility in general, is still by society’s standards a stigma not to be discussed. It is considered shameful. The New York Times reported in 2011 that “Mount Sinai Medical Center in New York, one of the largest providers of the procedure, reported that by 1997, 15 percent of reductions were to a singleton. Last year, by comparison, 61 of the center’s 101 reductions were to a singleton, and 38 of those pregnancies started as twins.”
Dr. Mark Evans, a pioneer of SR who initially only recommended SR for triplets and above, reversed his stance – and it wasn’t just because older women were now having kids. The NY Times article went on to say:
“Evans’s new position wasn’t just a reaction to changing demographics. The calculus of risks had also changed. For one thing, he argued, in experienced hands like his, the procedure rarely prompted a miscarriage. For another, recent studies had revealed that the risks of twin pregnancies were greater than previously thought. They carried an increased chance of prematurity, low birth weight and cerebral palsy in the babies and gestational diabetes and pre-eclampsia in the mother. Marking what he called a “juncture in the cultural evolution of human understanding of twins,” Evans concluded that “parents who choose to reduce twins to a singleton may have a higher likelihood of taking home a baby than pregnancies remaining with twins.” He became convinced that everyone carrying twins, through reproductive technology or not, should at least know that reduction was an option. “Ethics,” he said, “evolve with technology.”
As the procedure has advanced over the decades, the other thing to know is that the risks of losing the entire pregnancy during reduction used to be 10%, now it’s down to a tiny 3%.
Along with all that I’ve mentioned above is the irony that somehow even though they almost always producing multiple embryos during IVF and usually not transferring all of them, that there’s something different between not using the remaining embryos (i.e., donating for medical research and/or disposing of them altogether) and doing SR. Personally, I don’t see the difference – by the simple act of picking which one(s) to transfer, you are supporting selective reduction.
We started out with 13 blastocysts, y’all. No, they are not “embabies” or “totsicles”. They are embryos in a freezer. Three of them have already failed to implant. If we transfer one and it sticks, 9 will be destroyed. Are we killers? Hell no. So if we transfer two or three, and more than one implants, and we decide to only keep one, are we killers? Are we unethical? Or are we simply as women in control of our bodies and making the decision that is right for us and the child(ren) we choose to bring into the world?
“A multi-fetal pregnancy creates a physical danger to both the mother and future children. The larger the number of embryos, the greater the likelihood that the pregnancy will terminate prematurely, leaving the babies in danger of physical and mental damage. If some of the embryos are aborted the others stand a better chance of surviving, developing normally, and being carried to term.” (Stanford University)
The debate has been going on as long as women have had bodies. Do we have the right to make our own decisions about our own bodies?
From the evolution and accessibility of birth control and other forms of family planning, society has tried to tell women that they, not the woman herself, should be able to decide what she does with her own body. “Society judges reproductive choices based on the motives behind them,” the Times continues. Bonnie Steinbock, a philosophy professor at SUNY Albany who is on the ethics committee of the American Society for Reproductive Medicine, brought up in the article about our culture’s rigidity in that you chose something high risk, you should not get to fix it. As she said, “People may think, You brought this about yourself, so you should be willing to take some of the risk.”
But do we do that if someone gets AIDS after sharing a needle during the throes of addiction? Do we tell them “Hey, you chose to be an IV drug user, so you don’t receive treatment as it’s your own fault.” ? Hell no. That would be cruel and unusual punishment. So why when parents want what’s best for their family, whether it be for health, financial, and/or emotional reasons, why would we dare judge them negatively for making a decision that would POSITIVELY impact their lives and that of those they choose to bring into the world? As the Times goes on to say:
“Many studies show the vast majority of patients abort fetuses after prenatal tests reveal genetic conditions like Down syndrome that are not life-threatening. What drives that decision is not just concern over the quality of life for the future child but also the emotional, financial or social difficulty for parents of having a child with extra needs. As with reducing two healthy fetuses to one, the underlying premise is the same: this is not what I want for my life.”
And here’s the deal. If you have another child already, tripling or quadrupling that number in an instant is not the joy that many outsiders who watch stupid-ass reality shows admire.
“Studies report enormous disruption in families with multiples, and higher levels of social isolation, exhaustion and depression in mothers of twins. The incessant demands of caring for two same-aged babies eclipse the needs of other children and the marriage.”
So when you’re in the process of adopting, and are committed to bringing home a child from another country like we are, the thought of possibly getting pregnant with multiples is not just nervewracking, it can risk the whole family’s stability, both emotionally and financially, if you are not wanting twins yet do not choose to go forward without SR.
A great response to the Times article, Jenny is an asshole, and so, of course, am I was spot on addressing the hypocrisy and judgment involved:
“How many times have you heard someone describe him or herself as opposed to abortion exceptincasesofrapeorincest? Compare the sympathy you might have felt for the young woman working her way through college who gets pregnant unexpectedly while on contraception to the indignation that arises when you hear of someone fresh from her fifth abortion. Or, to bring this back to ART and the story at hand, think about how differently we view a selective reduction from quadruplets to twins from a reduction from twins to a singleton — 50% in either case. What’s interesting to me is not specifically what any of these women have done; it’s that our reaction to their actions changes radically based on how “necessary” we believe them to have been.”
Paige’s article in Elle also shone a light on the scientific backing:
“Studies have shown that after a reduction, pregnancies tend to proceed as if a woman had begun with whatever number of fetuses she ends up with. So given the roughly 8 percent chance of miscarrying twins, compared with 4 percent for a single baby, a woman who has a reduction cuts in half her odds of losing her pregnancy,” and in the journal Obstetrics & Gynecology, it was concluded that: “the likelihood of taking home a baby is higher after reduction than remaining with twins.”
And again, I’m not dissing those who want or have twins (or more). Totally your choice and good for you if you’re loving it! I just know myself. My husband knows himself. And we know what we want out of our lives, and what we want to experience as a family, and be able to give to our child(ren).
I’ve not spoken of this on my blog before, but my half-sisters from my dad’s second marriage are twins. My stepmother did not know they were even coming, as she didn’t learn there was a second kid in there UNTIL LABOR. I still remember that fateful call in 1988 from my dad at the hospital in Montana telling me how they delivered the first one at 4 pounds and found a second 2 pound baby, in there and pulled her out. Yep, pulled her out, that’s what I said.
And I also remember this: they were two preemies in incubators for months, with pacifiers half the size of their heads, and their relocation to Colorado was required so they would be near a hospital who could conduct the multiple heart surgeries the littler one would need from birth until she hit her teenage years.
So they dealt with it, and hey it worked for them. He wasn’t a world traveler with family in different countries, he had a longtime government job that enabled them to afford to support the family on his income alone, and well, he was a repressed Catholic so there’s no way even if he knew that the outcome would have been different.
Paige’s article continued on to talk in gut-wrenching honesty and vulnerability about her fears and the true lack of black-and-white that comes with the decision to do SR, and ultimately what led to her decision to move forward with it. These thoughts, her brutal honesty, and ability to do the best thing for them as a family (including respecting her husband’s emotions around it), are what gave me a tremendous amount of respect for her:
“All I knew was that ultimately, I didn’t think we could have twins and remain an intact, happy-enough family…(I couldn’t) anticipate the number of times that I’d think to myself—as I stumbled out of bed to breast-feed in the middle of the night, or yelled “No!” to my son as he threw a ball too close to the baby, or harangued my husband with the tally of how many diapers each of us had changed—thank God we didn’t have twins. We’d made the right decision, for us.”
The other thing that Paige said which struck a chord in both of us was about the fact that her family was not the type that would change their lives to become those super-involved nanny-esque awesome grandparents…
“For better or worse, people in my family take care of themselves.”
Our “family” is comprised of two dead fathers, two mothers we don’t have relationships with, a combination of siblings who range from a mentally unstable addict, to a nice but emotionally distant out-of-state one, to the other who lives out of the country and stopped communicating during our attempts to start a family (not even a Christmas card); and on the bright side, a kind and wonderful stepMum (who I adore and simply refer to as Mum because she deserves all the good connotations that come with the term) – but who lives 17 time zones away. My three younger half-siblings I’ve not seen since my grandmother’s funeral 5 years ago where they showed up in shorts and flip-flops and barely acknowledged my existence (not a surprise after hearing the trash talking my dad did about me to them when he was still alive). Along with this, we have the bonus of no longer having a circle of besties who we started out with 2 years ago because for one reason or another, they went their own ways, leaving us out in the cold, with most taking off after our infertility treatments went into high gear. We have good people we know and are friends with, but the drop-everything level that are like family? Not anymore.
Visitors we’ll have, sitters we will have to pay. Simple as that. We know our limits, and three is not the number we’re aiming for.
Selective Reduction: 2 Women, 2 Views showed two perspectives and came out showing real respect and support for our many different paths we are all on:
“Every situation is different – every pregnancy, every woman, every uterus. In life, in the hardest of situations, you have to step up and do what you feel led to do. And we challenge you to put yourself out there and see the other side… to have compassion for someone you may not know for the decisions they make that are not yours to make, whether you agree with them or not. To love and support your friend through their struggle to make this decision and make sure they know you’ll be there on the other side. Because everyone deserves support. Everyone deserves at least that.”
We still don’t have any idea what we’re going to do and of course if we do go forward with transferring to have no idea if any of them will stick. There’s a high probability at the end of June we will still have nothing, and we’ll say goodbye to this chapter of injections and massive hormonal fluctuations and emotional devastations. And I suppose it is possible that we make it our positive finally. Hopefully the decision will never have to be made but I’m absolutely glad I did my homework, found out what our options are, and can go into this more educated than when I started. Once again it’s all about taking learning into your own hands, advocating for yourself and then doing what is best for your family.