When is twins too many?

A New York City obstetrician and leading specialist in the field confirmed that the demand for twin reductions has increased and likely will continue to do so, especially among 40-somethings. Twins make up about 5% to 7% of the total reductions, said Dr. Mark Evans, who sometimes performs the procedure on Canadians.

While he once believed reductions were ethically warranted only for triplets or higher-order multiple pregnancies, he said the evidence now suggests that reducing twins to a singleton leads, on average, to better outcomes.

The classic twin-reduction case, however, involves a couple on their second marriage who have children and want just one more addition — and might end the whole pregnancy otherwise, Dr. Evans said. “In North America, couples can choose to have an abortion for any reason,” he noted.

Fetal reductions are most commonly conducted by inserting an ultrasound-guided needle through the mother’s abdomen and into the uterus, injecting a potassium chloride solution into the chosen fetus or fetuses, stopping their hearts. They are typically performed between the ninth and 12th week, often with the most accessible or smallest fetuses marked for reduction, unless one is abnormal.

There seems to be little ethical debate around reduction for triplets or more, when the technique clearly curbs the chances of a pregnancy being lost entirely or the babies born with serious health problems. Some experts, however, call even those cases a largely hidden symptom of a fertility industry whose work has helped increase the number of multiple births by over 40% in the past 20 years.

Often, those multiples are conceived because clinics transfer a number of embryos into a woman undergoing in-vitro fertilization treatment, boosting the chances of pregnancy.

"It troubles me a lot because it’s avoidable,” Dr. Jon Barrett, an obstetrician-gynecologist at Toronto’s Sunnybrook Health Sciences Centre. “We are forcing people to make a terrible choice because we haven’t been sensible.”

Fertility clinics, propelled by new standards from their professional societies, are working aggressively to reduce the number of higher-order multiples — and the resulting need for reduction. In Vancouver, reductions have become “extremely rare,” said Dr. Al Yuzpe of the city’s Genesis Fertility. At The Fertility Clinic in London, Ont. no patient has conceived triplets this year, said Christopher Newton, a psychologist at the centre.

Medical professionals often do not recognize that fetal reduction can be traumatic, said Ms. Haddon. She knows of one mother who years after a reduction still watches her children in the playground, thinking “there should have been more.”

"These poor parents are caught between a rock and a hard place,” she said. “They tried so hard to get pregnant and probably spent a lot of time, energy, emotion, money and now they have to kill some of them, now they have to reduce. Even though the child was lost through reduction, it lives on, in mind and fantasy.”

Dr. Barrett, who specializes in multiple pregnancies, said he is sure some of his patients’ marriages have fallen apart because of disagreements about whether to reduce or not.

The very notion of a procedure that selectively eliminates fetuses, letting others live, is little known and almost never debated in the broader community, said Maxwell Smith, a University of Toronto doctoral student.

"While there is a lot of discussion in academic circles and lay circles about abortion, you don’t have these discussions happening so much around pregnancy reduction,” said Mr. Smith, who spoke about the issues at a major U.S. bio-ethics conference recently.

"That puts a lot of patients and health-care workers in a situation where there might be a lot of moral distress, because they’re not sure what the ethical considerations are.”

In the medical community, the morality of the procedure — at least in its most controversial context — still seems a touchy matter. When the Burlington woman decided she wanted to reduce from two fetuses to one, her family physician at first claimed the procedure was illegal in Canada, then tried to talk her out of it, saying “you don’t need to worry, you can stay home with the kids.”

Most obstetrician-gynecologists she and her husband contacted wanted no part of a twin reduction. They were about to use Dr. Evans’ New York clinic, where the procedure and related tests would have cost at least $8,000, when they discovered a physician at Sunnybrook would do the reduction, funded by medicare.

"I do believe people should have the choice, given the cost of raising children today,” she said. “You want to be able to provide for your children ... to give them the things they need to become the best adults they can become.”