Considering multifetal pregnancy reduction in triplet pregnancies: do we forget the emotional impact on fathers? A qualitative study from The Netherlands.

STUDY QUESTION: What factors influence the decision-making process of fathers regarding multifetal pregnancy reduction or maintaining a triplet pregnancy, and how do these decisions impact their psychological well-being? SUMMARY ANSWER: For fathers, the emotional impact of multifetal pregnancy reduction or caring for triplets is extensive and requires careful consideration. WHAT IS KNOWN ALREADY: Multifetal pregnancy reduction is a medical procedure with the purpose to reduce the number of fetuses to improve chances of a healthy outcome for both the remaining fetus(es) and the mother, either for medical reasons or social considerations. Aspects of the decision whether to perform multifetal pregnancy reduction have been rarely investigated, and the impact on fathers is unknown. STUDY DESIGN, SIZE, DURATION: Qualitative study with semi-structured interviews between October 2021 and February 2023. PARTICIPANTS/MATERIALS, SETTING, METHODS: Fathers either after multifetal pregnancy reduction from triplet to twin or singleton pregnancy or ongoing triplet pregnancies 1-6 years after the decision were included. The interview schedule was designed to explore key aspects related to (i) the decision-making process whether to perform multifetal pregnancy reduction and (ii) the emotional aspects and psychological impact of the decision. Thematic analysis was used to identify patterns and trends in the father's data. The process involved familiarization with the data, defining and naming themes, and producing a final report. This study was a collaboration between a regional secondary hospital (OLVG) and a tertiary care hospital (Amsterdam University Medical Center, Amsterdam UMC), both situated in Amsterdam, The Netherlands. MAIN RESULTS AND THE ROLE OF CHANCE: Data saturation was achieved after 12 interviews. Five main themes were identified: (i) initial responses and emotional complexity, (ii) experiencing disparities in counselling quality and post-decision care, (iii) personal influences on the decision journey, (iv) navigating parenthood: choices, challenges, and emotional adaptation, and (v) shared wisdom and lessons. For fathers, the decision whether to maintain or reduce a triplet pregnancy is complex, in which medical, psychological but mainly social factors play an important role. In terms of psychological consequences after the decision, this study found that fathers after multifetal pregnancy reduction often struggled with difficult emotions towards the decision; some expressed feelings of doubt or regret and were still processing these emotions. Several fathers after an ongoing triplet had experienced a period of severe stress in the first years after the pregnancy, with major consequences for their mental health. Help in emotional processing was not offered to any of the fathers after the decision or birth. LIMITATION, REASONS FOR CAUTION: While our study focuses on the multifetal pregnancy reduction process in the Amsterdam region, we recognize the importance of further investigation into how this process may vary across different regions in The Netherlands and internationally. We acknowledge the potential of selection bias, as fathers with more positive experiences might have been more willing to participate. Caution is needed in interpreting the role of the mother in the recruitment process. Additionally, the time span of 1-6 years between the decision and the interviews may have influenced emotional processing and introduced potential reporting bias. WIDER IMPLICATIONS OF THE FINDINGS: The emotional impact of multifetal pregnancy reduction or caring for triplets is significant, emphasizing the need for awareness among caregivers regarding the emotional challenges faced by fathers. A guided trajectory might optimize the decision-making and primarily facilitate the provision of appropriate care thereafter to optimize outcomes around decisions with potential traumatic implications. STUDY FUNDING/COMPETING INTEREST(S): This study received no funding. The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

Saúde mental e abortamento voluntário na audiência pública da ADPF442/STF / Mental health and voluntary abortion in the public hearing of ADPF442/STF / Salud mental y aborto voluntario en la audiencia pública del ADPF442/STF

O estudo teve como objetivo identificar os argumentos da estratégia de persuasão dos discursos apresentados na audiência pública sobre a Arguição de Descumprimento de Preceito Fundamental-ADPF 442, realizada em 2018, cujo propósito era discutir sobre a interrupção voluntária da gravidez até a 12ª semana. Para tal, foi realizada uma pesquisa de abordagem qualitativa, analítico-descritiva e documental. O objeto de análise foi o registro da audiência, apresentado em vídeo, disponibilizado na plataforma digital YouTube, e em ata lavrada pelo STF, ambos de acesso público. A partir de uma análise do discurso, identificou-se os argumentos utilizados na estratégia de persuasão, que foram sistematizados em quatro categorias de argumentos para cada um dos dois grupos identificados: o grupo pró e o grupo contra a descriminalização do aborto. As três primeiras categorias, Saúde mental, Direito e Saúde pública, mesmo com diferenças na forma de apresentar o argumento, se repetem nos dois grupos. Todavia, a quarta categoria, Pressupostos, se diferenciou. No grupo pró descriminalização do aborto, apresentou-se como Pressupostos filosóficos e científicos, e no grupo contra, como Pressupostos morais. Por fim, a defesa da saúde mental das mulheres foi o principal argumento numa forma de humanizar o sofrimento vivido pelas que desejam abortar e não encontram o suporte do Estado para assegurar sua dignidade, cidadania e efetiva igualdade, garantidas constitucionalmente.(AU)

The study aimed to identify the arguments of the persuasion strategy of the speeches presented at the public hearing on the Action Against the Violation of Constitutional Fundamental Rights -ADPF 442, held in 2018, whose purpose was to discuss the voluntary interruption of pregnancy until the 12th week. To this end, a qualitative, analytical-descriptive, and documentary research was carried out. The object of analysis was the video recording of the hearing available on the YouTube platform, and in minutes drawn up by the STF, both of which are public. Based on a discourse analysis, the arguments used in the persuasion strategy were identified, which were systematized into four categories of arguments for each of the two identified groups: the group for and the group against the decriminalization of abortion. The first three categories, Mental Health, Law and Public Health, even with differences in the way of presenting the argument, are repeated in both groups. However, the fourth category, Assumptions, differed. In the group for the decriminalization of abortion, it was presented as Philosophical and Scientific Assumptions, whereas the group against, as Moral Assumptions. Finally, the defense of women's mental health was the main argument in a way of humanizing the suffering experienced by those who wish to have an abortion and do not find the support of the State to guarantee their dignity, citizenship, and effective equality, constitutionally guaranteed.(AU)

El estudio tuvo como objetivo identificar los argumentos de la estrategia de persuasión de los discursos presentados en la audiencia pública sobre el Argumento por Incumplimiento de un Percepto Fundamental -ADPF 442, realizada en 2018, con el objetivo de discutir la interrupción voluntaria del embarazo hasta la 12.ª semana. Para ello, se llevó a cabo una investigación cualitativa, analítico-descriptiva y documental. El objeto de análisis fue la grabación de la audiencia, que está disponible en la plataforma digital YouTube, y actas levantadas por el Supremo Tribunal Federal -STF, ambas de acceso público. A partir de un análisis del discurso se identificaron los argumentos utilizados en la estrategia de persuasión, los cuales se sistematizaron en cuatro categorías de argumentos para cada uno de los dos grupos identificados: el grupo pro y el grupo en contra de la despenalización del aborto. Las tres primeras categorías ("salud mental", "derecho" y "salud pública") aún con diferencias en la forma de presentar el argumento se repiten en ambos grupos. Pero difiere la cuarta categoría "supuestos". En el grupo a favor de la despenalización del aborto se presentó como "supuestos filosóficos y científicos", y en el grupo en contra, como "supuestos morales". Finalmente, la defensa de la salud mental de las mujeres fue el principal argumento en un intento por humanizar el sufrimiento que viven aquellas que desean abortar y no encuentran el apoyo del Estado para garantizar su dignidad, ciudadanía e igualdad efectiva, preconizadas por la Constitución.(AU)

No. 262-Prenatal Screening for and Diagnosis of Aneuploidy in Twin Pregnancies.

OBJECTIVE: To provide a Canadian consensus document with recommendations on prenatal screening for and diagnosis of fetal aneuploidy (e.g., Down syndrome and trisomy 18) in twin pregnancies. OPTIONS: The process of prenatal screening and diagnosis in twin pregnancies is complex. This document reviews the options available to pregnant women and the challenges specific to screening and diagnosis in a twin pregnancy. OUTCOMES: Clinicians will be better informed about the accuracy of different screening options in twin pregnancies and about techniques of invasive prenatal diagnosis in twins. EVIDENCE: PubMed and Cochrane Database were searched for relevant English and French language articles published between 1985 and 2010, using appropriate controlled vocabulary and key words (aneuploidy, Down syndrome, trisomy, prenatal screening, genetic health risk, genetic health surveillance, prenatal diagnosis, twin gestation). Results were restricted to systematic reviews, randomized controlled trials, and relevant observational studies. Searches were updated on a regular basis and incorporated in the guideline to August 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. The previous Society of Obstetricians and Gynaecologists of Canada guidelines regarding prenatal screening were also reviewed in developing this clinical practice guideline. VALUES: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS: There is a need for specific guidelines for prenatal screening and diagnosis in twins. These guidelines should assist health care providers in the approach to this aspect of prenatal care of women with twin pregnancies. SUMMARY STATEMENTS: RECOMMENDATIONS.

[Incidence and management of monozygotic twin conceived by assisted reproductive techniques].

OBJECTIVE: To analysis the incidence and management of monozygotic twin (MZT) conceived by assisted reproductive techniques (ART). METHODS: A retrospective analysis of clinical pregnancies and MZT that resulted from ART was performed in Reproductive Medical Center, the First Affiliated Hospital, Wenzhou Medical University between January 2011 and January 2014. RESULTS: A total of 5 908 pregnancies were diagnosed: 2 012 twins, 157 high-order multiple pregnancy (HOMP), including 4 quadruplets. Overall, 51 MZT pregnancies were identified of them including 32 cases HOMP and 19 cases MZT. The incidence of MZT resulting from cleavage-stage embryo transfer was similar to blastocyst transfer (P = 0.960). The percent of MZT resulting from in vitro fertilization [0.93% (28/3 022)], frozen-thawed embryo transfer [0.87% (13/1 502)] and intracytoplamic sperm injection [0.72% (10/1 384)] did not show statistical significance (P = 0.794). The expectantly managed MZT was associated with a significantly greater likelihood of miscarriage [6/19 vs 5.11% (101/1 976)], and low birth weight infant [73.91% (17/23) vs 42.89% (1 453/3 388), P < 0.01], when compared with dizygotic twin (DZT) did not undergo selective embryo reduction (SER). In monozygotic (MZ)-triplets with SER to 2 fetuses or to 1 fetus, there was no cases of preterm birth or low birth weight infant observed in MZ-triplets with SER to 1 fetus; when compared with MZ-triplets with SER to 2 fetuses, the low birth weight infant [56.00% (14/25), P = 0.021] has statistical significance. The likelihood of the survival of two babies was lower in MZ-triplets with SER to 2 fetuses when compared with non-MZ triplets with SER to 2 fetuses [42.86% (9/21) vs 75.21% (91/121), P = 0.003]. CONCLUSIONS: The incidence of MZT pregnancies following ART is high. It plays a significant role in the occurrence of HOMP. MZT pregnancies are at an increased risk of adverse outcomes, it should transform to a single embryo thansfer (SET) program to reduce them incideuce. Reduction of MZT contained in multiple pregnancies appears to be a safe option.

Elective Single Embryo Transfer: an update to UK Best Practice Guidelines.

A significant number of multiple pregnancies and births worldwide continue to occur following treatment with Assisted Reproductive Technologies (ARTs). Whilst efforts have been made to increase the proportion of elective single embryo transfer (eSET) cycles, the multiple pregnancy rate or MPR remains at a level that most consider unacceptable given the associated clinical risks to mothers and babies, and the additional costs associated with neonatal care of premature and low birth weight babies. Northern Europe, Australia and Japan have continued to lead the way in the adoption of eSET. Randomised controlled trials or RCTs, meta-analyses and economic analyses support the implementation of an eSET policy, particularly in light of recent advances in ARTs. This paper provides a review of current evidence and an update to the eSET guidelines first published by Cutting et al. (2008) intended to assist ART clinics in the implementation of an effective eSET policy.

Informed consent in medical decision-making in commercial gestational surrogacy: a mixed methods study in New Delhi, India.

OBJECTIVE: To investigate ethical issues in informed consent for decisions regarding embryo transfer and fetal reduction in commercial gestational surrogacy. DESIGN: Mixed methods study employing observations, an interview-guide and semi-structured interviews. SETTING: Fertility clinics and agencies in Delhi, India, between December 2011 and December 2012. POPULATION: Doctors providing conceptive technologies to commissioning couples and carrying out surrogacy procedures; surrogate mothers; agents functioning as links for surrogacy. METHODS: Interviews using semi-structured interview guides were carried out among 20 doctors in 18 fertility clinics, five agents from four agencies and 14 surrogate mothers. Surrogate mothers were interviewed both individually and in the presence of doctors and agents. Data on socio-economic context and experiences among and between various actors in the surrogacy process were coded to identify categories of ethical concern. Numerical and grounded theory-oriented analyses were used. MAIN OUTCOME MEASURES: Informed consent, number of embryos transferred, fetal reduction, conflict of interest among the involved parties. RESULTS: None of the 14 surrogate mothers were able to explain the risks involved in embryo transfer and fetal reduction. The majority of the doctors took unilateral decisions about embryo transfer and fetal reduction. The commissioning parents were usually only indirectly involved. In the qualitative analysis, difficulties in explaining procedures, autonomy, self-payment of fertility treatment and conflicts of interest were the main themes. CONCLUSIONS: Clinical procedural decisions were primarily made by the doctors. Surrogate mothers were not adequately informed. There is a need for regulation on decision-making procedures to safeguard the interests of surrogate mothers.

Multiple gestation associated with infertility therapy: an American Society for Reproductive Medicine Practice Committee opinion.

The purpose of this committee opinion, which replaces the 2006 ASRM Practice Committee document titled Multiple Pregnancy Associated with Infertility Therapy, is to provide physicians with pertinent information that may help to avoid multiple gestations and to aid in patient counseling regarding the associated risks.

Time to focus on the public health aspects of preterm delivery.

Preterm delivery is a leading cause of child death and results in substantial emotional and economic costs for both the involved family and for society. It increases later disease risk in both the mother and in her preterm delivered child. The proportion of preterm delivery is increasing in several populations. Public health interventions have so far been the only beneficial initiative in prevention and treatment of preterm delivery and there is a need for both larger research studies and an approach that centers more on this complicated condition as a public health problem. The public health and population focus is an important fundament for proper use of new molecular biology techniques that in the future may increase our understanding of the pathophysiological pathways of preterm delivery and result in causal treatment modalities that are applicable to the clinical setting.

[The progressive legal vulnerability of embryonic human life in Spain: the law 35/1988 to 14/2006 and law 14/2007]. / La progresiva desprotección jurídica de la vida humana embrionaria en España: de la ley 35/1988 a las leyes 14/2006 y 14/2007.

This article examines the Laws on Human Assisted Reproduction and Biomedical Research in Spain. The Laws permit the use of human ovules, embryos and fetuses. Close to the technical and ethical problems that carry the research on embryonic stem cells, the detection of induced reprogramming of adult cells to an embryonic stage (iPS) opens up new perspectives in regenerative medicine. It makes unnecessary the use of frozen embryos or produced by nuclear transfer. These reasons would involve a review of the Spanish Legislation in this matter, in order that the human life is an ethical barrier and a fundamental to actual biomedical research.

[Some remarks on the protection of human embryo in the Spanish law]. / Breves anotaciones sobre la protección del embrión en el ordenamiento jurídico español.

We study in this article the Spanish legislation regulating the juridical status of the human embryo, in a comparative analysis with the International Right and the legislation in other countries of our cultural environment, leading to the conclusión that ours contradicts the international compromises of Spain and is less protective with the unborn human life than the juridical systems which advocate for the human being from the very moment of conception.

Application of QF-PCR for the prenatal assessment of discordant monozygotic twins for fetal sex.

OBJECTIVE: To establish the utility of quantitative fluorescent polymerase chain reaction (QF-PCR) in order to determine the zygosity of multiple pregnancies, as well as to define the origin of the most frequent aneuploidies in amniotic fluid samples. METHODS: We describe the case of a monochorionic (MC) diamniotic (DA) pregnancy with phenotypically discordant twins (nuchal cystic hygroma and non-immune hydrops in twin A and no anomalies in twin B). QF-PCR was performed for rapid prenatal diagnosis in uncultured amniocytes and subsequently in cultured cells. Polymorphic markers for chromosomes X, Y, 13, 18 and 21 were used for determination of zygosity as well as sex chromosome aneuploidy. RESULTS: Twin A showed a Turner Syndrome (TS) mosaicism pattern by QF-PCR in uncultured amniocytes. The monozygotic origin of the pregnancy was determined. Interphase fluorescence in situ hybridization (I-FISH) in this sample showed a mosaicism X0/XY (83/17%). Cytogenetic analysis revealed a 45,X0 karyotype in twin A and a 46,XY karyotype in twin B. CONCLUSIONS: QF-PCR is a reliable tool for the determination of the zygosity independently of the chorionicity and the fetal sex in case of twin pregnancy. Testing both direct and cultured cells can provide useful results for genetic counselling in chromosomal mosaicisms.

Acardiac anomaly: current issues in prenatal assessment and treatment.

Acardiac anomaly is a rare condition affecting monochorionic multiple pregnancies. We review this condition with emphasis on its prenatal diagnostic features and treatment options. Due to the parasitic hemodynamic dependence of the acardiac twin on the pump twin, it is important to monitor the pump twin for signs of decompensation and, if indicated, intervene by interrupting vascular supply to the acardiac twin. The goal of treatment is to maximize the pump-twin's chance of survival. To assist with the decision of when to treat, we suggest a new classification system based on prognostic factors, specifically the size and growth of the acardiac twin and the cardiovascular condition of the pump twin. When the acardiac twin is small and no signs of cardiovascular impairment in the pump twin are present, we suggest serial ultrasound surveillance to detect any worsening of the condition. In cases with a large acardiac twin or rapid growth of the acardiac mass, we recommend prompt intervention. Once treatment is indicated, the intrafetal approach to interrupt the vascular supply to the acardiac twin appears to be superior to cord occlusion techniques as it is simpler, safer and more effective. The first line of treatment, if available, should be ultrasound-guided laser coagulation or radiofrequency ablation of the intrafetal vessels.

Prevention of triplets and higher order multiples: trends in reproductive medicine.

In the United States and throughout the world, today's healthcare providers are challenged by the risks of multiple gestation pregnancy. Assisted reproductive technologies (ARTs) often used to treat infertility raise ethical issues including informed consent, veracity, and nonmalificence. In the United States, there is the need to improve maternal and fetal/neonatal mortality and morbidity by proposing legislation regulating ART and supporting single embryo transfers with no more than 2 such transfers. Beginning with the diagnosis of infertility, providers have a responsibility to educate, inform, and treat infertile couples. From the moment pregnancy with multiples is confirmed, these families are faced with incredible stressors including decision making on multifetal or selective reduction. Full disclosure of risks involved throughout the course of care should be discussed and documented in the record and plan of care. Currently in the United States, legislation does not regulate ART, including ovulation induction/enhancement and in vitro fertilization. Although the United States does have self-regulation via limited reporting through their professional organization and the Centers for Disease Control and Prevention, an unlimited number of embryos may be transferred. Unfortunately, many healthcare providers have not recognized the responsibility and burden placed on families and society as a whole. Lack of regulation means women may become pregnant with high order multiples, which raises serious moral and ethical issues.

En route to an "instant family": psychosocial considerations.

Societal and cultural norms require that a worthwhile person engage in reproduction and formation of a family. Young adults who postpone childbearing may presume that fertility is granted. When all other measures fail, the use of assisted reproductive technologies is considered the ultimate salvation for these couples. It is highly stressful and may lead to significant negative psychological consequences (loss of self-esteem, confidence, health, close relationships, security, and hope). Assisted reproductive technology may produce multiple pregnancy, which is frequently overlooked or underappreciated by infertile couples. Despite the real risks associated with a multiple pregnancy and birth, infertile patients often express a desperate wish to have twins or triplets, thereby accomplishing an instant family. It is necessary to provide these couples with detailed information on the risks of multiple pregnancy and birth.

Multiple gestation and infertility treatment: registration, reflection and reaction--the Belgian project.

Multiple pregnancies associated with infertility treatment are recognized as an adverse outcome and are responsible for morbidity and mortality related to prematurity and very low birthweight population. Due to the epidemic of iatrogenic multiple births, the incidence of maternal, perinatal and childhood morbidity and mortality has increased. This results in a hidden healthcare cost of infertility therapy and this may lead to social and political concern. Reducing the number of embryos transferred and the use of natural cycle IVF will surely decrease the number of multiple gestations. Consequently, optimized cryopreservation programmes will be essential. For non-IVF hormonal stimulation, responsible for more than one-third of all multiple pregnancies after infertility treatment, a strict ovarian stimulation protocol aiming at mono-ovulation is crucial. Multifetal pregnancy reduction is an effective method to reduce high order multiplets but carries its own risk of medical and emotional complications. Excellent data collection of all infertility treatments is needed in our discussion with policy makers. The Belgian project, in which reimbursement of assisted reproduction technology-related laboratory activities is linked to a transfer policy aiming at substantial multiple pregnancy reduction, is a good example of cost-efficient health care through responsible, well considered clinical practice.