The Changing Face of Feticide in Multiple Pregnancies.

The selective termination of one or more fetuses in higher order multiple pregnancies began in the 1980s in response to the increased rate of multiples arising from assisted reproductive technology (ART). Multifetal Pregnancy Reduction (MFPR) was justified by improving outcomes for the remaining offspring and their mother, and while the evidence suggests prematurity and the morbidity associated with it are reduced, there is a cost in increased miscarriage and mortality. As perinatal care has advanced, the margins of improvement have narrowed and hence the cost/benefit ratio. At the same time, MFPR has morphed from a rare procedure undertaken for quadruplets and higher, to one in which triplets and twins are increasingly reduced to a singleton, and more so for social reasons. This review considers the evidence for MFPR's efficacy and risks, along with those changes over time. Notably absent is research on the surviving children or the ongoing physical and mental health of mothers. The ethical reasoning used by practitioners and others is also explored, as is the culture of ART and abortion that drive the practice.

Twin pregnancy complicated by esophageal atresia, duodenal atresia, gastric perforation, and hypoplastic left heart structures in one twin: a case report and review of the literature.

BACKGROUND: The antenatal diagnosis of a combined esophageal atresia without tracheoesophageal fistula and duodenal atresia with or without gastric perforation is a rare occurrence. These diagnoses are difficult and can be suspected on ultrasound by nonspecific findings including a small stomach and polyhydramnios. Fetal magnetic resonance imaging adds significant anatomical detail and can aid in the diagnosis of these complicated cases. Upon an extensive literature review, there are no reports documenting these combined findings in a twin pregnancy. Therefore we believe this is the first case report of an antenatal diagnosis of combined pure esophageal and duodenal atresia in a twin gestation. CASE PRESENTATION: We present a case of a 30-year-old G1P0 white woman at 22-week gestation with a monochorionic-diamniotic twin pregnancy discordant for esophageal atresia, duodenal atresia with gastric perforation, hypoplastic left heart structures, and significant early gestation maternal polyhydramnios. In this case, fetal magnetic resonance imaging was able to depict additional findings including area of gastric wall rupture, hiatal hernia, dilation of the distal esophagus, and area of duodenal obstruction and thus facilitated the proper diagnosis. After extensive counseling at our multidisciplinary team meeting, the parents elected to proceed with radiofrequency ablation of the anomalous twin to maximize the survival of the normal co-twin. The procedure was performed successfully with complete cessation of flow in the umbilical artery and complete cardiac standstill in the anomalous twin with no detrimental effects on the healthy co-twin. CONCLUSIONS: Prenatal diagnosis of complex anomalies in twin pregnancies constitutes a multitude of ethical, religious, and cultural factors that come into play in the management of these cases. Fetal magnetic resonance imaging provides detailed valuable information that can assist in management options including possible prenatal intervention. The combination of a cystic structure with peristalsis-like movement above the diaphragm (for example, "the upper thoracic pouch sign"), polyhydramnios, and progressive distention of the stomach and duodenum should increase suspicion for a combined pure esophageal and duodenal atresia.

Identifying families' shared disease experiences through a qualitative analysis of online twin-to-twin transfusion syndrome stories.

BACKGROUND: Twin-to-twin transfusion syndrome (TTTS) affects 10-20 % of monochorionic diamniotic (MCDA) births and accounts for 50 % of fetal loss in MCDA pregnancies. This exploratory qualitative study identified shared experiences, including potential emotional and psychosocial impacts, of this serious disease. METHODS: Forty-five publicly accessible, online stories posted by families who experienced TTTS were analyzed using grounded theory. RESULTS: Shared TTTS experiences included a common trajectory: early pregnancy experiences, diagnostic experiences, making decisions, interventions and variable outcomes. Families vacillated between emotional highs such as joy, excitement and relief, and lows including depression, anxiety, anger and grief. CONCLUSIONS: TTTS disease experience can be considered an "emotional roller coaster" exacerbated by TTTS's unpredictable and quickly changing nature with the potential for emotional and psychosocial effects. Increased TTTS awareness and research about its corresponding impacts can ensure appropriate patient and family support at all phases of the TTTS experience.

Reduction of the number of fetuses for women with a multiple pregnancy.

BACKGROUND: When couples are faced with the dilemma of a higher-order multiple pregnancy there are three options. Termination of the entire pregnancy has generally not been acceptable to women, especially for those with a past history of infertility. Attempting to continue with all the fetuses is associated with inherent problems of preterm birth, survival and long-term morbidity. The other alternative relates to reduction in the number of fetuses by selective termination. The acceptability of these options for the couple will depend on their social background and underlying beliefs. This review focused on reduction in the number of fetuses. OBJECTIVES: To assess a policy of multifetal reduction with a policy of expectant management of women with a multiple pregnancy. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2015). SELECTION CRITERIA: Randomised controlled trials with reported data that compared outcomes in mothers and babies who were managed expectantly with outcomes in women who underwent selective fetal reduction of a multiple pregnancy. DATA COLLECTION AND ANALYSIS: We planned that two review authors would independently assess trials for inclusion and risk of bias, extract data and check them for accuracy. However, no randomised trials were identified. MAIN RESULTS: There were no randomised controlled trials identified. AUTHORS' CONCLUSIONS: We found no available data from randomised trials to inform the risks and benefits of pregnancy reduction procedures for women with a multiple pregnancy. While randomised controlled trials will provide the most reliable evidence about the risks and benefits of fetal reduction procedures, reduction in the number of fetuses by selective termination may not be acceptable to women, particularly couples with a past history of infertility. The acceptability of this option, and willingness to undergo randomisation will depend on the couple's social background and beliefs, and consequently, recruitment to such a trial may prove exceptionally difficult.

Reduced versus nonreduced twin pregnancies: obstetric performance in a cohort of interventional conceptions.

OBJECTIVE: To describe the obstetric performance of a selected population of twin pregnancies, comparing reduced vs. nonreduced twin pregnancies after the successful completion of the 12th week. DESIGN: Prospective cohort study. SETTING: Outpatient fertility center. PATIENT(S): A cohort of 464 twin pregnancies including both ovulation induction and assisted reproductive technology pregnancies. INTERVENTION(S): Fetal reduction. MAIN OUTCOME MEASURE(S): Pregnancy outcome and prematurity rate. RESULT(S): The study group included a cohort of 464 twin pregnancies in a single outpatient fertility center: 70 cases of twin pregnancies after a reduction procedure (15.1%) and 394 cases of nonreduced twins (84.9%). Of the nonreduced twin pregnancies, 8.6% went through an abortion, as compared with 4.3% in the reduced group. Mean age at delivery was also comparable between the two groups (35.8 weeks in the reduced group, 35.6 weeks in the nonreduced group), as was the rate of severe prematurity (3.3% in the nonreduced group, 2.9% in the reduced group). CONCLUSION(S): Our work supports a lack of causative relationship between fetal reduction and pregnancy endpoint.

Psychological response to multifetal reduction and pregnancy termination due to fetal abnormality.

OBJECTIVE: To investigate the emotional response in cases of multifetal reduction and pregnancy termination and to compare the psychological response between these two groups. METHODS: A prospective study in a tertiary-care, university-affiliated medical center. The study group included 65 women who had been advised to terminate pregnancy because of a finding of a severe fetal abnormality on ultrasound screening (pregnancy termination group) and 41 women advised to undergo reduction because of the presence of multiple fetuses (multifetal reduction group). All women underwent psychological testing using validated questionnaires addressing perinatal grief and anxiety levels. RESULTS: Women in both the multifetal reduction and the pregnancy termination groups reported significant degree of grief and anxiety before and after the procedure, although the levels of anxiety on the day of procedure and anxiety and grief at follow up were higher in the pregnancy termination group (t = 2.438, p = 0.016; t = 2.441, p = 0.017; and t = 3.111, p = 0.03, respectively). In both groups there was a gradual decrease in the state anxiety with time (48.01 ± 8.26 to 37.59 ± 9.23; t = -9.931; p < 0.001). Several factors affected the emotional response in the cases, including marital status, level of education, employment status, and gestational age. There was no association between a history of prior perinatal loss and emotional response. CONCLUSION: There is need for a continuing psychosocial support of women undergoing multifetal reduction and pregnancy termination for fetal abnormalities.

Reduction of the number of fetuses for women with a multiple pregnancy.

BACKGROUND: When couples are faced with the dilemma of a higher-order multiple pregnancy there are three options. Termination of the entire pregnancy has generally not been acceptable to women, especially for those with a past history of infertility. Attempting to continue with all the fetuses is associated with inherent problems of preterm birth, survival and long-term morbidity. The other alternative relates to reduction in the number of fetuses by selective termination. The acceptability of these options for the couple will depend on their social background and underlying beliefs. This review focused on reduction in the number of fetuses. OBJECTIVES: To assess a policy of multifetal reduction with a policy of expectant management of women with a multiple pregnancy. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 June 2012). SELECTION CRITERIA: Randomised controlled trials with reported data that compared outcomes in mothers and babies who were managed expectantly with outcomes in women who underwent selective fetal reduction of a multiple pregnancy. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. MAIN RESULTS: There were no randomised controlled trials identified. AUTHORS' CONCLUSIONS: We found no available data from randomised trials to inform the risks and benefits of pregnancy reduction procedures for women with a multiple pregnancy. While randomised controlled trials will provide the most reliable evidence about the risks and benefits of fetal reduction procedures, reduction in the number of fetuses by selective termination may not be acceptable to women, particularly couples with a past history of infertility. The acceptability of this option, and willingness to undergo randomisation will depend on the couple's social background and beliefs, and consequently, recruitment to such a trial may prove exceptionally difficult.

Bipolar cord coagulation for selective feticide in complicated monochorionic twin pregnancies: 118 consecutive cases at a single center.

OBJECTIVE: To review the experience of performing selective feticide with bipolar cord coagulation (BCC) in complicated monochorionic (MC) twin pregnancies at a single center. METHODS: This was a retrospective analysis of BCC performed using 3-mm bipolar forceps under ultrasound control in cases complicated by twin-to-twin transfusion syndrome, selective growth restriction, discordant anomaly or twin reversed arterial perfusion sequence. RESULTS: The series comprised 118 cases with a median gestational age at the time of the procedure of 22 (range, 16-30) weeks. There were 14 (12%) intrauterine deaths of the cotwin, eight (7%) miscarriages and one (1%) termination of pregnancy. When BCC was performed before 19 weeks of gestation, the rate of miscarriage was 45%, whereas it was 3% (P < 0.001) when BCC was performed after 19 weeks. Preterm prelabor rupture of membranes (PPROM) occurred in 45 (38%) cases. The median interval between BCC and PPROM was 4 (interquartile range, 2-9) weeks. In 15 (13%) cases, PPROM occurred within 2 weeks after the procedure. Median gestational age at delivery was 34 (range, 24-41) weeks. The median birth weight was 2103 (range, 480-3875) g. Neonatal death occurred in 11 (9%) cases, and two (2%) children had severe neurologic morbidity. The overall survival rate was 71% (84/118). CONCLUSION: BCC is an effective procedure in complicated MC twin pregnancies for selective feticide or when one fetus is severely jeopardized and delivery is not yet an option. Better outcomes can be achieved when this procedure is performed after 19 weeks.

Nursing considerations in the case of multifetal pregnancy reduction.

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.

Babies with myelomeningocele in Poland: parents' attitudes on fetal surgery versus termination of pregnancy.

BACKGROUND: Recent surgical advances have resulted in fetal surgery becoming an option for children with myelomeningocele (MMC). However, there is little information about the parents' attitudes towards such therapy. METHODS: Following a lecture on the current status and problems of fetal surgery for MMC, a 12-item questionnaire was administered to 58 parents of children with MMC. Questionnaire topics included knowledge of the disease and treatment options, as well as attitudes and concerns towards fetal surgery or termination of pregnancy. RESULTS: Following the lecture, 14 (out of 58) parents felt that knowledge of the disease would allow for abortion to be an option, while 18 were uncertain. Once informed of potential risks and benefits of fetal surgery, 34 parents had a positive or rather positive attitude towards this procedure. CONCLUSIONS: On the basis of these results, it was concluded that this population is potentially interested in the use of fetal surgery.

Information and decision-making process for selective termination of dichorionic pregnancies: some French obstetricians' points of view.

BACKGROUND: In France, neither Bioethics Law nor law related to abortion make reference to selective terminations (ST). Because they apply in the context of multiple pregnancies, ST raises problems which differ from those we usually see in prenatal medicine.We wanted to know: 1) which approaches were used by obstetricians to inform couples about processes and risks of ST, 2) their role in the decision-making process of couples, and 3) their representations about the level of autonomy that couples are able to assume. METHODS: Qualitative research, eight semi-structured interviews performed with eight obstetricians from seven public hospitals in Parisian region. RESULTS: Similarities: *Necessity to devote a lot of time to information. *Importance to give the couples the maximum of time for reflection. *Belief that the final decision belongs to couples. Discordances: *Heterogeneity of revealed information. *Discrepancy in the will to assure a complete and non directive information transfer. *Divergence in representations of what is an ethical support. *Differences in the limits of the autonomy of couples. CONCLUSIONS: All physicians believe that they respect the autonomy of couples, arguing that final decision belongs to them. Paradoxically, some results are indicative of a sizeable level of directiveness from the physicians.

[Multifetal pregnancy reduction: indications, technical aspects and psychological impact]. / Réduction embryonnaire: indications, techniques, impact psychologique.

High-order multiple pregnancies (triplets and above) are associated with high pediatric mortality and morbidity, mainly due to their premature delivery. Maternal morbidity is also substantially higher than for singleton gestations. The main goal of multifetal pregnancy reduction (MFPR) is to decrease the rate of severe prematurity and its consequences, including neurodevelopmental handicaps. It may also reduce the risk of maternal complications. Transabdominal needle-guided procedures, performed at 10-12 weeks, are the most common technique for MFPR. Transvaginal needle aspiration can be used successfully earlier in gestation (7-8 weeks). Transcervical aspiration is no longer used. There is generally no medical indication for MFPR in twins. MFPR does not reduce the risk of loss of the entire pregnancy before 24 weeks and may increase the risk of a second-trimester miscarriage by 1-2%. MFPR substantially decreases premature delivery rates, cutting the risk of delivery at 29-32 menstrual weeks in triplet pregnancies in half for reductions to twins and by five for reduction to singletons. The positive effect of MFPR on perinatal outcome is incontrovertible for quadruplets and higher-order pregnancies. Advances in perinatal medicine have substantially reduced mortality in premature triplet deliveries, however, and this should be taken into account when considering the potential benefit of MFPR. MFPR is a distressing experience for parents, but seems not to have long-term adverse effects on women's psychological well-being. Maternal distress related to MFPR tends to fade with time. The negative psychological impact of MFPR should be weighed against that related to raising the children from high-order pregnancies. Prevention of high-order multifetal pregnancies is essential and requires careful monitoring of infertility therapies.

IVF patients' attitudes toward multifetal pregnancy reduction.

OBJECTIVE: To determine attitudes of in vitro fertilization (IVF) patients toward multifetal pregnancy reduction before and after embryo transfer. STUDY DESIGN: Women seeking IVF consultation were surveyed before and after embryo transfer regarding their attitudes toward multifetal pregnancy reduction. RESULTS: Thirty-one of 36 subjects completed the initial survey. The mean age was 32.9 years, 93% of subjects were Caucasian, and 61.3% were nulliparous. Most subjects described themselves as "pro-choice" (20 of 31, 64.5%). Overall, 22.6% (7 of 31) stated that they would never consider fetal reduction in a multifetal pregnancy and 77.4% (24 of 31) stated that they would consider multifetal pregnancy reduction. The threshold to consider fetal reduction was triplets. Prochoice subjects were significantly more likely to consider multifetal pregnancy reduction when compared to "prolife" subjects (p <0.01). Twelve of the 31 subjects underwent embryo transfer and completed the second survey. Patient attitude did not change significantly from the time of initial IVF consultation to after embryo transfer. CONCLUSION: Overall, women undergoing IVF would consider multifetal pregnancy reduction, and this view did not change after embryo transfer. Pro-choice subjects were more likely to consider multifetal pregnancy reduction.

Sometimes doing the right thing sucks: frame combinations and multi-fetal pregnancy reduction decision difficulty.

Data are analyzed for 54 women who made an appointment with a North American Center specializing in multifetal pregnancy reduction (MFPR) to be counseled and possibly have a reduction. The impact on decision difficulty of combinations of three frames through which patients may understand and consider their options and use to justify their decisions are examined: a conceptional frame marked by a belief that life begins at conception; a medical frame marked by a belief in the statistics regarding risk and risk prevention through selective reduction; and a lifestyle frame marked by a belief that a balance of children and career has normative value. All data were gathered through semi-structured interviews and observation during the visit to the center over an average 2.5h period. Decision difficulty was indicated by self-assessed decision difficulty and by residual emotional turmoil surrounding the decision. Qualitative comparative analysis was used to analyze the impact of combinations of frames on decision difficulty. Separate analyses were conducted for those reducing only to three fetuses (or deciding not to reduce) and women who chose to reduce below three fetuses. Results indicated that for those with a non-intense conceptional frame, the decision was comparatively easy no matter whether the patients had high or low values of medical and lifestyle frames. For those with an intense conceptional frame, the decision was almost uniformly difficult, with the exception of those who chose to reduce only to three fetuses. Simplifying the results to their most parsimonious scenarios oversimplifies the results and precludes an understanding of how women can feel pulled in different directions by the dictates of the frames they hold. Variations in the characterization of intense medical frames, for example, can both pull toward reduction to two fetuses and neutralize shame and guilt by seeming to remove personal responsibility for the decision. We conclude that the examination of frame combinations is an important tool for understanding the way women carrying multiple fetuses negotiate their way through multi-fetal pregnancies, and that it may have more general relevance for understanding pregnancy decisions in context.

Complicated grief after traumatic loss: a 14-month follow up study.

The traumatic loss of an unborn child after TOP due to fetal malformation and/or severe chromosomal disorders in late pregnancy is a major life-event and a potential source of serious psychological problems for those women. To obtain information on the course of grief following a traumatic loss, 62 women who had undergone TOP between the 15th and 32nd gestational week were investigated in a longitudinal study design and compared with 65 women after spontaneous delivery of a full-term healthy child. Grief, posttraumatic stress, depression, anxiety and psychiatric disorders were evaluated 14 days, 6 months and 14 months after the event, implementing validated self-report and clinician rated instruments. Compared to women after spontaneous delivery, women after induced TOP were significantly more stressed regarding all psychological outcomes at all three measuring points. Especially, 14 months after TOP 13.7% of the women fulfilled all criteria of a complicated grief diagnoses following Horowitz et al. (1997, Am J Psychiat 154:7904-7910). 16.7% were diagnosed as having a manifest psychiatric disorder according to DSM-IV. All in all, 25% of these women were critically affected by the traumatic loss. TOP for fetal anomaly is to be seen as a major life event, which causes complicated grief reactions and psychiatric disorders for a substantial number of women.

Information-sharing among couples considering multifetal pregnancy reduction.

OBJECTIVE: To determine the information-sharing strategies of couples considering fetal reduction, and the impact of these strategies on the chances of encountering hostility in their social networks. DESIGN: Cross-sectional design of semistructured qualitative interviews, coded with respect to sharing strategies and level of personally directed hostility encountered. SETTING: Multiple Pregnancy Management Program, Comprehensive Genetics, New York, New York. PATIENT(S) AND INTERVENTION(S): Fifty women and their partners who were making a first visit to our maternal-fetal management facility, in order to consider the possibility of multifetal reduction as a pregnancy-management strategy. MAIN OUTCOME MEASURE(S): Development of information-sharing strategies, and the chances of encountering personally directed hostility regarding multifetal reduction associated with more and less selective strategies. RESULT(S): Four information-sharing strategies emerged from the analysis. Two of these strategies were relatively open (extended network, and both parents). Two other strategies were relatively selective (qualified family and friends, and defended relationship). The selective strategies were significantly less likely to encounter to encounter personally directed hostility (odds ratio, 3.88; 95% confidence intervals, 0.87-17.30). CONCLUSION(S): Selective sharing of information for couples considering multifetal prgnancy reduction is a potentially useful strategy for moderating potentially stressful relationships in their social networks. Clinics should find a way of integrating the discussion of selective sharing into their clinic's cultural repertoire of patient-support services.

[Lived experience of multifetal pregnant women with fetal reduction].

The purpose of this study was to explore the lived experience of multifetal pregnant women who underwent fetal reduction. Using a qualitative research design, we recruited ten multifetal pregnant women with fetal reduction from an obstetrics and gynecology clinic in Taipei. The researcher, as a nurse counselor, collected data while providing care. Data were collected during the first counseling scheduled prior to the fetal reduction to five weeks post the procedure. Approximately five face-to-face interviews and eight phone follow-ups were completed for each subject. Data were recorded in a narrative form and analyzed based on interpretive research strategies of phenomenology. According to the data, the lived experience was categorized into seven themes: (a) pre-fetal reduction: feeling threatened by the confirmed diagnosis of multifetal pregnancy, facing guilt and conflict of undergoing fetal reduction; (b) undergoing fetal reduction: getting confused due to family's concern about fetal reduction, losing a sense of body boundary intactness, and worrying about the safety of the remaining fetuses; (c) post-fetal reduction: grieving for losing fetus, returning to the course of normal pregnancy. The findings indicate that undergoing fetal reduction impacted the physical and psychological well-being of multifetal pregnant women. Health care providers should provide individual yet holistic care in a timely fashion.

Lived experiences of Taiwanese women with multifetal pregnancies who receive fetal reduction.

This study explores lived experiences of Taiwanese women with multifetal pregnancies who receive fetal reduction. This qualitative study adopted a field method with observer-as-participant approach to collect data. Six subjects were recruited from a medical center using purposive sampling. Most of the subjects were contacted nine times. The total time of observation was 8-10 weeks. The collected data was analyzed by content analysis, and forming themes. The findings are as follows: (1) difficulty in accepting unexpected multiple pregnancies; (2) worry over danger/risk of multiple pregnancies and concern about fetal reduction; (3) decision to take fetal reduction for the safe delivery and health of two babies; (4) anxiety about the techniques of fetal reduction; (5) growing emotion of attachment to the fetus and guilty feeling; (6) unbearable physical/mental stress when facing the intrusion of fetal reduction; (7) being enmeshed in fear of unstable pregnancy and guilt; and (8) cloud of uncertainty diminished, return to normal pregnancy. The results indicated that the women with multifetal pregnancies, who received fetal reduction, encountered a difficult decision. They were exposed to tremendous emotional responses. The findings of this study can help nurses to gain a deeper understanding of those women's experiences. More sensitive, precise recognition, as well as suitable nursing intervention can be provided, in order to promote better acceptance of and adjustment to the fetal reduction.

Psychological aspects of prenatal diagnosis and its implications in multiple pregnancies.

Couples expecting twins are often unrealistically optimistic and are therefore unprepared for the complications as well as the practical and emotional impact the birth of twins can have on the family. All such couples will need information and support throughout the pregnancy and beyond. In this review, the various aspects that should be addressed are discussed, in particular, health care workers and counsellors need to be aware of the stress experienced by parents who have been through prolonged treatment for infertility or who face the special problems associated with the loss of one twin (implies the loss could be other than death).

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.