Trends of Selective Fetal Reduction and Selective Termination in Multiple Pregnancy, in England and Wales: a Cross-Sectional Study.

Selective abortion was shown to be increasingly common in England and Wales over a 9-year period, occurring most frequently as twin to singleton reductions in the 1st trimester. We analysed the trends in selective abortion (SA) in multiple pregnancies in England and Wales between 2009 and 2018. This is a cross-sectional study looking at 1143 women with multiple pregnancies in England and Wales undergoing SA. There were a total of 1143 cases of SA between 2009 and 2018 in England and Wales, representing 0.07% of total abortions. There has been a steady increase in cases, from 90 in 2009 to 131 in 2018, with 82.3% justified under ground E of The Abortion Act 1967. The majority of SAs were carried out at 13-19 weeks gestation, and intracardiac injection of potassium chloride was the most prevalent method (75%). Twin to singleton reductions accounted for 59%, the most common form of SAs. Over half of all cases (59%) were performed in women aged 30-39 years, and 84% of all women were of White ethnicity. SA has been an option available for couples diagnosed with multiple pregnancy, especially when there are discordant anomalies. Although SA may decrease multiple pregnancy-related complications, preventative methods must be championed.

Study of variables related to multiple pregnancy in cycles of ovarian Stimulation / Estudio de las variables relacionadas con el embarazo múltiple en ciclos de estimulación ovárica

Introduction: This paper analyzes cycles of ovarian stimulation followed by intrauterine insemination or timed intercourse that resulted in pregnancy. Our objective was to identify characteristics of the patient or ovarian response that are associated with multiple pregnancy. Material and methods: We performed a descriptive retrospective observational study of 261 cycles where pregnancy was achieved by intrauterine insemination or timed intercourse. The sample was obtained from 1,189 infertile couples treated from January 2009 to December 2014. We evaluated features that were potentially associated with multiple pregnancy and dependent on the patient, treatment, and ovarian response. Results: Of all the pregnancies analyzed, 88.9% were singleton and 11.1% multiple (8.4% twins, 2.7% triplet). In the multiple pregnancy group, the average number of intermediate follicles (14-16 mm), follicles measuring ≥ 17 mm, and the total number of follicles on the day human chorionic gonadotropin was administered were higher than for the singleton pregnancy group (p < 0.05). We found no correlation between multiple pregnancy and age, type and diagnosis of infertility, drug used for stimulation, initial and total dose of gonadotropin, number of treatment cycles, and motile sperm count. Conclusions: This study confirms the association between multiple births and increased number of follicles. When follicles were classified by size and multiple pregnancy as twin and triplet, we found that intermediate follicles were significantly associated with twin pregnancy. Consequently, they must be taken into account when deciding to cancel a cycle in order to try to reduce the risk of multiple pregnancy

Introducción: este trabajo analiza los ciclos de estimulación ovárica seguidos de inseminación intrauterina o coito programado que lograron embarazo. El objetivo es identificar las características de la paciente o de la respuesta ovárica asociadas con el embarazo múltiple. Material y métodos: es un estudio observacional retrospectivo descriptivo. Incluye 261 ciclos en los que se ha conseguido embarazo mediante inseminación intrauterina o coito programado. La muestra se ha obtenido de 1.189 parejas infértiles tratadas de enero de 2009 a diciembre de 2014. Se evalúan características potencialmente asociadas con el embarazo múltiple dependientes de la paciente, del tratamiento aplicado y de la respuesta ovárica. Resultados: el 88,9% de los embarazos fueron únicos y el 11,1%, múltiples (8,4% gemelares, 2,7% triples). En el grupo de embarazo múltiple, la media de folículos intermedios (14-16 mm), los folículos con una media de ≥ 17 mm y el total de folículos el día de la gonadotropina coriónica humana fueron mayores respecto al grupo de embarazo único (p < 0,05). No hemos hallado correlación entre embarazo múltiple y edad de la paciente, tipo y diagnóstico de esterilidad, fármaco utilizado en la estimulación, dosis inicial y total de gonadotropina, número de ciclos de tratamiento y recuento de espermatozoides móviles postcapacitación. Conclusiones: este estudio confirma la asociación entre embarazo múltiple y mayor número de folículos. Desglosando los folículos por su tamaño y el embarazo múltiple en gemelar y triple, los folículos intermedios se asocian significativamente a embarazo gemelar, por lo que deben ser tenidos en cuenta en la decisión de cancelación para intentar disminuir el riesgo de embarazo múltiple

Single center experience in selective feticide in high-order multiple pregnancy: clinical and ethical issues.

OBJECTIVE: This paper describes the 20-year experience with selective feticide (SF) of high-order multiple quadruplet and higher pregnancies in a single center. METHODS: The paper describes protocols, procedures, management, outcomes, and ethical issues. RESULTS: SF was performed in 49 pregnancies with 244 fetuses, with median gestational age of 12+2 weeks. The initial number was nine (one case), eight (one case), seven (three cases), six (11 cases), five (eight cases), and four (27 cases). Nuchal translucency was utilized prior to the procedure starting in 1996. The technique was transabdominal ultrasound-guided and intrathoracic injection of potassium chloride. One pregnancy (with seven fetuses) was reduced to three, 42 to two, and four (starting with four fetuses) to singletons. There were ten pregnancy losses (20.4%). A decreasing trend in losses was evident over the 20-year time period: 7/23 (30.4%) from 1994 to 2004 down to 3/26 (11.5%) for 2004-2014. No chromosomal abnormalities were present in any of the survivors. The ethical issues focus on the justification of SF in high-order multifetal pregnancies. CONCLUSION: In this series, pregnancy loss decreased with operator experience. Excellent outcomes can be achieved with the ethically justified use of feticide in high-order multiple pregnancies.

Perinatal outcome after fetal reduction from twin to singleton: to reduce or not to reduce?

OBJECTIVE: To determine whether reduction of twin gestation to singleton pregnancy is associated with improved perinatal outcome. DESIGN: A retrospective cohort study. SETTING: Single tertiary care medical center. PATIENT(S): A cohort of 63 singleton pregnancies after reduction from dichorionic-diamniotic twins gestation and 62 dichorionic-diamniotic nonreduced twins. INTERVENTION(S): Fetal reduction between 11 and 14 weeks of gestation. MAIN OUTCOME MEASURE(S): Obstetric outcome. RESULT(S): The rates of preterm delivery at <34 weeks (1.6% in pregnancies after reduction vs. 11.7% in nonreduced twins) and at <37 weeks of gestation (9.5% vs. 56.7%) were significantly lower in patients whose pregnancies were reduced to singletons. The rates of miscarriage of one twin (0% vs. 4.8%) and early pregnancy loss before 24 weeks of gestation as well as the rates of gestational diabetes (11.1% vs. 10%), hypertensive diseases of pregnancy (6.3% vs. 15%), and intrauterine growth restriction (0% vs. 3.3%) were similar in both groups. CONCLUSION(S): Fetal reduction of twins to singleton is associated with a lower risk of prematurity and superior perinatal outcome compared with nonreduced twins. Therefore, the option of fetal reduction should be considered in certain cases of twin pregnancies, where the risk for adverse outcome seems exceptionally high.

Perinatal outcome of twin pregnancies after early transvaginal multifetal pregnancy reduction.

OBJECTIVE: To compare the pregnancy outcomes of twin pregnancies following early transvaginal multifetal pregnancy reduction (MPR) with nonreduced twin gestations. DESIGN: Prospective cohort study. SETTING: Two tertiary medical centers. PATIENT(S): A cohort of 77 multiple pregnancies after reduction to twins and 78 dichorionic-diamniotic nonreduced twins. INTERVENTION(S): Early fetal reduction. MAIN OUTCOME MEASURE(S): Pregnancy outcome. RESULT(S): Triplet pregnancies reduced to twins (n = 55) and nonreduced twin pregnancies (n = 78) had comparable outcomes. The rates of preterm delivery ≤32 weeks (1.9% vs. 1.4%) and ≤34 weeks of gestation (15.1% vs. 19.2%) were similar among both groups. There was no difference in the mean gestational age (36.54 vs. 36.35 weeks) or mean birth weight (2,365 vs. 2,365 g) between the two groups. Similarly, there was no significant difference in the incidence of gestational diabetes (15.1% vs. 14.1%) and intrauterine growth retardation (IUGR; 1.9% vs. 9%) between the two groups. The incidence of gestational hypertension was higher in the study group (24.5% vs. 9%), but it was not associated with an increased risk for prematurity or IUGR. CONCLUSION: The perinatal outcome of twin pregnancies after early transvaginal fetal reduction from triplets seems to be comparable to the outcome of nonreduced twin pregnancies.

Evolution of gender options in multiple pregnancy management.

OBJECTIVE: Fetal reduction (FR) in multiples dramatically improves outcomes. We prioritize FR decisions for health and historically declined to factor gender. As male preferences apparently diminished, our bioethicist encouraged a re-evaluation. METHODS: Three hundred ninety-six patients reducing triplets or twins were categorized as 3➔2, 3➔1, and 2➔1, Major (M) anomaly or minor (m) anomaly, same gender (SG), and those for whom gender preference (GP) was possible. Higher order and non chorionic villus sampling were excluded. FR decisions were prioritized by M anomaly, Suspicious, or m anomaly. If neither, we considered GP. RESULTS: Of 319, 214 (67%) had either M/m or SG. Of those, 3➔2 with gender option: 71/79 chose male and female or had no preferences, one chose male/male, and seven chose female/female. We reduced monochorionic twins in 33/35 3➔1 cases. Of 20 with GP choice, 10 chose male and 10 chose female. Of 162 2➔1, 54 had M or m, 50 were SG, but of the 44 M/F twins, 20 chose male and 24 chose female. CONCLUSIONS: There has been a cultural shift mostly preferring one of each or having no preference. When reducing to one, >50% prefer a girl. In addition to identifying abnormalities, chorionic villus sampling before FR expands patient autonomy.

Multifetal pregnancy reduction: evolution of the ethical arguments.

Multifetal pregnancy reduction (MFPR) was developed over 20 years ago to rescue higher-order multifetal pregnancies and has become a major component of improving the outcomes in infertility therapies. By definition, MFPR will always be controversial, but opinions do not follow the traditional "pro-life/pro-choice" dichotomy that has sabotaged the more generalized abortion debate. If one defines SUCCESS as a healthy mother and healthy offspring, clearly, with multiples, fewer are always safer. The ethical issues surrounding MFPR are for most people not a clear black-or-white but varying shades of gray. The ethical principle of proportionality takes precedence (i.e., trying to obtain the most good for the least harm while looking for areas of moral compromise to achieve the best outcomes).

Fetal reduction 2008.

PURPOSE OF REVIEW: Multifetal pregnancies have skyrocketed over the past two decades as a consequence of infertility treatments. Multifetal pregnancy reduction has lowered the complications considerably. Here, we review the historical and current literature to determine reasonable statistics upon which to counsel patients RECENT FINDINGS: Several papers in the past year have updated the database of outcomes, shown that prenatal diagnosis by fluorescent in-situ hybridization prior to reduction improves outcomes and examined the psychological and emotion frame through which patients view the circumstances and options available to them. SUMMARY: Multifetal pregnancy reduction in experienced hands continues to dramatically improve the outcome of multiple pregnancies. The development of coping strategies for patients to deal with complex options and risks challenging their religious and other core beliefs now allows us to better counsel patients.

Evolving trends in 2000 cases of multifetal pregnancy reduction: a single-center experience.

OBJECTIVE: The purpose of this study was to examine changes in multifetal pregnancy reduction (MPR) procedures in 2000 cases and to evaluate evolving trends within the last 1000 MPRs. STUDY DESIGN: Two thousand patients who underwent MPR were identified. Data were collected from a computerized database. Comparisons were made between the first 1000 patients (group 1) and the second 1000 patients (group 2). In addition, changing trends within group 2 were also analyzed. Differences in proportions were evaluated by chi-square test and Fisher's exact test, as appropriate. RESULTS: There was a significant difference in the starting and finishing number of fetuses and a significant increase in the use of chorionic villus sampling before MPR in group 2 vs group 1 (43.7% vs 1.5%; P < .0001). The incidence of monochorionicity was significantly higher in group 2 (5.7%), compared with group 1 (2.1%; P < .001). CONCLUSION: Recent trends in MPR demonstrates significant increases in overall reductions to a singleton fetus, the use of chorionic villus sampling, and the presence of monochorionicity.

Update on selective reduction.

Over the past 25 years fetal reduction has been utilized to reduce the risks of higher-order multiple pregnancies that have resulted from overly successful infertility therapies. The demographics of multiple pregnancy patients have evolved over the past decade, with increasing proportions coming from IVF as opposed to ovulation induction, being older and a higher proportion with donor eggs. Genetic diagnosis prior to reduction is becoming more common and is very safe in experienced hands. For all starting numbers, including twins, reduction to a lower number of fetuses reduces fetal losses, prematurity, and infant mortality and morbidity.

Gestación heterotópica: tratamiento conservador y evolución favorable de la gestación intrauterina / Heterotopic gestation: conservative treatment and favorable evolution of intra-uterine gestation

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[Multiples births: a continuing problem with assisted reproductive techniques]. / Meerlingen: een blijvend probleem bij kunstmatige voortplantingstechnieken.

Assisted reproductive techniques (ART) such as in vitro fertilisation (IVF), ovulation induction and superovulation followed by insemination have caused a sharp increase in multiple birth prevalence rates. The perinatal morbidity of multiple birth infants is high because of the high incidence of premature birth. The social and psychological problems of multiple birth families are also considerable. In 1990 high-order multiple births were mainly the result of IVF. Although the number of IVF treatments has increased more than the number of other ART treatments, nowadays high-order multiple births are predominantly caused by superovulation. Since 1990 the number of high-order multiple births has stabilised, but the recent sharp increase in ART twins results in a further rise in births of severely preterm ART infants. More restraint should be practised in superovulation treatments to bring down the number of (high-order) multiple births.