4: Death of a twin in the second trimester

Chapter Four: the death of a twin in the second trimester

This was the most difficult chapter to write.  It's all about death and dead bodies.  Apart from twin to twin transfusion, abnormal development and other reasons for one twin to die,  the issue came up of MFPR.

I have written about this chapter before on this blog, but here is what I decided to say in this book.


Multi-foetal pregnancy reduction (MFPR)
Foeticide can be carried out on healthy foetuses in the second trimester, when there are too many foetuses developing in a multiple pregnancy. There there is a risk that they will all be lost if the numbers are not reduced somehow.  There is usually some natural loss of one or more foetuses in the early stages of a multiple pregnancy. However there may be too many in the second trimester and they may be “reduced” by the same surgical methods described above.  The controversial issue of “pregnancy reduction” (i.e. selective foeticide of one or more foetuses in the second trimester, who may or may not have some abnormality) follows an increase in the use of fertility-enhancing drugs and the resultant multiple implantations.  The intent is to reduce the number of developing foetuses from four or more to triplets or twins, in order to increase the possibility that the remaining babies will survive to term.
    Through the 1980s and 1990s, various forms of selective foeticide were developed.  These were based on an earlier system developed in the 1980s, of puncturing the heart of the selected foetus and injecting air into the circulation. The selection of foetuses for MFPR is usually made in the first trimester, but where possible it is  considered helpful to wait until the second trimester, when the foetuses are a little more developed and any abnormalities can be more easily diagnosed. The method of choice today for selective foeticide is potassium chloride injected directly into the heart of one or more of the selected foetuses.  This is a well-known method of causing cardiac arrest. 
    The policy now adopted by some assisted reproduction clinics is to transfer only one or two embryos during IVF. Also, some steps are being taken to limit the irresponsible use of fertility drugs, so the number of pregnancies with triplets and more is gradually reducing. However, the focus now is on twins. Because the reduction procedure is now available, some parents are asking for twins to be “reduced” to a single baby in order to guarantee delivery of one healthy baby.
    One study in Denmark of 44 multiple pregnancies reduced to two foetuses included sixteen pregnancies reduced from twins to a singleton.  In this study the good effects of reduction from twins to one were clear in terms of the size of the babies and the length of the pregnancy.
    In the light of positive reports such as this, the practice of selective foeticide is likely to continue, despite the misgivings of some professionals.  An article entitled “Do reduced multiples do better?” published in 2005 stated clearly that they do.  The same article reports that women over 40 carrying twins benefited from a relative lack of pregnancy problems when their twin pregnancy was reduced to a single womb twin survivor.
    The emotional problems experienced by the parents, who have the option of watching while a selected few of their multiples are destroyed, are only now being addressed.  It is known that the parents find MFPR very difficult, in particular the arbitrary nature of the selection. Some professionals have been voicing their concern about the emotional difficulties associated with MFPR, because no details are available about the possible effect on the survivors or how the parents should tell them, if ever. 
The survivors of MFPR
In published articles about MFPR there is little mention of any health and disability problems caused to the surviving babies.  We know that dichorionic DZ and MZ twins suffer fewer problems when their co-twin dies,  so it is to be assumed that most successful pregnancy reductions take place among foetuses who are developing in their own a separate chorion.  Held safe in their own private life-support system, dichorionic twins presumably suffer no physical ill-effects as a result of the sudden heart failure of one or more of their fellow womb-mates.  MFPR is a recent development, so the survivors are still young at the time of writing.  Consequently, no specific studies have yet been carried out to discover what, if any, physical or psychological effects they may be experiencing today.
    It seems to suits the interests of both parents and professionals not to emphasize the physical effects on the survivor when a co-twin dies, let alone a larger number of fellow foetuses.  This is understandable, as no one would want to cause unnecessary anxiety to a pregnant woman. However, more and more large-scale studies are being carried out and it is becoming clear that there are definite physical effects on the survivors, particularly if their MZ co-twin dies.

More about this book

Multifetal pregnancy reduction: what about the survivors?

I read this today:

Assisted reproductive technology (ART) and fertility drugs have greatly increased the number of multiple pregnancies in America.  The goal of MFPR is to increase the chance of a successful, healthy pregnancy. Multifetal pregnancy reduction:

• Is usually done early in a pregnancy, between the 9th and 12th weeks
• Is most often performed when there are four or more fetuses present.
• Can be used to reduce triplets to twins. This practice makes the fetuses' chances of a healthy outcome the same as that of the average twin pregnancy.
• Is known as "selective termination" when it involves a fetus with severe defects or one that is expected to die later in the pregnancy, which would threaten the life of the surviving fetus or fetuses. A multifetal pregnancy reduction improves your chances of avoiding miscarriage, carrying your pregnancy longer, and delivering one or more healthy babies.. Read more here

My thoughts: 
The loss of a triplet doesn't create a pair of twins. It leaves a pair of triplet survivors.
MFPR is a terrible decision for parents to make.


More...... 
Medical staff try to persuade women to go for single embryo transfer in IVF so there are not so many multiple conceptions:


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. more......


I'm glad they are considering the psychological risks for the mother, but what about the effect on the survivors?  There are plenty of little womb triplet or quadruplet survivors toddling about now, who will probably never be told that their parents decided to "reduce" their brothers and sisters.
I hope that this work with womb twin survivors will provide the insights that the psychologists will need in a few years time to help these kids.

I spent yesterday morning in an initial briefing with my personal Unltd mentor, Amy. This is such an excellent way to make use of public money - I say this not because some of it is coming my way, but because you get so much more than cash. You get legal and financial help and support; you get use of their offices for events; training in all kinds of skills; a chance to get to know other award winners. Making that application for an Unltd grant has proven to be one of the most rewarding things so far in this project, most of which has been fraught with difficulties and extremely isolating. So now I have friends and supporters and someone to turn to when all that positive energy drains away and I feel I can't do any more.

Then I spent the afternoon in the company of a TV producer, prospecting for a possible documentary on the survivors of abortion. I had pointed out that any fetus that survives an abortion attempt and is born reasonably intact is likely to have once been a fraternal twin. On that basis we had a session on the whole project:- twinning; my own story of the abortion attempt that killed my brother; abortion and how its done; the possible effects on the resultant child; the potentials for developing specific therapy and support for the survivor; funerals and rituals of mourning as part of the healing.

It will be many months before they begin to make this film. I do hope I can be in it. I also hope they dont forget to include "muli-fetal pregnancy reduction" which was once called "selective foetocide" but that was a bit too near the bone, so its now MFPR. It's abortion by another name, but this time it is intended that there will be at least one survivor, so that seems to be OK. That's when during IVF they get too many embryos developing and they kill several of the fetuses at about 10-12 weeks or so to reduce the number to twins or triplets.

Website giving advice to parents on MFPR

They worry about the effect on the parents, which is a start, but no one thinks about the survivors. That is, with the exception of Elizabeth Bryan, who highlighted this many years ago.

An interesting, if exhausting day......