Multifetal pregnancy and selective reduction



Miércoles, 12 de Agosto de 2009 11:25

Bioethics Research Notes 9(4): December 1997

Multifetal pregnancy and selective reduction
By Dr John I Fleming

 

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The birth of septuplets to American couple Bobbi and Kenny McCaughey has attracted significant world-wide media attention1. And no wonder. The birth of so many babies at one time, all of them seemingly in good physical condition is, to say the least, a highly unusual event. High order multi-fetal pregnancies are associated with significant risks to the mother and to her unborn children. For example, there is a very high risk that such pregnancies could result in none of the children surviving either through miscarriage or premature delivery. Surviving children are at significant risk of cerebral palsy, brain damage, blindness, retardation or developmental problems. The seriousness of problems associated with high order multiple pregnancy leads medical practitioners to offer selective reduction, ie the abortion of one or more of the fetuses, as a solution to the obstetric problems that they themselves have caused. The implications for the women concerned, their partners, and the unborn become secondary to considerations of cost, efficiency, and the medical desire to „control‟. What do I mean?
The Center of Bioethics, Catholic University of the Sacred Heart, Rome has identified the increase in multi-fetal pregnancies over the last few years as being caused by “an uncontrolled and unscrupulous use of assisted reproduction techniques”2. The Centre points out that the maternal-fetal complications identified above together with the serious metabolic and neurological sequelae in the newborn increase “in direct proportion to the number of embryos present in the uterus ... This is why a pregnancy with more than three embryos is considered an iatrogenic complication of assisted reproduction techniques.”3 This increase in multiple pregnancies has led to intense pressure on women to selectively abort some of the fetuses. Yet selective abortion itself is morally problematic and not only because of the unjustifiable killings of innocent human beings.
For example, the mean rate of spontaneous miscarriage of the remaining fetuses is about 15%, and ranges from 9% to 40%4. That is, there is a real and substantial risk that all the fetuses may be lost as a consequence of the deliberate selective abortion of some of the fetuses. Alexander et al, having noted the increase in multiple pregnancies and their associated perinatal morbidities and mortalities in IVF programmes, found that
1 Carol Zimmermann, “The Septuplet Babies: Raising Multiple Questions”, Catholic News Service, 21 November, 1997 2 Official Statement of the Centre of Bioethics, Catholic University of the sacred Heart, Rome, “Against so-called embryo reduction”, Bulletin of Medical Ethics, 127 (April 1997):8 3 Ibid., 9 4 Ibid. Cf Kanhai et al in whose study 19% of the women had no surviving child after multifetal pregnancy reduction, footnote 8 below.
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twins resulting from selective reduction had a lower gestational age (mean 34.5 weeks) compared to the normal twin delivery rate (36 weeks).5
The fact is that multiple pregnancy is a serious risk associated with artificial reproduction techniques. Austin et al have acknowledged that, where IVF is concerned, the risk of multiple pregnancy cannot be eliminated without decreasing the pregnancy rate.6
Leaving aside for a moment the issue of abortion and the serious ethical and human rights issues involved7, what needs immediate attention in the light of the conception and subsequent births of the McCaughey septuplets and what we know to be the serious maternal-fetal risks involved in such a high-order multiple pregnancy is this: what on earth did the McCaugheys‟ doctors imagine they were doing in allowing such a multiple pregnancy to be established in the first place? Let me explain. Ms McCaughey was prescribed and took the fertility drug Metrodin after the birth of her first baby 22 months ago. This drug is used to bring to full development eggs in the ovaries. Sometimes this treatment is further assisted by an injection of human chorionic gonadotrophin. Subsequently the couple hope to achieve pregnancy by natural sexual intercourse. A critically important step is the monitoring process after the administration of Metrodin to see how many egg follicles are developing. In South Australia if more than three follicles are seen to be present (more than two in some clinics) then the couple are strongly advised against intercourse, that is the treatment is abandoned. The reason for this advice is clear. As I have already shown, high order multiple pregnancies carry serious risks for the mother and the babies she is carrying. Further, multiple births can also put a strain on the couple‟s relationship. The serious questions that need to be asked of the American doctors concerned are these. What are their treatment protocols and were they followed? Was the monitoring process carried out before the encouragement to sexual intercourse? If it was, did they advise the couple against intercourse, and if not why not? Could it be the case that the doctors involved see selective reduction of multi-fetal pregnancies (ie abortion) as just another medical procedure, part of the total treatment? Was cost an influencing factor, ie are the procedures in the American system so expensive that doctors consider it best to give such dosages of Metrodin as to make sure that pregnancy occurs with abortion being used as a backup procedure to get the pregnancy „under control?
Kanhai et al have shown that, in the Netherlands, multiple pregnancies leading to multi-fetal pregnancy reduction are more often the consequence of ovulation induction than
5 Alexander, J M; Hammond, K R; Steinkampf, M P; “Multifetal Reduction of High-Order Multiple Pregnancy: Comparison of Obstetrical Outcome with Nonreduced Twin Gestations”, Fertility & Sterility 64:06 (December 1995), 121-03 6 Austin, Cynthia M; et al, “Limiting Multiple Pregnancy in In Vitro Fertilization/Embryo Transfer (IVF-ET)”, Jnl Asstd Rep & Genetics 13:07 (August 1997), 540-45 7 For a full treatment of the serious human rights issues involved in induced abortion see my recently published Fleming, John I; Hains, Michael G, “What Rights, If Any, Do The Unborn Have Under International Law”, Australian Bar Review, 16:02 (November 1997), 181-198
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of IVF8. Similarly Howard Jones has acknowledged that ovulation induction is a major culprit where multifetal pregnancies are concerned in the United States. But while the Ethics Committee of the American Society for Reproductive Medicine has addressed the problem of multiple pregnancies where IVF is concerned, the prevention of multiple pregnancies with ovulation induction has not been addressed.9
The failure of doctors in parts of the world to properly evaluate the impact on women of selective reduction, not to mention the catastrophic consequence for the unborn, is noteworthy. Kanhai et al studied 21 women who had become pregnant after infertility treatment (18) or IVF (3). The 21 pregnancies consisted of 3 septuplets, 5 quintuplets, 7 quads and 6 triplets. Fourteen of the twenty couples who agreed to be involved in the follow-up study said that they were not aware of the risks and consequences of the infertility treatment. Three said they were given no information before ovulation induction about the risk of a multiple pregnancy and eleven claimed they were told the risks were not very large. Nevertheless these authors still see selective reduction as an acceptable option in cases of excessive multiple pregnancies.10
Another ethically superficial evaluation of the problems involved suggest that a successful outcome of selective reduction makes the procedure ethically acceptable.11 However, all of this misses he point about the need to avoid multiple pregnancies in the first place.
In the Australian context septuplets following ovulation induction is highly unlikely to occur given best practice standards which require careful monitoring of the ovaries after the application of Metrodin, and an abandoning of the treatment when more than three follicles are present. In this way women and their babies are relieved of unnecessary risks, and women and their partners are less likely to be subjected to pressure from their doctors to destroy the human lives they are morally bound to protect.
8 Kanhai, H H et al, “Follow-Up of Pregnancies, Infants, and Families after Multifetal Pregnancy Reduction”, Fertility & Sterility 62:05 (November 1994), 955-59 9 Jones, Howard W, “Twins or more”, Fertility & Sterility 63:04 (April 1995), 702 10 Kanhai et al, op. cit. 11 Chervenak, F A et al, “Three ethically Justified Indications for Selective Terminations in Multifetal Pregnancy: A Practical and Comprehensive Management Strategy”, Jnl Asstd Rep & Genetics 12:08 (September 1995), 531-536 © 1997 Southern Cross Bioethics Institute Adelaide, South Australia