Multi-fetal pregnancy reduction (MFPR) to twins or singleton - medical justification and ethical slippery slope.

Multi-fetal pregnancy reduction (MFPR) is an ethically acceptable procedure aimed to increase survival and well-being of the remaining fetuses from high-order multiple gestations. In most cases we offer the procedure to triplets or quadruplets and opt to preserve twins; lately, the option to maintain a single fetus was suggested. We examined the outcomes of 140 pregnancies that underwent MFPR in our center and were followed to delivery - 105 were reduced to twins and 35 to singletons. The rate of procedure-related pregnancy loss was identical (2.9%). Leaving only one fetus was associated with a higher gestational age at delivery (35.4±2.4 weeks vs. 37.7±2.1 weeks, P<0.0001), with heavier neonates (2222 g vs. 3017 g, P<0.0001) and with a reduction in the cesarean section (CS) rate (76% in twins vs. 51.4% in singletons, P=0.02). Six pregnancies reduced to twins (5.8%) ended before 32 weeks as compared to one pregnancy reduced to a singleton. We conclude that reduction of triplets to singletons is medically and ethically acceptable, after thorough counseling of patients. However, considering the pregnancy loss risk of MFPR and the relatively good outcome of twin gestations, reduction of twins to singletons is ethically acceptable only in extraordinary maternal or fetal conditions.

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.

Struggles in Defining and Addressing Requests for "Family Balancing": Ethical Issues Faced by Providers and Patients.

This study - the first to explore how infertility providers confront several critical dilemmas concerning sex selection of embryos for nonmedical, social reasons - highlights key challenges and questions. Clinicians struggle, for instance, with how to define "family balalancing", when to offer it, and how to decide.

Selective Reduction: "A Soft Cover for Hard Choices" or Another Name for Abortion?

Selective reduction and abortion both involve the termination of fetal life, but they are classified by different designations to underscore the notion that they are regarded as fundamentally different medical procedures: the two are performed using distinct techniques by different types of physicians, upon women under very different circumstances, in order to further dramatically different objectives. Hence, the two procedures appear to call for a distinct moral calculus, and they have traditionally evoked contradictory reactions from society. This essay posits that despite their different appellations, selective reduction and abortion are essentially equivalent.

Application of legal principles and medical ethics: multifetal pregnancy and fetal reduction.

In the management of complex medical cases such as a multifetal pregnancy, knowledge of the ethical and legal implications is important, alongside having competent medical skills. This article reviews these principles and applies them to scenarios of multifetal pregnancy and fetal reduction. Such a discussion is not solely theoretical, but is also relevant to clinical practice. The importance of topics such as bioethical principles and informed consent are also herein addressed.

[Selective termination of pregnancy for monochorionic twins: a national survey of professional practice]. / Interruption sélective sur grossesse gémellaire monochoriale: étude nationale des pratiques des Centres Pluridisciplinaires de Diagnostic Prénatal.

OBJECTIVES: Selective Termination of Pregnancy (STOP) for discordant fetal condition in monochorionic twin pregnancy is a rarely performed procedure raising technical and ethical considerations. There are no epidemiological data available in France concerning STOP and no guideline or scientific consensus on how or when to perform has been published. MATERIALS AND METHODS: We conducted a study of national practice using a declarative questionnaire sent by e-mail to each medical coordinator of every 48 Multidisciplinary Center for Prenatal Diagnosis in France. The questions focused on the issues of 2010 and 2011. Two reminders were sent in case of no answer. RESULTS: The response rate to the questionnaire was 56 %; 81 % of centers have experienced at least once during the two years 2010-2011 a discordant fetal anomaly in monochorionic twin pregnancy. Only 59 % of centers perform all the techniques of STOP. When interruption of the umbilical blood flow is considered, bipolar forceps coagulation is the most used (75 %). Achieving STOP during a cesarean section is a common practice (75 % of centers). Locoregional anesthesia is the preferred mode of anesthesia for STOP. DISCUSSION AND CONCLUSION: STOP on monochorionic twin pregnancy is not practiced in all Multidisciplinary Center for Prenatal Diagnosis in France. The most widely practiced and most studied technique is bipolar forceps coagulation. The option of an expectant management should always be considered and its risks should be balanced with those of STOP. The practice of STOP during cesarean section is not unusual.

Fetal reduction: 25 years' experience.

Fetal reduction (FR) began in the 1980s to salvage the pregnancies of couples needing fertility therapy who were finally successful but with too many fetuses. Since then, it has gone from a rarity performed in only the highest risk situations to an integral fail-safe of infertility practice. Our understanding of the problems of multiple and premature births has increased - even twins carry 4-5 times more risk than singletons. Evaluation of fetuses before FR has permitted more intelligent choices and improved resultant outcomes. We now perform chorionic villus sampling in approximately 85% of cases, obtain fluorescent in situ hybridization (FISH) results overnight, and then perform FR the next day. Decisions about which to reduce prioritize anomalies, but now can include fetal gender in the decision process, as couples are now just as likely to want girls as boys. In Mendelian cases, sophisticated molecular analyses permit diagnoses before FR, and new uses such as paternity analysis can be performed. Ethical arguments have also evolved; as with many technologies in which the start was for only 'life or death cases', FR has also moved into 'quality of life' issues. FR of twins to a singleton now compromise about 30% of our cases.

Can ethics survive the onslaught of science?

The issue on which I will attempt to cast some light is certainly not novel. It has been ongoing for many years but the pace of scientific progress is gathering and the retreat of ethical barriers is relentless. I will illustrate my thesis by using examples of legal decisions from the realm of assisted human procreation and the posthumous conception of children from the sperm of deceased fathers e.g., the cases of Diane Blood, Parpalaix and Nikolas Coltan Evans. I will also highlight the recent case of Ashley X, a nine year old girl whose parents authorised radical medical treatment to arrest her development. I will argue that the law is being driven to roll back the ethical standards derived from our legacy of Natural Law by the imperatives of human rights e.g., the right to found a family, and the quest for patient autonomy. These are both admirable goals but fulfilling these goals comes at a cost to cherished ethical values e.g., that children are conceived by living fathers and that indulging the personal desires of every individual cannot forever be encompassed. As our legislators and courts chip away at our core network of ethical values, are they replacing them with equivalent values or do their decisions amount to a hollowing out of the core ethical values e.g., Thou shalt not kill and that human life is sacrosanct? Yet abortion is legal in many countries as is euthanasia. Paradoxically there is legislative protection for embryos by limiting experimentation on these clusters of cells. How do you construct a rational ethical framework with such blatant legal inconsistencies in the protection of human life? The sanctity of human life constitutes one of the fundamental pillars of ethical values which, in turn, support much more of the structure of ethics. Is a society that permits freezing the development of a nine year old child not a society whose ethics are so compromised that it is doomed to defend an ever diminishing mass of ethical values? Is there a core of ethics which is sacrosanct or is every ethical frontier fair game for invasion? Are the Ethics Committees, which approve and monitor research in the field of bioethics in Universities. Hospitals and laboratories failing in their duty as gatekeepers? They are after all the first line of defence for the survival of crucial ethical values. Can we continue to indulge the whims and needs of every individual under the guise of human rights or patient autonomy? Can a civilised society endure as such with an ever diminishing mass of ethical values?

Paternity balancing.

BACKGROUND: Gestational carriers and egg donors have been used by 'traditional' and now increasingly, gay couples. Three gay male couples, all using egg donors and gestational carriers with semen from both partners, had triplets. All desired reductions to twins for the standard medical indications, but requested, if reasonably possible, to have twins with one fathered by each partner. METHODS: Following our usual clinical protocol, we performed chorionic villus sampling at 12 weeks on all fetuses obtaining FISH and karyotype. For paternity analysis, 14 polymorphic molecular markers on villi were compared to DNA samples from the two men to include or exclude each. RESULTS: Standard assessments were all normal. Paternity testing showed that one partner fathered two of the triplets, and the other one. In all cases, one of the 'twins' was reduced with good clinical outcomes ensuing. CONCLUSIONS: Paternity balancing increases options for satisfying family planning desires of gay male couples. We believe it comparable to gender preferences in reductions, i.e. it can be considered but only completely subservient to any clinical criteria. Paternity balancing raises similar ethical issues as reduction with gender preferences, but may increase patient autonomy and mainstream acceptance of stable, gay families.

ACOG Committee opinion no. 553: multifetal pregnancy reduction.

Fertility treatments have contributed significantly to the increase in multifetal pregnancies. The first approach to the problem of multifetal pregnancies should be prevention, and strategies to limit multifetal pregnancies, especially high-order multifetal pregnancies, should be practiced by all physicians who treat women for infertility. Incorporating the ethical frameworks presented in this Committee Opinion will help physicians counsel and guide patients when making decisions regarding multifetal pregnancy reduction. In cases of high-order multifetal pregnancies, counseling should include the availability of multifetal pregnancy reduction. Fellows should be knowledgeable about the medical risks of multifetal pregnancy, the possible medical benefits of multifetal pregnancy reduction, and the complex ethical issues inherent in decisions regarding the use of multifetal pregnancy reduction. Physicians should not be required to act in ways that conflict with their value systems but should be prepared to react in a professional and ethical manner to patient requests for both information and intervention.

Ethical considerations arising from the use of assisted reproductive technologies.

The rapid growth of reproductive medicine has in many cases occurred faster than societies have been able to assimilate the changes and incorporate them into the social fabric. Oftentimes, the widespread use of reproductive techniques and fertility-enhancing medications has occurred before the ethical implications of these technologies have been considered. This article introduces ethical concepts that can be used as tools to understand the moral dilemmas inherent in the practice of reproductive medicine. These concepts are then used to form a framework for discussing specific ethically charged issues including the increasing prevalence of multiple pregnancies and the option of multifetal pregnancy reduction, ethical considerations in the prevention of ovarian hyperstimulation syndrome, and access to fertility treatments among different populations. Furthermore, considerations of when to offer these technologies and situations in which care may be refused are discussed. In closing, the role of ethics committees as an approach to navigating difficult clinical situations is introduced.

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).

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.

A preventive ethics approach to IVF in the age of octuplets.

A preventive ethics approach recognizes that ethical obligations of the in vitro fertilization practitioner should prevail, regardless of whether embryo transfer is regulated.

The Suleman octuplets: what can an aberration teach us?

The Suleman case shows that there are "heightened expectations" of our field on the part of our colleagues, the public, legislative and regulatory officials, and our patients. And it can teach us that we have both the history and the promise within our own field to fulfill those heightened expectations through continued clinical progress in promoting safe successful outcomes.

Elective twin reductions: evidence and ethics.

Twelve years ago the British media got wind of a London gynecologist who performed an elective reduction on a twin pregnancy reducing it to a singleton. Perhaps not surprisingly, opinion on the moral status of twin reductions was divided. But in the last few years new evidence regarding the medical risks of twin pregnancies has emerged, suggesting that twin reductions are relevantly similar to the reductions performed on high-end multi-fetal pregnancies. This evidence has appeared to resolve the moral debate. In this paper I look at the role of clinical evidence in medical ethics. In particular I examine the role of clinical evidence in determining what counts as a significant harm or risk. First, I challenge the extent to which these empirical claims are descriptive, suggesting instead that the evidence is to some degree normative in character. Second, I question whether such empirical claims should count as evidence for what are essentially difficult ethical decisions - a role they appear to play in the case of elective reductions. I will argue that they should not, primarily because the value-laden nature of this evidence conceals much of what is ethically at stake. It is important to recognize that empirical evidence cannot be a substitute for ethical deliberation.

[Effect of different embryo transfer strategies on the outcome of assisted reproduction]. / Effekt unterschiedlicher Strategien beim Embryotransfer auf die Ergebnisse der assistierten Reproduktion.

Currently, there is a rising trend to consider a multiple delivery as a genuine complication of assisted reproduction, which can be prevented by the replacement of one single, selected embryo. Particularly previously infertile women due to their poor reproductive function are at risk of complications during gestation leading to premature delivery. Cerebral palsy is the most common consequence of multiple gestation and a significant cause of disabling among the offspring. Particularly Swedish specialists in reproductive medicine have been at the forefront of the development of single embryo transfer (denominated SET), which has become the main therapeutic strategy in IVF since 2004. In Sweden, approximately 70 % of all treatment cycles with assisted reproduction are now being performed with SET. Despite the transfer of fewer embryos per cycle, acceptable pregnancy rates are being achieved thereby reducing the multiple delivery rate to approximately 5 %. In Switzerland, however, legal restrictions ban the selection of embryos, so that all available embryos (not more than three) are still being transferred.

An ethically justified practical approach to offering, recommending, performing, and referring for induced abortion and feticide.

We provide comprehensive, practical guidance for physicians on when to offer, recommend, perform, and refer patients for induced abortion and feticide. We precisely define terminology and articulate an ethical framework based on respecting the autonomy of the pregnant woman, the fetus as a patient, and the individual conscience of the physician. We elucidate autonomy-based and beneficence-based obligations and distinguish professional conscience from individual conscience. The obstetrician's role should be based primarily on professional conscience, which is shaped by autonomy-based and beneficence-based obligations of the obstetrician to the pregnant and fetal patients, with important but limited constraints originating in individual conscience.

[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.