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.

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.

Selective reduction of fetuses in multiple pregnancies and the law in Australia.

This article considers whether it is lawful in Australia to terminate one or more fetuses in a multiple pregnancy selectively and, if so, under what circumstances. It begins by addressing the preliminary question whether selective reduction is covered by laws relating to abortion and provides a brief outline of the law of abortion in Australian jurisdictions. The article then considers selective reduction of high-order multiple pregnancies, before turning to selective reduction of twin pregnancies in a range of circumstances. The article demonstrates that the law of abortion, as applied to selective reduction of multiple pregnancies, is uncertain and that there are considerable variations from one State to another. It concludes that the law in this area is in need of reform to recognise that some reductions are not performed prima facie to prevent danger to the mother's health and to remove the need for doctors to assert symptomatology of mental illness in order to guard against criminal law consequences. Further, there is a need to clarify whether selective reduction/ termination is abortion for the purposes of the law, and to achieve greater consistency across jurisdictions.

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.

Beyond abortion: why the personhood movement implicates reproductive choice.

In 2008, an amendment was proposed to the Colorado Constitution that sought to attach the rights and protections associated with legal "personhood" to any human being from the moment of fertilization. Although the initiative was defeated, it sparked a nation-wide Personhood Movement that has spurred similar efforts at the federal level and in over a dozen states. Personhood advocates choose terms like "fertilization," or phrases such as "human being at any stage of development, " to identify the "person"-defining moment in the reproductive process, and these designations have profound implications for reproductive choice. Proponents are outspoken in their desire to outlaw abortion, but they are less transparent about their intent with respect to other aspects of reproductive choice, such as contraception and infertility treatments. This paper describes the background of the Personhood Movement and its attempt to achieve legal protection of the preborn from the earliest moments of biological development. Following the late 2011 failure of the personhood measure in Mississippi, the language used within the Movement was dramatically changed in an attempt to address some of the concerns raised regarding implications for reproductive choice. Putting abortion to one side, this paper identifies why the personhood framework that is contemplated by the proposed changes does not eliminate the potential for restrictions on contraception and in vitro fertilization (IVF) that put the lives of these newly recognized persons at risk; nor should it if proponents intend to remain consistent with their position. The paper goes on to suggest what those restrictions might look like based on recent efforts being proposed at the state level and frameworks that have already been adopted in other countries.

[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.

[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.

[Some remarks on the protection of human embryo in the Spanish law]. / Breves anotaciones sobre la protección del embrión en el ordenamiento jurídico español.

We study in this article the Spanish legislation regulating the juridical status of the human embryo, in a comparative analysis with the International Right and the legislation in other countries of our cultural environment, leading to the conclusión that ours contradicts the international compromises of Spain and is less protective with the unborn human life than the juridical systems which advocate for the human being from the very moment of conception.

Multiple pregnancy: legal and ethical issues.

Multiple pregnancy is increasingly considered a complication of in vitro fertilization (IVF) and ovarian stimulation for natural fertilization. Harms to fetuses, newborn and older children, mothers, families, and healthcare systems are encouraging single embryo transfer. When patients knowingly accept multiple pregnancy risks from IVF or ovarian stimulation, they are unlikely to succeed in litigation against healthcare providers for wrongful pregnancy or wrongful birth. More challenging are impaired children's claims for "wrongful life." These are unlikely to succeed against parents, but courts are ambivalent to claims against healthcare providers. Historically, courts rejected these claims, under the principle that live birth is not a legal injury. European and other courts, however, have been more sympathetic to these claims. Multiple pregnancy treated by fetal reduction is not usually found to offend abortion laws. This poses ethical concerns, however, of "lifeboat ethics," involving how fetal reduction choices are made.

Attitudes of German infertile couples towards multiple births and elective embryo transfer.

BACKGROUND: In Germany, embryo screening programmes combined with elective embryo transfer are illegal, but there is controversial debate about their legalization. Studies about the attitudes of infertile couples towards multiples, elective embryo transfer and multifetal reduction may help to illuminate how this law shapes patient choices. METHODS: A survey of 265 German infertile couples was conducted. Different logistic regression analyses were performed to assess independent factors associated with the parity for multiple births, approval for elective embryo transfer and multifetal reduction. RESULTS: Despite prior information about the risk of multiple births, 81% of respondents saw no risk in twin pregnancies and a sizable minority saw no risk even in triplet pregnancies. Eighty-nine percent of the respondents rated a twin pregnancy as desirable, whereas 35% rated a triplet birth as desirable. When presented with a choice of having multiple births versus having no biological children, 99% of the respondents endorsed twins, 84% triplets and 58% quadruplets. Seventy-four percent of the respondents approve of legalizing embryo screening programmes to select a good-quality embryo combined with elective embryo transfer. Ninety-two percent of the respondents rejected fetal reduction of twins. CONCLUSIONS: German infertile couples might conceivably be more willing to accept elective embryo transfer if screening for viable embryos was permitted.

Litigation in multiple pregnancy and birth.

Multiple birth rates have increased in most developed countries. The potential of a medical legal dispute increases when complications are common. Failure to perform the basic and standard care follow-up often misses the complication and the chance of a timely referral to a center experienced in the diagnosis and management of these complexities of a multiple pregnancy. In this article, several examples are discussed in which departure from the standard of care of multiple pregnancies were the basis of the allegation.

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.

Multifetal pregnancy reduction and halakha.

The frequency of multifetal pregnancies has increased dramatically in recent years with the advent of assisted reproductive technologies. In an effort to ensure a successful outcome for both the fetus(es) and the mother, multifetal reduction is often medically recommended. Multifetal reduction may present a challenge to Orthodox Jewish law, as there is an apparent threat to the preservation of the fetuses lives. Yet, without medical intervention there is an increased risk of fetal and maternal morbidity and mortality. The issues involved in multifetal reduction have been thoroughly analyzed and recorded in Orthodox Jewish responsa, setting guidelines for rabbinic authorities to rule on the matter in specific cases based on the specific circumstances. The present article will analyze the medical procedure with respect to the halakhic literature published to date on the subject of multifetal reduction.