Selective Termination and Multi-Fetal Pregnancy Reduction A Procedure With No Clinical Place
This is the text of a medical paper given by Australian obstetrician Ian MacIsaac at recent (mid 1994) Obstetrics conference in Adelaide, South Australia. By all accounts, his was the only voice raised in this professional forum against the recent development of reduction by abortion of multiple pregnancies. It is preceded by a glossary of medical terms which occur in the paper and which may be unfamiliar to the general reader. -------------------------------------------------------------------------------
GLOSSARY **********
feticide - deliberate abortion of a living unborn.
iatrogenic - generated by the physician; usually referring to disease or injury caused directly by a doctor's actions.
I.V.F. - In Vitro Fertilization. [literally, "in glass"]
exsanguination - the forcible expulsion of the blood from a part. [of the body]
transcervical - across, or crossing the cervix, or neck of the uterus. FIMP - Feticide In Multiple Pregnancy.
chorioamnionitis - inflammation of the fetal membranes.
intravascular coagulopathy - a blood clotting disorder confined to the bloodstream.
cerebral infarction - blockage of blood supply and resultant "death" of a part of the brain; a type of stroke.
transabdominal - through the wall of the abdomen. -- -- -- -- -- -- -- -- --
SELECTIVE TERMINATION AND MULTI-FETAL PREGNANCY REDUCTION: A PROCEDURE WITH NO CLINICAL PLACE.
Ian A. MacIsaac MBBS (Melb), FRCS, FRACS, FRCOG, FRACOG.
INTRODUCTION
Fetal reduction has been advocated as an answer to the iatrogenic problem of multiple fetal pregnancies. This problem is a result of hyperstimulation of the ovaries by hormones, or by replacing too many embryos or ova in the IVF or GIFT programs.
The answer is not to kill the fetuses, but to get the technology right! The current situation and practices require appraisal not only from a medico-moral aspect but from a public health perspective as well.
THE IATROGENIC PROBLEM
With ovulation induction, or the use of IVF and GIFT, multiple pregnancy rates are reported to be between 10 and 25% One might imagine that an infertility center, eager to attract patients, could market itself on achieving a high pregnancy rate by aggressive treatment while ignoring the possibility of multiple pregnancies produced, and then advocating fetocide.
To more carefully address this iatrogenic problem, we require:
a. Stricter entry criteria to the assisted reproductive program. b. Better control of the dosage of ovarian stimulating drugs.
c. Better monitoring of the effects of stimulation with, perhaps, daily estrogen estimations and frequent ultrasound scans.
d. Abandoning the treatment cycle if excessive stimulation has occurred. e. Replacing fewer embryos and eggs in the IVF and GIFT programs.
f. Avoiding hyper-stimulation, allowing normal ovulation and accepting a lower pregnancy rate.
It is irresponsible to produce these multiple pregnancies. There is also a risk of the hyper-stimulation syndrome, which can be life threatening to the mother.
We must pay attention to the consequences of our treatment and modify, or even abandon some of the existing techniques, but not resort to feticide as a solution.
METHODS OF REDUCTION AND TERMINOLOGY.
Feticide may be achieved by transcervical suction, transabdominal and vaginal needling of the heart, exsanguination and air injection. A more effective method appears to be transabdominal injection of potassium chloride into the heart of each fetus to be killed. Sometimes this fails, requiring the procedure to be repeated. Most reductions are randomly carried out at 9-13 weeks, destroying the fetus most easily accessible to the needle. A small number are selectively performed at 18 - 24 weeks to kill an abnormal fetus.
Berkowitz has pointed out the difficulties in describing these new procedures, some terms being inaccurate and describing the outcome rather than the procedure.
1. Selective Birth
2. Selective Termination
3. Selective Reduction
4. Selective Abortion
5. Selective Continuation
6. Multi-Fetal Pregnancy Reduction
(7. Feticide in Multipe Pregnancy (FIMP))
I would suggest Feticide in Multiple Pregnancy (FIMP) as an accurate description of the procedure, covering both random and selective reductions.
MULTI-FETAL REDUCTION / RANDOM FETICIDE
The aim of this procedure is to increase the number of surviving babies and reduce complications, particularly those associated with prematurity.
Most reported series are small, but Evans collected from multiple centers over 1000 cases with almost 4000 fetuses. Feticide reduced the total number by one half to 2000. This fetal loss is conveniently excluded from future statistics. Of the remainder, 13% lost the entire pregnancy by the 24th week, 5.5% delivered before 28 weeks, and a further 10 before 34 weeks.
From these figures, it can be inferred that only 40% of the original fetuses survived. Also, there was a significant rate of premature births.
There have been no controlled studies looking at the outcome of fetal reduction in multiple pregnancies versus conservative management. However, analysis of the outcome of the conservative management of 28 triplet and 3 quadruple pregnancies in the 11 years 1981 - 1992 at the Mercy Hospital for Women, Melbourne, reveals that after 24 weeks, 78 of a total 96 fetuses, i.e. 80%, survived for at least 1 year. Of the surviving babies, 64% weighed greater than 1500 g, 23% were between 1000 and 1500 g whilst 13% were less than 1000 g. All babies under 1500 g are in a continuing follow-up study. Only 1 had cerebral palsy and died in the 2nd year of life.
SELECTIVE MULTI-FETAL REDUCTION / SELECTIVE FETICIDE
Today, selective feticide is being advocated for abnormal fetuses; perhaps tomorrow the sex of the fetus could also be selected. This procedure terminates fetuses which may have abnormalities ranging from lethal to minor. Many of these fetuses could go on to live fulfilling lives if given their chance.
There are risks associated with selective feticide:
Accidental loss of the entire pregnancy Present data suggest that the risk of losing the entire pregnancy is of the order of 15 to 20%.
Performance of the procedure on wrong "healthy fetuses".
Chorioamnionitis
Premature delivery
Permanent damage of surviving fetuses In a mono-chorionic (identical) twin pregnancy, the lethal injection of potassium chloride into the heart of the abnormal fetus can pass to and kill or damage the normal fetus. The retained dead fetus produces a risk of intravascular coagulopathy which may cause cerebral infarction and intellectual impairment in the survivor.
PSYCHOLOGICAL AND SOCIAL EFFECTS
Let's not forget that these pregnancies are very much wanted; the patients only enter the program after long periods of infertility, extreme anxiety and expense.
When pregnancy is achieved, and the fetus is identified on an ultrasound, even though is some cases there are more than wished, it must be abhorrent to even suggest that feticide could be considered. The mother has seen the scans of the fetuses, seen movements, the fetal heart beating, and realises that each of her fetuses are equal, and some will be picked out for destruction. The mother may see the needle on the screen enter the heart and watch it stop beating, which would be very traumatic. For the rest of their lives, both parents and surviving siblings could not help thinking of the ones who were sacrificed for the sake of the survivors. The "lifeboat womb" has had half the occupants thrown overboard.
ETHICS AND MORALITY
The moral rights of the fetus: The child who is born is the same human individual as it was immediately before birth and as it was as a fetus. The fetus posits values and has some rights (even if not "legal" rights) as separate human life to love and to develop without harm in the womb. The fact that the legal right to claim is recognised only at birth does not effect the continuity of identity of the individual or the existence of moral right not to be harmed.
There is a community sense that the fetus should be protected. For this reason we advise against the pregnant mother taking drugs and alcohol etc.. Just because it is legally admissible to abort a fetus for certain reasons it does not follow that it is morally right to do so (or kill it in the womb). The law and morals are not coextensive. Legal rights are normally the very minimum that can be expected of a society, and if that is all we are concerned about, then we will have a very poor, morally weak society.
THE RESPONSIBILITIES OF THE MOTHER (AND DOCTORS)
In this technological situation we can say that the mother (and Father) desperately want a child. She has made a deliberate decision to conceive and to have a child knowing the consequences of the procedure. Such a free and informed decision brings concomitant responsibilities to protect and nurture the life she has chosen to bring about. This is the normal understanding of decision making in ethics. The subsequent problem (multiple fetuses) is a man-made problem - forseen and freely chosen. It is not the result of outside force or an "act of God".
The obstetrician caring for a pregnant woman has two or more patients, and feticide is absolutely the reverse of providing proper medical care for the fetus or fetuses.
These reduction procedures change the perception of the medical profession in the mind of the general community from a group which protects life, to a group who are prepared to destroy human life,in defiance of their traditional ethic.
Some aspects of assisted reproduction are making medicine more analogous to veterinary practice, and selective feticide emphasizes this fact.
CONCLUSION
The incidence and severity of serious complications associated with multiple pregnancy are being exaggerated. There are no reliable data on which to conclude that fetal reduction improves the overall outcome in multiple pregnancy, although it probably reduces the incidence of premature birth. The main issue is not medical but social. The real question is: "Should medical procedures be used to address social problems?"
Multiple children, although a heavier burden, are often a great joy to parents and society. There is a need for wider community discussion of reduction procedures as the issues are different morally, psychologically and legally from abortion.
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Article transcribed with the permission of the author by Gregory C. Walker (GCPW-Aus)
