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.
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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.
(end of text)
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Article transcribed with the permission of the author by
Gregory C. Walker (GCPW-Aus)
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