Imagine experiencing infertility, and then finding out that you are pregnant — with triplets! Doctors then recommend that you reduce the pregnancy to twins because of the risk of trying to carry triplets for both mom and the babies. You weigh the potential of losing all three babies to a miscarriage or giving birth to three premature infants vs. intentionally ending the life of one. How do you choose which one?

There are no statistics to know how many women face this “Sophie’s Choice” each year; however, the use of assisted reproductive technology (ART), particularly fertility drugs, has increased the number of women faced with this decision. Liza Mundy explores this issue with great sensitivity in the Washington Post Magazine this week and follows up with an on-line chat on the topic. Mark Evans is to be commended for his willingness to discuss this sensitive topic with Mundy.

What Mundy doesn’t discuss is why these multiple pregnancies exist in the first place. Yes, she mentions that they are the product of ART, but she doesn’t talk about the controversy that exists in the ART community over practicing fertility medicine responsibly. Howard Jones and other outspoken infertility treatment providers have advocated for guidelines to limit the number of embryos transferred to a woman’s uterus during IVF treatment. ASRM has recently adopted guidelines, but they still allow for more than two embryos to be transferred. Other countries have taken to fining ART clinics that produce too many multiple births. We also need to work on educating IVF and fertility drug patients that multiples are not a blessing. It’s high time that every ART provider lose the cavalier attitude (that I’ve personally heard) that selective reduction as a simply way to deal with a multiple pregnancy. The risks of multiple pregnancy must be clearly explained to women as part of the consent process for both IVF and the use of fertility drugs. Responsible providers will follow the ASRM guidelines for the number of embryos to transfer and carefully monitor cycles using fertility drugs, canceling those cycles when too many ovarian follicles are developing.

A good follow-up study on the effects of selective reduction on women and families is also needed. It might help infertile couples who think they want a multiple pregnancy understand what responsible providers are trying to avoid.

-Andrea Kalfoglou