- The Washington Times - Friday, January 12, 2001

When Nicole Klan discovered she was pregnant with triplets, doctors suggested she "reduce" one of her offspring to create more room in the womb for the others.

"Selective reduction" is a procedure whereby a doctor injects potassium chloride into an embryo's heart, causing it to stop beating and thereby killing it.

Crisis hit the suburban Pittsburgh mother at 17 weeks, when doctors told her and her husband, Robert, that possibly two of the three had birth defects.

"I had three or four days to decide what to do," she says, "as it had to be done by the 18th or 19th week. We come from a pro-life bent, so we agonized over it. What it came down to is I could not imagine myself laying on the table killing two children when we didn't have a confirmed diagnosis."

In this era of increased multiple births, many doctors still are urging mothers of triplets to "selectively reduce" their threesome to two or one child.

But such advice has stirred debate among parents groups and some doctors who say reduction of triplets is no longer medically necessary.

The Centers for Disease Control says the ratio of triplet and higher multiple births has quadrupled from 37 per 100,000 in 1980 to 174 per 100,000 births in 1997.

An increasing number of these women are seeking out Arizona physician Dr. John Elliott, the co-founder of Phoenix Perinatal Associates and director of maternal fetal medicine at Good Samaritan Regional Medical Center in Phoenix. His successes at keeping high-risk women pregnant for more than 33 weeks including a quintuplet pregnancy he delivered at 34 weeks has landed him on television news magazines such as "48 Hours."

Dr. Elliott is so convinced that triplets and quadruplets can be delivered safely without "reducing" one or more fetuses that he plans to present a paper on the topic next month at a Society of Maternal Fetal Medicine gathering in Reno, Nev.

"We have taken care and delivered more sets of quads than anywhere in the world," he says of the 57 deliveries. "And 300 sets of triplets. We don't recommend to anyone with three or four babies that they selectively reduce. We tell them the potential for bad outcomes and compare the results of reductions with deliveries."

Perinatalogists have known for years that triplets are no more endangered in the delivery room than twins, says Denver physician Dr. Richard Porreco. He published a 1991 study comparing women who had triplets with women who had "reduced" one of their triplets to twins.

"The moms of triplet groups had harder pregnancies, but the infants did really well," he said. "We concluded that when you reduce from triplets to twins, the outcomes of the babies are very similar. In our study, there was not a statistically significant difference."

But the grief parents experience after doing a reduction was significant so much so, he said, that he did a 1995 study on its effects. But women are not getting enough information on the downside of reduction from their doctors, says Janet Bleyl, founder of The Triplet Connection, a Stockton, Calif., organization that operates www.tripletconnection.org. Mrs. Bleyl is the mother of 18-year-old triplets.

"Some reproductive endocrinologists don't want to be noticed as having more higher multiples than they should," she says, referring to doctors who provide fertility treatment that may increase the chances of multiple births, "so there's a lot of pressure [for reduction] from the get-go on these women."

Most upsetting, she says, was a recent letter she received from a woman in Minnesota who became pregnant with triplets in her fourth attempt with in vitro fertilization.

"This threw me into a state of shock," the woman wrote. "I thought, 'Oh my God, my husband will expect me to reduce one of these fetuses.' That was followed by the doctors giving us a talk on how triplets are much more difficult to raise than twins. Then he told us the divorce rate among parents of triplets is very high, not to mention the problems of raising three children of the same age through adolescence.

"I believe this talk further clinched it for my husband as he could not see himself as the father of triplets," the letter continued. "The doctor had the nurse bring in the phone number for the physician who performs the reductions. I wonder if the insurance companies influence the doctors to give this advice since triplets have a 90 percent chance of being born premature. It would save [insurance companies] a great deal of money."

The women did "reduce" her triplets to twins. She says she is terrified the surviving children will discover someday the fate of their sibling. Her letter ended with a description of her ongoing depression over the matter and a plea to Mrs. Bleyl to publicize her letter.

"Doctors talk about [risks of] mental retardation and cerebral palsy, and so people feel there is no other way they have got to sacrifice one of their babies for the others," Mrs. Bleyl said. "The doctors who do this don't have any idea what they are doing to these women. They treat it as though they were thinning tomatoes."

Dr. Michael Katz, whose California Pacific Medical Center Clinic in San Francisco does 30 to 50 "reductions" a year, says the procedures are "traumatic" for medical personnel too.

"Participating in these things is horrible," he said. He does not do the actual injection that stops the beating heart because, "I just cannot do it emotionally. It's so painful, it's unbelievable.

"I've heard some complaints from women that they felt pressured," he said. "I ask, are doctors listening to what the mother wants? Enemy number one is prematurity and the doctors who always see the bad side [of multiple births] are prejudiced against prematurity.

"But how many doctors know about the pain these women go through emotionally? There's a difference between the [providers of fertility treatment] and the obstetricians who have to take care of [the results]. And it's the obstetricians who are left holding the bag."

So are the mothers, says Jean Kollantai, founder of the Center for Loss in Multiple Births in Anchorage, Alaska.

"For someone who's been infertile, losing one embryo is not something you take casually, no matter how pro-choice you are," she says. "I knew someone who had eight who reduced to four and had four healthy babies. Then she was racked over the coals with remorse when she heard of the [McCaughey] septuplets being born [in 1997]. She wondered if she could have had another.

"We've had people who did not reduce and lost most or all of them. More and more I get calls and e-mails from people trying to decide whether to reduce or not, or people who have and who've had to deal with the aftermath."

Sue Treber, a Saline, Mich., mother of 3-year-old quadruplet girls, was told during her pregnancy that two of the girls had cysts on their brains. It turned out to mean nothing, but doctors still told her to reduce. Ignoring them, she flew to Phoenix to spend her last three months of pregnancy living near Dr. Elliott's clinic. She has since founded a national support group, the Quad Squad.

"Sometimes people reduce because they feel it would be an impingement on their lifestyle," she said. "OK, so my house is messy and life is hard, but I am so blessed. I have four healthy, beautiful little girls."

As for the Klans, one child turned out to have spina bifida, a birth defect where the spine fails to close properly.

They were born Aug. 27, 1997, and a fourth child was born six months ago. Jaden, the son with spina bifida, has had six surgeries and has no feeling or sensation below his hips. Other than that, "He's a typical 3-year-old," his mother says.

"Intellectually, he's all there and very bright, very funny, very social. He loves people. I can't imagine one of these children not being here."

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