Dear Dr. Halperin,
I need an answer quickly to know if I should reduce a twin IVF pregnancy where testing reveals complications. My doctor told me waiting to reduce my twin pregnancy will increase chances of complications for the remaining fetus and diminish advantages for it.
I am a 36 year old bipolar woman, 12 weeks pregnant with IVF twins. I'm scared and the reasons for that seems to multiply as prenatal testing progresses. Another baby is a challenge but I think twins will just keep me in a state of constant pressure and repeated psychiatric episodes. My OBGYN and Psychiatrist advised that a single birth would be healthier for me. My Psychologist thinks I could deal with the organization of healthy twins but not if there were medical complications especially long term which are more common in twins. My psychiatrist says that even if the twins are healthy, I would only be able to stay healthy if I hired live-in help in the house, I would not stay healthy otherwise. She said 7 hours sleep per 24 hour period was necessary to ward off postpartum psychosis and depression. Twins represent not only double care taking duties but also significantly increased risks of complications and long term health problems that would be lower if the pregnancy were reduced to one fetus. Specifically, my doctor said chances of premature birth would decrease by 25%, low birth weight would decrease by 21%, also odds of miscarriage, preecclampsia, cerebral palsy would decrease as well.
Moreover, medical tests already provide evidence of less than optimal fetal health. There was already one episode of heavy bleeding and ongoing spotting at the beginning of the pregnancy. Twin A has a nuchal fold of 3.0 at 10 weeks and 2.6 at 11 weeks and 1.7 at 12 weeks which could signal a heart defect. Downs was ruled out by CVS. My OBGYN says that the risks medically for the twins were equally acceptable if we proceeded to have them or if we reduced. Twin B's placenta tested positive for trisomy 14 mosaicism. (CVS results are attached) . I had never heard of trisomy 14 mosaicism before, I am attaching the article provided by the geneticist that explains it in case studies. It seems worse than Trisomy 21.
Trisomy 14 Mosaicism: Mosaic 14 in the placenta may not be true in the fetus itself.
Detecting fetal genotype is a two step process:
1. Amniocentesis at 17 weeks – can confirm mosaic 14 trisomy in the fetus. A negative 14 trisomy result would still be ambiguous.
2. A follow up UPD test would be needed to show if the two 14's came from different parents. For chromosome 14 there are problems if they didn't -like the trisomy cells corrected themselves but the phenotype will still reflect potential problems of mosaic trisomy 14. By the time these results are back I would be 20 weeks.
The risk of total miscarriage because of reduction are 2-2.5% for weeks 13 to 20 in Dr Stone's (my obgyn's) practice.
The geneticist advises that "If a pregnancy with mosaic trisomy 14 on CVS has a completely normal cytogenetic result on amniocentesis and normal UPD studies for chromosome #14, we would still recommend a comprehensive ultrasound and fetal echocardiogram at approximately 20 weeks gestation (even if earlier u/s and echocardiogram were normal). If all of these test results are normal, it is most likely that the fetus would be fine. I.e. the greatest likelihood is that there wouldn’t be abnormal outcome. However, we could not completely rule out the possibility that the mosaic placenta would not be functioning properly (which could impact growth etc.) nor could we completely eliminate the possibility of mosaicism in other tissues"
MY OBGYN advises waiting until microdeletion results for A are available in 4 weeks and doing the fetal ECG at that time. That should clear Baby A and make Baby B the prime candidate for reduction. However, the question of whether we are risking the reduction of a healthy Baby B may remain unresolved depending on the testing outcomes.
I aborted an IVF down syndrome pregnancy in October 2006 with a heter given by your institute. Then, in 2007 with no medical assistance, G-d blessed us with a healthy baby boy whose welfare must also be considered. When he was born, disputes from family politics about who would hold the baby at the bris resulted in my being medicated with Seroquel for several months in addition to my return to lithium to treat the beginnings of postpartum psychosis when symptoms emerged. Obviously family is not a resource on which we can rely for help in taking care of the children.
As you may remember, I have been manic depressive since age 17. I have been on Lithium since I was diagnosed in 1991, I am resending my psychiatric history until 2002 (attached). My history of Bipolar disorder includes 3 hospitalizations, suicidal gesturing and the knowledge that I will need lifelong medication.
It took me years to find a husband willing to be in my life despite my illness and the potential for episodes that disable me from functioning in my family and outside the home. The increased risk of twins for premature birth, low birth weight, preeclampsia, cerebral palsy, miscarriage can all be reduced by carrying a singleton. I do know increasing stress is always a threat to my health. My husband has demonstrated willingness and ability to care for me and my illness. If he had to care for a bipolar episode and (possibly unhealthy) twins in addition to our toddler simultaneously, while being the sole wage earner in our family he will certainly be overwhelmed. In that instance, both me and the 3 children under 3 years old would not have many of our acute needs met. The thought of being sent to a locked psychiatric ward for the fourth time in my life as a danger to myself and others curdles my blood particularly when I know that, for the first time, it would also mean being separated from my children who need a mother. They would no doubt be left in the care of an unsupervised nanny who I have never met so my husband could try to maintain his business to support the family. My 2 year old has never felt the effects of my illness yet in his lifetime and I would be devastated if my hospitalization became the first note on his psychiatric history. Being put in the position of deciding the life or death of my own fetus is already reliving a nightmare.
I am at a loss for how to navigate making a responsible decision with so many competing interests and stakeholders. Please tell me if halacha could allow a reduction to singleton as an option under my circumstances. Also at what point in the testing process would I be advised/allowed to act knowing that I may never have complete confirmation of health in the face of dubious CVS results?
Halacha allows a reduction to singleton as an option under your special circumstances.