[Selective embryonic or fetal reduction by surgical transvaginal ultrasonography].


The increased use of ovulation induction and of medically assisted fertilization procedures involving transfer of 3 or more ova has resulted in an increased frequency of multiple pregnancies. This paper describes 6 cases in which the number of embryos was reduced by a transvaginal transuterine route guided by sonography. 3 women with multiple pregnancies resulting from in vitro fertilization (IVF) in a fertility clinic in France and 3 patients referred to the clinic with multiple pregnancies after ovulation induction elsewhere underwent the procedure under general anesthesia in 1989-90. A needle was introduced through the vagina and the uterine wall and into the nearest gestational sac. A hypertonic solution of potassium chloride was injected into or neat the heart. The needle was withdrawn after verification that cardiac activity had ceased and that the remaining embryos were healthy. A follow-up sonography was done 24 hours later and the procedure repeated if necessary. The 3 IVF patients ranged in age from 26-37 years. The 2 triplet and 1 quadruple pregnancies were reduced to twin pregnancies and all resulted in births of healthy twins at between 36 weeks and term. The 3 patients in whom ovulation was induced ranged in age from 18-26 years. 1 had a miscarriage of undetermined etiology at 20 weeks and the other 2 pregnancies were still in progress after reduction to 2. The literature on the progress of multiple pregnancies is relatively limited. It is recognized however the multiple pregnancy increased the rate of prematurity, of low birth weight, and of intrauterine and perinatal mortality, with the risk increasing as the pregnancy order increases. It is generally advised that pregnancies of orders higher than 3 be reduced, but opinions are divided for triple pregnancies. Selective reduction represents a partial solution to the problem of multiple pregnancies, at the cost of psychological suffering for the parents and an increased risk of abortion with embryonic reduction by different existing techniques. All the series are small and the cases very greatly. It is difficult to compare a reduction from 3 to 2 to a reduction from 6 to 2. A truly comparative study of the different techniques has not been done, but operator experience seems to be a crucial factor. Triplet or higher order pregnancies should become increasingly rare after ovulation induction because of the improving possibilities of rapid assessment of serum hormonal levels and use of sonography. Complete prevention of such pregnancies is much more difficult in the case of IVF. The number of embryos to transfer should be individually decided for each woman as a function of risk factors, taking into account her age, the rate of cleavage, the appearance of the embryos, the indication for the IVF, the couple's feelings about multiple pregnancies, the number of IVF attempts made, and the number of embryos potentially available for freezing and future use.


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