Multifetal Pregnancy Reduction Research Articles

The outcome of the multifetal pregnancy reduction procedures in a single centre: A report of 202 completed cases

ObjectiveTo review the results of fetal reduction procedures in our institution, evaluate its effects on the pregnancy outcome in terms of miscarriage, preterm delivery, taking home healthy babies and discuss the factors that may have contributed to the outcome. Study designThis is a retrospective study performed at the Fetal Medicine Unit of the Sisli Memorial Hospital in Istanbul after ART therapies in our unit from 2000 to 2011. ResultsThe sample comprised 151 triplets, 35 quadruplets, 11 quintuplets, 3 twins, 1 sextuplet and 1 septuplet. The average maternal age was 30 ± 4.4 and the average week of interventions was 11.7 ± 1.3 weeks. In 40 cases two or more needle insertions were necessary. The two-week post-procedure loss rate, defined as ‘the procedure related loss rate’, was 0.7%; however, for the whole sample, the losses were 6.9% when they occured before 24 completed weeks and was defined as ‘the total loss rate’. 184 of the remaining 188 cases had at least one baby to take home (91.1% of 202 patients). The average birth week for those healthy babies discharged home was 35.5 ± 2.4. The rate of early preterm birth before gestational weeks of 32 was 9%. The mean birthweight of this “take-home” group was 2302 ± 525 g. ConclusionFetal reduction in multifetal pregnancy is associated with low miscarriage rate and preterm delivery rates. Fetal reduction in multifetal pregnancy should be considered for better pregnancy outcomes and the results of this study can be used in prenatal counseling.

Trichorionic triplet pregnancies: the effectiveness of multifetal pregnancy reduction after in vitro fertilization-embryo transfer

Trichorionic triplet pregnancies: the effectiveness of multifetal pregnancy reduction after in vitro fertilization-embryo transfer

133: Pregnancy outcome after multifetal pregnancy reduction of triplets to twins versus reduction to singleton

Multifetal pregnancy reduction (MPR) of triplets to twins results in improved pregnancy outcome compared with triplet gestations managed expectantly. However, it is not clear whether reduction to singleton may further improve pregnancy outcome. The aim of this study was to determine the rate of pregnancy complications and perinatal outcomes of MPR from triplets to twins versus reduction from triplets to singleton 268 trichorionic and dichorionic triplet pregnancies underwent abdominal MPR at 11-14 weeks' gestation. Cases were divided into two groups according to the final number of embryos: group A, reduction to twins (n=221) and group B, reduction to singleton (n=47). Main outcome measures were rates of pregnancy complications, late abortions, preterm delivery and neonatal outcomes. Non-parametric statistical methods were employed. Triplet pregnancies reduced to twins (group A) delivered earlier (36 vs. 38.6 weeks’ gestation, P<0.001) with lower median birth weight (2172g vs. 2820g, P<0.001) compared with triplets reduced to singleton (group B). The rate of preterm delivery prior to 37 weeks was significantly higher in group A compared with group B (61.2% vs. 21.9%, p<0.001), although twins were not more likely to be delivered prior to 34 weeks (20.1% vs. 14.3%, p=0.52). Regression analysis revealed that after adjustment for age, parity, BMI and gestational age at reduction, triplets reduced to singleton had lower risk for preterm delivery (OR=0.14; 95% CI 0.05-0.39, p<0.001). We did not find a significant difference in the rate of pregnancy loss before 24 weeks’ gestation (6.4% vs. 1.4%, p=0.07) or the rate of intrauterine fetal death after 24 weeks (4.3% vs. 0.9%, p=0.15). There was no significant difference in the prevalence of gestational diabetes, hypertensive diseases of pregnancy and intrauterine growth restriction. Both groups had comparable neonatal outcomes, except for higher rates of NICU admission (29.2% vs. 4.5%, p<0.001), oxygen support (8.2% vs. 0%, p=0.05) and neonatal hypoglycemia (13.2% vs. 0%, p=0.04) in group A. Reduction of triplet pregnancies to singleton is associated with a lower risk of prematurity and superior perinatal outcome compared with reduction to twins. Therefore, the option of reduction to singleton should be considered in cases where the risk of prematurity seems exceptionally high.

530: Comparison of pregnancy outcomes in 2-to-1 multifetal pregnancy reduction and ongoing twins

530: Comparison of pregnancy outcomes in 2-to-1 multifetal pregnancy reduction and ongoing twins

Multifetal Pregnancy Reduction

AbstractMultifetal pregnancy increases maternal, fetal and neonatal complications, most important being preterm delivery and complications of prematurity. Fetal reduction is a procedure for reducing the number of fetuses to a more manageable number. Reduction of triplet or higher order pregnancy is acceptable and the ending number is usually two. Fetal reduction reduces the risk of preterm delivery. Intracardiac/intrathoracic KCl is used for fetal reduction in multichorionic pregnancy. This is not a viable option in monochorionic pregnancy, where vaso-occlusive methods are used.

Transabdominal ultrasound-guided multifetal pregnancy reduction in 10 cases of monkeys.

Intracytoplasmic sperm injection (ICSI) and embryo transfer (ET) in nonhuman primates, e.g. rhesus and cynomolgus monkeys, has been widely used in researches of reproductive and developmental biology, and the success rate has been improved significantly. However, unwanted multiple pregnancy occurs frequently during the ICSI-ET in monkeys, most of which leads to miscarriages. To improve the birth rate of pregnancies and to safeguard health of host and baby monkeys, multifetal pregnancy reduction (MPR) is necessary. In this study, a total of 10 monkeys with multiple pregnancies received MPR through transabdominal ultrasound-guided potassium chloride injection into beating hearts of selective fetuses. To assess MPR efficiency, 31 monkeys with normal singleton pregnancies and 25 monkeys with twin pregnancies without MPR were used as controls. The aim of the reduction is to keep only one fetus, no matter twin or triplet pregnancy originally. Our results show that six cases of MPR were successful and all of them retained single fetus. Moreover, about 1 month (30.2±1.2 days) of gestation is a better timing for MPR than later stage (50.7±1.9 days). We also found that the remaining fetuses developed normally with full-term gestation and normal birth weight. In conclusion, transabdominal ultrasound-guided potassium chloride injection is a safe and effective MPR method for monkeys with multiple pregnancies.

Committee Opinion No. 719: Multifetal Pregnancy Reduction.

Although not all multifetal pregnancies occur after the use of assisted reproductive technology, fertility treatments have contributed significantly to the increase in multifetal pregnancies. In almost all cases, it is preferable to avoid the risk of higher-order multifetal pregnancy by limiting the number of embryos to be transferred or by cancelling a gonadotropin cycle when the ovarian response suggests a high risk of a multifetal pregnancy. When multifetal pregnancies do occur, incorporating the ethical framework presented in this Committee Opinion will help obstetrician-gynecologists counsel and guide patients as they make decisions regarding continuing or reducing their multifetal pregnancies.

OP23.05: Procedure outcomes of embryo reduction and selective feticide with multifetal pregnancy to twin or singleton pregnancy: a retrospective study

To study the procedure related adverse events and the outcomes of women with multifetal pregnancy, defined as twin or more fetuses that was reduced to twin or singleton pregnancy at different gestational ages. We analysed retrospective data consisted of 382 multifetal pregnancy cases that underwent embryo reduction and selective feticide between 2006.12 and 2017.01. Out of total cases, 179 cases underwent early transvaginal selective embryo reduction (mean 7.6 weeks gestation) and 203 cases underwent selective feticide (mean 13.4 weeks gestation) with KCL injection in the vicinity of the fetal heart via transabdominal approach after ultrasound screening for nuchal translucency and anatomical defects. Procedure outcomes were compared between the two groups. The results showed significant differences between 2 groups (embryo reduction vs. selective feticide) in incidence of procedure related adverse events. The percentage of women with all surviving fetuses after 4 weeks of procedure was significantly higher in selective feticide group (92.0% vs. 98.2%, p=0.009) and the percentage of women with overall procedure related pregnancy loss (defined one and two losses of fetuses after 4 weeks of procedure) was significantly less in selective feticide group (8.0% vs. 1.8%, p=0.009). Incidence of subchorionic hematoma defined by ultrasound after 1 and 4 weeks of the procedure was significantly higher in the embryo reduction group (1 week; 59.8% vs. 27.9% p<0.001, 4 weeks; 34.2% vs. 4.8% p<0.001). Selective feticide group showed less incidence of procedure related adverse events, such as subchorionic hematoma and fetal loss compared to embryo reduction group. Although both procedures are accepted approach in multifetal pregnancy reduction, spontaneous demise of one fetus may occur after embryo reduction, and selective feticide has benefit in enabling chorionic villus sampling and ultrasound screening for nuchal translucency and anatomical defects before the procedure.

Committee Opinion No. 719 Summary: Multifetal Pregnancy Reduction.

Although not all multifetal pregnancies occur after the use of assisted reproductive technology, fertility treatments have contributed significantly to the increase in multifetal pregnancies. In almost all cases, it is preferable to avoid the risk of higher-order multifetal pregnancy by limiting the number of embryos to be transferred or by cancelling a gonadotropin cycle when the ovarian response suggests a high risk of a multifetal pregnancy. When multifetal pregnancies do occur, incorporating the ethical framework presented in this Committee Opinion will help obstetrician-gynecologists counsel and guide patients as they make decisions regarding continuing or reducing their multifetal pregnancies.

OP23.04: Selective reduction in complex triplet pregnancy by radio frequency ablation: single centre experience

The risk of miscarriage and preterm delivery are significantly higher in multiple pregnancies with a monochorionic pair. Intra fetal anastomosis in monochorionic (MC) pair preclude the use of intracardiac potassium chloride and fetal reduction must be performed using cord occlusion techniques such as bipolar cord coagulation, interstitial laser or by radiofrequency ablation. We present our series of selective reduction in complex triplet pregnancy with an MC pair using radiofrequency ablation (RFA). This was a retrospective study of the procedures in our unit for the period between 2010 and 2016. We had 25 cases of complex triplets (19 Dichorionic and 6 Monochorionic triplets). The indications for fetal reduction include 14 of multifetal pregnancy reduction, 9 cases of TTTs in the Monochorionic pair, 1 of fetal anomaly in co twin and 1 of discordant growth in the MC pair. Outcome data was available in 24 cases. Median GA at procedure was 15.4 weeks (range 12.1-21.7) and at delivery was 32.9 weeks (range 17.4-41). We had 3 miscarriages; 2 cases occurred within 2 weeks of procedure. IUD of the co-twin occurred in 3 cases (2 in DCTA and 1 in MCTA). The median GA at delivery following MFPR in complex triplets was 34.6 weeks and in the TTTS group was 32.3 weeks. Complications included complex thermal injury to the co twin in 1 case resulting in the subsequent termination of the co twin. There were no cases of neurological impairment in the survivors post procedure. This is the largest case series of fetal reduction in complex triplets by RFA. Selective reduction by RFA in complex triplet pregnancies resulted in a total pregnancy loss in 12.5% of the cases with an 87.5% favourable outcome, in other words two live babies at discharge from hospital. The gestational age was higher at delivery in the MFPR group compared to other indications for selective fetal reduction. This data is useful in appropriate counselling of complex triplex pregnancies.

Conjoined twins after frozen embryo transfer: a case report and literature review

Objective: To present a case of conjoined twins (CTs) in a triplet pregnancy after frozen blastocyst transfer and a literature review. Design: Case report. Setting: Reproductive medicine center of a university teaching hospital. Case Report: A 24-year-old patient underwent in vitro fertilization (IVF) and received two frozen blastocyst transfers. Sequential examination by transvaginal ultrasonography and transvaginal multifetal pregnancy reduction were performed during early pregnancy. Ultrasound images of the fetus in the gestational sac were assessed. Two gestational sacs were found in the uterus at 30 days after the embryo transfer (ET). A germ with primitive heart beat was observed in each sac. At the seventh week of gestation, one heart was still observed in each sac. At the tenth week, a single fetus was observed in one sac, whereas thoracopagus CTs with one heartbeat were seen in the other sac. Selective fetal reduction of the CTs was performed at the 11th week. Unfortunately, abortion occurred at the 20th week because of premature rupture of membranes. Conclusions: The authors presented a case of CTs that occurred after the transfer of two frozen blastocysts, and suggested that factors such as ovulation induction, intracytoplasmic sperm injection (ICSI), preimplantation genetic diagnosis (PGD), culture time and culture condition, assisted hatching and blastocyst transfer, and maternal age might be responsible for the CTs. The importance of early transvaginal ultrasound in pregnancies resulting from assisted reproductive technologies (ARTs) is emphasized. Selective embryo reduction is an appropriate choice for the management of these pregnancies.

Multifetal Pregnancy Reduction of Trichorionic Triplet Gestations: What is the Benefit?

Objective This study aims to determine the efficacy of multifetal pregnancy reduction (MFPR) in improving obstetrical outcomes for trichorionic triplet gestations. Study Design Retrospective cohort study of patients with multiple gestations delivered by a single maternal-fetal medicine practice from 2005 to 2016. We compared patients with trichorionic triamniotic triplet gestations who underwent MFPR to those with an ongoing triplet pregnancy (TT), as well as primary dichorionic diamniotic twin gestations (DD). Logistic regression analysis was used to control for any differences at baseline. Results There were 42 patients in the MFPR group, 43 women in the TT group, and 693 women in the DD group. Comparing MFPR to TT, the likelihood of preterm birth &lt; 34 weeks was similar (31.0 vs. 39.5%, adjusted odds ratio [aOR]: 0.63, 95% confidence interval [CI]: 0.21, 1.87). There were no differences in gestational age at delivery, pregnancy loss &lt; 24 weeks, or the likelihood of all, none, or at least two babies surviving to discharge. Mean birth weights were significantly higher and cesarean delivery rates lower for MFPR (2,128 vs. 1,836 g, p = 0.028 and 69 vs. 86%, aOR: 0.25, 95% CI: 0.06, 0.94) as compared with the TT group. MFPR had significantly worse outcomes than DD. Conclusion In trichorionic triamniotic triplet pregnancies, our study suggests that obstetrical outcomes may not be as dramatically improved with MFPR as seen in older studies.

Determinants of Ethical Concern With Multifetal Pregnancy Reduction Among U.S. Women of Reproductive Age [17G

INTRODUCTION: Multifetal pregnancy reduction (MFPR) is recognized by the American College of Obstetricians and Gynecologists and the American Society of Reproductive Medicine to be a challenging ethical decision. This study explores the determinants of ethical concern with MFPR among U.S. women of reproductive age. METHODS: Data were obtained from the National Survey of Fertility Barriers (Wave 1, 2004-2007), a random digit dialing telephone survey of 4,794 women aged 25-50. Logistic regression was performed to determine the relationship between ethical concern with MFPR and religion, obstetric history, history of infertility, and history of infertility treatments. RESULTS: Only 14.7% of respondents had no ethical concerns with MFPR, while 44.3% expressed serious concerns. Serious ethical concerns were less likely among women with a history of abortion (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.31-0.58) or with no religious affiliation (OR 0.47, 95% CI 0.31-0.70). Serious ethical concerns were more common among women with a history of multiple gestation (OR 3.30, 95% CI 1.44-7.56) or who attend a weekly religious service (OR 1.55, 95% CI 1.16-2.08). After adjustment, religiosity remained a significant determinant of having serious ethical concern with MFPR (OR 1.18, 95% CI 1.12-1.24). History of infertility and its treatment had no significant association with ethical concerns about MFPR. CONCLUSION: A majority of U.S. women have ethical concerns with MFPR. While religiosity is a significant determinant of this concern, infertility and infertility treatments are not. The overall high level of ethical concern with MFPR underscores the importance of minimizing multiple gestations during infertility treatment.

Effects of fetal reduction in multi-fetal pregnancy on perinatal outcomes

ABSTRACTBackgroundThere is currently insufficient evidence regarding the prognosis of multi-fetal pregnancies reduced to twins or singletons. We compared the perinatal outcomes of deliveries following fetal reduction with the perinatal outcomes of deliveries without fetal reduction.&#x0D; MethodsWe carried out a retrospective cohort study of all births in British Columbia between 2009 and 2013, using information from a population-based database. Comparisons were made between all women who had a fetal reduction to a twin or a singleton pregnancy with those who did not undergo a fetal reduction procedure. The outcomes of interest were preterm delivery and composite severe neonatal morbidity or perinatal mortality. Generalized estimating equations adjusting for maternal age, parity, pre-pregnancy weight, use of in vitro fertilization and baby’s sex were used to estimate odds ratios (OR) and 95% confidence intervals (CI).&#x0D; ResultsAmong 207,273 deliveries, 139 (0.07%) had a fetal reduction. Of these, 89 women delivered twins and 50 delivered singletons. Women who had a fetal reduction were more likely to have conceived with in vitro fertilization (77.6%) compared with those who did not (3.31%). Twins delivered after fetal reduction had lower rates of neonatal morbidity/mortality (OR 0.19, 95% CI 0.08-0.42) compared with unreduced triplets but rates similar to those of twins without a reduction procedure (OR 1.44, 95% CI 0.81-2.58). Singletons delivered after fetal reduction had non-significantly lower rates of neonatal morbidity/mortality than unreduced twins (OR 0.75, 95% CI 0.36-1.57) but significantly higher rates of neonatal morbidity/mortality (OR 3.98, 95% CI 1.91-8.30), preterm delivery and being small for gestational age than singleton pregnancies without a reduction procedure.&#x0D; ConclusionPerinatal outcomes of twins delivered after fetal reduction are better than those of unreduced triplets and similar to those of unreduced twins.

Multifetal reduction of triplets to twins compared with non-reduced twins: a meta-analysis

The current systematic review and meta-analysis evaluates the perinatal outcomes in twin pregnancies following multifetal pregnancy reduction (MPR) compared with non-reduced twins. We considered all studies comparing perinatal outcomes of twin pregnancies following MPR to non-reduced twin pregnancies. Our search yielded 639 publications, of which 91 were assessed for eligibility. A total of 22 studies met our inclusion criteria. Overall, fetal reduction of triplets to twins resulted in comparable perinatal outcomes to non-reduced twins with regards to gestational age and birthweight at delivery, pregnancy loss prior to 24 weeks, as well as the development of gestational diabetes and hypertensive disorders of pregnancy. Of all outcomes, only the Caesarean section rate was significantly higher in the MPR group compared with the non-reduced twins group with an odds ratio of 1.95 (95% confidence interval 1.33–2.87). This meta-analysis suggests that MPR of triplet pregnancies to twins is associated with comparable perinatal outcomes to that of non-reduced twins. This information can further help in guiding, and probably reassuring, clinician and patient decision-making when faced with high-order multifetal pregnancies.

Diachorionic Triamniotic Triplets—Saline Cardiac Tamponade for Fetal Reduction: A Novel Approach

AbstractArtificial reproductive techniques are helping the infertile couples to conceive but with an inherent risk of multifetal pregnancy. Multifetal pregnancies more so; multiple monochorionic pregnancies endanger both the fetus and the mother with an increased risk for morbidity and pregnancy loss. The reduction of multifetal pregnancy using Potassium chloride (KCl) is a usual procedure to reduce multiple pregnancies; but gets complicated in case of monochorionic multiple pregnancies like diachorionic trimnioitc triplets in which KCl cannot be used. In this scenario, the usual procedure for fetal reduction might endanger both the fetuses with common placenta (monochorionic twins). Normal saline was used to create cardiac tamponade to achieve cardiac asystole, which is a novel way of reducing the multiple fetuses with common placentas without an adverse effect on the other co-twin and effect of maternal spillage of the drug commonly used.

Permissibility of Multifetal Pregnancy Reduction from The Shiite Point of View.

Advancements in medical technology have significantly increased the possibility of successful infertility treatment. Medical interventions in the initial process of pregnancy that intend to increase the chances of pregnancy create the risk of multifetal pregnancies for both mothers and fetuses. Physicians attempt to reduce the numbers of fetuses in order to decrease this risk and guarantee the continuation of pregnancy. The aim of this paper is to understand the Shiite instruction in terms of the risks multifetal pregnancies have for fetuses and if it is permissible to reduce the numbers of fetuses. An affirmative answer will lead to the development of Islamic criteria for reduction of the number of embryos. This analytical-descriptive research gathered relevant data as a literature search. We reviewed a number of Islamic resources that pertained to the fetus; after a description of the fundamentals and definitions, we subsequently analyzed juridical texts. The order of reduction was inevitably determined by taking into consideration the rules that governed the abortion provisions or general juridical rules. We also investigated the UK law as a comparison to the Shiite perspective. The primary ordinance states that termination of an embryo is not permitted and is considered taboo. However, fetal reductions that occur in emergency situations where there is no option or ordinary indication are permitted before the time of ensoulment. The goal of reduction can be chosen from different ways. According to Shiite sources, fetal reduction is permitted. Defective fetuses are the criteria for selective reduction. If none are defective, the criteria are possibility and facility. But if the possibility of selection is equally for more than one fetus, the criterion is importance (for example one fetus is healthier).

Outcome of early versus late multifetal pregnancy reduction

Multifetal pregnancy reduction (MPR) is an accepted method of reducing complications of triplet pregnancies and higher-order multifetal pregnancies. Eighty-three pregnancies that underwent early (68 weeks) transvaginal MPR were compared with 125 pregnancies that underwent late (11–14 weeks) transabdominal MPR. Rates of pregnancy loss, preterm delivery, gestational diabetes and hypertensive disorders were similar among both groups. Early MPR was associated with a lower risk for small for gestational age newborns (6.5% versus 19.2%; P = 0.034; OR 0.32; 95% CI 0.11 to 0.92) and a higher risk for single-fetus loss (6% versus 0.8%; P = 0.041; OR 10.58; 95% CI 1.1 to 101.94). Preterm delivery rates seemed to be similar between the two groups. In MPR from triplets, an apparent benefit was observed for early MPR in preterm deliveries before 37 weeks, whereas, in MPR from high-order pregnancies, a benefit was observed for late MPR in deliveries before 32 weeks. Perinatal outcomes of twin pregnancies after early and late MPR seem to be grossly similar. Optimal timing for multifetal reduction depends on other factors, namely, the selectivity of the procedure and patient's preference.

Expectant management versus multifetal pregnancy reduction in higher order multiple pregnancies containing a monochorionic pair and a review of the literature.

To compare the perinatal outcome in multifetal pregnancies containing a monochorionic twin pair, managed either expectantly or by fetal reduction (MFPR). This was a retrospective analysis of prospectively collected data on 47 triplet and 10 quadruplet pregnancies recruited between 10 and 14weeks. Main outcome measures were miscarriage <24weeks, preterm birth, fetal growth restriction, birth weight and survival rates. For triplets the miscarriage rates <24weeks were 6.3% after reduction and 20.0% for expectant management and MFPR, respectively. While we recorded no case of severe preterm delivery <30weeks in the reduction group, it was 25% in those with expectant management. Mean gestational age and birth weight were significantly higher after fetal reduction than for the conservative approach (37.7±1.6weeks vs. 30.9±3.2weeks, p<0.01 and 2676±705g vs. 1429±542g, p<0.01). Expectantly managed triplets were complicated by twin-twin transfusion syndrome in 18.8% and intrauterine fetal death in 8.3%. Survival rates were 85.4% for those managed expectantly and 80.0% after fetal reduction. Mean gestational age of ongoing quadruplets was 26.9±2.0weeks vs. 34.5±4.3weeks for those with reduction of the monochorionic pair (p<0.05). Survival rates were 100% in the reduction group and 58.3% in the expectant management group (p<0.05). There was an inverse correlation between the final number of fetuses and the birth weight. Fetal reduction in triplets and quadruplets including a monochorionic pair is associated with decreased early prematurity. While in quadruplets the overall survival is higher after reduction, there was no difference for dichorionic triplets with reduction or conservative management. Complications owing to monochorionicity are frequently observed.

Multi-fetal pregnancy reduction (MFPR) to twins or singleton - medical justification and ethical slippery slope.

Multi-fetal pregnancy reduction (MFPR) is an ethically acceptable procedure aimed to increase survival and well-being of the remaining fetuses from high-order multiple gestations. In most cases we offer the procedure to triplets or quadruplets and opt to preserve twins; lately, the option to maintain a single fetus was suggested. We examined the outcomes of 140 pregnancies that underwent MFPR in our center and were followed to delivery - 105 were reduced to twins and 35 to singletons. The rate of procedure-related pregnancy loss was identical (2.9%). Leaving only one fetus was associated with a higher gestational age at delivery (35.4±2.4 weeks vs. 37.7±2.1 weeks, P<0.0001), with heavier neonates (2222 g vs. 3017 g, P<0.0001) and with a reduction in the cesarean section (CS) rate (76% in twins vs. 51.4% in singletons, P=0.02). Six pregnancies reduced to twins (5.8%) ended before 32 weeks as compared to one pregnancy reduced to a singleton. We conclude that reduction of triplets to singletons is medically and ethically acceptable, after thorough counseling of patients. However, considering the pregnancy loss risk of MFPR and the relatively good outcome of twin gestations, reduction of twins to singletons is ethically acceptable only in extraordinary maternal or fetal conditions.