This procedure is performed between 10 and 12 weeks of gestational age, under local anesthesia. Prior to the procedure, ultrasound examination of all the fetuses is performed.

Abdomen is prepared with povidone-iodine solution. Fetus nearest to the ultrasound probe is selected.

Spinal needle no. 21 with stylet is advanced through the abdominal and uterine wall into the fetal sac. Stylet is removed.

Syringe is loaded with 2 ml of 2 mEq potassium chloride.

The needle is visualized on ultrasound and advanced into the fetal thorax.

After the needle is advanced in the fetal thorax, potassium chloride is injected. Needle is removed after confirming fetal cardiac asystole. Cardiac activity of other fetus is confirmed.

Post-procedural second look ultrasound is done after few hours and another scan a few days later.

A more detailed USG of the fetuses can be performed, and nuchal thickness can be assessed as it is measured between 10 and 12 weeks’ gestational age.

Chances of spontaneous reduction of multifetal pregnancy are ruled out.

Lower risk of infection.

In certain cases of MFPR, where difficulty is encountered in reaching the thorax due to the fetal position as well as the location of membranes and placenta, an alternative approach may be the insertion of the needle to the fetal cranium. This approach enables a technically easier procedure than the intrathoracic approach. However, this technique should be reserved for selected cases of MFPR and conducted only by experienced operators and centers.

Multifetal pregnancy reduction has been described as a “new moral problem” created by the advancement, but not perfection, of assisted reproductive technologies (ART) [12]. It is a moral conflict for recipients (i.e., women, couples, partners, and gestational surrogates) who use ART to build their families or assist others in building theirs and then find themselves at risk because of being “too pregnant” with too many embryos. Recipients are asked to make a decision between sacrificing one for the sake of the other(s) or continuing a pregnancy that will, more than likely, have lifelong consequences for the carrier, the children born, and the intended parents. For those with previous losses or failed fertility treatments, this position of having too many seems like another cruel twist to their already painful childless life. For surrogates who believe that they can carry any pregnancy to a healthy conclusion, the decision by the intended parents is often difficult to comprehend and accept.