Treatment options

So there are essentially two active treatment options for TTS; that is to say, two medical procedures one can elect if one decides not to simply let nature take its course. Again, the odds of twin mortality attached to the "let it run" approach are terribly high: 90%+. From our perspective, that's not acceptable when other options exist. Please note that the descriptions of treatments provided below are far from comprehensive and may even be inaccurate in some respects. As with everything else in this blog, we're just laying out what we've learned (we think) in a stream-of-consciousness sort of way.

TREATMENT OPTION 1: Amnioreduction (or serial amnioreduction, which is a fancy way of saying "amnioreduction lots of times")

Amnioreduction is the (relatively) straightforward process of using an extra-large needle to draw amniotic fluid out of the recipient twin's amniotic sac. It's essentially a "treat the symptoms" approach. In the short run, amnioreduction has the effects of (1) probably making mom more comfortable and (2) possibly giving the donor twin more elbow room and reducing the cardiac workload on the recipient twin. In the long run, it sometimes resolves the TTS entirely. No-one is sure why or how, medically speaking.

If, after amnioreduction, the amniotic fluid imbalance does not return, well and good. If, on the other hand, it does recur, additional amnioreductions can be done.

TREATMENT OPTION 2: Fetalscopic laser surgery

Fetalscopic laser surgery is the rather more complicated process of inserting an arthroscopic laser probe into the uterus and cauterizing ("zapping," to put it crudely) some of the blood vessel interconnections between the twins in the placenta. This is a "treat the root causes, as far as we know or understand them" approach to treatment. The intent is to solve the imbalance once and for all--and sometimes, it works. How often is a matter of discussion and debate in the scientific community.

INTERACTIONS BETWEEN TREATMENTS, or IMPLICATIONS OF ONE TREATMENT FOR THE OTHER

Is it possible to undergo both treatments? Potentially. Here's how we understand it:

- Amnioreduction is the less radical (and that's a loaded word, I know) of the two treatments; it's typically doctors' first recommendation because it can be done at nearly any neonatal treatment facility. For example, it can be done at five or six locations in Utah alone. Risks of procedural complications are pretty low because the procedure itself is minimally invasive and complex. But the complication that can result is critical. In the process of amnioreduction, doctors can inadvertently perforate the membrane(s) between the twins, so-called "septostomy." There's some speculation in the literature that this may actually be a good thing in and of itself and that unintentional septostomy is responsible for the "success cases" attributed to amnioreduction. It also means, however, that the laser surgery option is off the table from the moment septostomy occurs.
- Fetalscopic laser surgery is newer, more complex, and more invasive. It may also be more effective. The results of an extensive European study seem to indicate that it hikes the odds of infant survival significantly vs. amnioreduction. More on that later.

ODDS OF SUCCESS

This is where we cross over into the Realm of Significant Uncertainty. The success rates for both treatments are far from settled questions. Here are some odds we've run across in various places. I know they're contradictory to some extent.

- One doctor told us that, with either treatment, we've 60% odds of both twins surviving and 80% odds of at least one twin making it through. You'll find similar odds listed on various Internet sites (including the Wikipedia entry on TTS, I think).
- Another doctor (one of the laser surgeons we've consulted) says that, of couples he admits to his clinic, 33% leave with both babies, 33% leave with one, and 33% leave without either.
- Other doctors point to the major European study mentioned earlier. You can find data about this on the 'net, too. They indicate that the study showed 20-30% better odds of infant survival connected with fetalscopic laser surgery vs. serial amnioreduction.

So the odds are all over the board. I've sort of filed them all away under two major conclusions: (1) the odds aren't stellar no matter how you slice them, and (2) treatment is better than no treatment.