A recent survey conducted by The Yomiuri Shimbun has shed light on a significant aspect of high-risk obstetric care in Japan: approximately 30% of university hospitals have admitted pregnant women who underwent multifetal pregnancy reduction procedures at other facilities. This revelation underscores the critical role that Japan's university medical faculties play in managing complex cases arising from fertility treatments, particularly as in vitro fertilization (IVF) continues to contribute to a growing number of multiple pregnancies nationwide.
University hospitals, often affiliated with national and public medical schools, serve as the backbone for advanced perinatal care. These institutions not only provide specialized treatment but also train the next generation of obstetricians and gynecologists, ensuring that residents gain hands-on experience with challenging scenarios like post-reduction twin deliveries. The survey, targeting 90 hospitals linked to 82 universities and covering January 2020 to October 2025, received responses from 72 facilities, revealing at least 42 such admissions across 27 hospitals in 17 prefectures.
This development comes amid Japan's IVF boom, where over 85,000 babies were born via assisted reproductive technology in 2023 alone—one in eight births—leading to elevated rates of triplets and higher-order multiples despite efforts to promote single embryo transfers. As medical educators grapple with these realities, the integration of ethical training and procedural expertise becomes paramount in university curricula.
Multifetal Pregnancies in Japan: The IVF Context
Multifetal pregnancies, defined as carrying two or more fetuses, pose substantial risks including preterm birth, low birth weight, and maternal hypertensive disorders. In Japan, the rise in IVF cycles—exceeding 500,000 annually—has driven multiple gestation rates, though declining due to guidelines favoring elective single embryo transfer (eSET). The Japan Society for Reproductive Medicine recommends limiting transfers to one embryo for women under 35, yet triplets and quadruplets persist, particularly in frozen embryo transfers.
Step-by-step, a typical IVF process involves ovarian stimulation, egg retrieval, fertilization, embryo culture, and transfer. When multiple embryos implant, risks escalate: for triplets, preterm delivery occurs in over 90% of cases, compared to 10% for singletons. University hospitals like those at Tokyo University and Keio University are designated comprehensive perinatal centers, equipped with maternal-fetal intensive care units (MFICUs) to handle these emergencies, training residents in ultrasound monitoring, tocolysis, and cesarean planning.
Cultural context in Japan emphasizes family planning amid low fertility rates (1.26 in 2024), making IVF a national priority with government subsidies covering up to 1.56 million yen per cycle since 2022. Medical schools incorporate this into public health modules, preparing students for the intersection of reproductive tech and higher-order risks.
Decoding Fetal Reduction Surgery: Procedure and Rationale
Multifetal pregnancy reduction (MFPR), also known as selective fetal reduction or fetal reduction surgery, is a procedure to decrease the number of fetuses in high-order multiples (three or more) to improve outcomes for the mother and survivors. Performed between 11-13 weeks gestation, it involves ultrasound-guided transabdominal injection of potassium chloride (KCl) into the targeted fetus's heart or thorax, inducing asystole within minutes. Confirmation via absent heartbeat follows, with monitoring for 1-7 days post-procedure.
- Step 1: Patient counseling and consent, assessing maternal health and fetal viability.
- Step 2: Local anesthesia and IV sedation (e.g., propofol).
- Step 3: Needle insertion under real-time ultrasound.
- Step 4: KCl injection (1-2 mEq), cardiac arrest verification.
- Step 5: Post-op ultrasound, beta-hCG monitoring, psychological support.
Risks include miscarriage (5-10%), infection (<1%), and preterm labor, but benefits—reducing preterm rates from 95% to 60%—outweigh in selected cases. In Japan, clinics like Suwa Maternity Clinic pioneered it in 1986, but university hospitals rarely perform it, focusing instead on sequelae management.
Resident training at facilities like Wakayama Medical University emphasizes simulation for these techniques, fostering proficiency in high-risk obstetrics.
Survey Insights: University Hospitals' Involvement
The Yomiuri survey highlights that only Osaka University Hospital among respondents performed MFPR during the study period, aligning with its leadership in perinatal research. Meanwhile, 27 hospitals admitted post-procedure patients for high-risk monitoring—twins post-reduction carry 20-30% preterm risk—totaling 42 cases. Six facilities referred nine women, indicating a referral network where university centers act as safety nets.
Specific examples include comprehensive perinatal centers at Kyoto University Hospital and Saitama Medical University, boasting large MFICUs for maternal transport. These admissions provide invaluable training opportunities for residents, exposing them to real-world complications like oligohydramnios or growth discordance.Read the full Yomiuri survey report.
Participation interest in Osaka U's multi-center study—8 committed, 23 considering—signals collaborative research momentum across medical schools.
Osaka University's Pioneering Research and Training
Osaka University Graduate School of Medicine led Japan's first prospective MFPR trial (April-December 2024), treating 10 women (7 triplets, 2 quadruplets, 1 complicated twin). All procedures succeeded (100% completion), with 89.5% non-targeted survival; minor issues included one re-injection and one miscarriage. Anxiety scores dropped significantly, though depression persisted, highlighting mental health needs.
The study, IRB-approved, paves guidelines via 3-5 year follow-up. For medical education, it integrates into residency programs, teaching evidence-based ethics and technique via simulations.Access the study publication.
Post-trial, two more cases were treated, positioning Osaka U as a hub for fetal medicine training.
Ethical Dilemmas in Japanese Medical Education
Fetal reduction raises profound bioethical questions: selecting which fetus lives, akin to "playing God." Japan's Maternal Protection Law permits economic reasons for abortion pre-22 weeks, but MFPR treads gray areas. JSOG promotes eSET to prevent multiples, yet no explicit ban exists.
Bioethicist Yukiko Saito (Kitasato University) urges transparency: "Doctors must respond; guidelines are essential for safe practices." Medical schools like Kitasato incorporate bioethics curricula, debating autonomy vs. sanctity via case studies.
Core curriculum mandates ethics on life/death, preparing students for IVF-era dilemmas.
Training Residents in High-Risk Obstetrics
University hospitals train OB/GYN residents (5-year programs) in perinatology. Exposure to post-MFPR cases hones skills in Doppler ultrasound, cerclage, and NICU coordination. Centers like University of Tokyo Hospital, a perinatal hub, simulate reductions ethically.
- High-risk monitoring: Daily NSTs, biophysical profiles.
- Delivery planning: TOLAC risks post-reduction.
- Multidisciplinary teams: Neonatologists, ethicists.
This hands-on approach addresses Japan's OB workforce shortage, with unis producing specialists for rural clinics.
Stakeholder Perspectives and Challenges
Patients face stigma; clinics perform covertly. Faculty stress informed consent, genetic counseling. Challenges: Limited data (no national registry), resident burnout from 24/7 calls. Solutions: Multi-institutional trials, ethics modules.
27 admitting hospitals exemplify collaborative care ecosystems.
Photo by Andrew Leu on Unsplash
Future Outlook: Guidelines and Research
Osaka U's study heralds nationwide protocols, potentially reducing ad-hoc practices. Unis lead via JSOG collaborations, integrating AI for risk prediction. Outlook: Safer IVF, robust training, ethical frameworks balancing innovation and life sanctity.
Explore Asahi's coverage on the trial.
Implications for Higher Education in Medicine
This survey spotlights university hospitals as pillars of reproductive medicine advancement. Med schools must evolve curricula: bioethics electives, VR simulations, interdisciplinary ethics. Prospective students: Programs at Osaka, Kitasato offer cutting-edge exposure. Actionable: Pursue perinatal fellowships for expertise in this niche.
