STUDY QUESTION: How do patients and providers perceive and make decisions about possible reductions of multi-fetal pregnancies? SUMMARY ANSWER: Physicians may be transferring additional embryos, assuming that patients will later undergo reduction if need be; but decisions to reduce pregnancies are difficult for patients, who may agree to undergo the procedure in advance and later renege. WHAT IS ALREADY KNOWN: Implanting more than one embryo increases the likelihood that at least one embryo will successfully lead to a child but also that the patient may end up with twins or higher-order multiple births. STUDY DESIGN, SIZE, DURATION: In-depth interviews of ~1 h each were conducted with 37 ART providers and patients (17 physicians, 10 other health providers and 10 patients) and systematically analyzed. PARTICIPANTS/MATERIALS, SETTING, METHOD: The telephone interviews explored the participants’ views and decisions regarding pregnancy reduction. The answers were analyzed systematically. MAIN RESULTS AND THE ROLE OF CHANCE: Providers may be transferring additional embryos, thinking that doing so will increase the likelihood of a ‘take home baby’ and that the patients could undergo reductions, if need be, to avoid the risks and complications of twins or multiple births. Yet patients often appear to have difficulty confronting the prospect of fetal reduction and/or renege on prior agreements to undergo the procedure. Providers should thus be wary and exceedingly careful about these situations. LIMITATIONS, REASONS FOR CAUTION: The sample size was sufficient for qualitative research designed to elucidate the issues and themes that emerge, but not for statistically analyzing how various groups may differ (e.g. physicians versus patients). Future studies should investigate these issues with larger samples. WIDER IMPLICATIONS OF THE FINDINGS: These data, the first to examine how IVF providers and patients view and approach decisions regarding the reduction of fetuses, suggest several complications and dilemmas. This information has critical implications for future practice, guidelines, research and education of providers, patients, insurers, policymakers and others. STUDY FUNDING/COMPETING INTEREST(S): Funding was provided by grant #UL1 RR024156 from the National Center for Research Resources, the Greenwall Foundation and the John Simon Guggenheim Memorial Foundation. There are no conflicts of interest to declare.