Andrea Merkord was three months' pregnant when she got devastating news. Doctors told her that two of her triplets were sharing one heart and wouldn't survive. If they died, the third fetus likely would die too.

So Merkord, a 31-year-old medical clerk from Bend, Ore., didn't hesitate when doctors at the University of California, San Francisco, proposed experimental surgery to try to save one of her babies' lives. They would insert a small needle into her womb and use a laser to separate the two endangered fetuses from the healthy one. If the procedure worked, they said, it was possible they could save the healthy baby.

Just a few years ago, fetal surgeries were rare, and only a handful of top research hospitals, such as UC San Francisco and Children's Hospital Boston, performed them. That is quickly changing. Six fetal centers have opened throughout the country in the past four years, and as many as 10 other hospitals are considering similar programs, according to several experts. UC San Diego performed its first fetal surgeries this year.

Meanwhile, doctors are expanding the type of fetal conditions they are willing to treat. Until recently, doctors typically have intervened only when a fetus' life is at stake because of the risk to both the woman and the fetus. Today, however, more hospitals are performing fetal surgeries in cases where the fetus is not endangered.

One new intervention, for example, involves using a laser to cut away relatively common obstructions around a fetus' growing limb, a potentially difficult but clearly nonfatal condition. Doctors also are considering surgeries to repair cleft palates, as well as other cosmetic procedures.

As more hospitals enter the field, a debate is growing among doctors, researchers and medical ethicists. Critics point to a paucity of research about the safety and effectiveness of such procedures; until more studies are done, some are calling for stricter limits. Among their chief concerns: Smaller hospitals with fewer resources and less-experienced physicians are performing the procedures.

Critics say that might increase the risks associated with such surgeries. Several doctors say they are aware of three cases worldwide in which both the woman and her fetus died during surgery. The majority of women who undergo fetal procedures have premature labor, increasing the risk of death for the unborn child. The woman's uterus can rupture, which can require a hysterectomy, or she can have such severe scarring from surgery that she might have trouble conceiving again. And up to 5 percent of children who are born premature following fetal surgery develop cerebral palsy, doctors say.

In 2000, a woman died while undergoing a procedure to reverse a complication involving her twin fetuses. The incident in Florida, at St. Joseph's Women's Hospital in Tampa, was the first known maternal death during fetal surgery in the United States.

The surgeon who performed the surgery believes that the woman died from an amniotic fluid embolism after fluid leaked into her body and sent her into shock; both fetuses also died. The hospital settled a lawsuit with the family, according to spokeswoman Lisa Patterson, who would not comment further about the incident. She says the hospital believes its fetal program is safe and that complications are rare.

Dr. Edmund Yang, director of Vanderbilt University's Fetal Diagnosis and Therapy Center in Nashville, says he is confident that many fetal surgeries offered today will eventually be proved safe and effective. But Yang says the Florida case, as well as reports of medical complications during fetal surgeries elsewhere in recent years, have caused some physicians to rethink which surgeries are appropriate and which are not. This fall, Yang and a group of two dozen surgeons will meet in Dallas to discuss creating national standards for fetal procedures.

"Because of the proliferation [of the surgeries] and the risks, we need a better consensus about what we're doing among doctors, researchers and patients so that people don't get hurt," Yang says.

Because there is no national registry for fetal surgeries, no one can say how many procedures have been performed or their medical outcomes. In interviews with more than a dozen fetal surgeons, they estimated that 400 to 500 procedures will be performed this year at 15 hospitals. As more centers open, doctors predict a few thousand women per year could eventually be candidates for maternal-fetal surgery.

Doctors at UC San Francisco successfully performed the first major fetal intervention in 1981, when they corrected a potentially fatal blockage to a fetus' urinary tract. Doctors are now treating as many as 15 different conditions.

Some operations involve "open" surgery, where doctors cut into a woman's womb, partially remove the fetus and operate while it is still attached to the umbilical cord. Some newer interventions use a less invasive "fetoscope," which is only slightly bigger than a large needle and has a small camera attached to help guide surgeons. Doctors believe fetoscopic surgery is safer, although there is little evidence that's true so far.

Physicians recently have begun operating on fetal heart defects, an experimental procedure generally considered to be at the leading edge of fetal surgeries.

Proponents of fetal surgery insist that many medical innovations -- open-heart surgeries or organ transplants, for example -- contained a significant element of risk as doctors first tried to perfect the procedures. Many also maintain that this is the way medicine works: A small number of patients must agree to undergo experimental procedures so doctors can learn and improve their techniques for the benefit of future patients.

Still, critics say fetal surgery is unique because it involves the life of both the fetus and the woman, who isn't necessarily at risk until she agrees to have fetal surgery. Moreover, although surgery can save some fetuses, a significant number of the babies are born with severe disabilities.

These ethical questions have prompted some doctors to propose that fetal surgeries be performed only as part of large, national clinical studies, which would have to meet federal guidelines about the reporting of results and disclosures to patients.

Susan Wolf, professor of law and medicine at the University of Minnesota who has advocated for limits on fetal surgery, worries that fetal centers aren't doing an adequate job of explaining what they know -- and don't know -- to patients. "What nonlife-threatening condition would merit this level of risk?" she asks.

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