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Feature: Fertile attraction
Octuplets case puts the ethics of IVF back under the microscope...

by Jordan E. Rosenfeld

In this age of reproductive wizardry, where babies can be created in test tubes and implanted in women who would not otherwise be able to get pregnant, it sometimes seems that anything goes. Yet the recent media storm and public outrage over Nadya Suleman—the Los Angeles mother of octuplets born in January that were conceived by in vitro fertilization (IVF) and are still in critical care—has led many to think of fertility treatments as Frankenstein manipulations and Suleman as a selfish monster. Other medical professionals are calling her case a "failure of medicine" and defending their profession.

Yet Suleman's is not the first set of octuplets born in the past decade, and multiples ranging from four to six still turn up every couple of years, most famously the sextuplets that made the Discovery Health show Jon & Kate Plus Eight a ratings hit. The outrage over Suleman's case is inspired by revelations that the 33-year-old single mother has six other children ranging from ages 2 to 7, also conceived using IVF, and that she is unemployed and collecting money from state disability insurance.

In light of her case and the furor it has sparked, some Marin fertility doctors are expressing dismay at what they feel are ethical lapses on Suleman's doctor's part, and fear that this high-profile case may dissuade people from seeking fertility treatments, and attract unnecessary regulations to their field.

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WHEN THE REPORTS started tumbling in about "Octo-mom," as she's been dubbed in the press, the finger of blame eventually landed on Dr. Michael Kamrava of Beverly Hills, who is now under investigation for unethical conduct. Dr. Danielle Lane, a Novato fertility doctor, went on the offensive, contacting TV, radio and newspapers to express her concerns that this case might unfairly tarnish the reputation of her field.

Based on the information she'd gleaned from the press, Dr. Lane was horrified that six embryos (two of which allegedly split into twins, totaling eight) were transferred into the uterus of a 33-year-old woman with "proven fertility." Physicians are "mandated by oath to do no harm," she points out. "I would suggest that in a case such as this, some of the counseling to a patient who may want this many embryos transferred is 'doing harm.' Many times patients have asked me to transfer more embryos than I thought was reasonable or safe, and the response is always that my professional judgment is against this decision." Dr. Lane also takes into account people's beliefs and whether they would be willing to have a high-order embryo pregnancy reduced. "If the answer is no, then we are more conservative in the number of embryos we transfer," she says.

Dr. Marcelle Cedars runs the UCSF Center for Reproductive Health's satellite office in Greenbrae. She suggests that a number of factors must be considered beyond just the number of embryos transferred into a patient, including age and health of the eggs used to make the embryos. While six to eight embryos sounds outlandishly high to many, Cedars says, "The whole premise of transferring multiple embryos is that we can't identify which embryo will implant. The reason [fertility doctors] go to higher numbers of embryos is when the patient is an older woman, because the risk that any one embryo is abnormal goes up." That said, she in no way supports what was done in Suleman's case. "Transferring six to eight embryos in someone under 35 doesn't meet or even approach any guidelines from the American Society of Reproductive Medicine [ASRM]. No one would argue that hers was an optimal outcome. Eight at once is a huge burden, not only to society, but in the ability to raise and care for all eight. Even studies that look at families of triplets or quadruplets show that it's difficult for each child to get the attention they need. There's also a high degree of stress, depression and divorce in the parents."

Dr. Mary Hinckley, a fertility doctor with the Reproductive Science Center of the Bay Area, is hesitant to judge Suleman's case without all the facts, but speculates on some of the possible reasons her doctor might have implanted so many embryos. "Did the patient claim a right to [her] embryos and dictate what she wanted done, putting the doctor in a situation where he would have to 'abandon' her if he did not agree with her reproductive choice? How often does this doctor follow standard guidelines put forth by the ASRM? All of us reproductive endocrinologists have faced situations where patients do not fully comprehend the implications of their reproductive choices and we need to guide them appropriately with the years of medical training we have received."

In women 35 and younger, the average number of embryos transferred is one or two. In women ages 38 to 40, all three doctors say they would put two to three embryos back into the woman's uterus, if made from her own eggs. (Donor eggs cancel out the mother's age). In a woman over 42, Dr. Cedars says she might put as many as six embryos back, because each embryo has only a 5 percent chance of survival. She speculates that the doctor who transferred six or more embryos into the 33-year-old Suleman may have been trying to increase his clinic's "just get pregnant rate." All fertility clinics voluntarily report their statistics to the Society for Assisted Reproductive Technology (SART), which publishes fertility figures for all programs in the United States and makes the information available to anyone. This system, Dr. Cedars says, has built an unnecessary competitiveness into fertility programs.

Dr. Hinckley isn't convinced that this competitiveness drove Dr. Kamrava to implant a high number of embryos, but she acknowledges that it's an imperfect science driven by the high emotions of women desperate to become pregnant. "We physicians are always fighting against the high likelihood that no pregnancy will result from a given treatment. Therefore, until we get smarter with embryo culture and selection, we will always be struggling between the two extremes—not getting pregnant and getting too pregnant," she says.

Dr. Cedars feels that unusually high-number pregnancies distract from the true goal of successful IVF—a healthy single pregnancy. "In 2008, 74 percent of our pregnancies were singletons," she says. "Our goal is to eliminate anything more than twins and to get triplets to as low as we can go—our rate is 2 to 3 percent, but we'd like it to be zero."

The risks of birth defects and illness increase monumentally with more babies per pregnancy. Even twins have a six-fold higher rate of cerebral palsy than a singleton. There are also increased risks of brain bleeds, GI problems and respiratory problems; multiples over twins inevitably go into pre-term labor and delivery.

"Frankly, we weren't made to carry litters," says Dr. Lane. "When you increase the number of gestations you decrease the size of the babies and increase the risks of complications for mom including diabetes, hypertension and preeclyampsia. You pretty much mandate these women to bed rest at some point, increasing the healthcare cost and taking them out of the home and the workplace."

Anca Sira, an acupuncturist in San Rafael who specializes in fertility at her Ama Fertility Center, says that 80 percent of her clients have done, or are doing, IVF. She's heard much grumbling among her clients about the Suleman case. "Most people in my practice are pretty upset about it. Some feel 'I can't even get one baby and this kook has 14.' I would agree that it was irresponsible to put in so many embryos with her history of multiple children."

She believes Suleman's doctor is the "one exception to the rule." She says she has never known the fertility doctors she is connected with to be that aggressive with a woman of Suleman's age.

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THE FIRST SUCCESSFUL "TEST tube baby" was born in 1978 in Manchester, England, and the first American baby in 1981. Since then, in the United States alone, more than 37,000 IVF cycles were performed in 2006 (the most recently published figures) according to SART. Originally it was the rare family that could afford to pay for the high costs of these procedures. Though the prices have come down significantly as technology has advanced, and more fertility programs have become available, these treatments are still pricey, out-of-pocket medical expenses, covered by very few insurance companies. A fresh fertility cycle can run from $8,000 to $10,000 on the conservative end (and multiple cycles are often required to produce a viable pregnancy), and when hormone injections are required, another $3,000 to $5,000 alone—and these are just ballpark figures. Marin, with its wealthier demographic, has a slightly higher rate than other areas in the state of women who can afford the expense, but it also has the highest rate of first-time mothers over 30 in the California, according to the California Health Interview Survey. Since women over 30 have an increased risk for miscarriage, birth defects and pregnancy complications, they tend to turn to IVF to assist them more than their younger peers in becoming pregnant.

While fertility treatments are not generally covered by insurance, thanks to the California Family Health Program Bill passed in 1995, any pregnant woman is entitled to receive obstetrical care even if she is uninsured; the state absorbs the cost, even in high-risk cases. While Nadya Suleman is covered by Kaiser, most likely all she paid for the delivery of her babies as well as their treatment in intensive care was a simple co-pay. Dr. Lane estimates the cost of Suleman's delivery and care of her babies, at Kaiser Permanente hospital in Bellflower, to be in the millions and is upset by the "fiscal impact" of high-order multiples on taxpayers.

"Kaiser has to balance its books, which they do by increasing premiums or co-pays," she says. "Someone else is going to end up paying for her medical costs. I'm in a very fee-based area of medicine. My services are cash-based. Few insurance companies cover it. A lot of people choose to write a check for fertility treatments. If you then do something extravagant and have six embryos transferred with no reduction, then I think you have to be responsible for some of the cost of that."

None of these doctors strongly supports the idea of insurance entering the realm of fertility treatments, though they would like to see the treatments become available to more women. Dr. Hinckley says, "Insurance coverage hurts the patient without insurance to an even greater extent as rates are negotiated between insurance carriers and practices. If insurance stayed out of the infertility business altogether, it would likely lower prices."

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NEARLY A MONTH after the octuplets' birth, feelings still run hot—Suleman and her publicity firm have even received death threats. Bloggers and their readers continue to express outrage that this woman is taking up more than her fair share of resources and costing taxpayers' money. Some accuse her of seeking fame and fortune through her children. Her case has even encouraged discussion of whether the U.S. should put a cap on how many children a family can have, like China has, raising questions of reproductive rights.

Just as in the abortion debate, IVF raises the question of where life begins, and whose right it is to determine the outcome of unused embryos. Critics feel it is unacceptable to create fertilized embryos in a lab only to discard them if a patient successfully becomes pregnant, or reduce them after implantation in the case of unwanted multiples.

The most immediate strategy to reduce multiples and fetal reduction rates is for fertility doctors to be conservative in the number of embryos they implant and counsel patients more effectively to know the risks of multiple implantations.

Dr. Hinckley feels that trying to limit fertility treatments opens a door that leads to further ethical dilemmas. "Where do we draw the line on lifestyle choices?" she asks. "Most of us can't fathom raising six kids, let alone a set of octuplets. But should there be guidelines or laws regulating this? And how do we as a society help to optimize quality of life for the children? Certainly many are questioning what quality of life these kids will have given their prematurity and home situation, but where do we intervene short of child and family protective services?"

Dr. Cedars is also leery of talk about any regulations to her field. "First of all, you have to be careful not to jump from one bad example out of the tens of thousands of cycles done in a year when there's been a very strong effort on the part of the [fertility] society to limit multiple births."

She, like many in her field, is pressing for the government to create funding for research so that a process can be honed to identify embryos most likely to implant. Due to a congressional act passed under the Reagan administration, she says, "any research that might involve biopsy of embryos or study of embryos that aren't for the purpose of procreation has been prohibited."

While the government can remain in the gray area in its determination of whether an embryo qualifies as a human being, religious groups do not shy away from stronger opinions. The Vatican publicly made its case last year, condemning IVF. In the official Church document, an embryo is referred to as a "human being in his or her embryonic state," not a cluster of cells. That being said, the Vatican failed to come up with a conclusive answer on what should be done with unused (frozen) embryos.

Bill Berry, a pastor for the Evangelical Christian Church of San Rafael, finds this to be a tough area to talk about. When asked whether he considers an embryo to be life he says, "As best as I understand it, yes." He does not support IVF treatment both because he feels it usurps God's plan for the individual, and because many fertilized embryos are discarded or "die" in the process.

"When we destroy that which is life, then we destroy the potential of that life in the world and its coming to full maturity—what God intended for the world," Berry says.

If he had to counsel members of his congregation who were considering IVF for infertility, Berry says he would tell them, "From my perspective as a follower of Jesus, I would counsel you to trust God. God's in control of our having children or not having children. My recommendation is that you wait upon God."

Not all religions are opposed to IVF, however. Many denominations, in fact, welcome it. Rabbi Michael Lezak of Congregation Rodef Sholom in San Rafael, who calls himself a "Reform progressive Jew," interprets the first commandment from the Torah—"Be fruitful and multiply," in a more open way. "A central text for us is to choose life, but to me that can be read a million ways. I believe we should do everything to treasure life and uphold it, and make informed decisions."

For him, "choosing life" means using whatever resources are available to parents seeking to have children, including IVF. "Thank God medicine can help potential parents achieve that goal. It's a true miracle."

He does concede that the "willful discarding of fetuses" goes against his policy of upholding life, but he admits to not having enough information about IVF to take a firm position.

Dr. Cedars naturally takes the scientific approach. "When there are arguments about when does life begin you have to think about how it happens in nature. Seventy-five percent of all fertilized eggs never make babies. Not all embryos, even in the best environment—the mother's womb—make healthy babies. Fifty percent fail to implant before a woman misses her menstrual period. So when you think of it in this context you have to recognize that the minute an egg and sperm fuse, that's not a baby. It absolutely has the potential to be a baby, and all our embryologists have great respect for them. These aren't just random cells—they deserve a different type of ethical and emotional respect and value, but they're not the same as you and I."

A "fresh" cycle of IVF—in which freshly collected eggs and sperm are cultured to make embryos rather than using frozen ones—costs the patient more money. So many women opt to have multiple embryos cultured and frozen in case the fresh cycle doesn't work. However, frozen embryos have lower success rates, so patients often want more of the fresh embryos to be implanted in them at once.

Patients, perhaps understandably, also tend to feel attached to their embryos, which can often lead to the decision to implant more or undergo more cycles of IVF simply because the embryos have been created. Nadya Suleman said in her NBC interview with Ann Curry, "Those are my children, and that's what was available," leading to speculation that she had her extra frozen embryos implanted rather than destroy them.

Dr. Hinckley has seen emotions drive her patients' desires numerous times. "I have a few patients that struggle with wanting their embryos back in them and not in a laboratory waiting for them, but most patients I see want to know that their embryos are well taken care of until they are ready to use again, and do not have an overly emotional need to transfer high numbers back in a single cycle."

"A doctor is not required to put all embryos in a patient just because she owns them," says Dr. Cedars. "You can't discard them [without permission] either, but it's difficult for the physician to make the balance between the patient's desire and need for expediency and the financial costs and obligations of the process and trying to practice good but safe medicine. It's an imprecise line, which is why we still have triplets. These aren't cavalier or off-the-cuff decisions."