Preventing Octuplets: an insider's view

Preventing Octuplets: An insider's perspective...

Tuesday morning, as I cared for a patient going through in vitro fertilization (IVF) at our infertility center, I cringed at an interview with Ms. Suleman, the now famous mother of octuplets. This case casts our field in a terrible light. I am pleased that Ms. Suleman is doing well and that her children are somewhat stable, under intensive care. I also understand that the health and outcome of these children will not be known for some time.

What we do know is that carrying multiple babies at once leads to prematurity and low birth weights, which are both risk factors for lung disease, cerebral palsy, and other conditions which can lead to lifelong disability. Our bodies were simply not designed to nurture so many fetuses at once. Unfortunately, it is hard to judge which egg will develop into a healthy pregnancy and therefore we often put more than one embryo back in hopes of achieving a singleton pregnancy.

Dr. Kamrava has appropriately come under professional scrutiny. While I share concerns that he may not have followed the guidelines of our professional society and performed procedures that were outside of our standard practices, I have yet to hear anyone asking critical rather than judgmental or voyeuristic questions. How did this happen? Have we done anything to encourage this? And how can we prevent this from happening again? I want to examine the circumstances that could permit and even encourage this?

The Fertility Clinic Success Rate and Certification Act of 1992 mandates that IVF clinics report pregnancy rates to the Centers for Disease Control, and that these numbers are made available to the public. This creates an incentive for competing clinics to transfer more embryos to increase their pregnancy rates and attract more patients (especially at places like the West Coast IVF clinic, where the implantation and pregnancy rates are below those of many other successful practices). If the law were revised to mandate only reporting the probability of a pregnancy or live birth for each embryo transferred, patients would have a more realistic measure of quality when comparing programs and IVF centers would no longer have an incentive to transfer more embryos to boost their pregnancy rates. Healthy pregnancies should be the goal.

Another issue relates to the way we pay for IVF in the United States. Multiple gestations (especially triplets or more) are expensive to care for and tend to have worse health outcomes for both the babies as well as their mother. Yet our system encourages patients to transfer more embryos because most insurance plans do not cover the procedure; patients usually pay all or most of the costs out of pocket. Given that each cycle costs upwards of $10,000, economic pressures may influence patients to request that more embryos are transferred back each cycle. More embryos however, means a greater risk of multiple gestations (twins, triplets, or more).

In the United States, nearly a third of IVF pregnancies result in twins, half of which will be born premature. Similarly, the rate of triplet pregnancies in the United States has more than quadrupled since the introduction of IVF in the early 1980s, and 90% of triplets are born premature. Again, in IVF the single biggest risk factor for multiple gestations is the number of embryos transferred. Yet, by separating the cost of IVF (paid for by patients) from the cost of obstetric and pediatric care (paid for by insurance), our system indirectly encourages patients to demand that more embryos transferred in order to maximize her chances of getting pregnant. In the end, the cost to society (in dollars and in health) is higher.

Many European countries pay for IVF as part of their national health programs. Since such governments also pay for obstetric and pediatric complications, public health officials deemed it more economical to pay for the IVF procedure but regulate the number of embryos transferred. The result is that more people who need it are able to get IVF infertility care and fewer twins and triplets result. Within the United States, when a few states mandated that insurance cover IVF procedures, a similar trend emerged. The rate of multiple gestations has fallen and the number of infertile patients who are able to receive IVF has increased.

Reducing the number of embryos transferred is fairly well proven to be cost effective, once the loss of productivity and obstetric costs are considered.

Many questions have been raised about whether Dr. Kamrava and the West Coast IVF clinic ignored the ASRM guidelines on number of embryos to transfer, which place the patient's health at a premium. That said, it is important for us to consider the existing factors that encourage such practices. The United States strongly favors state and individual autonomy in our political culture and this does not easily permit regulation of new technologies, including IVF.

The current rate of multiple gestations from IVF is unacceptably high and results in unnecessary health and economic burdens. Yet laws regulating the disposition of embryos risk interfering with privacy rights that lie at the core of women's reproductive rights. And neither I nor my patients want a politician or lawyer dictating the care that I provide. So can we find balance between government regulation and the rights of the patient?

Some suggestions: For starters, clinics should only be mandated to report births or pregnancies per embryo transferred. Patients should be encouraged to transfer no more than the recommended number of embryos (as determined by professional guidelines and the specific history and conditions of each patient). If patients demand to transfer more embryos, perhaps they could be asked to bear part of the economic burden of that choices. A surcharge could be added if patients transfer more than the recommended number of embryos (as the ensuing obstetric and pediatric costs to society will be higher. Such economic risk sharing might encourage patients to be more conservative about their embryo transfer strategies.

I am not sure our system can afford to universally cover IVF or that people would accept the restrictions that would likely follow, but in the absence of clear regulatory jurisdiction or mandates, an appropriate first step would be to reduce irrational incentives when healthier alternatives exist.

Comments

[Fam8511]

This is a wonderful article and I agree with you Peter. I think smart regulation is key to avoiding consequences in which neither the patient nor the doctor would want. In this case Nadia had success in her past, So Why was there encouragement of putting more than one embryo in her? In my opinion I would have only placed one embryo in her. I also agree with you in searching for prominent solution in avoiding a similar situation to occur again. ~Felisha M

[MJinCanada]

Thank you for your explanation. I suspected that Dr. Kamrava was using Suleman as a human guinea pig for his dubious methods but now realize he might also have been using her to improve his clinic's success rate.

A set of rules to protect parents and their prospective children from such unethical practices, without infringing on the rights of women to become parents, is a good idea.

[llisa]

Thank you for this article. I am in total agreement. The goal should always be to produce a healthy baby.

I like your idea of changing the way the statistics are measured.

[zoozey]

Very good article from someone who is very knowledgeable. I did hear her say in her interview on NBC, that each and every time she had been implanted with 6. She had a total of 6 pregnancies. So, all total, she was implanted with 36. This seems preposterous by any scale. I hope that an ethics committee looks into this particular Dr. She delivered only one each of 4 times, and 2 one time, before he agreed to implant the last 6 in her. Why? She claims she didn't want to throw them out. I think all had been done early on and she wanted to deplete the whole batch. Why she wouldn't opt to donate the others to other childless couples is just beyond ME and shows something of her true nature. I am sure she is the exception, not the rule.

[Stephanie Gerson]

speaking of voyeurism, though I caught this via Facebook, I decided to reply here. (hopefully you opted to be notified when someone comments on your post.) anyways, without knowing almost anything else about this issue, what you write sounds super sensible. at the very least, reduce incentives for extra transfers - whether by requiring clinics to report births/pregnancies per transfer, charging patients for more than the recommended number, or otherwise.

is this a conversation that is being had in fertility health? and/or did Nadya Suleman's story make it louder?

[bub26]

"And neither I nor my patients want a politician or lawyer dictating the care that I provide." As long as you pick up the bills, I'm with ya. Go right ahead and implant a plethora of eggs and if all of them take and your patient insists she wants to carry them ALL, you can pay ALL the bills. Oh noble one, playing Santa must be so much fun. Playing God must be as well, eh?

PS I would of used "regulating" instead of "dictating"... got to own it, Doctor.

[Dr. Peter Klatsky - Huffpost Blogger]

Thank you for your feedback. To be clear, I am not opposed to regulation, as long as it is smart regulation and tries to avoid unintended consequences as seen with the Fertility Clinic Success Rate and Certification Act.

I also do not favor putting as many embryos as possible back in. Without knowing the details of this case, I cannot imagine putting more than one or 2 embryos in a woman Nadia's age. Given the fact that she had success in the past, I would have really encouraged her to put in ONE embryo, and would have referred her elsewhere if she wanted to put 6 back (again, that is conjecture, I do not know the details of the case).

Thanks for your feedback. I really appreciate it.

[evaesthetic]

But it WOULD be dictated. Whether you call it that or not. And what this doc doesn't mention is that many women, who transfer multiple embryos, choose to selectively reduce them to a more normal, responsible level. I'm all for common sense guidelines, but as an infertility patient myself, I am fearful what strict government control would disallow. Many clinics discriminate by weight, age and other factors. I would fear what else would get thrown in there with a strict limit on # of embryos transferred, not to mention that people with different diagnoses/­situations need different levels of care.

[MartiWilkinson]

Unfortunately it's this practice of implanting multiple embryos in the hope that one would 'stick' that has resulted in situations like this. I just read that Nadya Suleman has been receiving death threats and, in my opinion, that is way over the top. If my information is correct she apparently had several eggs harvested in her attempts to get pregnant and the six that had been implanted in her were part of the original batch.

Perhaps what specialists need to consider is placing limits on how many eggs get harvested and fertilized. This way someone like Suleman doesn't have to choose between implanting the embryo's or destroying them. I also think there needs to be a limit on how many times a person is allowed to undergo IVF with or without success. I'm thinking of people who have undergone the process several times only to be met with disappointment and heartache. There really needs to be a point to where we can say enough is enough.

[evaesthetic]

And I suppose YOU get to decide how many cycles we infertile folks "deserve"? When do you say "enough is enough"? 1 unsuccesful cycle? 2? Why do you think you are empowered to decide this?

As for limiting the number of eggs harvested, that's a bad place to draw the line. Not all eggs are created equal, and there is generally a very HIGH attrition rate during the course of the procedure. Typically, more than half of harvested eggs do not successfully make it to be transferred.

[voting4BO]

Very informative. I wasn't aware of The Fertility Clinic Success Rate and Certification Act . That would cause some physians to become a bit overzealous in producing high success rates.
I agree, we should look for solutions to prevent this from happening again. Its the kids who ultimately suffer.