By Dr. Lorna Marshall

As specialists in the field of fertility, we cringe every time a higher order multiple pregnancy (three or more gestations) receives special attention. Almost every Mother’s Day contest for “Mother of the Year” selects a woman who has carried and delivered four, five, or six babies at once. Jon & Kate Plus 8, which chronicles a couple raising twins and sextuplets, has become one of the most popular reality TV shows. To fertility specialists, such pregnancies are associated with preterm labor, tiny babies that need weeks or months of special care in the nursery, and likely one or more children with long-term health or behavioral difficulties. So, in a way, the public outcry against the recent birth of octuplets by Nadya Suleman can have a positive effect.

It’s hard to believe that any conscientious professional would ever consider transferring six embryos into a young woman’s uterus. The current guidelines by the American Society for Reproductive Medicine state that women less than 35 should have one or two embryos transferred into their uterus. Indeed, there are times when medical judgment suggests that perhaps three instead of two embryos can be transferred when their quality is poor or when there have been multiple failed cycles. And, yes, a patient has a right to make her own decisions about health care, but her physician has an obligation to ensure that those decisions are well-informed. Dr. Kamrava’s decision to transfer six embryos into the uterus of 32-year-old Nadya Suleman deviated so much from professional guidelines that every agency that has the power to sanction him should.

When medical care falls below the standard of care, there are many avenues available to reprimand the physician. Hospitals can withdraw privileges, medical societies can expel a member, state licensing boards can suspend the physician’s license, and patients can file a liability claim. Whatever official sanctions are imposed, the negative publicity has significantly harmed, if not ruined, Dr. Kamrava’s career. The public backlash should strongly deter other physicians as well.

So why the cry for new laws to “protect” the public from another set of octuplets? Professional guidelines by the American Society for Reproductive Medicine are strong and have been shown to be effective in reducing the number of embryos transferred and risk of multiple pregnancies. Those who label fertility care as the “wild west of medicine” aren’t aware that the clinical delivery of fertility care in the United States is one of the most regulated areas in medicine. Since 2004, fertility clinics and sperm banks must register with the FDA, which sets standards on infectious disease screening of egg, embryo and sperm donation. Many in our field believe that the FDA’s attempt to regulate the field of fertility has neither improved care nor protected patients, only increased the cost to deliver already costly services.

A recent attempt in Georgia to prevent another “octuplet mom” shows how misguided politicians can be when trying to regulate health care. The original Georgia proposal was drafted by the Arizona-based Bioethics Defense Fund, which opposes embryonic stem cell research and abortion, and the proposal was introduced by Georgia Right to Life. Clearly, the agenda included more than the prevention of multiple pregnancies.

Most higher order multiples are not the result of in vitro fertilization, but are due to the use of injectable fertility drugs, also known as gonadotropin therapy. With gonadotropin therapy, it is difficult to control the number of eggs that ovulate, become fertilized, and eventually implant. Jon and Kate of “Jon and Kate Plus 8” conceived their sextuplets this way. A bill like the one initially proposed in Georgia would actually do very little to affect the risk of quadruplets, quintuplets or octuplets. Because most patients have to foot the bill for IVF, many choose gonadotropin therapy first because of its lower cost. Only 14 states make insurers cover some infertility treatments. In the current state of the economy, it would not be popular to suggest legislation to extend this, although this additional service has been shown to cost insurers very little and may even save them money by lowering the risk of higher order multiple pregnancies.

In response to the birth of the octuplets, we should punish the rogue physician who completely ignored established standards of care in the field of reproductive medicine. But until the government mandates insurance coverage for IVF, don’t let lawmakers who know nothing about reproductive medicine -- and often have other reproductive agendas -- pass regulations that protect neither patients, the public, nor future children.
Marshall is a practicing specialist in reproductive endocrinology and infertility in Seattle, WA. She is president-elect of Pacific Coast Reproductive Society and a former member of the ethics committee of the American Society for Reproductive Medicine.
Copyright (C) 2009 by the American Forum. 3/09

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