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Q&A: Octuplet Birth Raises Questions

by Rita Rubin,  USA TODAY,  Feb 2, 2009

Initial reports about a California woman who delivered octuplets last week evoked wonderment over the fact that all seemed to be doing well.
But as more details about the woman dribbled out, wonderment turned into disbelief for many. The Associated Press has reported that the mother is a single 33-year-old named Nadya Suleman who already had six children at home, and that all 14 of her children were conceived via in vitro fertilization, or IVF.

How she could afford expensive IVF, and why a doctor would transfer enough embryos to result in octuplets, a rare, extremely risky "high-order multiples" pregnancy, is unknown.

"We're certainly trying to find out who the treating physician was so that we can find out the circumstances of the conception," says Sean Tipton, a spokesman for the American Society of Reproductive Medicine.

The octuplets, believed to be only the second set ever born in the USA, have raised a number of questions for fertility specialists:

Q: Are there any laws against transferring more than a few embryos to a woman's uterus?

A: There is in the United Kingdom, which has a national health program, but not in the USA.

To reduce the number of multiple births resulting from IVF, the American Society for Reproductive Medicine (ASRM) and the Society for Assisted Reproductive Technology (SART), one of its member organizations, have drawn up guidelines suggesting limits based on a patient's age and other factors related to her chances of conceiving.

In general, the older women are, the less likely they are to conceive with embryos created with their own eggs. Under ASRM guidelines, only one or two embryos should be transferred to women under 35. The upper limit in women over age 40 is five.

SART could revoke a clinic's membership for blatantly ignoring its guidelines, Tipton says. "Being a member of SART is an important credential, because many insurance companies who pay for IVF will only pay for it at SART clinics," he says.

Q: What are the odds that every embryo will "take" and result in a baby?

A: Remote, says Terrence Lee, a reproductive endocrinologist in Brea, Calif., who writes a blog called Fertility File. "If you hear that a baseball player got eight hits last week, you usually don't think that he had only eight at-bats." Eight babies suggests many more embryos were transferred.

Q: Can't doctors just say no when patients ask that more than the recommended number of embryos be transferred, especially if they question a woman's ability to care for multiples?

A: Not really. The ASRM ethics committee addressed the question in 2004, when it said fertility programs can withhold services only if they have "well-substantiated judgments" that the patient won't be able to provide adequate child-rearing.

That bar is high, says Robert Stillman, a reproductive endocrinologist in Rockville, Md. Drug abuse, child abuse or psychotic behavior could be grounds to withhold treatment. "We're not in a position, nor should we be in a position, of deciding who's going to be good parents or how many children we want them to have," Stillman says.

Q: News reports have said Suleman didn't want to discard any of her frozen embryos. Did she have other options besides transferring them all at once?

A: "This is an avoidable consequence of fertility care," says Anne Lyerly, a Duke University obstetrician/gynecologist and bioethics researcher.

"If she couldn't bear to discard those embryos or to have them be in somebody else's family, they could have been transferred one at a time or two at a time." If that had been done, Lyerly says, Suleman might have decided to stop trying to have more children before using all of her embryos.


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