- The Washington Times - Wednesday, March 4, 2009

In the month since the birth of Nadya Suleman’s octuplets, reaction has gone from curiosity to sympathy to anger. The public has questions about everything from who the father is to how she will pay for diapers and medical care.

Fertility specialists also are asking questions.

Many reproductive endocrinologists have concerns about the doctor who performed in vitro fertilization for Miss Suleman. They wonder how a profession that has highly refined the art and science of helping women who have struggled to get pregnant could be so misused.

“Most in my specialty are outraged,” says Suheil Muasher, medical director of the Muasher Center for Fertility and IVF in Fairfax. Dr. Muasher has been performing IVF and other fertility procedures for more than 20 years.

“It really reflects badly on us. While we don’t really know the exact facts of the case, whatever was done here was outside the guidelines,” he says.

Those guidelines were set by the American Society for Reproductive Medicine (ASRM), the professional organization for fertility specialists. The organization issues recommendations rather than a strict code because each medical case is a complicated mix of factors, including age, fertility problems and previous pregnancies, he says. Doctors come up with the protocol that will be most effective for each case.

Current ASRM guidelines call for women younger than 35 with a favorable prognosis (such as Miss Suleman, who already had delivered six healthy children before she conceived the octuplets) to have no more than one embryo transferred to the uterus during an IVF procedure. Women younger than 35 with a more complicated case and women ages 35 to 37 should have no more than two embryos transferred; women ages 38 to 40, no more than three. The guidelines say women older than 40, who have a slimmer chance of getting pregnant, should receive no more than five embryos.

Miss Suleman said in an interview with NBC that six embryos were transferred during the procedure that produced the octuplets.

R. Dale McClure, president of the ASRM, says he is pleased that the California Medical Board will be investigating the case.

“Physicians have known for many years about the dangers of multiple pregnancies,” Dr. McClure says. “ASRM and its affiliate, the Society for Assisted Reproductive Medicine, have worked steadily to formulate evidence-based guidelines for the number of embryos to transfer in assisted reproductive technology [ART] cycles.”

Dr. McClure points out that the number of births of higher-order multiples has been decreasing since 1997, the year after the ASRM issued its first guidelines. In 1996, 7 percent of ART pregnancies were triplets or more. By 2005, that number had fallen to 2 percent. Meanwhile, success rates for fertility doctors continued to improve, from 28 percent in 1996 to 34 percent in 2005.

Many fertility specialists are concerned that a highly publicized event such as the births of the octuplets will negate their hard work to build a practice high on ethics and success rates and low on higher-order multiple births.

“When I started doing this 20 years ago, it was not uncommon to transfer four, five, even six embryos,” says Stephen R. Lincoln, a reproductive endocrinologist with the Genetics and IVF Institute in Fairfax. “We were not every good at this. Now, despite the case in California, we have seen a significant reduction in higher-order births of triplets or more. We can do better, and we are trying. There are a lot of factors that pressure people to transfer more.”

Dr. Muasher says he is concerned that the publicity over Miss Suleman’s case will cause some would-be parents to reconsider treatment in fear they would conceive six, seven or even eight babies. He says the vast majority of reproductive endocrinologists follow the ASRM guidelines.

“The particular case makes a lot of people fearful,” Dr. Muasher says. “They don’t want to have octuplets.”

That is not to say assisted reproductive technology is without risks. There are risks to the mothers, such as ovarian hyperstimulation, and of course, the risk of conceiving more than one baby. Risks of multiple pregnancies include high blood pressure, gestational diabetes and premature delivery. Most fertility clinics discuss the risks of multiples with patients before they sign consent forms to begin treatment.

Doctors also discuss selective reduction, or reducing the number of fetuses in a multiple pregnancy. Obviously, termination is a tough topic to bring up with a woman who has been eager to become pregnant.

“You have got to have a long discussion with your patient before they get into the IVF cycle,” Dr. Lincoln says. “You have to present what can happen and say: ‘This is our plan.’ What we do is certainly inform them, and they sign consent forms. We talk about selective reduction if multiples are conceived. We are not advising patients to do anything; we are presenting the facts. Obviously, it is their choice.”

Some doctors are concerned that the publicity over the octuplets will lead to an investigation, which will lead to laws regulating specialists. Some European countries have laws regulating the number of embryos transferred. If there were such laws in the United States, they would affect the success rates of many doctors and patients, Dr. Lincoln says.

“We have to remember [the octuplets case] is very much the exception to treatment,” he says. “We have to be careful that we don’t make laws that hurt success rates and deter patients from getting the best treatment possible.

“We are always cautious when the government wants to impose restrictions. Technology is outpacing our ability to morally look at things, and we may make laws today that three or four years down the road may be obsolete.”

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