Octuplet Pregnancy: Poor Medical Judgment, Patient Indiscretion, or Both?

The entire debacle surrounding Nadya Suleman and her IVF “Octuplets” raises serious ethical issues. A formal complaint to the California Medical Board was recently filed, resulting in the censuring of the doctor who performed the IVF procedure that led to this travesty. This has sounded an alarm that it is time for all well intended people involved in Reproductive Health Care to take action. The situation represents an example of “medical science gone wild,” but at the same time it evokes concern about the unregulated field of Reproductive Medicine in general and invites the question, “Is this field on the verge of going out of control?” There can be no tiptoeing around the fact that the Hippocratic Oath which binds physicians to “do no harm” was ignored in this unfortunate case.

Notwithstanding the magnitude of understandable outrage surrounding the IVF octuplet debacle, it must be recognized that it merely scratches the surface of a far larger issue, namely, the fact that far too many IVF practitioners in the United States still feel compelled to transfer multiple embryos at a time. Such practice has resulted in a virtual explosion in the rate of IVF multiple births, which are associated with a markedly higher risk of prematurity, low or very low birth weight, perinatal death and more frequent lingering neurological complications, as well as an increased risk of birth defects.

When comparing singleton with twin and triplet pregnancies we find the following:

• Twins have 3-times greater mortality rate and triplets, 6-times greater than singleton pregnancies.
• Twins have a 6-times greater likelihood of developing cerebral palsy and triplets an 11-times greater likelihood.
• Twins are 50%, and triplets 80% more likely to be born prematurely.
• Mothers of twins are 3-times, and mothers of triplets, 7-times more likely to experience serious pregnancy-induced complications.

First, most infertile patients simply do not perceive any great risk associated with multiple gestations, especially when it comes to twins. In fact most, consider multiple pregnancy to be a “bonus”…a favorable outcome. Faced with the high emotional and financial cost associated with IVF treatment, most couples prefer to complete their families in one attempt so as to “maximize the use of their resources.” In fact, when asked, almost 90% of couples undergoing IVF in the United States are desirous of having twins. Some are even interested or covet having high order multiples (triplets or beyond). Education is urgently needed to make IVF candidates fully aware of the risks associated with multiple gestations.

Second is the relative inability to reliably differentiate between embryos that will propagate a healthy pregnancy and those that will not. Most IVF patients erroneously believe that a “pretty”, embryo (one given a high embryo grade because it fulfils the microscopic criteria of “good quality”) should invariably propagate a baby. This is simply not the case.

Numerous studies have demonstrated that the cumulative birth rate after single embryo transfer (SET), followed by subsequent transfers of individual thawed left-over embryos, is as effective in achieving pregnancy as implanting multiple embryos at one time. And by this approach, the risk of multiple births can be virtually eliminated. Moreover, using the SET approach, more than 80% of women under 40 years will have a baby within 4 attempts.

But it was the recent the introduction of genetic tests such as comparative genomic hybridization (CGH) that, by allowing for the identification of those embryos that are most likely to propagate a viable pregnancy, promises to make it even easier to avoid multiple births. Yes indeed, the transfer of a single CGH-selected embryo results in a healthy baby more than 60% of the time. And what is more, such genetic embryo markers can also improve the efficiency of the IVF process by reducing miscarriages and minimizing the risk of chromosomal birth defects such as Down’s Syndrome. With such new technology, the dream of “one embryo, one baby” will hopefully soon become a reality.

No physician seeks to limit the freedom by which he or she practices medicine. On the other hand, when outrages such as IVF-octuplet pregnancies occur, it is time to go back to the drawing board and re-examine/revamp existing practices so as to avoid repetition of such blunders.

Perhaps the time has finally come for mandated regulations that would limit the number of embryos permitted to be transferred to IVF patients in this country.