As a fertility specialist, I am calling on the Medical Board of California to investigate the circumstances involving the treatment of Nadya Suleman, the mother of the octuplets born last week at Kaiser Permanente Hospital in Whittier, California. I am also asking for understanding and support for Ms. Suleman, acknowledging that this mother of 14 children has a tremendous task ahead of her regardless of the circumstances that led to her present situation.
We need to know how this happened, so steps can be taken to prevent it from ever happening again.
The information available through the media so far is so concerning that it is imperative the decision-making process that led to the octuplet pregnancy be thoroughly investigated. The Medical Board of California needs to examine the circumstances underlying the Suleman case and to take disciplinary action as appropriate.
In general, physicians are loath to question the actions of another physician. I am speaking out, however, because events like this can have two very negative consequences. First, some couples who would benefit from advanced fertility treatments may now be dissuaded because this news has reinforced a common fear that high-order multiples are routine, or somehow unavoidable when undergoing such treatments. I have already had a number of patients ask me for reassurance that something like this would not happen as a result of their treatment. Second, because the octuplets are doing well, and will almost certainly remain in the public spotlight for some time, the extreme dangers of such a pregnancy may not be appropriately addressed or understood.
I have seen a number of negative comments about Ms. Suleman's decision to allow eight embryos to be transferred to her uterus. She is apparently not receiving the public and corporate support normally afforded women with high-order deliveries such as these (www.foxnews.com/story/0,2933,487518,00.html). This criticism and lack of support is both unfortunate and unwarranted. Ultimately, any support that is given to the family by corporations or individuals will benefit the children, and whatever one might think of this situation, clearly they are innocent and will need all the help they can get.
We don't know what conversation Mrs. Suleman and her fertility specialist had prior to the decision to transfer eight embryos. But even if she specifically requested, even demanded, that eight embryos be transferred, and there is no evidence that she did so by the way, the responsibility for implementing a decision of this type rests only with the treating physician.
Virtually every physician has been asked to prescribe medications or perform procedures that are clearly not in a patient's best interests or are outside acceptable medical practice. Frankly, it's routine in our practice. A significant percentage of those undergoing treatment through IVF request that we transfer an inappropriately large number of embryos, because they have failed so many times on their own and want to "make sure" they get pregnant. Their overwhelming concern is becoming pregnant at all not avoiding multiple pregnancy, because they have been disappointed so many times before. It is the physician's responsibility to provide a patient with only those treatment options that fall within the standard of care for the condition they are treating. Under such circumstances, even obtaining "informed consent" from the patient does not eliminate or even diminish the physician's responsibility.
Here's an extreme example to make my point...
If a patient were to ask to have one of their legs amputated due to chronic knee pain from a sports injury, it would clearly be unacceptable for a physician to comply even if the patient insisted on proceeding after being informed that doing so would be an extraordinarily bad decision fraught with devastating long-term consequences. There is only one person ultimately responsible for providing treatment that falls outside the standard of care--the physician. A patient's consent to it is irrelevant.
According to statements by the octuplets' grandmother Angela Suleman, published in the Los Angeles Times on Friday, January 30, 2009, her daughter had eight embryos transferred in 2008, and "they all happened to take."
If that is true, it's an unconscionable breach of medical ethics and violates the cornerstone of all doctors' primary ethos: "First, do no harm."
Having a child is a monumental life decision. In addition to the responsibility a fertility specialist has to the infertile woman/couple, he or she also has a profound responsibility for the health of any children that might arise from the procedures they perform. Particularly because a third-party (the potential children) can be affected, the infertility specialist must understand the motivation of the person requesting assistance in having a child or children and make sure that treatment decisions are in the best interests of the potential children as well as the infertile patient.
If these media reports are accurate, Ms. Suleman is a young woman with "plugged tubes." Performing IVF in these types of patients yields an extremely high overall pregnancy rate, as well as high implantation rates (the chance that any given embryo will lead to a pregnancy). Obviously Ms. Suleman had a multi-proven history of using advanced fertility procedures successfully, and had previously even given birth to twins. She is probably the last patient any fertility specialist should have been aggressive with in terms of number of embryos transferred into her uterus. She apparently told the physician she only wanted "one child," a girl. In a case like this, it is indefensible to transfer more than one or two embryos.
Guidelines from the American Society for Reproductive Medicine (ASRM) and the Society for Assisted Reproductive Technologies (SART) do not allow more that two embryos to be implanted in a situation like this in "the absence of extraordinary circumstances." (ASRM Guidelines November, 2006.) And there are no circumstances extraordinary enough to warrant transferring eight embryos.
Every birth is a cause for celebration, and like the rest of world I am overjoyed to see positive updates on the health and progress of these eight little miracles. That they were born healthy and continue to flourish is a great testament to the skill and dedication of a very talented Kaiser team and to the babys' will to survive and thrive. But as I celebrate these births, and the remarkable strength of a mother who carried them for an astonishing 31 weeks, as a medical professional with more than 16 years in this highly specialized field, I realize that on occasion luck grants a very poor decision a good outcome. Decisions cannot be judged solely by their outcomes.
Ms. Suleman's fertility doctor put in jeopardy the lives and health of 8 unborn children, not to mention the mother herself. But for the planning and skill displayed by the team of delivery doctors and nurses, what has been heralded as a medical miracle may very well have been an unprecedented tragedy of ego.
UPDATE: According to a CBS News report, the Medical Board of California has initiated an investigation into the transfer of eight embryos in this case (www.cbsnews.com/stories/2009/02/05/earlyshow/health/main4777292.shtml).
Dr. Samuel Wood is one of the country's most highly respected fertility specialists. His distinguished academic background includes an M.D., an M.A. in Psychology, a Ph.D. in Biochemistry and Molecular Biophysics, and an M.B.A. He is Board Certified in Reproductive Endocrinology and Infertility and has served on the Clinical Faculty at the University of California San Diego. Dr. Wood is a frequently sought-after commentator on the myriad ethical issues surrounding infertility and embryonic stem cell research, and has been featured in numerous newspaper, radio, and television segments on the subject of reproductive medicine and stem cell science, including appearances on the Today show, Frontline, Good Morning America, the Discovery Channel, and a BBC documentary that has now been seen in over 50 countries. He is a listee in the 2009 edition of Who's Who in America and was recently named one of the Top 50 To Watch by San Diego Magazine. For more information, visit www.fertile.com.