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Friday, January 30, 2009

Fertility Treatments Under Scrutiny Again

I am sure that most of you heard about the successful births of octuplets last week.  The birth of so many children at one time does raise some, ok many, issues.  The LA Times reports,

Even as the birth of octuplets at Kaiser Permanente Bellflower Medical Center drew attention and applause from around the country, questions arose Tuesday about whether the mother's doctors did enough to prevent such a risky pregnancy.

The chances that the eight babies born Monday were conceived naturally are infinitesimal, infertility specialists and doctors in maternal-fetal medicine say. Today's reproductive experts have the tools and the know-how to avoid such high-risk pregnancies -- and often try desperately to do so.

"When we see something like this in the general fertility world, it gives us the heebie-jeebies," said Michael Tucker, a clinical embryologist in Atlanta and a leading researcher in infertility treatment. Tucker added that in his opinion, "if a medical practitioner had anything to do with it, there's some degree of inappropriate medical therapy there." . . .

The American Society for Reproductive Medicine and the American College of Obstetricians and Gynecologists say "doctors should be making efforts to curb these higher-order multiple gestations," said Dr. Geeta Swamy, an assistant professor of obstetrics and gynecology at Duke University. "But it really is still up to the individual physician. There aren't any laws or legal ramifications to it."

The babies could have been conceived through in vitro fertilization, in which eggs and sperm are combined in the lab and a specified number of the healthiest-looking embryos are transferred to the uterus. That scenario seems unlikely because fertility doctors are asked to adhere to strict guidelines that limit the number of embryos transferred. As a result, higher-order multiple births resulting from in vitro fertilization are uncommon.

A more likely scenario is that the mother of the octuplets received infertility drugs in a procedure called controlled ovarian hyperstimulation. The treatment, which is typically used to achieve pregnancy in women who do not ovulate, stimulates the ovaries to produce a number of eggs. As the eggs near maturity, the patient usually has artificial insemination.  An oral drug, clomiphene, can be used to stimulate the release of one or two mature eggs. But more powerful, injectable medications may produce eight to 10 mature eggs, said Dr. David Diaz, medical director of West Coast Fertility Centers in Orange County.  "That's the most common way these higher-order multiples occur," he said.

Some patients with infertility problems opt to try controlled ovarian hyperstimulation instead of in vitro fertilization because it is far less expensive -- about $2,000 to $3,000 instead of $10,000. Kaiser Permanente does not cover in vitro fertilization for its members. Although the octuplets were born in a Kaiser hospital, it's not known whether the mother is a Kaiser member.  Ovarian stimulation is far less controllable than in vitro fertilization, Swamy said, "because you can't control how many embryos you put back."

Even so, doctors typically go to great lengths to monitor treatments involving infertility drugs, Diaz said. If tests show too many eggs have been stimulated, doctors often will not follow through with a second medication that releases the eggs. They can also drain some of the follicles to reduce the number of eggs released.

If patients choose to proceed with the treatment -- even facing the potential of a large number of eggs being released -- they can later abort some of the embryos if a higher-order pregnancy occurs. Many patients dislike this practice, called selective reduction, said Dr. Harold Henry, director of maternal-fetal medicine at Kaiser Permanente. Some have religious or ethical objections to aborting any of the fetuses; others don't want to risk losing the entire pregnancy.

Infertility experts generally try to prevent multiple births because of the myriad potential health problems for mother and babies and because such births consume enormous financial resources for hospitals, health insurers and families . . . .

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