March 30, 2017

Frozen embryo octuplets

I’m still in disbelief despite this news update from a few hours ago, which goes into more detail regarding the octuplets and the way that they were conceived. According to this story, these babies were conceived through a frozen embryo transfer. I guess at some point, my skepticism will have to give way, but up until now, I still had a strong leaning towards believing that this was not through IVF but rather through ovulation induction with either IUI or intercourse.

I highly questioned the fact that these were through IVF for two types of reason – hard medical reasons and human nature reasons. The hard medical reasons are based on the unlikelihood of someone having enough embryos to transfer that they could have eight successfully implant. Many people don’t realize that you don’t always transfer two embryos and get twins or transfer three and get triplets. Rather, if we transfer three, we may get zero, one or two babies. Rarely (but it certainly happens), we transfer three and all three take. It’s mathematically even more improbable to transfer eight and get eight. It would be more likely to imagine transferring, say 14 embryos and having eight take. However, this second scenario, while mathematically more likely is even MORE unlikely from a human nature viewpoint, because it is hard to imagine any physician eager to transfer eight (let alone fourteen) embryos under these circumstances.

Our phones were ringing yesterday with inquiries from reporters fishing for information, asking if we could comment on which RE did this. In all honesty, I have no idea which RE was involved in this case. My colleagues and I have been privately tossing around a lot of conjecture regarding certain of our colleagues, but we have no real proof. I have been flooded with questions regarding this case, but since I don’t have any inside information, I’ll focus my commentary on providing science to answer some what-if questions.

How many embryos would you have to transfer in order to get eight embryos to implant?
This is a question that can only be answered with probabilities and not with certainties. It is akin to asking how many free throws must a basketball player shoot in order to sink eight of them? The answer is it depends. It depends on the skill level of the player and it depends on how the luck factor played out. In yesterday’s post, I worked out the calculations for a few scenarios. If we start out with an assumed 60% chance of implantation per embryo and eight embryos being transferred, the odds that a perfect eight out of eight would take is 1.68%. This is not impossible, but it certainly improbable. However, let’s say that these are top quality embryos from a very young woman who already has proven IVF success, then we might really really stretch things and give her a generous estimate of 75% chance of implantion per embryo. Bear in mind that even if a woman is in her 30’s today, transferring frozen embryos that were created and frozen back when she was in her 20’s give her the same fertility potential today as if she were still in her 20’s. This is why we are excited about the prospect of someday helping women who wish to delay childbearing while still preserving their fertility at the same level as when they were younger. This can already be done, but there are practical limitations of cost and of the fact that the eggs would have to be fertilized in order to optimize their survival and later usefulness. Anyway, if we assume a 75% chance of implantation per embryo, then the chance of a perfect eight out of eight taking would be 10%. So if this pregnancy was indeed from a FET, it is more probable that greater than eight embryos were originally transferred in order to end up with the eight which took.

There was some talk that this patient was actually paid to do IVF. Is that possible?
Egg donors are routinely paid to participate in IVF. The big difference is that the donor does not retain possession of the embryos. Rather, the embryos are transferred into another woman who will be the rightful mom to the baby. There are instances where a shared cycle is done so that one woman donates eggs, retains some of the embryos for herself while relinquishing some to a sponsoring couple. The eggs would typically be fertilized with different sperm respectively (ie the husband of the recipient woman and the husband of the donating woman. I’ve not heard of a case where the donor was both paid and given some of the eggs.

Would it be possible for an insider, say an employee of a fertility program, to pull this off without the consent or knowledge of the doctors?
This was a question posed to me by the KCAL news team. I expressed my opinion that it would not be probable that an untrained technician, nurse or medical assistant could have secretly pulled this off. Even if the embryos were originally created with a legit IVF cycle, I don’t think anyone could have singlehandedly, or with an untrained accomplice, thawed the embryos and performed a transfer that would have resulted in eight babies. It’s conceivable that they could have tried, but it probably wouldn’t have worked. Again, if this indeed was an IVF case, there almost certainly were doctors involved.

Do doctors ever refuse to do IVF on patients or do they accept anyone who has the money?
Haha. I had to add that last part, because a lot of the cynical comments out there on the internet express anger at the doctors who did this, citing the ever-popular complaint of corporate greed as the motivation for them performing this procedure. I’ve even come across some remarks stating that the“three moronic smiling doctors” should have their licenses taken away. I guess that reader did not realize that those doctors pictured in the news are the delivering perinatologists, who had nothing to do with the initiation of this pregnancy. They were the heroes who were forced to save these babies.

We RE’s do sometimes refuse treatment to patients, based on medical unsuitability, age or suboptimal life circumstances. I’ve taken care to always do so tactfully. One example was a woman who wanted to do IVF using donor sperm without her husband’s knowledge. Despite my offer to discuss this jointly with her and her husband, she was very angry at me for refusing to do it. As it turns out, there are some natural checks and balances that prevent some inappropriate candidates from doing IVF. For example, if a financially unstable single woman wanted to have babies so that she could get better welfare benefits, she would run into the problem right away that she could not afford the IVF. There is no shortage of women who want to get pregnant even though they may lack the maturity, finances or life stability to provide for a child. We get phone inquiries at our office from women asking if we would accept their Medi-Cal. On my Google report, I noticed the other day someone who hit my site after searching “gubermint paid fertility treatment”. So yes, while we do at times turn away paying patients, we have a tricky balancing act, because there have been instance of RE’s being sued for refusing to provide services, for example, to gay couples.

How does HIPAA protect this woman’s right to privacy?
HIPAA only applies to “covered entitities”, such as her doctors, insurance companies, etc. It does not apply to her friends, family or to strangers, including reporters. On the news, we have seen the crews near her house, interviewing neighbors. The patient’s father was stopped and interviewed by news crews. There is no absolute legal restriction to this, as the reporters are doing their jobs providing information to a hungry public, but there are certainly moral restrictions, that often are self-imposed. For example, this morning, one of my patients who knows someone who knows someone at the schools of the six older children, told me that there were news crews at the kids’ schools. Is that a little too much?

  • http://unyielding.blogspot.com/ Syn

    “They were the heroes who were forced to save these babies.”

    Yes, they are and it is a shame that they are being dragged over the coals.

  • http://www.mloknitting.com/ MLO

    I do not believe an ethical RE would do this. Something is very, very wrong here. I don’t have any proof, but I smell fraud. Some of the facts just don’t fit.

    Is there certainty that this was even done in an American clinic? Seriously, we do not know anything for sure right now.

  • BB

    “Is that a little too much?”

    What’s a little too much is a mother of 6 approaching an RE and clinic for infertility treatments.

  • IVF-MD

    Come on now. What OJ did was even worse (the first example I could think of, sorry), but wouldn’t it be a little too much to send news crews to his kids’ schools? I’m certainly not defending the actions of this woman. I am all for her being held accountable, but I don’t think doing things to disrupt her kids at their school is the best way. That’s just my opinion. I could be wrong.

  • IVF mama

    1) I believe in some Scandinavian countries, regulations limit REs to transferring 2 embryos, which seems prudent. The main ethical problem in this case is not how many children she has, but the risk to both mother and babies in transferring at least 8 embryos. Most of the octuplets are very likely to suffer negative health consequences due to their pre-natal environment, premature birth, and low birth weight. This strikes me as malpractice on the part of the RE.

    2) Of course, she could have some sets of identical twins in there. I know a woman who had 2 embryos transferred, and she gave birth to triplets.

    3) Since one reference was made to her getting paid, I guess that she was an egg donor. She has been pg 5 previous times via IVF. She seems to have a track record of terrific fertility. She could have used money she received from egg donation to pay for a separate cycle or two to create a bunch of embryos for herself. Possibly, she negotiated being paid and allowed to also keep a few eggs from each cycle for herself.

    I don’t think it is relevant that she is a single mother. What is relevant is how she planned to be able to support and raise these children.

    But there are many, many excellent poor mothers in the world, and many of them have large families (though not too many have 14! But this woman was aiming for 7, which is a more common number… there are many poor mothers of 7 children in the third world…). Of course, before birth control, I think most women who survived childbirths and illnesses had many children. Probably many of the “founding fathers” of our country, and other heroes and great men, were raised along with many siblings by poor mothers.

  • BB

    @IVF mama, most of our Founding Fathers were wealthy or at least relatively well-off: George Washington, Thomas Jefferson, John Adams, John Hancock.

  • http://www.mloknitting.com MLO

    IVFMama, I am one of those patients for whom it is appropriate to transfer more than 2 embryos because pregnancy is so hard to achieve. That being said, due to a variety of life circumstances, I really don’t consider a fetus a baby. And, I have had a late miscarriage. So selective reduction – in the wildly unlikely case of HOMs – would not be a problem.

    There is zero guarantee, to my way of thinking, of a baby at the end of a pregnancy. I have never comprehended women who think there is – and had trouble with DH when he thought everything was ok once we got pregnant. I wouldn’t have told anyone about the pregnancy until the baby was born if I had my way. But that is a difference in family circumstance.

    I want there to be safe and sane guidelines, but I definitely do not want politicians involved. They had to have a Sesame Street style tutorial to understand a beehive. When most non-RE reproductive health professionals don’t understand IVF properly, do you really think a politician can?