I had to be a little bit sneaky today.

In the past week, three couples returned for a second baby. These three had similar stories in that all of them conceived with IVF within the past few years and were now back for another baby using their frozen embryos.  Two of these couples came back for their re-consultation as a family (husband + wife + baby/babies). One of the big perks of this job is the opportunity to actually see, hear and touch (sometimes even smell, ugh) the babies we helped conceive and to learn that they are happy and healthy and that the parents are glad they did the treatment. I have yet to encounter a couple who tell me “You know? It’s really a lot of hard work to raise a baby. I don’t know what we were thinking and now we wish we hadn’t done it.” Perhaps there ARE couples out there who feel that way, but they just are so mad at me for getting them pregnant that they don’t wish to ever speak to me again. Who knows?

Anyway, two of these couples came back all together with a whole family, but the third one came back as wife and baby alone. She said that her husband was too busy at work to make it. This created a problem for me – not a medical problem but more of a legal one. Hypothetically, how was I to know 100% for sure that this couple was still married since the time of the original IVF? How was I to know for sure that this was not a case of an ex-wife wanting to get pregnant again WITHOUT the blessings of the ex-husband? How was I to know that a disgruntled estranged husband, who is now on the hook for child support payments for a child that he did not wish to have conceived, won’t get mad at me for helping this to happen? Sure the scenario sounds far-fetched, but there have been lawsuits reported in just such a case.

I have to confess I may not have been as diligent about this ten years ago, but over the years, especially with this recent octuplets case, it has come to our attention that we, as RE’s can stand to be a little more aware of the overall picture of future social implications, rather than just be embryo-placement technicians. Even though there are consent forms required for the FET, which require signatures from both partners, it’s fairly easy to fake a signature. We don’t require notarization on our consent forms.

So I picked up the phone and played detective. I called her husband on the pretext of just saying hi. Then I subtly said, “Hi ‘John’, this is Dr. Lee. How are you? I just met with ‘Jane’ and we discussed the upcoming embryo transfer. I was wondering if you had any questions for me.”
He acknowledged that he had no questions. I then asked him if he was in agreement with our future strategy on how many embryos to transfer. He replied that he would not mind twins this time, but was really hoping for just one. We then exchanged a few friendly words regarding basketball and then ended our conversation. It took all of three minutes, but I was then able to document in the chart that I spoke with the husband and I am assured that he is on board with our upcoming baby-making project. Notice I didn’t overtly call him and say, “Hey John. I see your signature on the consent form here in front of me, but I need to hear from you explicitly that you are aware and in favor of Jane doing a frozen embryo cycle. You ARE, aren’t you?”

That would just sound too untrusting of me.

As a welcome relief from all the sadder posts about the octuplets, I’m reminded that there are many optimistic diligent students who might someday be the RE’s of the future. Here are some of their questions:

How do you become an RE? What classes do you suggest I take in highschool? in college? I’m a freshman in highschool and I think I might be interested in this career. Is there anything I should know?
And another afterthought, are there any depressing side effects like couples (mainly females, I assume) that break down?

Ashley

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I thought it would be appropriate to introduce myself. I am a third year medical student that follows your blog. I have always been interested in Ob/Gyn and have been fortunate to shadow a couple REI’s from my hometown in Wichita, KS.

I am an aspiring REI. I was wondering if you could give me some suggestions on how to reach this goal. Also, do you feel it would help if completed an M.D. residency rather than a D.O. residency? I did read the part of your blog where you address that REI is extremely competitive and to make sure to be happy as a general Ob/Gyn if you weren’t able to get a fellowship.

I just completed my required Ob/Gyn rotation, and I really loved it. My attending did quite a bit of infertiity for a general Ob/Gyn, including FSH injections because of her unique situation of being in a small town. It was a great rotation.

Keep blogging! Thanks in advance.
Paige

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Hi Dr. Lee,

I’m Jay, a third-year medical student at the University of Missouri School of Medicine, undergraduate degree from UCLA 2005. I know you’re probably inundated by millions of messages like this, but I am EXTREMELY interested in going into REI as a career choice. My father is a general OBGYN but I’ve determined that REI is the way for me. Do you have any pearls of wisdom as I embark upon the rigorous application process for OBGYN residency? Anything would help. Thank you so much Dr. Lee, and congratulations on all your success. I came across your blog from StudentDoctorNetwork and have bookmarked it now to visit daily. Thanks!

Sincerely,

Jay

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Hello Dr. Lee,
I recently came across your blog and it’s so informative. I am currently an OB/GYN intern at Meharry and I have had a longstanding intrest in REI. I was just curious to know how you knew that REI was what you wanted to pursue. I guess a part of me is hesitant due to the competitiveness of getting IN to the field, but I am also not trying to let my possible future escape me due to fear! Any advice?
Look forward to hearing from you,
Nke

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Thank you all for your questions. I’ll start with the straightforward part. Ashley, in order to become an RE, you first graduate from college, and then go to medical school for four years. Afterwards, you do a four-year residency in OB/Gyn and then an additional three years of a fellowship in Reproductive Endocrinology and Infertility. You’re probably thinking “That is a quite a lot of schooling”. I’m sure you can do the math yourself, but I personally took an accelerated route (started early and skipped one year) and even so, was already 30-years-old by my final year of fellowship. Other RE’s who take a less direct route are already over 40 when they finish their training. So one big question to ask yourself is whether or not you’re willing to dedicate such a big chunk of your life to learning the knowledge and skills that it takes to be a good RE. The good news is that you don’t have to commit to that decision right this moment. You can take it one step at a time, focusing now on making the most of your high school experience and doing your best to get into a college that is good for you. By the way, if you want to immerse yourself in the field of fertility and don’t want to go the long route to becoming an RE, you could participate as a medical assistant, nurse or Physician Assistant. I realize that it’s not the same thing as being an RE, but it has its good points too. You could also choose to be an embryologist, although the everyday atmosphere is very different in that you would interact mostly with egg, sperm and embryos rather than directly with patients.

Ashley, right now, while you are in high school, rather than restricting yourself to any specific MUST-TAKE classes, your best strategy is to make the right decisions so as to maximize your options. What does that mean? I’ll share with you an answer your teachers and school counselors may never tell you. Here’s the secret. When it comes to a career in something competitive like medicine or law, there is a delicate balance between doing what it takes to “play the game”, and doing what it takes to really grow and learn as a person. Shall I explain? On one hand, many pre-med students take the extreme “Cutthroat PreMed” approach and focus single-mindedly on what it would take to get into the best college or the best medical school. Somewhere along the way, they find themselves losing their humanity and falling into the trap where every major decision is geared towards getting accepted and not necessarily towards becoming a well-rounded doctor. “Hmm let’s see, I will need to spend next summer pushing wheelchairs at the hospital so I can say I have some hospital volunteer experience and I’m going to run for Assistant Vice-Treasurer of the Lithuanian Pre-Med Students Association so that I can have some extra-curriculars to list”. If you single-mindedly focus on getting great grades, great MCAT scores and a long list of activities on your resume, but ignore developing yourself as a human being, your odds of getting into medical school will still be pretty darn good, but you have sadly missed out on a some great years of your life. And worse of all, you might find yourself being a very depressed resident or graduated doctor someday.

On the other extreme, some people take the “Rebellious Anti-PreMed” approach. They adamantly refuse to the play the game. “I’m not going to waste time studying for Organic Chemistry since I know that 99% of doctors will never use it in their daily practice. And I refuse to obsess about the MCAT. How does my performance on multiple choice questions reflect how caring and empathetic I’ll be as a doctor? I’m going to focus my energy on the practical courses like microbiology and anatomy and then round myself out with a lot of psychology, literature and history classes, as well as enriching my writing skills”. While I personally agree with this in spirit, I also have to warn you that in actual practice it doesn’t work. This attitude of not taking things like Organic Chemistry and the MCAT’s very seriously is one easy way to NOT get into medical school.

Furthermore, Ashley, it’s so good that you’re already asking questions at this point in your life, trying to get an edge for your future. If I could go back in time and meet my past self when I was in high school, one of the many things I would tell myself (besides save all my paper-route money and invest in Microsoft) is to develop a habit of regular reading. Many smart thinkers throughout the centuries have “figured things out” and put their discoveries down in words. Even if you could gain just 1% of their pearls of wisdom, your life could be significantly easier and happier. Now I know there are people who scoff at self-help books because we probably all know a friend who reads them or goes to self-help guru seminars, but yet their lives are not something that we would care for. Reading self-help books but not acting on the advice learned is like trying to get in shape by buying more and more exercise equipment. It’s not as powerful if you just read and don’t apply what you’ve learned.

Now if you want to know which specific books I would recommend, I would start by telling you that I’ve read tons of books and some of them have been tremendously helpful to me and others have been a waste of time. There are people out there who have read my “waste of time” books and found them to be the most helpful while my “changed my life” books did nothing for them. So the point is that everybody is different. To get started, visit this site and print out the books listed. Check out a few from the library. Devote at least two hours every week (more if you can) to leisurely looking through them. If a particular book does nothing for you, let it go. By the way, even if a book does not thrill you today, you can always give it another try a few years later. If however, you DO find a book that grabs you, share it with a friend and discuss it together. Anyway, Ashley, thank you for your question. I hope I was of help. If my answer was not what you were looking for, I only ask that you revisit it every few years as you progress in school. One day it will click. Oh by the way, in answer to your question about dealing with couples who break down emotionally, you are correct in guessing that this field of medicine contains some of the most emotional extremes. lt comes with the territory. You will share the agonizing pain of many couples as they have failed cycles and miscarriages, but the trade-off is huge as you get to rejoice with the many more couples who end up as happy parents! I can’t imagine many jobs that have more of these types of highs!

Paige and Jay, since the two of you are already in medical school, congratulations! You have already set yourselves above the rest of the pack, demonstrating that you have figured out what it takes to succeed. Maybe you would be better suited to give high school students like Ashley advice, since the timeline for your successful decisions is much more recent than for mine.

As for what tips I can give medical students, there is nothing secret other than to get into a good OB residency. One question is this: Is it better to go to a great OB residency that does not have its own REI fellowship? Or better to go to a lesser residency that does have a fellowship program? The answer, as always, is ‘it depends’. First of all, the question is tricky because it assumes that we know what makes a program better than another and the fact is that we don’t. Keeping all this in mind, when you are deciding how to rank your program choices, my opinion is that presence or lack of a fellowship SHOULD come into the equation. The reality is that people do their fellowships at the same place they do their residency much more frequently than could be attributed to chance. There are several reasons for this. One is familiarity. As a fellowship director, it’s safer to take someone who is well known to you and to the other faculty in your department than someone who is a total stranger.

Paige, as for your question about DO vs MD residencies, my general advice is to aim for the most competitive program that you can get. As some of you know, I am on faculty at UC-Irvine College of Medicine as well as Western Health Sciences, so I regularly lecture to hundreds of MD students and DO students each year. And while it is more than possible to become an RE through the DO route (I personally know some excellent RE’s who are DO’s), it is much easier to get there through the MD route. Again, some of this is out of our control. It’s easier for a football team to win the Super Bowl by first winning their division and getting a bye than it is to win as a Wild Card team that barely made the playoffs. However, as the 1980 Oakland Raiders, 1997 Denver Broncos, 2000 Baltimore Ravens, 2005 Pittsburgh Steelers, 2006 Indianapolis Colts and 2007 New York Giants have proven, it happens more often than one would expect.

One general tip for medical students, residents and doctors is to realize that our lives are “different”. With so much expected of us, we really need to make the most of our God-given 24 hours each day. This means we should strive to always do the best thing at any given minute. This should NOT be interpreted to mean that we should always be studying or at the hospital, because sometimes the best thing to be doing at the time is to be watching the sunset with a loved one or to be sleeping or to be at a funny movie, because only then can we be recharged to go back into the hospital at our fullest energy level. There is a term called ‘lifehacking’, which I define as squeezing the most out of each minute of life. I am a big believer in the concept. That’s why I try to learn and find the most efficient ways to do things like setting up macros for repetitive tasks on the computer and listening to audiobooks during commuting or while at the gym to make the most double use of each hour. One specific book that I highly recommend is Getting Things Done. If you find that it completely changes the way you organize your life, please drop me a line to let me know.

As for the tricky fact that in order to do REI, you have to go down the OB pathway, I can say this for myself. I’m guessing that had I not gotten into an REI fellowship and was now practicing general OB, I would still be happy. I can’t imagine I’d be as happy as I am right now, but it wouldn’t be that terrible. I say this even though I realize that the work-day (and work-night) of a general OB is very different from the work-day of an RE. So if you think that you would love being an RE, but hate OB, then my advice is not to take the gamble. As you can see from a previous post, the ratio of applicants to acceptances is around 2 to 1.

Last but not least, Dear Nke. Congratulations on not only making it through medical school but already being in the world of OB/Gyn. I hear words similar to yours all the time, not with respect to applying to a fellowship, but with respect to trying infertility treatment. Patients sometimes are afraid to try even a Clomid/IUI cycle because they have a fear that it might not work. They don’t worry about the cost or the time commitment or the risk of multiples so much as they worry about the misery of doing a cycle and failing. Sure it’s sad to do treatment and not get pregnant, but is it really all that much better to remain not pregnant because you never tried to do any treatment? As for your question about when I decided to pursue going into REI, it wasn’t until I was on my way to applying to Gyn-Onc that I changed my mind.

Anyway, I commend your attitude. You have already committed to OB, so that’s one bridge crossed. Now that you’ve done it, I encourage you to explore it open-mindedly. After all, this is just your first year of residency. Who knows? You might end up loving Gyn-Oncology or Maternal-Fetal. But I agree with you in any case. Don’t let fear of not succeeding prevent you from trying.

To the best of my knowledge, this pregnancy did not involve IVF. There seems to be a lot of news lately involving pregnancies in which the identity of the father is unclear. If any of you are worried how a 13-year old and a 15-year old are going to support a child, rest assured that everything is well-taken care of.

What a coincidence that it happened in a country which is even more of a nanny-state government than the US. Well, than we are so far anyway.

For those wondering what actions our regulatory board is taking, here’s a letter from the esteemed Executive Director of our society that I received yesterday by email:

I am sure all of us have followed with interest and concern the unfolding story of the Suleman octuplets in California. I wanted to take a moment to share with you some of what ASRM and SART have been doing in response.

Our Public Affairs office began taking calls (after business hours on the East Coast) the evening the birth of the octuplets was announced on Wednesday, January 28. In these early days of the story we focused on reminding the media that while the successful delivery of the octuplets was novel, such a high order multiple birth should not be considered a desirable medical outcome.

On Friday January 30th an interview with the children’s grandmother made it appear that IVF treatment had indeed been involved. That morning we released a statement from ASRM President Dale McClure MD. That statement emphasized that we did not have the facts in this case, but that in recent years ASRM and SART had been working very hard, and with a fair amount of success, to reduce the number of high order multiple births. (That statement, and all our press releases are available at www.asrm.org.) By weeks end the Public Affairs Office had responded to well over 100 calls, and ASRM staff and leaders had done dozens of interviews.

Over the course of the next week, the volume of media calls remained very, very high. However, since no new information emerged, the media questions and coverage became increasingly speculative in nature. Because we did not feel it was responsible to engage in that speculation, we began to curtail our responsiveness. Meanwhile, SART sent a communication to its membership seeking any information anyone had on the situation.

As the Today show began to air its interview with the mother on February 6, she indicated all her children were the result of IVF and all from the same physician, and subsequent media reports named the physician. On Monday February 9, ASRM President McClure issued another statement, again emphasizing the field’s success in reducing the number of high order multiples, and indicating we were interested in looking into the matter. On Tuesday, February 10th I sent a letter to the California Medical Board stating our interest in this matter and our willingness to assist them in their inquiry. SART President Elizabeth Ginsburg, MD sent a letter to the physician named in media reports to ask for information about the treatment of this patient.

Examining and learning from both successful and unsuccessful cases is a vital component of medical education and an important tool in improving clinical practice. We are seeking information so that all of us may better understand how to avoid additional extreme high order multiple births. Moreover, we have all worked too hard to improve care and reduce the number of high order multiples to allow one unfortunate outcome to taint the whole field. Both ASRM and SART have membership standards and disciplinary procedures and should the facts warrant, those procedures will be used.

It is important to note that we do not have all the facts. At present I would say we have very little information, and most of what we think we know has come from sometimes conflicting media reports. All of us need to be very cautious before coming to any conclusions. We will keep you  informed as additional information becomes available.

Robert W. Rebar, M.D.

Executive Director

American Society for Reproductive Medicine

The following excerpt from another recent press release shows just how much we, as a society, have accomplished in lowering the risk of high order multiple pregnancies.

We issued our first embryo transfer guidelines in 1996 and began to see a reduction in high-order multiple pregnancies the very next year. According to the CDC, in 1996 7% of fresh, non-donor ART cycles reaching embryo transfer and resulting in a live birth were triplets or more. By 2005, that number had fallen to only 2% of such cycles. This was achieved without hurting the pregnancy rates for our patients. In fact, during the same period, the success rate from fresh non-donor embryo transfers increased from 28% in 1996 to 34.3% in 2005.

I was watching this clip of Nadya Suleman’s interview and noticed a few interesting things. For one thing, I’m not a psychiatrist, but I have a strong suspicion of her having some Axis II psychopathology. What I AM more qualified to comment on are some medical inconsistencies in her statements. In part of this clip, she mentioned that what she did to conceive the octuplets was “the same procedure” as how she got her other six children. BUT, then later on, the narrator of the piece completely says the opposite by stating these eight babies came about as a result of a DIFFERENT procedure. Nadya herself then goes on to support this, saying:
“So then when I did this, I actually was very reluctant, because it wasn’t familiar to me. It was very new. And I thought it wouldn’t work at all. That was pretty ironic because he said ‘Oh No, it’s less invasive and maybe it will work with…you know. it’ll be the same, it SHOULD be the same.’ But we didn’t know.”

Her words are a bit disjointed, but still, what could this mean? I will feel a greater sense of clarity if/when the medical details of this case are corroborated by Dr. K himself. But, I wonder, what did she mean when she said that this procedure wasn’t familiar to her? Could she possibly mean that she had an IUI instead of IVF or FET as she keeps insisting? Again, this is purely conjecture on my part, but I was not alone in initially suspecting IUI rather than IVF in this case. It wasn’t until later when she publicly announced it was FET, that many of my colleagues and I finally backed down on our insistence that this was likely IUI, with its greater unpredictability, rather than a willful controlled transfer of a set number of embryos.

It would take a great number of eggs to bring about eight live births, but there are other stories coming out regarding other patients whom Dr. K allegedly stimulated aggressively. It adds to the mystery the fact that Nadya may have had ectopic pregnancies before. After a tubal pregnancy, sometimes the Fallopian tube on the affected side is completely removed and in other times, it is left intact with just the ectopic pregnancy itself scooped out. In still other cases, the ectopic pregnancy can be treated non-surgically with just medication to stop its growth. So, if one or both of her tubes are gone, it would lower the odds or even eliminate the possibility of this being from IUI.

A reader had commented on few things that didn’t make sense:
He brings still another doctor into this equation, the embryologist. He states that while the ultimate decision to implant six embryos (and remembering that Nadya claims six embryos were implanted each time she became pregnant)was Dr. Kamrava’s, the embryologist is the consulting doctor on the viability of each embryo implanted, the adjective “quality” comes to mind. In last night’s Dateline Nadya stated that her doctor told her that her reproductive system was prematurely aging, that if she wanted to do this, she needed to hurry up.
I’ve read that each cycle the ovaries are hyper-stimulated to produce multiple eggs BUT that there may be few OR many eggs produced each cycle, this does not mean each one is of the quality needed to produce a successful pregnancy.
Since Nadya stated each time six eggs were implanted (and that she was consulted each time it could result in multiple gestations)that would be a total of 36 eggs implanted in her.
That sure doesn’t sound like an aging reproductive system to me.
HOWEVER, in last night’s full Dateline, Nadya claims she had two failed procedures after the twins, one ectopic pregnancy. That would bring the total of all of her procedures to 48 total implanted embryos in one woman! It would also total EIGHT times Nadya had Dr. Kamrava treat her by IVF. Dr. Kamrava CLAIMS that his procedure has eliminated ectopic pregnancies because the embryos are implanted directly into the endometrial lining.
Does any of this make sense?

Let me address some of those issues.

What is the role of the embryologist in deciding how many embryos to transfer?
It is true that the embryologist gives the clinician information about the embryos. This information (along with the patients’ age and history) is what we use to decide the number of embryos to transfer. I have two embryology labs that I work with, so the procedure is a little different at each one. But, generally, before each transfer I meet with the embryologist. He/she will show me a photograph of the embryos as well as a grade and description. We’ll discuss things briefly. Then I sit with the couple and explain to them my recommendation of how many to transfer. Often, I will give them a choice of two options, like 2 vs 3 or maybe 3 vs 4, depending on whether they want to be more aggressive (higher chance of pregnancy) or less aggressive (lower risk of twins/triplets). I DO ask the embryologists for input, but what’s nice is rather than just relying on a verbal description, I have the pictures as well, so I can see for myself. I’m not sure if someone is suggesting that the embryologist be partially at fault in this case? I personally can’t imagine how they could be to blame, because the decision is ultimately that of the physician.

Is it consistent that somebody’s reproductive system is prematurely aging and yet they have enough eggs/embryos to make octuplets? This is highly unlikely. However, I can imagine a scenario with frozen embryos where someone once made a lot of eggs in the past, had their retrieval, had the eggs fertilized and then had the embryos frozen. Years later, their FSH starts to go up, meaning their reproductive system is aging. Then, because of all the “young” embryos saved up from before when their age was less, they now have enough embryos to have many babies.

Can IVF result in ectopic pregnancy? It certainly can. This is very unfortunate. One would think putting embryos in the uterus would result in them staying there. However, it’s reported that about 1% of IVF cases can result in ectopic, only a little less than when compared with getting pregnant naturally. Apparently embryos can move after transfer. In the past, some thought that these ectopic cases were due to inadvertent transfer of the embryos into the wrong place, ie the tube. However, evidence now suggests that even if you make sure to put the embryos in the correct place, it can happen. I’m not talking about the silly hysteroscopic method that Dr. K describes, but rather, ultrasound-guided transfers, which many RE’s have already adopted as an accepted way to improve IVF success. I once had a case where the patient wound up with a healthy baby in the uterus AND a coexisting ectopic pregnancy, after IVF, indicating that one of them must have moved. By the way, my closest RE colleagues and I totally discount the “hysteroscopic implantation into the endometrium” technique advertised by Dr. K.

I’m still hoping that nothing ends up happening that will hinder the many patients who are being managed by us other RE’s as a result of this one doctor’s actions, but I certainly do understand the public’s gut reaction to all this. I feel it myself. I think back to years ago when an elderly driver plowed his car into a crowd of pedestrians, running over several of them. There was a similar uproar that arose demanding that all old people should be banned from driving or at least be subjected to greater scrutiny. And I know how I felt about that.

In closing, I’ll take this opportunity to address the readers who were offended by my entitling my first post on this matter, “Miracle Octuplets“. I truly find the fact that all eight survived to be a medical miracle pulled off by the amazing team of perinatologists at Kaiser. I do not think in any way that this case was positive from a reproductive endocrinology standpoint. Thanks to everyone for the input. The unfortunate infertile couples in the world and I are saddened, alongside the general public, with each new revelation about this case.

I met with nine other RE’s and embryologists last night in Pasadena for our almost bi-monthly journal club. I was reminded then by one of the attendees that these journal club meetings originated from my own idea over a year ago. I don’t really care if I get credit for these meetings but I must say I love the fact that we have them. We are friendly competitors in a sense, but yet, we come together for the purpose of intellectual debate and the sharing of information and experiences, all to further hone our clinical decision-making skills.

The official topic of discussion was PGD, especially with respect to how PGD is sometimes used as a way to avoid the implantation of genetically abnormal embryos. I’ll make a note to possibly write here someday on this topic. But I’ll just share our conclusion that in general, it is NOT a good idea to use PGD in the hopes that it will increase pregnancy rates, because it just doesn’t work well that way. There are other good reasons for doing PGD, but the evidence shows that trying to use it to raise pregnancy rates doesn’t work. Basically, the bad outweighs the good.

One thing that I’m reminded during these meetings is the high dedication to innovation we have in our field, especially from the embryology sector. As clinicians, the people who deal directly with the patients, we can tweak our protocols here and there in an attempt to find better ways to do things, but the most significant advances in our field which have led to a huge jump in IVF success over the years, come not from the clinical side, but rather from the people in the lab. Every day, there are many people who never have contact with patients, but who are diligently working, coming up with better ways to nourish embryos so as to boost success rates. We all know that the better the value of the product that we can offer to our patients, the more business we will earn. This benefits our practices AND it benefits our patients. I can tell you that this would not be happening as successfully if there were no economic incentive to do so. If we had socialized medicine in a way that would give little financial incentive for new discoveries, then sure, scientists would still be trying to make new discoveries, but they would be like government workers, clocking in and clocking out, doing their time to collect their benefits and paychecks, but they would NOT be furiously burning the midnight oil, busting their butts to competitively get these improvements out there for the people as soon as possible. Look at how much postal service and public education has improved (or not) over the past twenty years. Compare this to how much cell phones and computers have improved. Regardless of your political beliefs, I would invite you to ask yourself – do people work harder when there is also a personal incentive driving them or do they work the same as when they are doing something solely for the so-called “public good”?

Inevitably during the evening, after a few glasses of wine, the conversation turned to the topic of the octuplets. Some of us, specifically the RE’s from West LA, knew the doctor better than the rest of us. We discussed our experiences with this doctor and his brother, who is also an OB/Gyn. Some of us also shared our own “war stories” of our own cases in which we transferred five or more embryos. No, none of us ever came close to getting octuplets. Our most somber conclusion, at least in my opinion, is the very real worry that the California government will overreact to this outlier event by taking our ASRM guidelines on number of embryos to transfer and turning them into strict laws. For years, things have been good the way they are. But now, because of this one incident, we could find our hands tied and forced to practice medicine as dictated by politicians and not as dictated by our years and years of medical experience and training. It’s as if someone committed gruesome serial murders with a bowling ball and now the government will outlaw bowling balls. Who suffers as a result? Well, we RE’s will suffer with respect to having our autonomy curtailed, but we will also end up doing more cycles as the success rate drops. So in my opinion, the real victims will be infertility patients. Consider this sobering thought. Several years ago, if these guidelines would have been turned into strict inflexible law with no leeway for wise clinical judgment, then many happy children laughing in playgrounds today would never have been born. I am 100% certain of that.

The story of Nadya Suleman’s interview on the Today show gives the name of a fertility clinic and a doctor in Beverly Hills. It doesn’t blatantly declare that he is the one who did her treatment, but if he is, we can look at the CDC data for some further insight.

The most recent CDC report is the 2006 report. There is a lag between the time the data is collected and the time the data is released publicly, so I don’t know about 2007 and 2008 yet.

In 2004, the doctor who was mentioned in the article reported his outcomes to the CDC. In 2005, he did NOT report. In 2006, he reported again. It is unclear whether the practice was idle for 2005 or just failed to report. You are supposed to report, so I’m not sure why there was none for that year.

Anyway, taking the data that we do have, let’s look at one of the most relevant indicators, the % of live births per embryo transfer.

This is the data for the mentioned center from 2004:
UNDER 35: Average # embryos transferred = 3.8. Live birth rate per transfer = 4 out of 18 = 43%
35 - 37: Average # embryos transferred = 5.3. Live birth rate per transfer = 0 out of 4 = 0%
38 - 40: Average # embryos transferred = 3.5. Live birth rate per transfer = 0 out of 8 = 0%
41-42 :  Average # embryos transferred = 2.4. Live birth rate per transfer = 0 out of 7 = 0%
Donor cycles: Average # embryos transferred = 4.0. Live birth rate per transfer = 2 out of 18 = 11%

Compare this to the national averages for 2004 (See page:
UNDER 35: Average # embryos transferred = 2.5. Live birth rate per transfer = 43%
35 - 37: Average # embryos transferred = 2.7. Live birth rate per transfer = 36%
38 - 40: Average # embryos transferred = 3.0. Live birth rate per transfer = 25%
41-42 :  Average # embryos transferred = 3.3. Live birth rate per transfer = 15%
Donor cycles: Average # embryos transferred = 2.4. Live birth rate per transfer = 51%

So the first thing that we see is that this program does not do a whole lot of cycles. Even for a solo practice, the volume is quite small. Next we see that the number of embryos transferred in this program is higher than the national average for the younger patients, especially the 35-37 age group. Younger patients are the ones in whom you typically have a choice of how many to transfer. This is because younger women produce more eggs and have more embryos to choose from. In older patients, you often end up transferring every favorable-looking embryo you have, which can sometimes be just one or two.

The pregnancy rates here for patients 35 and over could not be any worse than the zero % success rate reported by this program. However, it is theoretically possible that with such a small sample size, this program just happened to attract only 19 patients in this age group for 2004 and they happened to have poor egg quality. To get around this, one way to better measure a clinic’s success that is less dependent on patient sampling is to look at the donor success rate. Cycles with donor eggs are more uniform, because egg quality doesn’t play into the equation signficantly. For the mentioned center, their fresh donor cycle live birth rate was 2 out of 18 cycles. This is well below the national average of 51% nationally. Also the number of embryos transferred with egg donor cases deviated from the national average by a lot (4.0 vs 2.4).

As I mentioned earlier, there is no data for this center from 2005.

The 2006 report is not published on the internet yet, but the data is publicly available if you order the report. As RE’s ,we get a complimentary copy of the report.
So here is the data for the mentioned center in 2006:
UNDER 35: Average # embryos transferred = 3.5. Live birth rate per transfer = 2 out of 15 = 13%
35 - 37: Average # embryos transferred = 2.3. Live birth rate per transfer = 0 out of 6 = 0%
38 - 40: Average # embryos transferred = 2.3. Live birth rate per transfer = 0 out of 8 = 0%
41-42:  Average # embryos transferred = 2.5. Live birth rate per transfer = 0 out of 8 = 0%
Donor cycles: Average # embryos transferred = 3.0. Live birth rate per transfer = 0 out of 3 = 0%

Again, compare to national averages for 2006 (which don’t differ drastically from 2004):
UNDER 35: Average # embryos transferred = 2.3. Live birth rate per transfer = 45%
35 - 37: Average # embryos transferred = 2.5. Live birth rate per transfer = 37%
38 - 40: Average # embryos transferred = 2.9. Live birth rate per transfer = 28%
41-42 :  Average # embryos transferred = 3.2. Live birth rate per transfer = 15%
Donor cycles: Average # embryos transferred = 2.3. Live birth rate per transfer = 54%

So, in summary, in a previous post when I was discussing the decision process of how many embryos to transfer, I mentioned that it depended on the expected % of successful implantation. The above data would suggest that in this particular practice, the expected % of success per embryo is really low, perhaps less than 2%. So, if you’re expecting that low of a chance, then why NOT put in a lot of embryos and see what sticks? The problem arises when you have an outlier case that surprisingly behaves very differently from your standard cases. I think it’s a lot like trying to have a conversation at a loud crowded party. You end up getting very accustomed to shouting, but if someone all of a sudden turns off the music and the room goes quiet, you could find yourself embarrassingly shouting something very loud for all to hear. Looking at the 2004 data, if he transferred an AVERAGE of 5.3 embryos for the four cases in women 35-37, that means in some he transferred fewer than 5.3, but in others he transferred MORE than 5.3. But it didn’t cause any harm with multiples. In fact, not a single embryo resulted in live birth at all! Note that programs with very high numbers of embryos transferred and very low pregnancy rates could have a population of patients that is particularly challenging or could have issues with their embryology lab, or both. But how far can we suspend our disbelief when in the last two years of published data, there was not one single live birth in anyone over 34.

Now another question that comes up is this. Is the data reported by a clinic accurate? Well, in the past, we have been routinely audited by the CDC people. They come and look at our charts and make sure that the data we report is truthful. It’s kind of a pain because it totally disrupts our practice for 1-2 days as they come and pore through our charts and nicely interrogate us. However, after it was over, because we passed, it was a welcome relief and we felt very vindicated. Now you should know that we all have to submit some sort of registeration data on our patients once their cycle is started, BEFORE the outcome is known. This prevents people from just conveniently leaving out and not mentioning the failed cycles. So it would be hard to lie about your stats. You could theoretically lie about the number of embryos transferred if you could get your embryologist to be in cahoots with you regarding the charting, ie putting in eight embryos, but only charting that you put in three. However, this would be as unlikely as a teacher deliberating falsifying a student’s grades or a lawyer coaching a witness to outright lie. I am still skeptical and think that more than eight were transferred to get the eight that took, but I am basing this on logic. I guess I’ll have to take them on their word that this pregnancy was indeed from six embryos transferred and a miraculous implantation of a perfect six out of six took PLUS a even more improbable splitting of two of them.

I guess the bigger question is how does a program that has outcomes like these stay in business? Perhaps spending on advertising and marketing can go a long way in Beverly Hills. But that’s a topic for another post.

By the way, I do personally know this doctor. All of us RE’s know each other, for the most part. But what I’ve written in this post is based on the CDC data and I’m judiciously reserving any comment, good or bad, based on any inside information.

It’s kind of fun writing on breaking news. I had to patiently wait until I saw all my patients this morning before I could race to my desk and whip out this post.

I came upon this blog post because it had linked to me. There was some good detective work done here, with some interesting observations revealed. I sort of felt like I did when I was reading the DaVinci Files.

I may turn out to wrong, but I still think it’s possible that the reports about the octuplets being from transfer of eight embryos will turn out to be inaccurate. Rather than this being a case of eight hits out of eight chances, it’s more plausible that this is a case of eight hits out of MORE THAN eight chances. Either this was ovulation induction with more than eight eggs ovulated or this was transfer of more than eight embryos. I gave some sample calculations in a previous post. Excerpts of my comments appear today in USA Today.

I recently had an interesting journey into another world, all without leaving the comfort of my computer. One of the fun things about having your own website is to check out where the referring traffic is coming from. So whenever I notice a large number of hits coming from any new site, I will often go to that site and find the page or reference from which my site was linked. Well after the recent flurry of activity regarding the octuplets, I followed the traffic back to a certain site which turned out to be a bulletin board for a special-interest group. I could not access it without first registering as a member. So I went ahead and made a quick account under my old internet alias “IVF-MD”. I entered the site and spent a little time browsing. I found out it was a safe haven for people who call themselves “child-free” (the hyphen is my own doing). I have previously heard the distinction between childless (want children, but still don’t have any) vs. child-free (willfully do not want children) and this was a site for the latter group. The site was a place where they could safely congregate and support each other’s desire never to have kids without being judged, questioned or pulled into a debate. The members of the site were in an uproar about the octuplets, but then again, who isn’t? As I was navigating the site, I noticed a section at the top of the page announcing “WHO’s ONLINE” with a listing of the different members who happened to be online at the time, and my identity was pasted across the top of the list. There I was — “IVF-MD” on a website for people whose very worldview is generally not in favor of people who do fertility treatment. I felt like a male who had just stumbled into the ladies room by mistake. With a little sense of panic, I glanced at the FAQ of the site, where it encouraged people to “introduce yourselves”. I found the section of the site entitled “INTRODUCE YOURSELF”, and I went on and jotted the following apology:
“I am a physician who helps couples who want babies. This is one of the last places for me to come. However, please allow me to explain my visiting. I am likely perceived by many of you as part of the enemy. I apologize for upsetting you, if that’s how you take it. But, I’m never going to post anything further. I just came by to learn a little and to be open-minded and enlightened. I found your site when I noticed a number of hits to my blog from this site, meaning that some of you dropped by to visit ME.
Anyway, I strongly support your right to be child-free and I do counsel patients to consider that as another good option.”

In retrospect, I later realized that this was a mistake. Putting myself in the shoes of the members of the site, I later understood that this was their safe place, where they could support each other in their shared belief of not wanting children. In life, they are often inundated with questions from well-intentioned family members or strangers asking them “when are you going to have kids”. People would offer sympathy at their being infertile, and they would have to clarify (sometimes in a less than smiley-friendly tone) “No, I’m not infertile. I CHOOSE not to have children”. In their posts, they often talk about their encounters with misbehaving children. Having run into my share of unruly children at the mall, as I’m sure all of you have, I could certainly empathize with them in that aspect. Furthermore, I later learned that people with opposing views would sometimes come and invade their site for the expressed purpose of stirring up an argument. These were often people from the mommy special-interest-groups who would come over and be in-their-face with comments like “How could you not like kids? Kids are the greatest joy in the world!”

So anyway, I thought I would leave that apologetic post and be done with it. Well, after I posted, I started getting replies to my thread. The first one asked if I had any children. Apparently, if I would have taken the time to completely read their FAQ, I would have learned that parents, while welcome to read all they wanted, were not allowed to post anything on their site. I had said I would not post anything further, but I felt it rude not to answer a direct question so, I replied that I had two dogs, but was not a parent yet. I did add that I might like to be a parent in the future and reserve the right to be one someday. Next, another nice reply came, welcoming me “since you are childfree” and then went on to vent and direct my attention to many of the issues that child-free people face. One of the complaints was directed against doctors who refused to do hysterectomies or refused to do tubal sterilization on patients who did not have children already. I wasn’t aware that this was a huge problem, because most of the complaints I have heard in the past are about doctors who are TOO QUICK to sterilize or to do hysterectomies. I wrote a reply agreeing with the notion that doctors should not assume to know better than the patient what that patient wants. But, as to why a doctor would deliberately withhold treatment from a patient, doctors have to be careful of doing something even if a patient says she wants it because of later accusations that they didn’t counsel the patient enough. If a 22-year-old woman without children demands to have her tubes tied, any doctor that does it could be subject to a major lawsuit if that woman later changes her mind. Cases like this have happened.

So the thread progressed into a civil exchange of ideas about doctors being too condescending in refusing to do what a patient wants vs doctors getting in trouble for doing something that the patient would later regret. It was an informative mutually respectful exchange. Then some more replies trickled in.

One of the replies simply reminded everyone that I may or may not be lying when I said that I had no children and that they can only take me at my word regarding that. Perhaps I was already in a hyper-sensitive state, but I was a bit irked at being falsely accused, albeit indirectly. Then two more replies came in questioning me further. They brought up the point that if I really intended to just come into their domain and lurk (ie silently read what others had to say but not say anything myself), then why did I do the direct opposite and not only introduce myself, but also continue to post rebuttals to their questions.

My first reaction was to defend myself (and I did), going into detail as I have above about how I happened to stumble on their site when I followed the traffic back from my own site. After giving it a little more thought, I was able to see it from their point of view. This is their official public policy about whether or not parents were allowed to post on their site:
“This board is a safehaven for the Childfree where we do not justify ourselves, thoughts, decisions, or actions to any non-CFers. This is a companionship board, not a debate board, and posts questioning the Childfree or extolling the virtues of parenthood will not be tolerated.
We’ve had parents posting here before. We’ve seen parents post at other childfree-only boards. What we have never seen is a parent who could carry on the sort of conversation we have here without getting offended sooner or later and pulling the “as a parent, I…whatever” out of their arsenal.
This board is not the place to discuss regrets, if any, about having children, because this board is not the place to discuss child-rearing issues of individual posters AT ALL. The places on the internet where those conversations are available are legion. The places on the internet where the childfree are free of parents are about 6.
Childfree non-custodial stepparents and fencesitters are, and have always been, welcome to post. Just as the intro says we do not care to hear the virtues of parenthood extolled, neither do we wish to hear the regrets.
You are to be commended for announcing yourself as a parent. Many people have tried to be a part of this community and lied about their childed status. Unfortunately, not one single parental poster on this board has ever managed to keep their kids out of their posts. We don’t care. We really don’t care. Every day in our jobs, in our families, we are inundated with people and their children. We come here to be free of that- childfree, in fact.
Parents should not post here. We ask you to respect the intention of the board. Feel free to read.”

So for me to intrude and engage in a debate, no matter how polite, was just not right. After that, I asked them to delete my account and I left.

As much as my profession sways me to be biased as to the virtues of having children, even to the extent of being proactive about it when it doesn’t happen naturally, I can see the arguments that the child-free make. If they don’t want kids themselves, who are we to judge them, question them or to tell them that they don’t know what they’re missing? I respect anybody’s right to want kids (that they will properly provide for) or to not want kids. Furthermore, the child-free make the point that government funding for IVF is unfair to THEM, because it adds insult to injury to make them incur the burden, as taxpayers, of paying for other people to have kids when they themselves are so against it. Before you get the idea that I agree with them completely, I have to draw the line when I hear some of them rant that they want to unilaterally ban people from having children, even if the parents fully support the children on their own with no government assistance. Their argument is somewhere along the line that each additional person is harmful to the planet and therefore should not be allowed. Some day, when I’m in the mood, I’ll debate this head-on, but I will not make the mistake of doing it on the sacred ground of the websites of the child-free. Rather, I’ll do it here on my own turf.

Anyway, this little adventure was a learning experience for me. I used to be a lot less tolerant than I am today. Nowadays, I make a conscious effort to at least try and see the other side’s viewpoint. One side argues that the government does not do enough to help infertile couples. The other side argues that it’s unfair to force someone to subsidize the conception, birth and maintenance of other people’s children. One side argues that unfit parents should not be allowed to raise children. The other side argues that the state is being too heavy-handed in taking children from their natural parents. I optimistically look forward to the way the world could be some day if we would all make a better effort to see the other viewpoint.