Octuplets doctor may have been lulled by past poor success
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.
February 9th, 2009 at 4:35 pm
So I did a little of my own research before getting to your blog. The doctor in question reportedly did a study on “350″ patients - but given his stats over the past 6 years, he hasn’t seen 350 patients. Comments??
http://www.conceiveonline.com/index.php?option=com_content&task=view&id=161&Itemid=105
February 9th, 2009 at 5:40 pm
Smart pickup, Larisa. As patients become more savvy and as the internet allows for more transparency, it will be harder for businesses (including medical practices) to get away with relying on a big marketing budget to bring them customers. I am not familiar with anybody reputable even talking about that particular technique. It doesn’t make any sense to me logically either. The lining is so fragile that putting a scope into the uterus at the time of transfer is just asking for failure. I wonder if it’s only done on their patients over 34?
I guess I should share a story as a disclaimer in case I’m accused of bias. A few years ago, a friend of mine pleaded with her infertile coworker to come see me. Her co-worker asked for my brochures. I didn’t have any. So she went to this doctor instead (the one we’re talking about) because he had much slicker marketing materials AND because he claimed to have the unique techniques that only HE knew. I later heard that patient wound up not get pregnant. So my friend was sad and gave me a tip that I should spend more money on nicer brochures. To this day, I still haven’t.
I’m approached by companies on a regular basis offering to teach me how to market my practice. Marketing works. I know that. There are practices which spend over $1,000,000 on it annually. However, it is not working as well as it used to. Smart patients who do their research will eventually benefit as the internet empowers them with the truth. I’ll do my part to contribute.
February 9th, 2009 at 7:55 pm
So interesting. I think the 2006 stats for this clinic are available online at the link below. When I looked at these I thought they looked abysmal - very happy I’m at a clinic which comes close to or better than the national average. If Ms. Suleman has used this clinic before and really did transfer 6 embies each time and only had singletons and one set of twins maybe she truly believed a high-order multiple pregnancy wasn’t possible.
https://www.sartcorsonline.com/rptCSR_PublicMultYear.aspx?ClinicPKID=2400
February 11th, 2009 at 9:28 am
I came across your site from another IF blog. Do you have a specific time/posting where you answer questions?
Thanks in advance.
February 11th, 2009 at 9:45 am
Ashley, people send me questions and comments through the comments section (as you’ve done) or more individually through Facebook. In general, I answer questions publicly, so that others can benefit from reading the answer.
February 11th, 2009 at 9:59 am
Thanks for speaking up. It’s disheartening to see what plays out in the MSM and the misapprehension it engenders. You’ve gone a long ways towards clarifying things.
February 11th, 2009 at 10:55 am
Dr. Lee,
Have you seen the interview done by Matt Lauer of Dr. Jeffrey Steinberg?
http://www.msnbc.msn.com/id/21134540/vp/29129331#29136289
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?