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.
With all due respect, Doctor, I sincerely hope that the Wild West that is the infertility specialty gets tamed by legislatures. You can’t seriously be against that, especially in states where IF coverage is mandated?!?!??!
Restrictions, guidelines, SOMETHING is needed. No, I frankly don’t trust you to police yourselves. The OctoMom may be an egregious example, but there are plenty of others out there.
If some outside party is harmed or bearing a cost, such as in mandated states, sure, they have the right to have a say, because they have a stake. But everything still has to be balanced.
Let’s say scenario A is the status quo of how the world truly is today with doctors and patients making their own decisions, but with outcomes like the octuplets happening once every few years.
Let’s say scenario B is a world where the US is like the UK and the government imposes a strict limit of 2 embryos allowed per transfer in women under 40.
Now let’s say that out of all the successful IVF pregnancies in the past 10 years, about 10000 of them would have failed rather than have succeeded if only two embryos would have been transferred rather than the number (3, 4 or 5) that were actually transferred. By the way, that is a very very low estimate. There would probably be a lot more newly failed cycles in this scenario.
Which world is better? The one where this octuplet case did not happen, but 10000 singleton and twin babies born to mostly loving stable parents also did not happen or the world as is it today where all 10000 of those babies were actually born but the octuplets also exist? You might also want to directly ask the parents of those 10000 babies, by the way.
The kneejerk “Someone HAS to do something” attitude is usually more harmful that the event that precipitated it.
We could prevent a whole lot of highway fatalities if we strictly enforced a 40 mph speed limit. But is that the best for the overall good? Why don’t we criminalize the eating of dessert for anybody with BMI over 27?
Also, I would argue that politicians with their lack of medical training and their own personal agendas are NOT the best people to make medical decisions.
Dr., I completely agree with you that restricting the number of embryos that can be transferred is a slippery slope. Even if this was restricted, aren’t the high-order multiples usually born from ovarian stimulation with IUI and not from IVF? I thought that the McCaughey and Gosselin septuplets and the Chukwu octuplets were NOT a result of IVF. What’s the point of restricting embryo transfers in IVF when hyperstimulation with IUI is the cause of most high order multiples?
One way to stave off inflexible rules created in backlash to the Suleman adventure,
would be to ensure that the physician in this case pays the fullest possible price in reputation and accreditation.
Without knowing the degree of merit to the civil actions filed against him previously, there is some smoke indicating shady practices on his part. It would be a mistake to the profession to strain to view his acts in the light most favorable to him.
It is obvious to me he knew or should have known his patient was an unsuitable candidate for another mass implantation IVF cycle.
A nanny reports Suleman’s assertion that she was PAID to undergo IVF – and I think her physician may have used her despite or even because of her situation to boost his clinic statistics and promote his SEED technique in order to boost his reputation and bottom line.
If you are unwilling to police unethical practices withing the specialty, expect to have it done for you.
I can’t even type about the octuplet plus mom…it makes my blood boil.
I am however intrigued on PGD. My husband and I tried IVF with PGD 4 times to overcome my husband’s balanced translocation. One chemical pregnancy resulted. We tried one more time and skipped the PGD even though we were counseled on the low chance. (there were quite a few other variables as well on this attempt, for the 4 other I was travel from CA to MD to cycle) My daughters 1st birthday is in 11 days. My pregnancy started off as twins (we transferred 3 embryos) and by 10 weeks one had stopped developing (her brother is celebrating his 1st birthday today, surprise chance to adopt 11 days before I delivered)
Now I have to go turn off the news before I hear how much of my tax dollars will be paying for someone else’s family.
Sarah, I love your idea of letting the consequences dictate the punishment rather than have inflexible rules. That way, in 10 years of practice, let’s say I might encounter twenty cases in which I judge putting in six embryos to be the best thing to do. Let’s say that in those twenty cases, we get 5 singleton pregnancies, 1 twin pregnancy and 10 negative cycles with zero quads or zero triplets even, then my judicious choice of strategy in those 20 cases would turn out to be right.
I am willing to police my OWN actions and be held accountable if I show any pattern of poor judgment and I’m all for punishing those who deserve punishment.
It is a little trickier for me to monitor my competitors because that would be like a girl telling a guy that she likes, “Hey don’t date THAT OTHER GIRL, because she is evil and dishonest and high-maintenance. You should go out with me instead.” There would be potential conflict-of-interest clouding the opinion. If I were to quit working and my sister wanted to do IVF in Southern California, I would very strongly warn her about certain RE’s who are unethical, marketing-savvy scam artists. However, if the general public were to ask me, I would have to cautiously temper my comments. Does that make sense?
Liz, I’m on your side with dismay at our hard earned salaries going to pay for the support of these octuplets. I wonder if Americans are then wildly supportive of welfare $$ for girls who just get pregnant on their own and have kids that they can’t care for. Apparently so, from the way this country votes.
Dr. Lee,
I’m afraid Dr. Kamrava is at it again.
Octuplets fertility doctor at center of another multi-pregnancy
1:22 PM, February 12, 2009
Kamrava_2 The Beverly Hills doctor who helped Nadya Suleman conceive octuplets also provided fertility treatment to a 49-year-old woman who is pregnant with quadruplets and is hospitalized at County-USC Medical Center.
Further down:
“I do think it is concerning, and dangerous, especially to the mother,” said one doctor with knowledge of the case. “She is close to 50. When women get to be that age, our fear is the cardiovascular complications, such as stroke or heart attack. That’s how serious this is.”
The woman in the latest case arrived recently at Good Samaritan Hospital for treatment but was transferred last week to County-USC because she lacks insurance, the sources said. Doctors placed her on bed rest until the birth of the babies, which, they added, could be two or three months from now.
So there is ANOTHER case this doctor has provided the tax payers with.
Here’s the REAL kicker:
Kamrava could not be reached for comment and has declined previous interview requests. A woman who answered the phone at his West Coast IVF Clinic said, “If [a] mother wants to bring four kids, so what?”
Honestly Dr. Lee, this man is a criminal. He MAY not have broken the law (although he certainly has breached standards of care) but his man is a MORAL criminal who is bad bad bad for your profession and is bad bad bad for all of us who have to foot the bill! And his “treatments” end up in DANGEROUS pregnancies both for the mother and the children.
I am MORTIFIED.
http://latimesblogs.latimes.com/lanow/2009/02/the-beverly-hil.html
Cautiously temper your remarks about colleagues – but of course. Denigrating competitors is not the same, however, as policing one’s own profession, and holding other members of the profession accountable for clear breeches of standards of ethical or safe practices.
Lawyers, oddly enough, have very strict standards of conduct, and reporting requirements for breeches of professional canons by other members of the profession.
Overseeing bodies investigate and discipline members, in fairly transparent proceedings.
Would that this medical specialty would work to act responsibly in the creation of new life, and to avoid preying on the vulnerable patients seeking reproductive technologies.
Sarah, you are absolutely right. There is a difference between policing and denigrating. I may have blurred the two in my comment because years ago, a friend tried to refer someone to me, but that person said that Dr. K’s marketing materials and claims were more impressive and went to see him instead. I guess I could have offered an opinion specifically regarding seeing HIM in particular, regardless of whether she ultimately came to me or not.
Every field has it’s good and bad. There are bad teachers, bad lawyers, bad politicians, even bad priests and bad nuns. It’s sad. Alas, the American people are no better protected against them than they are against bad RE’s.
I agree with you that deceptive practices and advertising by RE’s can “prey on vulnerable patients”, but there is some hope on the horizon in that the spread of information via the internet can help improve transparency everywhere, including in this field.
I totally disagree with you on the part about lawyers successfully policing themselves to prevent there from being unscrupulous lawyers in this country. In fact, I am of the opinion that there are far far more unscrupulous lawyers than unscrupulous RE’s, even percentage-wise. (Actually, I don’t think you said that. Sorry)
You merely stated that lawyers have established rules by which they must abide. We do too. One of the hospitals where I have privileges is among the strictest in overseeing physicians.
One of the reasons I started this blog was to help empower patients with more information. I get feedback from patients from far away who say that the information here helped them make better decisions. For now, I’ll keep trying to do my part. I encourage patients to do theirs as well.
Here’s another one Dr. Lee, this woman in Georgia is speaking out. She claims Dr. Kamrava was so careless he almost killed her. She ended up in the hospital from ovarian hyper-stimulation, breahtless, in a life threatening situation, pregnant with triplets which she didn’t find out til she went to the hospital!
http://www.11alive.com/news/local/story.aspx?storyid=126883&catid=3
Kellie Toothman will file a complaint with the Medical Board of California against Dr. Michael Kamrava — and wants to tell as many people as she can.
I agree that micromanaging medicine is a bad idea – on the level of embryo transfer. I am reticent to not suggest that perhaps the California licensing board has been lax around this Kamrava character. If what we are hearing is true, why has he been allowed to continue to practice?
His practices, if the allegations are true, are, well, shady.
MLO, thanks for the comment.
There are so many different unrelated aspects of this whole story including:
The issue of the government paying women for children they can’t support on their own
The issue of one particular physician being allowed to run unchecked
The issue of the potential of IVF as a whole to result in high order multiples
The issue of a person using willful initiation of an adverse event to capitalize on the press’s willingness to pay for a story
The issue of doctor’s power to decide who should be allowed medical assistance to become a parent
It will be interesting to see if there have been OFFICIAL past complaints sent to the board on Dr. K and how they were handled.
One worrisome note that my husband brought up was that perhaps complaints were not taken seriously because the complainants (if there were complaints) were taking fertility drugs.
This is a very real, and disturbing possibility that brings into light the way women’s medical issues are treated differently than men’s medical issues.
I hope that he is wrong and that it is just a case of no one thought to make complaints about his behavior.