More questions raised regarding octuplets

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.