December 12, 2017

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.

  • http://thehollytree.blogspot.com/ Robin

    Dr. Lee,
    As a layman reading your post here, thank you for the homework assignment, I sincerely mean that becauae I want to make sure I’m understanding the medical terminology. Are the following definitions correct in layman’s terms?

    IUI: Simple artificial insemination with washed (?) sperm done ideally six hours either side of ovulation? This of course, or I THINK it would mean that her fallopian tubes couldn’t be blocked. It also could or may not involve hyperstimulating the ovaries. Am I correct?

    IVF is what I would call in layman’s term the “petri dish” method. Retrieving the ova, fertilizing it outside the uterus and then implanting it. In reading one of Dr. K’s presentations he stated he implants blastocysts which I THINK means day five after fertilization. Question, if Nadya lets say had minimum of 30 (6×6-6)embryos frozen for later use, can these frozen blastocysts then split into twins as she claims? I am asking because thus far no one has named which of the 8 are twins.

    FET: woops, this is covered in my stab at trying to figure out this terminology I think. IVF would be immediate transfer (day five) without freezing whereas you are now saying that FET (frozen embryo transfer) could very well be the case here. Is that right?

    There are also a few other reports coming out on Dr. K.
    This one is by a former colleague now working in GB who successfully sued him.
    http://www.timesonline.co.uk/tol/life_and_style/health/article5721333.ece

    This one is from still another former patient
    http://www.momlogic.com/2009/02/i_used_octuplet_moms_ivf_docto.php
    Is her accusation correct that his donor egg operation was in direct conflict to his fertility practice, that these operations are usually run completely separately by different individuals? She certainly refers to some shady behavior at his office.

    As to the Axis II psychopathology, I looked this one up too as part of your “homework” assignment for laymen. (and I have a little bit of background in studying this)

    Common Axis II disorders include personality disorders: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, histrionic personality disorder, avoidant personality disorder, dependent personality disorder, obsessive-compulsive personality disorder, and mental retardation.

    Not going into great detail NOR being any sort of expert whatsoever, just from observation, my layman’s take would be definite borderline personality disorder, definite NARCISSISTIC personality disorder, DEPENDENT PERSONALITY DISORDER, OBSESSIVE-COMPULSIVE DISORDER and I’m going to toss in mental retardation because her out of touch with the realities of TRUE adult life, her la-la land explanations of how she’s going to pull this one off is RETARDED! (and I am definitely using layman’s terms when I say this)

    Yesterday Dr. Phil’s show was excellent because he had several experts on. After each one spoke he said that as a therapist he was taking this all in and to him is MORE than evident Nadya needs MAJOR therapy.

    Question: When RE’s do their internships, are there classes provided in how to screen patients for the appropriateness of treatment? Plastic surgeons for instance are trained (and hopefully they DO) to prescreen their patients psychologically. In the case of a fertility doctor who is helping a woman bring into this world CHILDREN which is certainly not simply affecting oneself, but CHILDREN, what is the process SUPPOSED to be? Would a woman coming to you with no means of supporting her already SIX children be a candidate to treat for #7 let alone “gamble” with as Nadya chose to do. In other words, what does your profession see as the proper evaluation prior to treatment, not for a first case scenario,but in a case where it is more than evident the woman is NUTS. (layman’s term)

  • Campbell

    Nadya said her last transfer was the result of FET. If she put back 6 embies each time, that means she had a cycle where she made 12 embryos – 6 to put back fresh and 6 left over for the later FET. Have you ever seen a person get that many embryos? In your opinion how many eggs would you have to retrieve to get 12 embryos out of one cycle?

  • IVF-MD

    Campbell, having 12 embryos to transfer/freeze is fairly uncommon when we talk about day-5 embryos or blastocysts. It’s the rare patient less than 5%) with an excellent excellent combination of egg quality and quantity who will produce 12+ blastocysts. It’s a lot more common with donor eggs, by the way. Having said that, I recently had a patient who bountifully generated more than 12 blastocysts. When it comes to day-3 embryos, having 12+ is relatively common. I’d say that more than 15% of patients can achieve that. They won’t all be good quality. Again, it depends a lot on the age of the patient and her history.

  • SarahW

    Another patient-experience link here.

  • Elizabeth

    Maybe, instead of IUI, the “less-invasive” procedure she had this time was standard IVF, instead of the weird endometrial implantation?

  • IVF-MD

    Good point, Elizabeth. I thought of that. That could be the case.

  • http://waitingwomb.blogspot.com Larisa

    I was wondering if she’d just never done a FET before? Maybe all her previous cycles were fresh IVF cycles. And maybe that’s why she had so many embryos to transfer. It’s hard for me to fathom 6 cycles transferring 6 each cycle and still having so many remaining.

  • IVF-MD

    Again, who knows the facts? I wonder if any lawyers could comment on how HIPAA would protect her if she should decide to have her doctor stay completely silent on the facts of this case.

  • http://? MELONIE

    SHE’S A LIAR,
    DR K IS A QUACK…

  • Kari

    I echo Robin’s post in the opinion that there is something very wrong with this woman, and she shouldn’t have been allowed to have more children while unable to work or care for her current children. Are there guidelines for allowing patients to have fertility assistance? When I decided to get pregnant using donor sperm, it required a meeting with my PCP and her signature approving that I was considered healthy enough to undergo the procedure – and that included financial, emotional, and physical health. I’m surprised as much consideration isn’t given to a woman hoping to conceive her 7th+ child through IVF who’s currently on disability, living with a parent, on state aid, etc.

  • IVF-MD

    There are “implied” guidelines in that we, as physicians (or as responsible human beings in general), should use our judgment to do what’s best in this world, but no, doctors are not expected, or in some cases, not permitted to make decisions on who can and cannot receive medical services. Again, some have been the victims of major lawsuits, because they dared to judge who should get fertility services. I am in agreement with you that there should not be careless indiscriminate offering of fertility services to everyone, but then this also begs the question: Should anything be done at all to prevent the many more cases of women who have children they can’t care for but then go out and get pregnant again, not with medical help, but through plain ol’ sleeping around?

  • Kari

    “Should anything be done at all to prevent the many more cases of women who have children they can’t care for but then go out and get pregnant again, not with medical help, but through plain ol’ sleeping around?”

    YES! I feel that as long as taxpayers are supporting people who continue to have children they cannot afford or in other ways adequately care for, a reversible form of sterilization should be required in order to qualify for free food, housing, and medical care. If they turn their situation around, the sterilization is reversible. But if they don’t, they can no longer bring children into the world they can’t afford to raise.

  • SarahW

    11. – of course. Men should refuse to sleep with women they are not married to.

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