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.

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 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’m still in disbelief despite this news update from a few hours ago, which goes into more detail regarding the octuplets and the way that they were conceived. According to this story, these babies were conceived through a frozen embryo transfer. I guess at some point, my skepticism will have to give way, but up until now, I still had a strong leaning towards believing that this was not through IVF but rather through ovulation induction with either IUI or intercourse.

I highly questioned the fact that these were through IVF for two types of reason – hard medical reasons and human nature reasons. The hard medical reasons are based on the unlikelihood of someone having enough embryos to transfer that they could have eight successfully implant. Many people don’t realize that you don’t always transfer two embryos and get twins or transfer three and get triplets. Rather, if we transfer three, we may get zero, one or two babies. Rarely (but it certainly happens), we transfer three and all three take. It’s mathematically even more improbable to transfer eight and get eight. It would be more likely to imagine transferring, say 14 embryos and having eight take. However, this second scenario, while mathematically more likely is even MORE unlikely from a human nature viewpoint, because it is hard to imagine any physician eager to transfer eight (let alone fourteen) embryos under these circumstances.

Our phones were ringing yesterday with inquiries from reporters fishing for information, asking if we could comment on which RE did this. In all honesty, I have no idea which RE was involved in this case. My colleagues and I have been privately tossing around a lot of conjecture regarding certain of our colleagues, but we have no real proof. I have been flooded with questions regarding this case, but since I don’t have any inside information, I’ll focus my commentary on providing science to answer some what-if questions.

How many embryos would you have to transfer in order to get eight embryos to implant?
This is a question that can only be answered with probabilities and not with certainties. It is akin to asking how many free throws must a basketball player shoot in order to sink eight of them? The answer is it depends. It depends on the skill level of the player and it depends on how the luck factor played out. In yesterday’s post, I worked out the calculations for a few scenarios. If we start out with an assumed 60% chance of implantation per embryo and eight embryos being transferred, the odds that a perfect eight out of eight would take is 1.68%. This is not impossible, but it certainly improbable. However, let’s say that these are top quality embryos from a very young woman who already has proven IVF success, then we might really really stretch things and give her a generous estimate of 75% chance of implantion per embryo. Bear in mind that even if a woman is in her 30’s today, transferring frozen embryos that were created and frozen back when she was in her 20’s give her the same fertility potential today as if she were still in her 20’s. This is why we are excited about the prospect of someday helping women who wish to delay childbearing while still preserving their fertility at the same level as when they were younger. This can already be done, but there are practical limitations of cost and of the fact that the eggs would have to be fertilized in order to optimize their survival and later usefulness. Anyway, if we assume a 75% chance of implantation per embryo, then the chance of a perfect eight out of eight taking would be 10%. So if this pregnancy was indeed from a FET, it is more probable that greater than eight embryos were originally transferred in order to end up with the eight which took.

There was some talk that this patient was actually paid to do IVF. Is that possible?
Egg donors are routinely paid to participate in IVF. The big difference is that the donor does not retain possession of the embryos. Rather, the embryos are transferred into another woman who will be the rightful mom to the baby. There are instances where a shared cycle is done so that one woman donates eggs, retains some of the embryos for herself while relinquishing some to a sponsoring couple. The eggs would typically be fertilized with different sperm respectively (ie the husband of the recipient woman and the husband of the donating woman. I’ve not heard of a case where the donor was both paid and given some of the eggs.

Would it be possible for an insider, say an employee of a fertility program, to pull this off without the consent or knowledge of the doctors?
This was a question posed to me by the KCAL news team. I expressed my opinion that it would not be probable that an untrained technician, nurse or medical assistant could have secretly pulled this off. Even if the embryos were originally created with a legit IVF cycle, I don’t think anyone could have singlehandedly, or with an untrained accomplice, thawed the embryos and performed a transfer that would have resulted in eight babies. It’s conceivable that they could have tried, but it probably wouldn’t have worked. Again, if this indeed was an IVF case, there almost certainly were doctors involved.

Do doctors ever refuse to do IVF on patients or do they accept anyone who has the money?
Haha. I had to add that last part, because a lot of the cynical comments out there on the internet express anger at the doctors who did this, citing the ever-popular complaint of corporate greed as the motivation for them performing this procedure. I’ve even come across some remarks stating that the“three moronic smiling doctors” should have their licenses taken away. I guess that reader did not realize that those doctors pictured in the news are the delivering perinatologists, who had nothing to do with the initiation of this pregnancy. They were the heroes who were forced to save these babies.

We RE’s do sometimes refuse treatment to patients, based on medical unsuitability, age or suboptimal life circumstances. I’ve taken care to always do so tactfully. One example was a woman who wanted to do IVF using donor sperm without her husband’s knowledge. Despite my offer to discuss this jointly with her and her husband, she was very angry at me for refusing to do it. As it turns out, there are some natural checks and balances that prevent some inappropriate candidates from doing IVF. For example, if a financially unstable single woman wanted to have babies so that she could get better welfare benefits, she would run into the problem right away that she could not afford the IVF. There is no shortage of women who want to get pregnant even though they may lack the maturity, finances or life stability to provide for a child. We get phone inquiries at our office from women asking if we would accept their Medi-Cal. On my Google report, I noticed the other day someone who hit my site after searching “gubermint paid fertility treatment”. So yes, while we do at times turn away paying patients, we have a tricky balancing act, because there have been instance of RE’s being sued for refusing to provide services, for example, to gay couples.

How does HIPAA protect this woman’s right to privacy?
HIPAA only applies to “covered entitities”, such as her doctors, insurance companies, etc. It does not apply to her friends, family or to strangers, including reporters. On the news, we have seen the crews near her house, interviewing neighbors. The patient’s father was stopped and interviewed by news crews. There is no absolute legal restriction to this, as the reporters are doing their jobs providing information to a hungry public, but there are certainly moral restrictions, that often are self-imposed. For example, this morning, one of my patients who knows someone who knows someone at the schools of the six older children, told me that there were news crews at the kids’ schools. Is that a little too much?

When I first heard about the octuplets who were born earlier this week, my first theory of how this came about was that somebody went to Tijuana, bought fertility drugs, injected herself indiscriminately without medical supervision and then went on to have sex. According to the latest updates, this may have been a result of IVF. This news comes as a huge shock for several reasons.

In the first scenario I described, it is feasible to think that somebody injected herself with medication, unmonitored and unaware of exactly how many follicles she was developing. Therefore it would be more understandable that she subjected herself to the risk of octuplets when in fact, she thought she had much fewer eggs. However, if it is true that these babies are a result of IVF, that brings up many questions.

It’s one thing to post flyers announcing a party at your house and then being surprised when 100 people show up. It’s entirely another thing to send out 200 personalized invitations and then being surprised when 100 people show up. In other words, when you take fertility drugs and have an insemination or just have sex, you might not know how many eggs are actually growing. You would need to monitor using ultrasound to get an idea of how many eggs there could be. Even if you did monitor and count the follicles, it’s still uncertain how many eggs will physically wind up in the right place. With IVF, it’s an entirely different matter. In this case, an exact number of embryos are transferred right into the uterus. Therefore, in order to have eight, someone would have to deliberately and knowingly put eight or more embryos into uterus. Why? That’s the big question.

One of the most important decisions in IVF is how many embryos to transfer. In general, the more embryos you transfer, the higher the chance of success, but also the higher the chance of multiple gestation. The goal is to maximize the chance of having one or two babies. Zero is not good. Three or more is certainly not preferred either.
In order to understand the thought process that goes into deciding how many embryos to transfer, let’s use a deck of cards as an example. Pretend that you have a well-shuffled stack of 1000 cards and you were told that in each deck, some cards are green and some cards are red. You are then given a very specific deck of which exactly 50% were green cards and 50% were red cards. And then you are told that for every green card you draw, you get one baby. For every red card you draw, you get nothing. Now you are asked. “How many cards would you like to draw?” If you decide to draw just one card (ie put in one embryo) then you have a 50% chance of coming away with nothing and a 50% chance of coming away with a single baby. The math is simple on that one.

Let’s say however, instead of drawing one card, you decide to draw two. Now, you will wind up with a 25% chance of no babies, 50% chance of one baby and 25% of twins. This is a very popular choice for many couples. The exception would be couples who are very much against having twins. Then they would be more conservative and prefer only transferring one. On the other extreme, couples who are very aggressive may prefer to put in three rather than two. What happens in this case if we put in three?
Chance of zero babies: 12.5%
Chance of one baby: 37.5%
Chance of twins: 37.5%
Chance of triplets: 12.5%
By putting in that third embryo, you have reduced the chance of a completely failed cycle from 25% down to 12.5%. You have lowered the chance of a single baby from 50% down to 37.5%, and you have raised the odds of twins from 25% to 37.5%. You have also increased your risk of triplets from zero to 12.5%.

When people ask me “How many embryos should I transfer?”, my answer would be “It depends.” It depends on how aggressive you want to be. What do you fear more? A completely failed cycle? Or a cycle where you end up with more than twins. It also depends on what is the estimated % of success for each embryos, ie what % of cards are green? The final variable is “What actions are you prepared to take in the event of getting quadruplets or more?”

So let’s take what the news has reported regarding these octuplets. This is a woman, supposedly in her early 30’s with a history of having six children on her own. Those are fairly favorable condition. Let’s say that the embryos in question were blastocyst embryos and that we estimate (generously) that each embryo has a 60% chance of becoming a baby. If you were to transfer eight embryos that each had a 60% chance of becoming a baby, then what are your possibilities?
Chance of zero babies: 0.07%
Chance of one baby: 0.79%
Chance of twins: 4.13%
Chance of triplets: 12.39%
Chance of quadruplets: 23.22%
Chance of quintuplets: 27.87%
Chance of sextuplets (6): 20.90%
Chance of septuplets (7): 8.96%
Chance of octuplets (8): 1.68%

Just to clarify, what I have just listed are the predicted outcomes if you put in eight embryos, each with a 60% chance of “taking”. As you can see, there are a few odd things. When you put in eight, the odds of all eight taking are actually quite low at 1.68%. So when the patient’s family member said they were surprised that all eight took, that has a teeny bit of validity. However, that validity flies out the window when you realize that even though the chance of all eight taking is small, the chance of four, five, six, or seven taking is cumulatively 80.95%. So how can anyone justify putting in eight embryos when the odds of quadruplets or more is so overwhelmingly high.

We also can infer from these calculations that if this truly was IVF, then it’s quite possible that even MORE embryos than eight were transferred so that eight actually took.

OK, for the sake of argument, let’s say that whoever made the decision on transferring so many embryos felt in his heart that each embryo only had a 25% chance of implanting. Would that justify putting in so many embryos? Let’s do the calculations…
Chance of zero babies: 10.01%
Chance of one baby: 26.70%
Chance of twins: 31.15%
Chance of triplets: 20.76%
Chance of quadruplets: 8.65%
Chance of quintuplets: 2.31%
Chance of sextuplets (6): 0.38%
Chance of septuplets (7): 0.04%
Chance of octuplets (8): 1 out of 65,536!

In this case, it’s a bit more reasonable, but still very very risky given that the chance of quads is 9% and the chance of triplets 20.76%. But if this were the case, then this octuplet birth would really be a miracle in mathematical terms because it would have really defied the odds.

We don’t have all the facts and it’s well possible that the family members providing the new information were mistaken or just not telling the truth. In any case, we in the RE community are waiting a little nervously to see how this all plays out. Our fear is that the powers that be will seize this extreme case use it as an opportunity to put draconian restrictions on physicians in this field, despite the fact that the majority of us have not been careless.

In the US, it is against the law for somebody to sell their kidney or other organ. This is clear, even if getting a kidney could well be the difference between life or death. It’s true even if the recipient is eager to pay and even if the potential kidney donor is rational, intelligent and voluntarily willing to make the exchange with no coercion.

This is certainly one of the most complex ethical dilemmas in medicine and although the law is simple and clear-cut, the overall ethical answers are not so clear cut.

Two recent news stories bring this issue up for discussion. One reporting an increase in egg and sperm donor applicants and one reporting about people turning to internet sites such as Craigslist to solicit organ donation.

In contrast to kidneys and other organs, when it comes to the donation of sperm and eggs, the law in the US is different. Egg and sperm donors are regularly paid for their participation. Technically, an egg donor does not sell her eggs. At least that’s the official spin. She undergoes injections and a medical procedure to enable her eggs from that month to be removed. This is what she officially gets paid for, not for her eggs per se. But no matter how you label it, the fact is the recipient couples pay her with the intention of using her eggs to help themselves have a baby.

So for kidneys and other organs, it is illegal in the US for there to be any financial compensation given to the donor. For eggs, it is legal in the US, but it is illegal in other countries, such as in the United Kingdom.

Kidney donation and egg donation have some key fundamental differences. Kidney donation is done to save a life. Egg donation is done to voluntarily conceive a baby. A kidney donor loses half of his/her potential kidney function. An egg donor loses only surplus eggs from THAT month, which were going to be wasted forever anyway. The same goes for a sperm donor. However, the sperm and egg donation have social repercussions in that afterwards, there could be a child walking around with the donor’s genes that he/she will never know. So keeping those in mind, let’s look at the different arguments.

PAYMENT SHOULD BE ALLOWED TO GIVE INCENTIVE FOR PEOPLE TO DONATE:
- “It is sheer agony to watch my wife waste away day by day. The dialysis is barely keeping her alive. I’ve read stories of how life greatly improves after a successful transplant and I wish for her to have her once-happy life back again. We have been on the waiting list for over a year and we’ve already pleaded with all our family and friends. Of the few that offer, none have been a match. Yesterday, I saw someone on Craigslist offering to donate a kidney in exchange for money. The money in my retirement account is worthless to me in the future in comparison to what it could do now to save my wife. Yet, I am afraid I will have to risk breaking the law if we make an under-the-table arrangement.”

ALLOWING PAYMENT FOR ORGANS IS UNFAIR TO THOSE WHO DON’T HAVE THE MEANS TO PAY:
- “My wife has been on the waiting list for a kidney for a year now. We are on welfare, because neither of us work and we just don’t have the financial means to purchase a kidney. We are so thankful that kidneys can not be bought, because otherwise, it would be unfair for the rich people to jump ahead of us in line. By making it not about money, then it is fair for everyone, rich or poor. The decision of who gets to live should not be based on ability to pay”

- “My cousin was ready to donate his kidney to me. Then he heard that other people were getting thousands for their kidney and he decided he longer wanted to give me his kidney. Instead, he wanted to shop for the best offer instead. I don’t make enough money to pay him and therefore, I am losing the kidney that I was entitled to. It should be illegal for someone to offer money.”

PAYMENT WILL RESULT IN MORE OVERALL DONATIONS, THEREBY BENEFITTING THOSE WHO ARE WAITING FOR ORGANS:
- “There is no doubt that money talks. Look what’s happened to the number of sperm and egg donor applications with the current drop in economy. There are not many people lining up to volunteer their kidneys today. If there were financial compensation, the number of willing donors would skyrocket. So let’s say there are 10 rich people and 10 poor people waiting for kidneys and at the current rate of new donors, 1 rich person and 1 poor person would be saved by getting a kidney. Now let’s say that the rich people are allowed to offer a reward for donated kidneys as long as they help subsidize kidneys for the poor. As a result of this policy, all 10 rich people get kidneys as well as 5 of the poor people. While this is still biased in favor of the rich, the overall number of people saved is much higher.

OFFERING TO PAY FOR ONES BODY PARTS EXPLOITS THE POOR:
- “Can you imagine all the people who are so desperate for money that they will be forced to donate a kidney just to survive? It is cruel and inhumane to turn our bodies into replacement parts”

IT’S MY RIGHT TO DO WITH MY BODY AS I WISH:
- “I work a minimum wage job. I have always dreamed of of going to Hawaii, but there’s no stinking way I can ever afford it. I’m more than willing to give up a kidney in exchange for a chance to realize my dreams. I know that there’s a 5% chance that I will have problems and regret it, but I’m willing to take a little hope for my life in exchange for no hope at all. With the money, not only could I go to Hawaii, but I could also go to Europe and do many other things I could never have done otherwise. I would also have something leftover to give to my children to help brighten their future.”

COUNTRIES WITH MORE RESTRICTIONS HARM THOSE WHO NEED THE DONATIONS:
- “In England, there is a severe shortage of egg and sperm donors. Couples are resorting to drastic measures in order to find the help they need in order to have babies. More and more, couples are coming to the US and to other less-restricted countries in order to do their cycles that require donor eggs or donor sperm.

DONORS ARE TAKING A RISK AND SOCIETY COULD END UP BAILING THEM OUT:
- “Look. If somebody donates a kidney and is left with just one remaining. Then, they go spend all the money they got. What if something happens to their remaining kidney and now, my tax money or my insurance premiums will go to pay for their needed medical care. That’s certainly not fair to burden society just so that those people can have more spending money.”
- “Then what about someone who donates altruistically for no money compensation. If something happens to their remaining kidney, doesn’t society face the same burden?

Where do I stand? I see the arguments of both sides because, well there are some good and bad things associated with either a free policy to accept payment for donating or a restricted policy banning financial compensation. Because there are good arguments in favor of and against the restriction of paying donors, I don’t agree with the government’s black-and-white policy of just saying NO to every case. There needs to be some flexibility with reasonable checks and balances against abuse. A blanket ban is not the best for everyone involved.

17 February update:
Here’s a story about how things are in China.

I ran into a fellow RE at the hospital we eventually came around to discussing the news of the octuplets who were born yesterday. Our initial reaction was like a fishing expedition for gossip with each of us asking the other “Do you know who the RE was? I wonder if it was so-and-so.” We both said “It wasn’t me.” Neither of us knew, but it’s likely that in the next few days, we’ll eventually hear more of the details.

Although I know zero specifics of the case right now other than what was reported in the news, my professional opinion is that I’m more than 99% sure this involved injectable fertility drugs. This doesn’t necessarily mean that this was the work of an RE. Some general OB/Gyn’s also prescribe injectable gonadotropins. In fact, I’ve also heard of cases in which patients went to Mexico, procured the drugs and self-medicated without a doctor’s supervision.

My medical curiosity springs up with two immediate questions. How old was the mother? How many follicles did she have? What was her infertility history? If forced to speculate, I would venture to guess that she is not over 35 and that there were at least twenty follicles and that this might have been her first treatment cycle.

Hopefully, the public is not misled by this into thinking that all octuplet pregnancies will have this good of an outcome. On the contrary, there has only been one other time in history, where there were surviving octuplets. On another note, I hope the public is not misled into thinking that this type of high-order multiple pregnancy is a common occurrence when taking fertility medications.

This article makes a lot of sense. People make the best decisions and take responsibility for their actions when they are held accountable.

If your car breaks down or gets damaged, then you are responsible to get it fixed. That’s why people actually care about driving carefully and performing routine maintenance. Imagine a world where government paid for unlimited cars for you. If your car breaks down, they will pay for the repair or a replacement at no cost to you, even if it’s your fault. If this rule were put into place, I can guarantee you that people would be a lot less diligent about getting oil changes and I can guarantee you that people would care a lot less whether their car got a dent or not.

In the case of universal healthcare, suppose that I choose to smoke and eat a lot of junk food. Now I get fat and my lungs get dirty. If I get diabetes, a heart attack or lung cancer, my personal tragedy and misfortune doesn’t affect only me. It also affects those of you out there who are diligent about watching your weight and diligent about avoiding cigarettes, because you will have to pay for my medical care.

There are two ways to try and fix this. Either make each person responsible for their own health. Smokers, by virtue of a higher risk of lung cancer, would pay higher health insurance premiums. Healthy individual who are less likely to need expensive healthcare woud play lower premiums. We already have a system like this in place for auto insurance. If you have five accidents and four speeding tickets on your record, you are going to be paying more for insurance. The second way to try and fix this is what they are doing in Japan (as cited in the article) - putting restrictions on the lifestyle of the people to whom you are providing the free healthcare.

Is this really what we want?

This is a continuation of my previous post with my opinions regarding the new California laws that go into effect for 2009.

Mobile homes: Requires, at time of sale, all mobile homes and manufactured housing to have smoke detectors in all rooms designed for sleeping and to have seismic braces on gas-fired water heaters.
I have smoke detectors in my home, but that was by my choice. Hmm, I don’t have any Radon detectors and I certainly hope I’m not forced to get some.

National guard: Authorizes a state employee who is a member of the National Guard or reserves to receive government benefits for four additional years, if they were ordered to serve on or after Sept. 11, 2001, as a result of the war on terrorism.
It’s a nice gesture, but again, who is paying for this? This could be potentially very costly for the state of California.

Oil drilling: Permits development of additional oil reserves beneath submerged lands of the Wilmington oil field.
I don’t know enough about the details, but offhand, I would like to have more American oil sources and rely less on OPEC.

Pets: Provides for enforcement of “pet trusts” set up by animal owners to pay for continuing care of their pets after the human owners die.
I’m all for this. People should have a right to show love for their pets. Personally, mine are not getting a penny from me.

Phone cards: Requires refund within 60 days to any holder of a card if the provider’s services fail to operate in a commercially reasonable manner. Also mandates that phone-card firms maintain a toll-free customer service telephone number.
It’s odd that there should be a specific law to state this. I thought this was a given. Any business should be held to a standard that if they don’t deliver the services they promise, then the consumer has the option of a refund.

Press freedom: Prohibits discipline of high school and college journalism advisors for the content in a student newspaper.
The way I read this, it’s giving freedom to school journalism advisers when they themselves give freedom to their students who are doing the writing. So I support this.

Privacy: Makes it a misdemeanor to use radio waves, without consent, to remotely read another person’s identifying information. The measure is in response to the practice of having personal identification information included on government-issued identification cards that can be read with radio-frequency identification devices.
This blow for personal privacy is very important, but will be difficult to enforce.

Real estate: Allows the state Department of Real Estate to suspend or bar a person who has committed a violation of real estate laws.
What’s the point of having a supervisory board if they don’t have the power to discipline someone who violates the law anyway? This should have been another given and not requiring a separate law to state the obvious.

Schools: Allows Los Angeles Unified School District and other districts to continue tapping state funds even as they withdraw from a program to fund multitrack, year-round schools.
I honestly don’t know what this is all about. Can somebody explain it to me, please?

Senior homes: Assisted-living homes are required to show potential customers their history of rate hikes, tell local prosecutors about suspected abuse and plan for emergencies such as blackouts.
If this is a move towards more transparency, I agree with it. Consumers choosing a home for their loved ones should be armed with adequate information on which to base their decisions.

Smoking: Allows the state director of the Department of Mental Health to prohibit the possession or use of tobacco products on the grounds of state mental hospitals.
Remembering what I learned in medical school about the high prevalence of smoking among psych patients, this could well cause a few riots.

Spousal abuse: Prohibits jailing of alleged victims of domestic violence for refusing to testify against their abusers.
I realize many domestic violence victims call for help when they are imminently threatened, but then are caught in a quandary about leaving their abuser, so they refuse to testify. I don’t profess to know the answer to this complex problem. I would be open to hearing the views of those who work in this field whether jailing of the victims is or is not helpful to the overall situation.

Tax breaks: Allows taxpayers to exclude forgiven mortgage debt from their incomes for state income tax purposes.
I don’t know too much about this and this would be of no personal benefit, but you know me. I’m generally in favor of lower taxation for everyone.

Taxis: Allows local agencies to disconnect the telephone service of a taxicab operator that fails to obtain proper permits and insurance if other enforcement remedies have failed.
The role of the government is enforcement when people violate the rights of others. So if a taxi operator failing to obtain permits and insurance constitutes a violate of other people’s rights, then giving more ammo for enforcement agencies to do their job is a good thing.

Teacher crimes: Includes “no contest” pleas in the definition of convictions when the Commission on Teacher Credentialing decides whether to suspend or revoke teaching credentials.
If I read this correctly, prior to this law, teachers accused of violations could opt to plead “no contest” and then not be held accountable for those incidences when decisions are made to revoke their credentials. This law closes that loophole. Good.

Toll roads: Allows local transit agencies to create carpool lanes that can be used by lone motorists willing to pay a toll on stretches of the 15 Freeway in Riverside County and portions of the 10 and 110 freeways in Los Angeles County.
If this end up easing traffic, then I’m all for it. People should have more choices.

Used cars: Allows police officers to impound vehicles of anyone cited for acting as a car dealer without a license.
I don’t know what it entails to obtain a car dealer license.

Veterans: Requires the state Department of Veterans Affairs to develop plans to reach out to National Guard members or veterans returning to California from combat, and assist them in obtaining a screening for post-traumatic stress disorder and traumatic brain injury. Another law authorizes, after local approval, veterans whose vehicles display one of a number of special-recognition license plates to park free in metered spaces.
I profess to having limited knowledge regarding the prevalence of PTSD among National Guard veterans. My reading is that this law goes beyond just rendering the standard care to veterans, but instead pushes the limit towards hand-holding grown men and women and assisting them in just getting screening. It is already controversial whether or not the label of PTSD is overused as a way to tap into money from the government.

Wave pools: Requires operators of wave pools at amusement parks to increase safety steps, including assignment of lifeguards, provision of life vests and restrictions on children shorter than 42 inches.
All operators of public venues should take responsibility for the reasonable safety of participants. Whether or not these arbitrary guidelines constituted a good balance of safety and individual choice remains to be seen.

Overall, my personal views are founded on a healthy respect for other people’s freedoms and rights. In general if we were to ask if our lives today would be made better by more government control and less individual freedom or less government control and more individual freedom, I think it’s pretty clear where I stand. The balance needs to shift back towards the middle, or our standard living will stop growing or even go backwards, while the standard of living in China and India continue to improve for their people.