A lesson learned the hard way (update)

Nadya Suleman (a/k/a ‘Octomom’) shares the lessons she’s learned the hard way—with PETA helping her out, too.

Nadya Suleman is the infamous single California woman at the center of an ethical firestorm because of her use of assisted reproductive technologies to implant IVF embryos and carry 8 babies, all at once, to term.  In addition to this, she had 6 children at home, all brought into being with the help of IVF.  Her actions and the actions of the physician who implanted 6 embryos (2 split to become twins) prompted an outcry in the medical ethics community, prompting questions such as “How far does reproductive autonomy go?” and “How many children is too many?”

As I had noted in a blog entry here previously, there are multiple ethical considerations at play when an IVF specialist is approached by any woman and a ‘burden vs benefit’ analysis is employed. IEET Fellow George Dvorsky blogged: “By implanting 8 embryos in a mother predisposed to multiple births, they put her health at risk and they significantly increased the likelihood of her introducing a multiplicity of babies into a family that was already over-extended.” Bioethicist Art Caplan noted that “Society is getting stuck with the bill when she made this choice to be an infertility patient; It is more than her interests. It affects her kids and it affects the rest of us.”  The media attention to this case prompted medical ethicists to question the adequacy of ART (Assisted Reproductive Technologies) oversight: the American Society for Reproductive Medicine convened a conference to start a dialogue on this issue and a summary of discussion can be seen here and here. Fortunately, more than a year out, this case has turned out to be a real outlier and does not represent a trend in the ART industry.

And since then, Nadya Suleman has expressed deep regret at her decision—the costs have been extreme; the home in which she is living is being threatened with foreclosure and the impact of her decision is now coming down to bear heavily.  And as ticked off as everyone was at her and her IVF physician, no one I know thinks that her children should suffer more for her bad decision.  And, fortunately, most Americans (I would like to believe, anyway) have the heart to forgive someone who admits they have screwed up—and we love to hear stories about redemption.

And the redemption here is that the Associated Press has reported that Nadya Suleman (a/k/a ‘Octomom’) doesn’t want your pet to suffer the same fate:  PETA has negotiated a deal with the Ms. Suleman that allows them to post a PETA sign in her front yard trumping the value of spaying or neutering pets. The deal was in exchange for a one-time payment and a month’s worth of veggie burgers and veggie hot dogs for her and her children. The full story can be seen here.
Sounds like a win-win situation to me.

[Cross posted over at the IEET blog]

Bioethics Joke

[Hat tip to Art Caplan for passing this one along!]

Have you heard about the new Denny's breakfast? In honor of the mother of the octuplets, Denny's is offering the 'Suleman': Fourteen eggs, no sausage, and the guy next to you gets to pay the bill.

Making Multiple Births Fun and Profitable

[Hat tip to Art Caplan for bringing this story to our attention] With all the recent attention given to Nadya Suleman and her brood of 14, comparisons have been made to the popular show on TLC, Jon & Kate Plus 8, which chronicles the life of the Gosselins raising a set of twins and sextuplets. Philly magazine examines the way that the Gosselins have found a way to make the family business quite a profitable one -- and the article asks the uncomfortable question "when do your kids stop being your kids and start becoming your meal ticket?":

"TODAY THE TWINS are eight and the sextuplets four, but Jon and Kate actually look younger than when the show began, more camera-friendly and polished. They’ve had their teeth whitened; Jon’s been working out and got a (free) hair transplant. The Gosselins have turned up on Oprah and Good Morning America, and inside the pages of In Touch Weekly and People. The show is TLC’s most popular series.

As a result, the family now goes on more free trips, and is treated to swag and catered to at every outing. Phils skipper Charlie Manuel let Jon and some of the kids run the bases after a game last season (they had box seats, and got an autographed bat from Shane Victorino); a zoo tour included getting to privately feed the giraffes. “They get the publicity of the trip, we get the trip,” Kate explains in one of the “Viewer FAQ” episodes. The kids model the latest tyke couture from Gymboree. They frolic with Wii Music, Play Doh’s Fuzzy Pumper Barber and Beauty Shop and Little Tikes Jump ’n Slide Bouncer as Jon gushes about why these are such great playthings and the camera zooms in on the logos. Nielsen ranks the series eighth out of 149 cable shows for product placement."

For the rest of the article, click here.

Octuplets Mother Speaks Out

Nadya Suleman, mother of the recent octuplets born in California, has done her first interview with a major news outlet. (Although Suleman was seeking USD 2 million for the interview, NBC maintains that they did not pay her. However, that doesn't rule out "compensation" in other forms.)

Unfortunately, Suleman's interview has continued to raise, rather than answer, questions. Foremost among them, for me, is her claim that she had six embryos implants per IVF procedure. This... simply does not ring true. Or at least plausible, if she was using a US fertility expert.

Consider this: in order to have done so, this means Suleman would have needed to find, at age 26, a fertility doctor who would implant six embryos. ASRM guidelines are no more than 3 embryos for a woman under the age of 35, and that's if she has a history of problems with conception. With a 'clean' history, only 2 embryos are recommended. Now, it sounds like Suleman might have qualified as having difficulty conceiving, with several ectopic pregnancies and miscarriages prior to IVF. But even accounting for that, it's double the recommended standard. For each pregnancy.

But stop to do the math. While one vial of donor sperm would be more than enough for all of this, it means that they collected at least 36 eggs from Suleman, and that all of those eggs were viable enough to implant once fertilized. Realistically, not every egg retrieved is going to be mature, and not every egg is going to fertilize (unless you're using something like ICSI). Realistically, you're looking, at the very least, at 1/3rd more eggs than that being pulled out (and even that is a very, very low number - remember, they're saying that there were six viable eggs to implant per cycle. A quick web search shows that 1/3 of the eggs removed at any time are not mature, and of the ones that are mature, only half reach the point of being "good enough" to implant).

Now let's go over to CDC stats. While the last data is from 2005, which was going on 5 years ago, Suleman started her IVF course in 2001, so some of this data is specifically applicable (and some of it only extrapolation). According to the CDC, only 35% of ART cycles resulted in a pregnancy, and of those, 82% resulted in a live birth. So again, Suleman seems to have defied the odds. A lot. And as the CDC says about frozen eggs, "[b]ecause some embryos do not survive the thawing process, the percentage of thawed embryos that resulted in live births is usually lower than the percentage of transfers resulting in live births." While only 15% of embryos transferred were frozen, of those 15%, only slightly more than 1/4 ended up in live births.

Again, the odds make this seem incredibly unlikely.

Finally, fertility clinics are required by law to report their ART data, under the Fertility Clinic Success Rate and Certification Act. This gives us a decent way of tracking ART results - and also who is doing ART. In 2005, eleven clinics in California did not report their ART data (which would include embryo transfers/live birth data/etc). Of those eleven places, it looks like seven were within an hour of her home (keeping in mind her back injury likely limited the distance she could travel). Of the clinics that did report their data, 35 are within an hour of Whittier, California. However, given these clinics are compliant with reporting their data, it seems safe to eliminate them from immediate suspicion. (As for the potential Mexcio connection, Tijuana is approximately two hours away. Certainly not out of the question; an hour was a random number drawn from thin air. Suleman has certainly shown herself to be willing to go to significant length, and pain, to achieve her goals.)

All in all, what does this mean? Not much. Over 300 pages of records on Suleman have been released to the press, under a public records request to California's Division of Workers' Compensation. While it doesn't appear that the fertility clinic (or doctor) that treated her is in those records, there is ample evidence to support that she did have problems conceiving, and that she had known psychiatric issues, including what was diagnosed as either postpartum depression or PTSD. Issues that should have limited, if not prevented, future implantations.

Ultimately, until Suleman names her doctor, or said doctor speaks out, little will be conclusively known. But the facts remain simple: the facts do not add up.
-Kelly Hills

Reproductive Autonomy Runs Amok

In a follow-up post to Kelly's previous post, it seems that Nadya Suleman's use of IVF technology is clear misuse and abuse of ARTs (Assisted Reproductive Technologies). The doctor who implanted the embryos should be investigated, because in helping this woman become pregnant with 8 children, he or she violated one of the basic tenets of medicine -- "Do No Harm". Hopefully, the Board of Medical Licensure will investigate and determine what the possible motivation was for this doctor's actions, whether it was a one time lapse in judgment due to extreme personal difficulties, or if it represents a small part of a larger pattern of unethical behavior and practice for the doctor and the fertility clinic.

There are multiple ethical considerations at play when an IVF specialist is approached by any woman and a 'burden vs benefit' analysis is employed. When someone who has already had six children through the procedure seeks more, I cannot imagine a valid or justifiable benefit -- the burdens include physical and financial costs to the mother (who has already declared bankruptcy), to the grandmother, to the siblings, to the children born, and to society. And while one might argue that this is an exercise in reproductive autonomy, we, as a society need to ask 'how far does reproductive autonomy go?' Does it include the right to create children who been disabled or dis-enhanced? (A nightmare scenario vaguely reminiscent of Dean Koontz' novel, One Door Away from Heaven). How we answer this question will have an impact on how we deal with future cases, such as those involving genetic engineering.

Hopefully, this case will call attention to the need for regulation and oversight of Assisted Reproductive Technologies. Currently, we have a laissez-faire attitude towards ARTs and fertility clinics; we have trusted the doctors and clinics to regulate themselves, via the American Society for Reproductive Medicine --and this case demonstrates that we can no longer simply turn a blind eye.