Friday, January 30, 2009

lady 8

“This woman’s sense of entitlement is mind-boggling”- G&M commentator

“The government has to step in and start controlling the situation before it gets completely out of hand." -Laura Bergeron-Blais, a mother of twins from assisted reproduction, both of whom died.

Really, what should we think about the “miraculous experience” in California of an anonymous woman (Lady 8), who gave birth this week to octuplets through assisted reproduction? Should the government step in to set limits on how many babies we can have? Is the mother unreasonable, selfish, and deluded? Is her doctor?

Imagine it happened in Canada, where hospital maternity and newborn care is publicly financed, but clinic-based fertility treatment is not. Because fertility treatment is paid for out of pocket, and because of the frequency of failure, we know women often and very rationally opt to have more than one embryo implanted in the hopes that at least one will be viable. Cost of repeated rounds of treatment is not the only factor- it is physically and emotionally painful to repeat fertility treatments. Ultimately, the shortage of healthcare providers affects this accounting too- how long will she have to wait in line for another session if this one fails?

The memory of failed attempts at “natural” conception is usually fresh and real for women seeking assisted reproduction, so fear about the status of the pregnancy is weighted more heavily towards the front end. The strong possibility of poor outcomes from multiple births is, in comparison, a distant concern.

Not to mention the fact that as long as you stand a chance of being able to afford to care for them, having multiples is, well, “a miracle”, or rather “cool”, and perceivable as karmic recompense for the struggle to conceive.

So even if fertility treatment was part of Medicare, we could not expect women to opt to have fewer embryos implanted. It isn’t just the money: it is her body, her heart, her patience, and, ultimately, her lack of experience of the dangers of multiple births. These dangers include higher rates of perinatal mortality, preterm birth, low birth weight, gestational hypertension, placental abruption, and placenta previa. Perhaps she would feel less “entitled” to ask for more embryos to be transferred if she wasn’t paying, but with most Medicare-funded treatment patients are (and should be) offered options and given informed choice: fertility treatment would be no different.

So what are those options, anyway?

It appears Lady 8 should never have had anywhere near the at least 8 embryos implanted that she did. The American Society of Reproductive Medicine (ASRM) and the Society for Assisted Reproductive Technology have guidelines recommending a woman under 35 (and Lady 8 is 33) be implanted with no more than 2 embryos per transfer procedure. The joint Society of Obstetricians and Gynecologists of Canada and Canadian Fertility and Andrology Society guidelines (2006) are the same. At older ages the upper limit is higher, with women over 40 allowed a maximum of 5 embryos per procedure in the US, and women over 39 allowed a maximum of 4 embryos in Canada. These rates are based on evidence, and are actually generous: on average, for women under 40, one in two embryos will survive.

Looking into success rates at IVF clinics, largely half of the embryo transfer sessions among women under 35 result in pregnancy. Live birth rates are, when shown, slightly lower. Last year at Genesis Fertility Centre in BC, the pregnancy rate per embryo transfer among women under 35 was 55%, at a rate of 1.6 embryos per transfer. Half of the transfers resulting in pregnancy is no the same thing as half of the embryos becoming viable fetuses. At Pacific Centre for Reproductive Medicine in 2007, the rate was 51%, at 2 embryos per transfer. At Toronto’s Centre for Advanced Reproductive Technology the rate was 53% in 2008; at the Atlantic Assisted Reproductive therapies centre that rates was 63%.

Assisted reproduction works better than I expected.

Lady 8 had six kids. It is safe to say she used assisted reproduction to conceive some/all of those 6. She obviously is an ART success story. And it is strange to pursue more assisted reproduction when you already have six kids. Stranger still if you are single and living with your parents, as is Lady 8. But no one has the right to dictate the make up and size of our families. Even in the fertility industry, no one has the right to say, enough- this is the last time we help you conceive. Strange choices among lay people are not inherently unethical and certainly not illegal.

Doctors cannot make strange choices. They cannot violate practice guidelines and knowingly, egregiously, put their patients in harms’ way. Transferring 8 embryos into a woman who is very likely to carry all 8 to term is harmful. It increases her risk of injury or death in childbirth. Never mind how the babies may fare.

The case of Lady 8 is not about reproductive choice. Adhering to practice guidelines about embryo transfer is not a slippery slope towards abortion prohibition. It is good medicine. There is a world of difference between recklessly using a patient as an experimental farm for fertility’s margins of possibility, and protecting a woman’s right to control her life and her reproductive self. Crafting a connection between these two belittles the seriousness of a choice to abort. It belittles the seriousness of a struggle to conceive.

Lady 8 is ridiculous. She is tabloidal in her narcissism. But she lives with her parents and is possibly pathologically juvenile. What is her doctor’s problem? Her physician had a duty to protect her from harm, even harm generated from her own cabbagepatch delusions. Her physician is at best weak, and at worst exploitative.

Patients will ask for all kinds of things. They will ask for what is usually impossible- to be brought back from death. They will ask for dangerously minimal treatment. They will ask for their own children to be denied treatment. They will ask for unnecessary treatment, for unnecessarily pricy treatment, for delays and hurry ups and brands names and private rooms. A physician has to judge what is reasonable to grant. If you want to pay out of pocket for the purple pill, fine. If you want antibiotics for a cold, fine. If you want to endanger your life with treatment that is legions outside of the scope of acceptable practice, no.

Lady 8 is a crazy story making its way into every blog and newsroom. But there are likely swarms of Lady 2 and Lady 3's out there...women who are not crazy-eights, but likely over-eager, misplacing caution with excess, and asking for over-transfering. Are we watching over the physicians who are supposed to be watching over them?