Saul's piece concentrates mainly on the fertility industry's inability to reduce the rate of twins being born to IVF recipients, and the difficulties that the pressures of mulitiple births have not only on a woman's body, but on the health of the children and on the economic system set up to support premature babies as they struggle with long-term intensive care hospital stays. "While IVF creates thousands of new families a year," Saul writes, "an increasing number of the newborns are twins, and they carry special risks often overlooked in the desire to produce babies."

The normalization of twins, Saul argues, which springs not only from celebrity births but from record numbers of twins being born in the U.S. each year, has contributed to a culture where the medical risks of multiple births are often overlooked. 60% of twins are born prematurely, Saul notes, adding that "their chances of death in the first few days of life, as well as other problems including mental retardation, eye and ear impairments and learning disabilities. And women carrying twins are at greater risk of pregnancy complications."

The fertility industry, however, is serious business, and a need to supply customers with a successful pregnancy leads many clinics to implant multiple embryos in order to increase their success rate, and as Saul notes, increase their chances of attracting new clients. "A busy fertility clinic can be extraordinarily lucrative, generating millions of dollars a year. And fertility doctors can take on godlike status in their communities for delivering their priceless commodities."

It is a heartbreaking piece, in that Saul speaks with many families who put themselves through serious financial, physical, and emotional strain to conceive children, and often enough, once those children are born prematurely, the stresses continue to take their toll. However, one gets the sense from all of the families interviewed that the ends justified the means, and that speaks to the real heart of the IVF industry—a desire for a child, no matter what it takes. All of these families, I'm sure, would tell you that the risks were well worth it. But the skyrocketing prematurity rates, strain on resources, financial hardships, and the difficulties faced by the children once they are born tell a slightly more pessimistic story.

One only hopes that someday the focus will be shifted to a more rounded measure of success; IVF shouldn't just be about implanting embryos for exorbitant sums and upping a clinic's success rate; it should be about providing families with a safe, healthy option where the focus is more on the safety and overall wellbeing of families, their children, and society rather than on cashing in a family's desires and hoping for the best.

[Photo by Kevin Moloney for the New York Times]

The Gift Of Life, And Its Price [NYTimes]

Gautam Naik writes in the Wall Street Journal that, despite a 2007 guidance from the American Society for Reproductive Medicine, there is zero evidence that PGS increases the rate of live births among older women undergoing IVF procedures, and doctors have continued to perform (and encourage women to have) it. Why? Naik has a potential answer.

Backed by limited positive data from a decade ago, some U.S. fertility clinics have aggressively marketed the PGS technique to older women. It isn't cheap. Embryo screening can add $2,000 or more to the typical cost of roughly $10,000 per treatment cycle of in-vitro fertilization. While some insurance companies cover IVF treatment, very few pay for PGS, which insurers consider experimental.

In other words, PGS is the new undercoating.

While doctors who use and market PGS in their practices despite the ASRM's guidance defend its use and effectiveness, rigorous studies showing otherwise have been available since 2004.

A randomized trial in 2004, in which a Belgian research team studied nearly 300 fertilization procedures, was among the first to indicate that embryo screening may not improve the live birth rate.

A recent Swedish trial, which included more than 100 women over the age of 38, suggests that embryo screening may actually hurt a woman's chances of having a baby. The study found that the pregnancy rate in a PGS group was 8.9% compared with 24.5% in a control group that didn't use PGS. The study, published in the journal Human Reproduction in December, was stopped midway after the data showed the sharply lower pregnancy rate.

Most randomized studies (and sometimes even the doctors don't know which is the control and which is the experimental group) are only stopped if the evidence shows convincingly that they are doing more harm than good.

Scientists have a potential hypothesis for why the post-PGS pregnancy rate was nearly 3 times lower than the non-PGS rate: PGS is often performed on a 6-cell embryo, likely to mitigate the political hot potato of destroying the embryos that are found to be malformed. This, however, might represent a bigger problem than doctors initially envisaged.

Doctors postulated that in performing PGS, the process of removing a single cell could damage other cells in the embryo. "The probability of doing harm with PGS turned out to be higher," says Thorir Hardarson, biologist at Carlanderska Hospital Fertility Center in Gothenberg, Sweden, who led the trial.

Doctors looking at embryos from otherwise healthy fertile couples have a further explanation, after discovering that the rate of abnormality in their PGS screenings was very despite the theoretical probability being very low.

The answer appears to be that the single cell extracted from each embryo could be genetically slightly different from the others, and therefore not representative of the overall embryo, a condition known as mosaicism. In fact, removing an error-free cell from an embryo might lower the chances that that embryo will grow into a healthy baby, because the remaining cells might not be as viable, Dr. Vermeesch says

Either way, women being pressured into or sold on PGS as a way to improve their chances at conceiving through IVF are paying money for something that, at best, has little effect on their chances of conception and, at worse, might actually be harming it.

Fertility Method For Older Women Spawns Doubts [Wall Street Journal]

There have been four malpractice suits filed against Kamrava since 1991, reports Time. Michael Verdi and his wife Eva Menen filed one of those lawsuits after receiving treatment from Kamrava in 1994. Verdi says Kamrava was rude and didn't answer questions appropriately. "We did research and figured out he was doing a lot of stuff wrong. He overmedicated her and he was doing insemination when she wasn't ovulating," said Verdi. They stopped seeing the doctor after Menen did not get pregnant after three months. Dr. Jeffrey Steinberg, a fertility doctor who has known Kamrava for 20 years, speculates that the doctor began increasing the number of embryos he transferred because he was under pressure to up his success rate. Among patients younger than 35, Kamrava transferred an average of 3.5 embryos versus the nationwide average of 2.3. But, he had a 10% success rate versus a nationwide average of 39% of procedures resulting in live births.

In other news, Victor Munoz, Suleman's second publicist has quit. "It just got to be too much," says Munoz. "It's pretty much a free for all over there right now. They are freaking out right now." He added, "Nadya got real greedy. This woman is nuts."

[
The Fertility Doctor Behind the "Octomom" [Time]
Exclusive: Octo Mom's New Publicist Quits: "This Woman Is Nuts" [Us]

The bill, titled the "Ethical Treatment of Human Embryos Act," is the most sweeping state legislation on fertility procedures introduced since Suleman gave birth to her octuplets in January, according to the Wall Street Journal. Republican state Senator Ralph T. Hudgens, one of the sponsors of the bill, said in an interview:

Nadya Suleman is going to cost the state of California millions of dollars over the years; the taxpayers are going to have to fund the 14 children she has ... I don't want that to happen in Georgia.

The proposed bill would limit the number of embryos implanted in a woman at one time to two, or three for women over 40. It also goes a step further, with limitations on the number of embryos created in the lab to the number being implanted. This would essentially eliminate a woman's ability to freeze her eggs, which is unsurprising, considering the bill was drafted in part by the Georgia Right to Life organization. The group's president, Daniel Becker, tells the Journal, "To us it's a human-rights issue," adding that embryos deserve legal protection "as living human beings and not as property."

Several scientific organizations are opposed to the bill because it would end embryo freezing, and because they say in some cases it's necessary to implant more than two or three embryos. Sean Tipton of the American Society for Reproductive Medicine says the lawmakers "don't understand the complicated medicine behind it." Currently, the organization urges doctors to transfer only two embryos at a time into patients under 35, and no more than five in a woman over 40, but the guidelines aren't mandatory.

Resolve, a national fertility association, also opposes the bill. Executive Director Barbara Collura says: "It's the right of the person who has gone through this procedure to decide what they can do with those embryos, not their doctor, and certainly not the government."

While up to this point, we've watched the Nadya Suleman story turn into a tabloid media circus, this legislation marks the beginning of the octuplets' birth spurring actual legal changes. Georgia lawmakers point out that other countries, such as Britain, already limit the number of embryos transferred per cycle. Other countries have found ways to reducing risky multiple births, but they've also adopted policies that don't severely limit women's rights. Hopefully in the U.S., as more states introduce limits on embryo transfers inspired by Nadya Suleman, lawmakers will consult with doctors and create legislation backed by fertility specialists that doesn't also seek to limit reproductive rights.

In-Vitro Fertilization Limit Is Sought [The Wall Street Journal]
Ethical Treatment Of Human Embryos Act [Georgia General Assembly]

Dr. Michael Kamrava, the doctor who helped Nadya Suleman become pregnant with octuplets, transferred at least seven embryos into another patient a few months after treating Suleman, reports The L.A. Times. The 49-year-old woman already has three children and is now five months pregnant with quadruplets. The woman is hospitalized at Los Angeles County-USC Medical Center, where she was transferred from another hospital because she doesn't have insurance. She spoke to The L.A. Times in a phone interview:

"Please respect my privacy," she said, adding that her circumstances are much different from Suleman's.

The woman has three grown children from a previous marriage but wanted another child with her second husband, who is in his early 30s and doesn't have any children, sources said. She works as an apartment manager; her husband is a contractor.

She started fertility treatments seeking one baby, but after becoming pregnant with quadruplets, declined medical advice to reduce the number of fetuses, the sources said.

The woman's situation is different from Suleman's. For a start, she's employed. But, having multiples is still very risky, and unlike Suleman, this mother's age is a factor.

"I do think it is concerning, and dangerous, especially to the mother. She is close to 50. When women get to be that age, our fear is the cardiovascular complications, such as stroke or heart attack. That's how serious this is," said Dr. John Jain, a fertility specialist with knowledge of the case.

Dr. Jain also appeared on The Today Show this morning, and explained that usually the age of the egg donor determines how many embryos will be implanted. In this case, the donor was 29, so only one or two embryos would usually be implanted. "It's just common sense, this is not what you do," says Jain in the clip below. "This is irresponsible, careless."

Nearly a third of in vitro births involve twins or more, but the government and professional associations want fertility doctors to reduce that number, reports the New York Times.

The American Society for Reproductive Medicine, the association of fertility doctors, even adopted guidelines in 2008 encouraging the transfer of only one embryo for women under 35, and no more than two, except in extraordinary circumstances. The guidelines allow more for older women, up to a maximum of five.

But unlike some other countries, the United States has no laws to enforce those guidelines. The Centers for Disease Control and Prevention has a surveillance system that collects data on fertility clinics, but reporting is voluntary and there are no government sanctions for not reporting.

Part of the problem may be the way that the cost of fertility treatments are covered in the U.S. In Europe, where many countries have banned the transfer of more than one embryo, the countries also cap costs for in vitro fertilization or require health insurance to cover the procedure. One cycle of in vitro costs about $12,000 in the U.S., and since the cost is often not covered by insurance, doctors say they are urged by their patients to implant more embryos. "There was greater pressure for U.S. clinics to deliver, no pun intended, on the first try," Dr. David Hill, who runs a Beverly Hills IVF clinic, told The New York Times, "so they would put back more embryos, and hopefully one of them would take."

A recent Slate article argues that the way to reduce the number of multiple births in this country is actually to increase the number of IVF procedures being performed.

In 2002, Harvard Medical School researchers found, unsurprisingly, that compared with women who pay out of pocket, those whose insurance fully covered IVF were significantly less likely to have multiples since they chose to have fewer implanted embryos. And while international comparisons are fraught with confounders, it's worth noting that Sweden and Australia have almost twice as many IVF births per capita as we do, yet their infant mortality rates remain comfortably lower.

One contributing factor may be that in those countries national health insurances subsidize IVF. Sweden even creates an incentive to reduce multiple births by fully covering repeated IVF attempts if a woman implants one embryo, but limiting coverage if a woman chooses to implant multiple embryos.

The Nadya Suleman case has caused such a furor that she is reportedly receiving death threats, and police are investigating the hundreds of angry emails and phone calls she receives. It's obviously an extreme example and there are other deeply troubling circumstances surrounding her case. But perhaps the Suleman-inspired criticism being leveled against women and doctors who choose to implant multiple embryos isn't entirely justified. Part of the problem is that America has a health care policy that is encouraging multiple births. Slate refers to a study that found making IVF coverage mandatory for health insurance providers would only increase yearly premiums by about 0.1 to 0.3 percent, which amounts to about $20 per year. The extra money may even lead to savings overall, since less taxpayer money would go to medical costs for babies born with health problems due to multiple births.

The idea of limiting the number of embryos a woman can have transferred has come up frequently over the past few weeks. But only limiting the number of embryos transferred may solve the problem by penalizing the vast majority of IVF patients who don't want to have risky multiple births, but can't afford to spend $100,000 on repeated treatments. The United States does need to reexamine its policy on fertility treatments, but the country should adopt a policy that actually fixes the problem without vilifying women who just want to have a child.

Octuplets Doctor Has Another Patient Expecting Quadruplets [L.A. Times]
Birth of Octuplets Puts Focus on Fertility Clinics [The New York Times]
Pregnant Pause [Slate]
LA Police To Investigate Threats To Octuplets Mom [Breitbart]
An Estimate Of The Cost Of In Vitro Fertilization Services In The United States In 1995 [Pub Med]
Is 'Octomom' America's Future? [The Wall Street Journal]

Related: When Eight Children Is Seven Too Many [New Scientist}

While the parents of the octuplets delivered today probably wouldn't describe the birth of their children as "tragic" as The Daily Mail does, multiple births do pose health risks for mothers and babies. Multiples are often born prematurely and are more likely to have cerebral palsy or not survive the first week of life. Women who carry multiples have a greater risk for pre-elcampsia, miscarriage, and hemorrhaging. This month, the UK's Human Fertilisation and Embryology Authority enacted a new "single embryo transfer" policy, under which IVF doctors are limited to implanting one embryo at a time unless circumstances are extenuating. Under this new Code of Practice, all UK fertility treatment centers must have in place a documented strategy for reducing their annual multiple birth rates. Though the parents of the U.S. octuplets refused to say whether they received fertility treatments or not, experts believe they probably used fertility drugs taken before artificial insemination. According to Peter Bowen, a fellow of the Royal College of Obstretricians and Gynacologists, it is unlikely the mother used IVF because "no doctor in his right mind" would put eight embryos in a woman's womb. [The Daily Mail, HFEA]

In only the second live birth of octuplets in U.S. history, a woman delivered six boys and two girls on Monday at Kaiser Permanente Bellflour Medical Center by Caesarean section, according to USA Today. Doctors thought the woman was carrying seven babies, and were surprised when they found there was an eighth baby (a boy). The parent's names have not yet been released, but doctors say the babies weighed between 1 pound, 8 ounces, and 3 pounds, 4 ounces and were born nine weeks premature. Two were placed on ventilators that have now been removed, and a third needed oxygen, but they are all in stable condition.

"It's a risky decision to try to have all eight babies," said Dr. Richard Paulson, director of the fertility program at the University of Southern California, who doesn't treat the octuplets. "I would not recommend it under any circumstances, but I respect a parent's decision." The first set of octuplets born in the United States were born three months premature in 1998. The smallest died a week after birth and the surviving children turned 10 in December.

Dr. Mandhir Gupta, a neo-natologist caring for the new octuplets says the next week will be critical for the infants, who may be in incubators for six to eight weeks, and in the hospital for the next 10 weeks. "She's a very strong woman, so she probably will be able to handle all eight babies," said Dr. Gupta. But caring for eight children isn't simply a matter of a woman being strong or weak. The uterus is only capable of taking care of a certain amount of foetuses and multiples have a much higher risk of developing health problems or dying. Plus, taking care of eight babies is incredibly difficult for the parents, especially when trying to breastfeed all the babies, like the California mother says she intends to do.

Doctors usually try to get mothers who have had several embryos implanted during in vitro fertilization to reduce the number of embryos, but the number of multiple births is still high. While of course, multiples rarely do occur naturally, The Times of London reports that in 2004 alone 19,049 babies were born in multiple births of two or more, amounting to one in every 67 births.

The number of multiples born as a result of IVF may start to decline however, as doctors have developed a way to test the viability of eggs fertilization and implantation begin. Time reports that in two months, a previously childless 41-year-old British woman will give birth to the first baby who underwent the test. The main reason so many embryos are not viable during IVF procedures is that especially in older women, some eggs carry chromosomal abnormalities that make a full-term pregnancy impossible. Chromosomal testing damages the egg, but doctors have discovered that after eggs begin developing, half of the 46 chromosomes are shed and ticked into a genetic bundle called the polar body, which is safe to test.

While as with other procedures that genetically test embryos babies in the womb, the procedure could theoretically allow parents to test for genetic diseases or more trivial things. While some people are concerned the test could lead to people aborting babies with a certain hair or eye color, the test also holds the promise that a woman undergoing a costly and painful IVF procedure will be able to implant the number of embryos that she wants, rather than having to undergo several unsuccessful procedures, or implant multiple embryos and decide whether to reduce the number of embryos or deliver multiples in a risky pregnancy.

8 Babies Born To California Parents Who Expected Only 7 [USA Today]
Rising Multiple Births Carry Health Risks [The Times of London]
Building a Better Baby: A New In-Vitro Test [Time]

Professional jealousy? Not really, but anti-abortion activists are concerned that the sheer absurdity of Burton's law and the eventual challenge to it could undermine their years of work convincing Americans that they aren't all crazy. They're even more scared that the eventual challenge to the underpinnings of Roe V. Wade they've been ginning up for when the Supreme Court gets that last, coveted conservative will be naught but a dream if Burton succeeds and then, at the Supreme Court, fails.

The problem with Burton's amendment is that it wouldn't just eliminate abortion (or enshrine a particular religious Weltanschauung into Colorado's constitution), it would also make illegal: certain kinds of birth control — from the Pill to IUDs to Plan B; the destruction of unused embryos from in vitro fertilization (if they get to remain unused at all, if the practice even remains legal since it generally involves the loss of some fertilized eggs); and research on embryo-initiated stem cell lines. Would they stop me at the border and forcibly remove my IUD if I chanced to have sex in Colorado? Force you to check your birth control pills at the border? Burton doesn't say — but she doesn't much care, either, because the Protection of The Unborn is more important than any right that the Supreme Court might have offered American women in Roe v. Wade or Griswold v. Connecticut. Oh, that's right! Burton's law, if upheld by the Supreme Court, wouldn't just invalidate Roe, it would dismantle Griswold, which protects our right to birth control — which the fundies know most Americans consider settled (and important) law.

Clark Forsythe, the president of Americans United for Life, opposes Burton's bill because he thinks the time isn't ripe for a Supreme Court challenge to Roe (since he doesn't have his last required judge) and because he recognizes that most Coloradans are going to think it's just a little crazy for the state to start outlawing methods of birth control:

"If it's defeated 60-40, or even 70-30, what does that say to lawmakers?" says Forsythe. (A mid-October poll shows 35 percent of the voters support the amendment, 55 percent oppose it and 10 percent are undecided).

They're afraid Burton's eventual defeat will actually set them back further in their efforts to convince you to let the government tell you what you can put into your body or take out of your uterus, or that it might convince the Supreme Court to reiterate its stance on Roe in a way that makes it nearly impossible to challenge in their lifetimes. So, ironically, Burton may do more good for the reproductive choice movement than it's ever done for itself. Funny that.

Roe v. Wade v. Kristi [Newsweek]

Related: They Just Won't Quit [Wonkette]

• Another woman has accused Bloomberg L.P. of discriminating against the pregnant. Monica Prestia has joined the Equal Employment Opportunity Commission's lawsuit against the financial giant. Apparently a barren supervisor was "openly hostile" to the fertile Prestia. That sort of sounds like the fertile crescent. Now I can't stop thinking about vaginas. [NY Times]
  
• Doctors say that exercise helps people who suffer from fibromyalgia. You know, for those few minutes a day when they're not experiencing crippling pain. [Science Daily]
  
• Most hysterectomies are still done the invasive way, by opening up the abdomen and taking out the uterus. Another, less invasive option? The uterus can be extracted through the vagina. On the upside, it leaves no scars. The downside is they're taking your uterus out through your vagina. [Reuters]

• Ugh, this guy deserves the chair: a man in Tennessee is accused of shocking his two teenage daughters with electric collars used on dogs and then raping them. [ABC News]
  
• President Moron vetoed a bill that would have provided $310.9 million in family-planning services which would have provided services for 139,000 women. I can't wait for election 2008. [Feminist Majority Foundation]
  
• Some obese women with BMIs over 35 are being denied in-vitro fertilization because of their weight. The British Fertility Society says that IVF should only be offered to women whose BMI is 30 or under because "Obesity reduces the chances that a woman will conceive naturally and decreases the possibility that fertility treatment will be successful." [BBC News]