Eight Babies at Once: A Fertility Controversy

By:
Mary Y. Choi

When a woman in Southern California gave birth to octuplets, it sparked immediate attention.

To help you understand fertility treatment and multiple births, we talked to Dr. Richard Paulson, director of the fertility program at the University of Southern California (USC), and Dr. Karine Chung, founder and director of USC’s fertility preservation program.

Q: How do multiple births, specifically octuplets, occur? 

Dr. Paulson: Multiple gestation is a serious complication of fertility therapy. We’re not as good as nature is, to make sure only one egg is produced. Even though that is always our goal, sometimes we overshoot it and get multiple eggs, which can then lead to multiple births.

Dr. Chung: The purpose of fertility treatments is to help patients conceive one baby at a time. Fertility treatments stimulate a woman’s ovaries to produce eggs. Increasing the number of eggs increases the chances of conception. Higher-order multiples result from super-ovulation with intrauterine insemination (inserting sperm into the uterus), or combining that with intercourse. We try to optimize the dosing of the medications, but there’s no way to control it 100 percent. That’s the type that results in multiples—most frequently twins and triplets, and occasionally quadruplets. Octuplets…10 years ago it happened in Houston. With the current guidelines, there’s about a 20 to 30 percent chance of twins and about a 5 percent chance of triplets.

Q: How does in vitro fertilization (IVF) work?

Dr. Chung: With in vitro fertilization, the same medications are used to stimulate women’s ovaries but instead of intrauterine insemination, we extract the eggs and fertilize them in the lab, then decide how many embryos to put back into the uterus. Typically in a woman at [Nadia's] age [33], it’s two embryos. With three embryos, serious counseling needs to take place first. Triplets is a bad outcome—selective reduction [terminating one fetus or more] needs to be considered. Some people aren’t aware that triplets aren’t a good outcome. My job is to tell them it’s not a good outcome; it’s not healthy for the mom or the baby.

 

Q: So then the best situation for women getting fertility treatments is to have one successful pregnancy?

 Dr. Chung: It’s never the goal of a physician to put a patient in the position of considering selective reduction. Singleton pregnancy [having one baby] is the best outcome.

Q: What are the risks associated with multiple-birth pregnancies?

Dr. Paulson: We work hard to avoid octuplets because it can be very dangerous. It’s dangerous for the mom and baby. The risks are relatively small for the mother if she’s in her 30s. Young and healthy people can usually adapt.

The bigger danger by far is to the babies: prematurity. The uterus is designed to carry one baby to term. Even with twins, there’s a much higher risk of premature delivery. It’s even more dangerous to try and carry more babies to viability. They are almost always born prematurely. Severe prematurity can lead to neonatal death or neurologic problems. Eight babies at one time is a bad idea.

Q: Why would someone with children seek out fertility treatment?

Dr. Paulson: We don’t know…I’m reluctant to pass judgment. There may be all kinds of extenuating circumstances. These are private, profoundly felt decisions.

Dr. Chung: Secondary infertility is where something changes, when you’re not able to be pregnant again. There are often very complex social issues involved. For example, a new male partner who has no children of his own might want to have children. We don’t know the social circumstances in this case.

Q: How much control do doctors have over preventing higher-order multiple births?

Dr. Chung: In IVF, you have complete control over the number of embryos that you put back into a woman’s uterus— the American Society for Reproductive Medicine has guidelines about this. If you do replace two embryos at a time instead of one embryo it will increase the odds of pregnancy. If it was IVF, and the doctor replaced eight embryos, then whatever doctor was treating in this case was practicing out of the bounds of care—professional, not legal, boundaries.

Q: Why do women opt for fertility treatments that increase their risk of multiple births?

Dr. Chung: Most women who are undergoing fertility treatment have been trying to get pregnant for over a year without success. The treatment is designed to increase their chances. Some patients welcome the idea of twins, but anything beyond twins the medical profession will advise against.

 

Q: Under what circumstances would you deny a woman treatment?

Dr. Paulson: We deny fertility treatment in cases where pregnancy would be dangerous—if they have medical problems. That’s about it. Then, certain types of treatment might not be appropriate in certain circumstances. Take, for example, someone who does not think that selective reduction is an option for religious or philosophical reasons. In this case, we would do IVF and transfer one or two embryos. We would not recommend treatment with fertility medications followed by insemination or intercourse. With that type of treatment, the eggs come out of the ovary on their own, so it’s more natural, but we have much less control over how many eggs are ovulating at one time. Most of the time, only one or two are released, but in rare instances, several can come out at one time, and then there is the clear risk of high-order multiples.

Dr. Chung: It’s a reproductive choice; a reproductive rights issue. It’s not my position to deny care to someone. There are situations where people have strange ideas that I don’t agree with or are beyond the normal fertility treatment indications. In those instances, it’s the medical professional’s obligation to say, "If I’m not going to treat you, here are three other professionals who might be able to treat you."

We run medical tests, but as far as looking into their social situations, there are no social guidelines. That would be unfair because people trying to get pregnant at home—nobody’s subjecting them to that same type of scrutiny. So it would be discrimination.

Q: How do you counsel women who see news of the octuplets and are not successfully conceiving?

Dr. Chung: Anyone’s reaction is, "I don’t want that to happen to me." And we don’t want that to happen to them either.

More: Join the conversation on the In Vitro (IVF) message board and read about when eight isn't enough.