"There's a bit of magic in everything, and some loss to even things out." -Lou Reed

Saturday, March 7, 2009

The Real Person to Blame for the "Octomom" Situation


I have kept quiet here about Nadya Suleman, now often referred to as the "octomom" in the press, because my frustration level was so high, and also I didn't want to give any more time or words to this story. However, as some of my friends who desperately want children are getting fertility treatments now, I think there are a few issues to be addressed, beyond Nadya's issues.

If you have watched any of the interviews with this woman, I think it is clear that she is troubled, and has more than a little blurred vision of reality. With six children at home, and upon talking to this woman, any decent, educated doctor would have counseled her differently, perhaps had her speak to a therapist or some other professional, and would have, at the very least, not implanted that number of embryos. This doctor is the real person to blame, for worrying more about the success rate of his practice, than the safety and sanity of a patient in his office. Now there are eight innocent children in the world who will no doubt suffer at least one or more disabilities, with a mother who is ill-equipped in more ways than one to handle this responsibility.

For those that don't know, insurance does not cover the cost of IVF. I haven't heard anyone asking where Nadya got the money for this procedure, but let me tell you, it isn't cheap. It can be in the tens of thousands for just one attempt.

I think this is one of the core problems. Nadya's doctor is clearly negligent--the article points out more than one area of concern--but doctors across the country with good intentions do often implant more embryos than they might otherwise because they know their patients can only afford one attempt.

Now, these doctors are not implanting eight embryos, and they are not implanting them in women that have six children at home. They are trying to give couples who have tried everything else a chance to have a baby. But the increase in multiple births is the result of this. Why insurance won't cover this process is beyond me (although I think I have an idea and it is all about money). If insurance covered IVF, and the guidelines were reasonable--covering couples that could not conceive otherwise, doctors could be more cautious, implanting single embryos and giving the process a chance to work naturally, and give couples one child at a time.

In the end, the "octomom" situation is such a mess, that I fear that some well-meaning law makers are going to try and over correct the situation, and that parents who do need IVF, and who are doing all the right things, will pay the price.

The Fertility Doctor Behind the "Octomom"
By Alison Stateman / Los Angeles Saturday, Mar. 07, 2009

To Nadya Suleman, Dr. Michael Kamrava was a hero. Suleman sought treatment at Kamrava's West Coast IVF Clinic, in order to conceive all 14 of her children - the last batch of whom generated worldwide headlines as only the second living set of octuplets born in the United States. However, to other fertility practitioners and professional reproductive associations, Kamrava's reported means were troubling. And at least one former client had little heroic to say.

"I didn't like him at all. He was very rude," says Michael Verdi, 59, who, with his late wife Eva Menen, went to Kamrava in the early 1990s for infertility treatment. (Menen died of an unrelated illness in 1998.) "When the treatment started, I was asking him questions and I wouldn't get proper answers. I would get psychiatric answers, clinical answers." After three months without success, the couple stopped treatment. "Eva was getting emotionally upset because nothing was happening and he wasn't explaining things," says Verdi. "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." The couple filed a medical malpractice suit against Kamrava on April 22, 1994 and settled a few months later. Verdi could not recall the sum they settled on or further details. The malpractice suit was one of at least four filed against Kamrava since 1991. (Calls for comment to Dr. Kamrava's office and to his current lawyers were not returned.)

One approach of Kamrava's has come in for particular criticism: implanting large numbers of embryos. Suleman said during her first interview on the Today show that she had been implanted with six embryos during each IVF cycle, far in excess of the maximum recommendation of two for a woman her age by the American Society for Reproductive Medicine (ASRM). Days later, the Los Angeles Times reported that a 49-year-old uninsured woman was pregnant with quadruplets after being treated by Kamrava a few months after he helped Suleman become pregnant. In that case, Kamrava transferred at least seven embryos made from younger donor eggs, according to the Times.
Dr. Jeffrey Steinberg, medical director of the Fertility Institute, has known Kamrava for 20 years and used to work out of the same lab as part of a multi-physician program at the now-defunct Century City Doctors Hospital. He speculates that Kamrava may have chosen the path of multiple-implantations because he was under pressure to up his success rate. To keep to the Fertility Clinic Success Rate and Certification Act of 1992, that rate must be reported to the Centers for Disease Control and Prevention annually. Steinberg says that after the law went into effect, fertility centers implanted more embryos per cycle and there was an explosion in the number of multiple births. ASRM responded by urging its members to stop the practice and multiple births declined dramatically as the number of embryos used went down.
The 1992 act, says Steinberg, "was sort of a regulatory control that was supposed to empower patients by providing more information to them, which is great in it's intent. I think it proved more detrimental than positive because it made [some practices] more aggressive."
Despite Kamrava's practice of using more embryos than most doctors practicing IVF, his overall success rates remain low when compared to nationwide averages. According to statistics provided by the Society for Assisted Reproductive Technology, in 2006 — the most recent data available — among patients younger than 35, Kamrava transferred an average of 3.5 embryos versus the nationwide average of 2.3. However, he had a 10% success rate versus a nationwide average of 39% for procedures resulting in live births. John Scodras, an embryologist who worked as lab director for Kamrava from 1993 to 1995, says when he joined the practice the pregnancy success rates were low. "The culture system they were using was not up to par," says Scodras. "I bumped up the pregnancy rate from around 10% by about 25%. So we were running about 35 percent by the time I left."

"To me as a scientist," says Scodras, "that tells me that his lab isn't functioning up to par. If you get six embryos from a cycle and they don't look good I could see where he would say you know these don't look good, I'm going to transfer them all because the likelihood of them resulting in a pregnancy is slim." Adds Scodras: "I guess he did it once and they had a singleton so he didn't think anything of it the other times. That's a dangerous thing to do."
In the meantime, professional reproductive societies have taken notice of the controversy. Kamrava was removed from the American Fertility Association's Physician Network on Feb. 9, the day it became public that Kamrava's clinic had treated Suleman, pending the outcome of the investigation, according to an AFA spokesperson.

The website for Kamrava's practice used to trumpet his lab's certification with leading professional societies including the American Association of Bioanalysis. However, after being notified by TIME of its inclusion, a representative for the AAB said Dr. Kamrava was never certified through the association's board, the American Board of Bioanalysts (ABB). In fact, according to Mark Birenbaum, Ph.D., administrator for the organization, Kamrava had been denied certification when he applied 15 years ago. Because of confidentially rules, Birenbaum could not disclose the reasons for the denial, but requested that Kamrava remove the claim from his site. (There is no mention of the certification on the revamped site for West Coast IVF Clinic.)

Meanwhile, as the Medical Board of California continues its investigation into whether the treatment Suleman received violated the "standard of care" for the profession, legislators have responded by proposing additional regulation of the industry. California State Sen. Gloria Negrete McLeod (D-Chino) introduced Senate Bill 674 late last month, which would bring fertility clinics under the jurisdiction of the Medical Board of California and their approved accrediting agencies, and set accreditation standards and guidelines for the operation of the clinics.

Steinberg strongly opposes additional industry regulations. "There's two octuplets reported in all of history. There are over a million IVF babies. It's been going on for 33 years so in 33 years there have been a handful of problems," says Steinberg. "It's not cookbook medicine. Every single case, every single couple, every single single woman is a unique situation and regulations tend to address things in general."

Kamrava's working style also left his employees wanting. "If something went wrong that he didn't like, he was a yeller. He did yell at the office staff. I didn't experience that. I'm kind of in a different position. In any fertility practice, I'm treated as more of an equal to the physician than a simple employee," says Scodras.

When Scodras decided to take his current position as lab director of Southwest Florida Fertility Center in Fort Meyers, Fla., Kamrava hired Dr. Shantal Rajah, an embryologist he recruited from England. "Honestly, I was surprised he hired a woman because, although with his patients he got along very well, I just pictured him as more suited to a male in the lab," says Scodras. After just three weeks in Kamrava's employ, Rajah found herself at odds with the doctor over the heating of the laboratory and was abruptly asked to leave the practice. She sued him for breach of contract, reaching a settlement in 2003. Rajah declined to comment further about the case.
article and picture courtesy of Time.com

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