The unprecedented birth of septuplets in Iowa sparked intense criticism from ethicists and doctors Thursday, with several warning that fertility treatments are being used indiscriminately and irresponsibly at great medical risk to women and their offspring and at growing expense to the general public.
Preliminary tests suggest that all seven children born to Bobbi and Kenny McCaughey are doing well. But multiple births beyond triplets usually are characterized by some degree of physical or cognitive disability, critics said, and in most cases they can and ought to be avoided.
Katherine Hauser, the fertility doctor who worked with the McCaugheys, defended her care at a news conference Thursday, saying she used the same dose of a fertility drug that she had used with the Iowa couple two years earlier. In that instance the drug led to the birth of a single daughter. But for reasons that remain unclear, she said, “in this cycle we achieved more success than we could ever hope for.”
Critics, however, said they were unsatisfied with that explanation. When the McCaugheys’ doctors saw that their fertility treatment had led to the maturation of about three times the expected number of eggs, they said, the prudent move would have been to withhold addition of the husband’s sperm and try in another month or two when a more modest number of eggs were produced.
“Here we had a nice ending,” said Mark Sauer, chief of reproductive endocrinology at Columbia-Presbyterian Medical Center in New York. “However, if she would have died or the babies had lifelong problems with cerebral palsey or some other complications, it would be a nightmare. Even now, with the potential for psychosocial problems, it may still become a nightmare. And society certainly has the right to ask why did this happen and were there alternatives.”
Roger Kempers, medical director of the American Society for Reproductive Medicine in Birmingham, Ala., said the society’s guidelines call for doctors to avoid large-scale multiple births. One problem is that ovarian overstimulation can cause swelling and bleeding of the ovaries and severe fluid retention that can lead in rare cases to heart failure.
Women carrying multiple fetuses also are at risk of potentially fatal blood clots and other complications during pregnancy and delivery, and the children often require expensive follow up care for years. A set of Indiana sextuplets born in 1993 required three years of state-funded special care, for example, and several sextuplets born last year in Albany, N.Y., have serious medical problems including one case of partial blindness.
Kempers said Germany recently passed legislation prohibiting doctors from using a common fertility technique to create more than three offspring per mother. But he said there are many ways to avoid multiple births without legislation and without having to resort to aborting one or several of the fetuses - an option the McCaugheys said they opposed on religious grounds.
“We think it’s better if we can self-regulate this than having the federal government coming in,” Kempers said.
Reproductive medicine is effectively unregulated in this country, in large part because the government, under pressure from opponents of abortion, has banned federal funding of research involving human embryos.
“By and large, infertility treatment in this country has grown up as an entrepreneurial field rather than as a scientific field, so many of the things doctors are doing in the way of fertility treatments have not met the same standards of scientific scrutiny,” said Thomas Murray, director of the Center for Biomedical Ethics at Case Western Reserve University.
Murray said he was gratified the McCaughey children are doing well, however, and does not begrudge the parents’ decision to carry all seven fetuses to term.
Like most women, Bobbi McCaughey was born with ovaries full of immature eggs. But the pituitary gland in her brain produces too little of a substance called follicle stimulating hormone (FSH), which normally spurs a few of those eggs to mature each month.
Her doctors prescribed the drug Metrodin, rich in that key hormone. It is made from urine collected daily from 100,000 postmenopausal women in Europe.
Typically doctors track the egg maturation process in fertility patients with ultrasound imaging, which allows them to see the small eruptions that develop on the surface of the ovaries as eggs mature. When three or four or more are ripe, doctors give an injection of another hormone, human chorionic gonadotropin (HCG), to release those eggs from their ovarian nests and make them available to sperm, which are injected into the vicinity with a syringe or through intercourse.
Sauer said it would have been obvious that McCaughey’s ovaries had overreacted to the drug. “She must have had a dozen or more eggs going, and if she was being monitored correctly they had to know she was grossly overstimulated before she got her HCG shot,” he said. “That’s not even a borderline call, it’s a cavalier decision to give a woman like that a shot of HCG. If we see more than four or five we cancel those cycles.”
It was not clear Thursday whether Hauser was aware of the number of stimulated eggs and, if so, whether she considered cancelling the fertility cycle. She said she had treated hundreds of patients with the drug in the past 18 years and no mother had given birth to more than triplets.
Canceling a treatment cycle means the patient is out several thousand dollars, and sometimes women insist on going forward. “There’s a tremendous pressure to deliver the goods, but doctors have to draw the line,” Sauer said. Otherwise, he said, “you get the backlash.”