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A Guest Post by Eric Fiedler, M.D.

Note: Dr. Eric Fiedler is medical director of the Central Pennsylvania-based Advanced Center for Infertility and Reproductive Medicine.  Portions of this correspondence were originally published in the Sunday Harrisburg Patriot News on February 21.

Recent news reports concerning the questionable practices of the “Octomom” doctor, Michael Kamrava, M.D., underscore the importance of knowledgeable and ethical medical conduct in the treatment of infertility.  As medical director of The Advanced Center for Infertility and Reproductive Medicine, RPC, one of Central Pennsylvania’s most respected fertility clinics, I am concerned that a similar situation could occur here in Pennsylvania.

While public interest has focused on Nadya Suleman, the Octomom case came about through the “far outside the box” practices of her fertility physician, Dr. Kamrava, and not the mother herself.  Standard and safe medical practice in reproduction cases generally calls for the uterine placement of no more than two embryos, with the hope that one actually develops into a fetus.  The  transfer of more than two embryos in such a young woman, while believed by some to significantly increase the chances for a successful pregnancy, in fact mainly increases the chance of high order multiple pregnancy and its attendant risks for both mother and babies.  Transfer of more than two embryos should never be undertaken without regard for the consequences of what happens if more than two embryos actually take hold and an accepted contingency plan is in place.

I can almost assure you that Dr. Kamrava never discussed these issues with Ms. Suleman, and that if he had conducted proper patient screening, she would have been referred for appropriate counseling before any further attempts at conception, considering her existing child rearing situation at home.

Why a similar circumstance can occur here in Pennsylvania is due in large part to the unregulated nature of fertility treatment.  As state law stands, only those fertility treatment centers with in-house licensed surgery facilities undergo any kind of state inspection or regulation.  Further, as is the case with Dr. Kamrava, not all fertility practitioners in the state are board certified in the field of Reproductive Endocrinology and Infertility.  To give you an idea of the importance of Subspecialty Board Certification when choosing an infertility physician, as of the Fall of 2009 there are only 1061 board certified Reproductive Endocrinologists in this country compared to over 39,000 board certified Obstetrician/Gynecologists.  Board certification in Reproductive Endocrinology and Infertility is a distinction that carries with it the necessary formal training and knowledge to appropriately evaluate and treat infertility, which is a very complex medical issue.

What is occurring here, and why it should be of concern to all Pennsylvanians, is that while limited basic infertility evaluations and treatments are appropriate in the hands of general Ob-Gyns, many advanced fertility treatments are performed by Ob-Gyns as a side element of their obstetrics and gynecological practices.  Few centers have a licensed in-house surgical facility or CLIA certified laboratory, which raises substantive questions about patient safety and quality control.

A high order multiple birth event has already occurred in Pennsylvania with our own Kate Gosselin, of reality television’s Jon and Kate Plus 8.  The main difference between these two cases is that Jon and Kate (being married professionals and having only two other children at the time of the birth of their sextuplets) became celebrities with their own TV show, while Ms. Suleman has been publicly vilified.

I was personally and professionally relieved to see that authorities are holding Dr.  Kamrava responsible, as it was most assuredly his negligence that led to the multiple birth event.  Had Ms. Suleman gone to a Board Certified Reproductive Endocrinologist, I can assure you that, as a single mother, she would have been referred for counseling after her first three or four children had been born.  No additional embryo transfers would likely have occurred.

Unfortunately, we can expect more of these types of multiple births so long as lawmakers and the medical oversight community continue to turn a blind eye to the unregulated nature of fertility treatment in Pennsylvania.  This is stated with the full understanding that the wrong type of regulation can have the undesired effect of interfering with the doctor-patient relationship and the individualization of medical care that is more necessary and more critical the more complex the medical issues to be addressed.  Infertility treatment is about as complex (medically, ethically, physically and financially) as any medical issue that exists.  The answer is not in regulating the number of embryos that may be transferred, but rather the type of training that must be required for providers of such fertility services and the types of facilities that are required for performance of fertility related procedures.  The public needs to be protected now.

Let’s hope it will not take the death of a woman undergoing fertility treatment or of a mother delivering multiple births for this issue to receive the attention that it deserves.


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