Case narrative: a case of in vitro fertilization

OM is a 34-year-old woman with two previous children born with the assistance of in vitro fertilization (IVF). In the course of IVF treatment six additional embryos were created and frozen. Now, 6 years after the birth of her second child, she plans another pregnancy using the frozen embryos. She requests that all six embryos be returned (transferred to the uterus using a transcervical catheter: a simple outpatient procedure) for potential implantation. She asks for this number in spite of guidelines suggesting that, for a woman of her age and health, no more than two or three be transferred. All six are transferred and she becomes pregnant with what proves to be octuplets (the pregnancy contains two sets of identical twins). After a prolonged period of maternal bed rest and hospitalization, the babies are delivered via cesarean section at 30 weeks of gestation.

Introduction

This “case” mirrors some circumstances of the 2009 California pregnancy of a woman named Nadya Suleman, quickly nicknamed “Octomom.” The birth of her octuplets engendered a media storm, which included the revelation that she was a single mother who had six other children, all conceived through IVF. Many of those expressing outrage about the Suleman case questioned whether she was fit to be a parent. We have argued elsewhere that matters of fitness to parent are difficult for physicians to evaluate, and only in the most extreme and exceptional circumstances, none of which were present in the California case, should providers use such concerns to limit access to assisted reproductive technologies (Minkoff & Ecker, 2009). This chapter will focus on a question we feel more appropriately evaluated by medical professionals: what is the right number of embryos to transfer? This discussion touches on important principles of patient autonomy and respect for autonomy, two principles we believe are related but not equivalent. We will argue that the principle of respect for patient autonomy does not require physicians to accede to any request by a patient, to consider whether the number of embryos transferred in assisted reproductive technologies should be regulated, and, if so, to reflect on the appropriate nexus for such regulation.