HASTINGS CENTER REPORT 23 May-June 2009 ust over a week after her eight babies were delivered by caesarean section in a California hospital, Nadya Sule- man explained to an NBC reporter that her extraordi- nary pregnancy was the result of in vitro fertilization. Having conceived her first six children—four singletons and one set of twins—using IVF, Suleman said she visit- ed her fertility doctor in 2008 and insisted that he trans- fer all of her six remaining frozen embryos at once. After warning her of the risks associated with a multiple birth, he’d done as she asked. All six embryos implanted, and two divided to create twins. Awe at the successful delivery of her children quickly turned to ire when the press discovered that Suleman not only has six children already, but is an unemployed single mother on public assistance. Many feel she has irrespon- sibly created more mouths than she can possibly feed, and that the taxpayers of California are going to be left holding the babies, as it were. Like many familiar with the ins and outs of fertility treatment, I initially assumed that the octuplets resulted from Suleman’s body “overreacting” to fertility medica- tions. I guessed that her physician had either failed to monitor her egg development adequately before insemi- nating her, or that she had intercourse around the time her body released a large number of eggs. The idea that IVF—the most controllable form of assisted reproductive technology—had been used in such clear contravention of current professional guidelines and practice was almost unthinkable. In the early years of IVF, it was not unusual to trans- fer six embryos to a woman in the hope that just one would successfully implant. But as the technology has improved, multiple births have become more frequent. While high-order multiples were welcomed by some pa- tients, a few sued their physicians for the costs and harms to mothers and infants associated with complicated pre- mature births. In 1992, the Centers for Disease Control and Prevention began collecting statistics from fertility clinics and reporting clinic-specific success rates that highlighted not just the number of pregnancies achieved and infants born, but also the number and degree of multiple births. Among other goals, the CDC’s reports aim to improve the safety of assisted reproduction tech- nologies for women and their babies by pinpointing clin- ics that generate high numbers of multiples. As noted on the program’s Web site, “Multiple birth is associated with poor infant and maternal health outcomes, including pregnancy complications, preterm delivery, low birth weight, congenital malformations, and infant death.” The American Society for Reproductive Medicine also seeks to reduce the number of multiples born to its mem- bers’ patients. To this end it recommends that when treating women of Nadya Suleman’s age (under thirty- five years) who have a favorable prognosis, physicians consider transferring only one and no more than two blastocysts (embryos at five or six days of development). 1 There is clearly some wiggle room here—for example, if Suleman’s doctor was transferring embryos at day three of development (which are less likely to survive than em- bryos that have developed in the lab to the blastocyst stage), he might have argued for transferring two or three Judging Octomom BY JOSEPHINE JOHNSTON Josephine Johnston, “Judging Octomom,” Hastings Center Report 39, no. 3 (2009): 23-25. J When Nadya Suleman gave birth to eight babies in January 2009, the story ignited a media frenzy—first because the babies were only the second set of octuplets born in the United States, and later because of the irregularities of their conception by in vitro fertilization and the personal details of their mother’s life. Hidden beneath the sensational aspects of the story, though, are a number of fundamental ethical, medical, and legal issues concerning assisted reproductive technologies. Three essays examine these questions.