Eight is more than enough

ADVANCES in assisted reproduction for infertile couples were among the great medical successes of the last century. The downside was the frequency of triplets, quadruplets, and even higher-order multiple births, which carried risks to both the mother and the babies she delivered. In the last decade, fertility specialists have adhered more closely to professional codes that limited the occurrence of multiple births.

And then came Nadja Suleman.

She is the 33-year-old single mother of six from southern California who last month gave birth to eight premature babies, all of whom have survived. Neither she nor the doctor who assisted in her pregnancy has disclosed the technique she used, but Suleman's mother has indicated that she used embryos that had been fertilized in vitro and left over from her earlier pregnancies.

If a fertility doctor approved the implantation of eight embryos, he or she did not follow guidelines of the American Society of Reproductive Medicine. Under its standard, no more than two should be implanted in women under 35. The society's president, Dr. R. Dale McClure, said in a statement that it is investigating the case.

As well it should. In addition to the risk to the mother, babies in high-order multiple births face an increased chance of lung, brain, and intestinal problems, or such severe disabilities as cerebral palsy. "Over the last decade," McClure said, "we have worked diligently to reduce the number of high-order multiple births resulting from [in vitro fertilization] treatments."

McClure's society should look not just at the decision to implant so many embryos but also at the doctor's willingness to assist a woman who already had six children to deliver more. A former president of the society, Dr. David Adamson, said he had never provided fertility treatment to a woman with six children or heard of such a case.

Doctors are allowed to inquire about a patient's psychological motives in deciding whether to offer treatment. But some say it isn't their place to tell a mother she shouldn't have more children. The profession needs a fuller ethical debate on this issue.

Adamson fears a backlash against his specialty, which is likely to take the form of demands that his society and the Society for Assisted Reproductive Technology take tougher disciplinary action against doctors and clinics that ignore their guidelines. According to David Magnus, director of the Stanford Center for Biomedical Ethics, "You've got a virtually unregulated marketplace with tort law serving as regulation in the United States." The professional organizations risk the heavy hand of government regulation if they do not turn their guidelines into rules.