Thursday, July 1, 2010

Should the business of geriatric reproductive endocrinology exist?

This morning I saw a news item about a 71-one-year-old woman becoming a mother for the first time. She was Indian, and the reporter explained that in rural regions of her country, a social stigma still exists against barren women. With the help of a fertility clinic, she conceived through IVF and gave birth by cesarean eighteen months ago. Her son appeared healthy, but she herself looked haggard and worn, and the reporter went on to say she was still suffering complications from the operation.

When the reporter asked her doctor whether his patient was up to the task of parenting a child, or whether, given her less than perfect health, she would be likely to live to see her son into adolescence, he shrugged and basically said, not his problem. He's in the business of creating pregnancies, not parents.

And business looks like it's booming in his clinic and in similar clinics around the world.

Reproductive endocrinology is a fascinating and rapidly advancing field of medicine, which helps thousands of women have children each year. Many caring specialists spend a great deal of time counseling patients about their options and encouraging responsible, healthy choices. I'm sure good reproductive specialists engage in candid conversations with older prospective first time moms about the physical stamina required to parent a child.

But at the end of the day, fertility medicine is a huge for-profit business. Don't think so? I challenge you to name another department of any major hospital that sends new patients home clutching a promotional DVD. And IVF cycle costs anywhere from $15,000 to $20,000, and most states do not require health insurance to cover it - which means it's more profitable than many other procedures that routinely take place in hospitals. According to literature from several major clinics, the chances of success per cycle are roughly 25 per cent. Most patients elect to try more than once. The bills add up fast.

For comparison, consider the price of a month of Clomid, a pill designed to improve and spur egg development, and the gateway drug for so many women seeking help with fertility. It runs about $60-$80 a month. Guess which route the DVD highlights.

People were quick to condemn LA's infamous "octomom," but what possessed the physician who agreed to implant all those embryos in the first place? Reputable reproductive endocrinologists were quick to point out that voluntary guidelines exist; it's generally considered medically reasonable to implant two, or at the maximum, three, embryos during an IVF procedure. Outraged members of the public demanded the doctor lose license, but what he did wasn't unlawful. Should it be? Or have these these highly educated, highly regarded doctors earned the right to police themselves?

Would it be too much to ask that the medical boards of the various states impose some mandatory limits on the number of embryos implanted per IVF attempt? How about a maximum maternal age? In my opinion, getting into the record books - or the New England Journal of Medicine - is not a legitimate reason for a doctor to perform an otherwise inadvisable procedure.

We're not talking about a risky, never-been-tried-before transplant as a last ditch effort to save someone who is days from fatal organ failure. We need to remember that pregnancy is an elective condition that, especially for the post-menopausal, involves a significant possibility of serious complications to mother and child alike.

Pregnancy puts a major strain on a healthy young body; some older women's circulatory systems simply cannot handle the shock. Risks to mother and child increase dramatically after menopause. Recently, a 60-something-year-old great grandma in California gave birth to her twelfth baby. Really? Did the doctor truly believe that feat was in anyone's best interest?

I know a lot of sixty year olds. None of them possess the physical stamina of women twenty years their junior. It's just basic biology. Unfair? Of course. But also unchangeable. As is the decision to have a child once that baby takes its first breath.

If a woman wants more than three embryos implanted, could voluntary guidelines recommend that the fertility doctors offer a psych consult to assess why the patient would want to raise four plus infants at once? Aside to potential future octomoms: ambitions of reality television stardom do not justify making eight babies with one (high risk) pregnancy.

Or is it good to push the limits of reproductive science, no matter what the cost to the resulting children? Should the post-menopausal be encouraged to procreate? I'm all for control over one's body, so my knee jerk, default response is a qualified yes.

But only if their doctors are duty-bound to explain the risks and assess their patients for health limitations that would render them unable not just to give birth but to parent. When the fertility doctor's work is done, the woman's journey is only beginning. The DVD's never mention that.

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