The birth of a living healthy set of octuplets in California this week raised a host of weighty ethical issues. Was it irresponsible to attempt to bring 8 babies to term when the option of selective reduction was available? Why was an octuplet pregnancy allowed to occur in the first place? When it became clear that an excessive number of follicles had developed, why did the fertility specialist continue the cycle knowing that disaster was likely to occur?

Now, amazingly enough, we learn that those were not even the biggest ethical issues involved. The babies’ grandmother revealed yesterday that the octuplets mother is young, apparently single, lives at home with her parents and … already had 6 children!

This raises the very disturbing possibility that octuplets were conceived deliberately for the attention and money that could be expected. In an age of Jon and Kate plus 8 (the hit television show about a family with twins and sextuplets), and the new show about the Duggars  (the family of 18 biological children) premiering soon, it is entirely possible that this woman set out to conceive a set of higher order multiples for the fame and fortune she imagined it might bring.

If so, she would not be the first. The Frustaci septuplets were born in May 1985 after treatment with fertility medication. The doctor alleged that Patti Frustaci took the medication, but then refused to have the recommended ultrasound evaluations that would have revealed that too many follicles were developing, because she wanted to have multiples. Frustaci had intercourse, became pregnant with septuplets and refused reduction. The outcome was tragic, 4 babies died within weeks, and the other 3 have multiple serious medical issues.

How did the octuplet disaster occur? We don’t yet know, but it is difficult to imagine that any infertility specialist would knowingly treat a young woman with 6 children for infertility. In fact, it is difficult to imagine that a young woman with 6 children could be diagnosed with an infertility problem, unless the other children were conceived with fertility treatments.

It seems very unlikely that the octuplet pregnancy resulted from in vitro fertilization. Regardless of the number of fertilized eggs produced, doctors exercise tight control over how many embryos are returned to the uterus. In the early years of in vitro, three to four embryos might be placed in the uterus, but that has changed in light of the many triplet and quadruplet pregnancies that ended in disaster (and lawsuits). Now most clinics will place only two embryos in the uterus at any one time, and save the others to use in a future cycle. In fact, some clinics recommended placing only one fertilized egg at a time.

In light of the medico-legal issues, let alone the ethical issues, it is difficult to imagine that any doctor would take the extremely risky step of returning 8 fertilized eggs at one time to the uterus. That means that the pregnancy was likely the result of powerful infertility medications like Pergonal. Pergonal stimulated the ovaries to produce more eggs in any given cycle. For women who typically don’t produce any eggs at all, Pergonal can coax the ovaries to produce one of two eggs. The possibility exists that more eggs could be produced in a cycle, so each cycle is monitored carefully with daily ultrasounds to make sure that there are not too many follicles developing. If the number of follicles is dangerously high, the doctor will not use medications to trigger ovulation, and will not perform artificial insemination during the cycle.

Not everyone needs the triggering medication or insemination in addition to the Pergonal. Once a safe number of follicles have been identified, some women can get pregnant spontaneously the old fashioned way. Once again, it is difficult to imagine that any doctor would advise a woman to proceed with a cycle that had produced 8 follicles. Such a woman would be instructed to refrain from intercourse until days after the eggs were released so that there would be no possibility of a higher order multiple pregnancy occurring.

That suggests that the mother is in some way responsible for the octuplet pregnancy, either by refusing to follow medical advice or by treating herself with fertility medications without the aid of a doctor. The Kaiser clinic where the mother received her pregnancy care has already announced that they were not responsible in any way for this pregnancy. The mother came to them at 12 weeks, and they diagnosed a septuplet pregnancy (when there are so many babies, it is difficult to count accurately). In addition, while they strongly counseled her to reduce the number of babies, the mother refused.

I want to emphasize that these thoughts are pure speculation, but an octuplet pregnancy is inconsistent with responsible infertility care. In the current medico-legal environment, where infertility specialists can be held responsible for medical expenses associated with a higher order multiple pregnancy, it is difficult to imagine that any doctor would take the risk.

Something does not add up here. A young, presumably unmarried woman, living at home with her parents, who already has 6 children is exceedingly unlikely to be diagnosed with infertility, is unlikely to be treated for infertility even if she is having difficulty getting pregnant, could not have had 8 embryos placed in her uterus by in-vitro fertilization and would almost certainly be counseled to avoid intercourse in any cycle where 8 follicles were developing. Add to that the fact that the woman showed up for care already pregnant with octuplets and suspicions are raised that this pregnancy was conceived in a deliberate effort to have a spectacular outcome, including any publicity and money it might generate.