Long before she gave birth to her octuplets, Nadya Suleman delivered for her fertility specialist.
Like clockwork, she had babies every year but one between 2001 and 2006. The six children she had during that period accounted for a big share of the success stories at Dr Michael Kamrava's clinic. And Kamrava touted his feats with Suleman on the local news.
But that track record - together with the birth of the octuplets on January 26 - has raised eyebrows among doctors and ethicists who wonder whether Kamrava disregarded professional standards and used Suleman to boost his stats, and improve his standing in the highly competitive and lucrative fertility field.
"A motivation would be improving his rate of live births," said Alex Capron, a professor and bioethicist at the University of Southern California. "If she was already a huge percentage of them, he may have felt: 'implant six, get three. That's three more in my plus column.' And for him, that would be a noticeable percentage. That would help to explain his behaviour." Kamrava, 57, has not given any comment on this.
Suleman births upset clinic figures
Suleman, a 33-year-old unemployed single mother, has said Kamrava implanted her with six embryos for each of her six pregnancies – an apparent violation of national guidelines that specify no more than two embryos for a healthy woman under 35. In her last pregnancy, two of the six embryos split to create eight babies.
Reports from the Centres for Disease Control and Prevention show that between 2000 and 2006, Suleman's children accounted for five out of 24 live births to women under 35 who underwent the same procedure at Kamrava's clinic. (She had six children in all during that period, including a set of twins, which are counted as one live birth in CDC data.) The figures do not include 2005, when Kamrava did not file with the CDC.
During that same period, no more than one in five fertility cycles at Kamrava's clinic in any given year resulted in a live birth for women under 35 using fresh embryos and their own eggs.
The national average for US fertility clinics in 2006, the most recent year reported, was about 30%. In 2006, when Suleman was pregnant with the twins, she was featured with Kamrava in a KTLA-TV news story about an embryo implantation procedure he pioneered that he claimed could boost pregnancy rates by 70%.
IVF can cost up to R150 000 per cycle
The controversial technique buries the embryos in the uterine lining. A high success rate could turn heads in the highly competitive field, where doctors keep close tabs on their standings in clinic-by-clinic statistics.
That pressure is magnified in the Los Angeles metropolitan area, where there are many high-volume clinics, said Dr Hal Danzer, of the Southern California Reproductive Centre.
"You look at what everybody else is doing across the country and if everybody is doing better than you do, you start looking at your lab," Danzer said.
The field is also lucrative: In vitro fertilisations can cost up to R150 000 per cycle, and many patients undergo multiple cycles.
Some fertility doctors said they doubt Kamrava, a 25-year veteran in the field, would attempt to plump up his overall statistics with one patient.
"That's a real stretch," said Dr Jeffrey Steinberg, medical director of Fertility Institutes, with locations in Los Angeles, New York and Mexico. "I've known him for a long time, and that's not the impression I get."
'Damned if you do, damned if you don't'
He also noted that fertility specialists come under pressure from their patients. "We've all had this, we all talk about it. You've got four embryos sitting in the dish, you want to give her two and she wants all four," he said. "You're damned if you do and you're damned if you don't."
By Suleman's own account, that may have happened in her case.
Suleman was in her early 20s and had had several failed pregnancies when she first underwent in vitro fertilisation with Kamrava. She has gone on record in a television interview as saying she persuaded her doctor to implant more embryos because "he knew I wanted a big family and this is my only option". – (Sapa, February 2009)