Infertility Breeds Infamy

My penchant for remembering minutia and the esoteric sent my gray matter into high gear when I read the recent headline:

Indiana fertility doctor used his own sperm 'around 50 times,' papers say.

Made for Television

I remembered seeing this story on an episode of Law and Order, Season 5, Episode 15, and it was titled Seed. But that episode aired February 15, 1995.

Could the above headline really be true? Who would do that outside of a television show?

The gray matter continued its high gear processes. Wasnt there an The X-Files episode about babies being born in a small town, all with a genetically unique feature a tail that indicated a single sperm donor? Such stories must be more fiction than fact. Yes, in fact, there was during Season 4 an episode (20) titled Small Potatoes. In that episode, the fertility doctor was suspected, but it turned out to be a man who had shape-shifter abilities and could change his appearance into that of the womens husbands.... Alright, we get the picture. This is sci-fi, fantasy, and therefore in the realm of the abstract and absurd.

So how could the headline above be true?

Stranger Than Fiction

Yet, it is true, and it appeared on CNN.com atop an article by Susan Scutti on September 14, 2016. Dr. Donald Cline, a fertility doctor in Marion County, Indiana, had promised his patients that they were being inseminated with fresh sperm from a medical student or resident. But, in fact, he was using his own sperm. He now faces two counts of obstruction of justice and faces up to five years in prison if he's convicted.

In the article, Eleanor Nicoll, spokesperson for the American Society for Reproductive Medicine, noted, "This kind of thing happens very rarely. Yet my fascination with the above television drama episodes kept my wheels turning. Why have we seen such TV episodes? Doesnt art imitate life? Didnt U2s "Sunday Bloody Sunday" lyrics state, When fact is fiction and TV reality?

So I looked at the details on Law and Order. The episode Seed was based on Dr. Cecil B. Jacobson , an infertility specialist in Virginia who, on March 4, 1992, was convicted on 52 counts of fraud and perjury for artificially inseminating unwitting patients with his own sperm and for telling them they were pregnant when they were not. He may, in fact, have fathered 75 children through the use of his own sperm for artificial insemination, according to prosecutors.

Then I recalled a report I had heard on the BBC regarding a British doctor who had committed similar acts. Tom Kelly of DailyMail.com reported on April 8, 2012:

A British scientist fathered up to 600 children after founding a fertility clinic that promised to provide sperm donors from intelligent stock." This was at Londons Barton Clinic, a fertility clinic started by Bertold Wiesner and his wife, Mary Bartons, operated between the 1940s and the 1960s. Of note: Wiesners wife eventually destroyed the medical records, so that these children would not have access to pertinent health information.

Jacobson, Wiesner, and Cline. Perhaps as many as 725 children fathered by these three men. This is in addition to the occasional one-time episodes - for example, Dr. Ben Ramaley , of Greenwich, CT, who used his own sperm instead of that of his patients husband to impregnate her in 2002. Her twins clearly did not resemble the father, eventually leading to the revelation that the doctor was also the father. And, as time goes on, with the availability of consumer-level DNA tests (which exposed the Cline case), we may find other such instances.

The Verdict Is In

For me, as a physician, what is my take on all of this? Im not a lawyer, so it is not clear to me which laws, if any, are broken in such situations. The Cline case will involve two counts of obstruction of justice. The Jacobson case resulted in conviction on multiple counts of mail fraud, wire fraud, travel fraud, and perjury. I am not aware of any charges regarding Wiesner. Ramaleys case did not involve any criminal inquiry, although it is noted that he paid a fine to the Connecticut Public Health Department and was ordered to stop artificial inseminations. He maintained his Connecticut license to practice, but was reported to have forfeited his New York medical license.

What motivates these physicians to undertake these activities? One could even question what the wrongdoing was here. In the case of Cecil Jacobson, it has been noted that some patients were happy to have a baby and, therefore, did not testify while others felt they had been lied to and, therefore, did testify. Court documents in the Cline case mention that doctor admitted to doing wrong by inseminating the women with his own semen, but felt that he was helping women because they really wanted a baby." Jacobson offered several explanations for his actions, including his concern that a patient may miss a window of opportunity to become pregnant so, in the absence of a scheduled donor, he would use his own sperm. So is the argument here one of altruism, allowing these families to achieve the goal of parenthood?

Is this a matter of greed? Wiesner was noted to have charged high fees and, therefore, had clients who were mainly middle class and some upper class members, including peers of the realm .

In 2014, the infertility service markets reached a figure of $3.5 billion. Reports indicate that average costs to a family for one cycle run in the vicinity of $19k (a cycle of IVF being between $10k and $15k, but with additional medications running $3k to $5k). Three cycles of IVF may run around $33k.

Is this a matter of ego, or even the God complex? Wiesner spoke of providing donors from intelligent stock (ultimately, it was himself). The actions of these other physicians can be extrapolated perhaps, at least in my opinion, to the belief that they knew what was best for the patient, that they could provide a baby when other methods had failed, and that they were overseeing the greater good.

Ill admit it - doctors have often been cited as having big egos. In the movie Malice, Alec Baldwins character Dr. Jed Hill states, You ask me if I have a God complex. Let me tell you something: I am God.

Im sure my surgical ego has come through at times. Face it, Im a surgeon and my avocation is playing lead guitar. Talk about egos Im like the Reeses Peanut Butter Cup of egos. Yet, Ill show my cards here and state that I could never imagine ones ego driving someone to do what these doctors have done.

I cant imagine doing what they have done.

We Know It When We See It

Ultimately, my opinion is that these doctors did the wrong thing. Wiesners actions occurred before there were any laws against using the same donor multiple times, let alone against using his own sperm. Convictions have been along the lines of fraud and obstruction of justice. Yet my gut feeling, and probably yours as well, is that these actions are far more reprehensible than what those charges seem to indicate.

For me, these actions are about abuse of power, about lack of integrity, about betrayal of trust.

Patients come to physicians and healthcare providers with expectations and assumptions that the doctor will be trustworthy, adept, and honest. In many situations, patients are vulnerable due to illness or due to a desire for a certain outcome. The physician stands in a potential position of power. We cannot exploit this power not for money, ego, our own sense of altruism, or whatever other motivation we may have that is not one of integrity.

At times, it is hard to find a rule or law that describes the correct action, yet we understand, down deep, what it means to do the right thing. Call it passing the sniff test, gut feeling, instinct, or Gestalt, but I think most of us (sadly not all), physician and lay person, recognize it. SCOTUS Justice Potter Stewarts famous line in Jacobellis v. Ohio comes to mind, I know it when I see it.

Consider the following facts from the CDC :

About 6% of married women in the United States are unable to get pregnant after a year of unprotected sex, while 12% of women have difficulty getting pregnant or carrying a child to term. Between 2006 and 2010, 12% of women (7.3 million), or their husbands or partners, had used infertility services at some point in their lives.

Add to this the fact, as stated in an article by Rebecca Smith in The Telegraph April 8, 2012, regarding Wiesner, that the danger of using the same sperm donor to create so many children lies in the risk that two of the offspring will unwittingly meet and start a family of their own, which could cause serious genetic problems in their children.

Consider seeing one of these patients or couples in your office, desiring a child that the mother has carried to term (or that a surrogate has carried), willing to pay large amounts out of pocket, and setting as their highest priority the goal of parenthood. Practitioners have a duty and responsibility to act with integrity, to provide care, and to avoid taking advantage of such patients. Our dictum Primum Non Nocere, First Do No Harm, includes not only physical harm but also psychological harm, social harm, and harm to integrity and trust. If we bill excessively, misrepresent our skills, lie about results, or fraudulently conduct fertility treatment we are doing harm.

For me, these infertility cases are morally and ethically reprehensible. And, although I have cited more cases than I believed had existed, I know that the majority of healthcare providers do answer to the call of integrity and trust that our patients not only demand but, in fact, deserve.

The Hippocratic oath states, I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing. The Modern Hippocratic Oath states, I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm. I think its safe to say that integrity is one of those obligations.

Arthur M. Lauretano, MD, MS, FACS

9-17-16

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