LOS ANGELES -- Nadya Suleman's fertility doctor implanted a dozen embryos in the pregnancy that gave her octuplets, a state attorney said Monday, a number that another doctor said was unheard of and surpasses Suleman's assertion that only six embryos were implanted.
Dr. Michael Kamrava's action endangered the mother and violated national standards of care, Deputy Attorney General Judith Alvarado said at the Medical Board of California's hearing to consider revoking or suspending the Beverly Hills physician's license.
Kamrava "knew that a 12-embryo transfer was unsafe," Alvarado said in her opening statement. National guidelines issued by the American Society for Reproductive Medicine specify no more than two embryos are to be used in in vitro treatments for a healthy woman under 35. Suleman was 33 at the time of her last treatment.
Dr. Victor Y. Fujimoto, an expert witness for the medical board and director of the University of California San Francisco In Vitro Fertilization Program, testified Monday that 12 embryos, or blastocysts, being transferred into a uterus is unheard of.
"I cannot imagine any colleague of mine transferring that many embryos," said Fujimoto, adding he had never transferred that many himself.
High-order multiple births can result in long-term developmental delays, cerebral palsy and various life-threatening ailments.
There are no hard-and-fast rules, but fertility specialists have criticized Kamrava's methods, saying he endangered Suleman's health and the long-term health of the babies. Suleman's babies, born nine weeks premature in January 2009, are the world's longest-surviving set of octuplets.
Suleman, a divorced single mother of 14, has said Kamrava implanted her with six embryos for each of her six pregnancies and two of them split when she had octuplets.
Fujimoto said Suleman, identified as "N.S." by the medical board, actually requested 12 blastocysts to be transferred into her, but it's the physician's job to make a decision not to transfer embryos, even when a patient insists.
Fujimoto said Kamrava also made an "extreme departure from standard of care" by failing to refer Suleman for a mental health evaluation after she said she wanted twins shortly after delivering her second child.
"For me it raises a huge red flag," Fujimoto said. "It's a very unique request for twins after having just had a second child."
Typically, expenses, health concerns or other factors preclude parents who are struggling to conceive from having more than one or two successful in vitro treatments.
Records obtained by The Associated Press show that before 2001, Suleman was treated with Celexa and Sonata for depression and sleeplessness, and Clonopin for anxiety.
During cross-examination, Kamrava's lawyer, Henry Fenton, noted that in vitro fertilization is expensive, and asked Fujimoto what a doctor should do if a patient insisted on having a higher number of embryos implanted to better her chances of becoming pregnant.
Fujimoto said that wouldn't be advisable "because any transfer, on any given day, can result in full implantation of all those embryos," and result in a dangerous multiple birth.
Monday's testimony also called into question claims Suleman has made in past interviews that she underwent the in vitro treatment that led to the octuplets because she didn't want her frozen embryos to go to waste. Fujimoto testified that she never used frozen embryos and has 29 frozen embryos available.
Before the octuplets' birth, the unemployed Suleman and her six children lived with her mother, relying on food stamps, school loans and disability payments for her two autistic children to get by.
More recently, Suleman has tried to use her notoriety for income through the tabloid media, but she struggles to pay rent and is facing a $450,000 balloon payment on her La Habra home.
Unlike Suleman, Kamrava has kept a low profile and declined repeated requests for interview from The Associated Press. In July, he made a rare appearance in an ABC "Nightline" interview, defending his treatment of Suleman by saying it was "done the right way."
Though other doctors in the field say they're not impressed with it, Kamrava has long touted a method of in vitro fertilization that implants an embryo - or sometimes sperm with an unfertilized egg - directly into the uterine lining.
Kamrava suffered a blow to his prestige last year when he was kicked out of the American Society for Reproductive Medicine, which does not have authority to prevent him from practicing medicine.
The board's accusation says Kamrava was also negligent in his treatment of two other patients.
He is accused of implanting seven embryos in a 48-year-old patient, resulting in quadruplets, but one fetus died before birth.
Fujimoto called the number of blastocysts implanted "an extreme departure" from standards of care.
In another case, Fujimoto said that Kamrava went ahead with in vitro fertilization instead of referring his patient with a history of cancer to a specialist after tests detected atypical cells, which can indicate presence of a tumor.
The patient was later diagnosed with stage-three cancer by another doctor and had to undergo removal of her uterus and ovaries before undergoing chemotherapy.