The case cast a spotlight on the business of fertility treatment: in the United States fertility clinics are largely unregulated. Although the American Society of Reproductive Medicine (ASRM) issues guidelines on how doctors should administer fertility services, in most states there are no laws regulating what doctors can and cannot do in this regard. Though critics called Suleman’s doctor irresponsible, he had not violated any laws.

Infertility treatment wouldn’t be nearly as controversial if it didn’t increase the odds that a woman will conceive more than one child during the treatment. “Multiples,” as these babies are called, are often born prematurely. Consequently, they are underweight and have underdeveloped organs, and so are at risk for birth defects such as cerebral palsy and infant respiratory distress syndrome. Carrying multiples also increases the risk that the mother will develop dangerously high blood pressure, diabetes, vitamin deficiencies, or one or another of several other medical conditions during her pregnancy that may affect her health or that of her unborn children. Even women who have twins have a higher risk of medical complications during pregnancy, and their babies are at a higher risk of premature birth than singletons. Suleman’s eight children are the only surviving set of octuplets ever.

Multiple births without fertility treatment are extremely rare. Scientists estimate that the incidence of natural triplets is 1 in 6,000 to 8,000 births—of quadruplets, 1 in 500,000 births. The incidence of higher-order multiple births is even rarer. But because the use of assisted reproductive technologies has skyrocketed, so, too, have the number of multiple births. The number of triplet births rose 400% between 1980 and 1998, according to statistics compiled by the Centers for Disease Control and Prevention. The medical complications associated with such pregnancies place a large burden on the health care system.

Although there have been efforts to improve assisted reproductive technology and therefore reduce the likelihood of multiple births, extreme cases such as Suleman’s have drawn lawmakers to the scene. Many states are considering legislation that would place restrictions on fertility doctors. Working from another perspective, some groups are fighting for legislation that would require health insurance providers to pay for fertility treatments. Because many patients pay out of pocket, patients with limited financial resources can, because of their circumstances, pressure doctors to be aggressive with treatment, despite the health risks associated with carrying multiples. The goal of this legislation is to make assisted reproduction safer for everyone, not just for those who can afford it.