Front page of the Sunday New York Times agrees with Dr. Silber on octuplets issue

It was the last piece of advice Thomas and Amanda Stansel wanted to hear. But their fertility doctor was delivering it, without sugarcoating.

Reduce, or you will lose them all, he told them.

For more than a year the Stansels had been relying on Dr. George Grunert, one of the busiest fertility doctors in Houston, to produce his industry’s coveted product — a healthy baby. He was using a common procedure called intrauterine insemination, which involved injecting sperm into Mrs. Stansel’s uterus after hormone shots.

But something had gone wrong. In April, an ultrasound revealed that Mrs. Stansel was carrying not one but six babies, and Dr. Grunert was recommending a procedure known as selective reduction, in which some of the fetuses would be eliminated.

The Stansels rejected Dr. Grunert’s advice and, since then, their vision of a family has collapsed into excruciating loss: the deaths of four children after their premature births on Aug. 4, including one who died late Sunday night. The two other infants remain in neonatal intensive care, their futures uncertain.

“I feel like we bonded with all of them, the short time they were here,” Mr. Stansel said. “We were able to hold them before they passed away.”

The birth of octuplets in California in January placed the onus for large multiple births on in vitro fertilization, a treatment in which eggs are joined with sperm in a petri dish and returned to the womb for gestation.

But the procedure the Stansels used is actually the major cause of quadruplets, quintuplets and sextuplets — the most dangerous pregnancies for both mother and children. While less effective than IVF, intrauterine insemination is used at least twice as frequently because it is less invasive, cheaper and more likely to be covered by insurance, interviews and data show.

Multiples can occur when the high-potency hormones frequently used with the procedure overstimulate the ovaries and produce large numbers of eggs. Parents are then left with the kind of tough choices the Stansels faced: whether to eliminate some of the fetuses or keep the babies and face extraordinary risks.