Fertility, age and egg freezing

There’s an interesting piece on the Guardian’s Comment is Free written by Barbara Ellen about a paper in the Lancet suggesting young women might freeze their eggs or ovarian tissue for future use.  She is quite right to be concerned about the uncertainties around freezing as a solution – it is relatively new, expensive and comes with no guarantees – and yet having come across many women who are still unaware of the realities of their fertility I don’t think all women are aware of the way that fertility declines.

There may be endless screeching about this through the “media megaphone” as she describes it, and yet I regularly meet women in their forties who think that being fit and healthy and still having periods must also mean being fertile. I’m not sure where the disconnect is here, and whilst it is quite true that there are many women who may be unnecessarily anxious about their fertility in their early thirties, the realities of fertility in your forties still comes as a surprise to many others.

I’m not sure why this is – is it that women who are now in their forties didn’t get this message when they were younger? Is it that they are putting too much faith in fertility treatments to solve any problems? The realities of IVF success rates of less than 2% at the age of 45 combined with miscarriage rates rising to 93% at that age are still something too few women really appreciate.

Fit and healthy doesn’t always mean fertile

I was listening to a woman talking yesterday about access to IVF for women in their mid-forties. She thought the NHS should fund treatment for women who were past the age of 42 (which is the current cut off recommended by NICE) if they were “fit and healthy”.  It’s a point of view that some may share – that age isn’t as important as how you look after your body and that those who eat well, who exercise and who appear younger than their years must still be fertile.

In fact, fertility doesn’t work that way; of course, being fit and healthy is always going to help, but by the time you reach your mid-forties, it’s your personal biological clock which is more important when it comes to your chances of conceiving –  and that’s not something that any amount of healthy eating can alter.

The HFEA success rates for IVF show this very clearly; women who are 35 and under have an average chance of success of 32% but for 38-39 year olds this is already reduced to 20%.  Once you get into your forties, the decline is very sharp – for a woman of 40-42 there is a 13% chance of success, at 43-44 that drops to 5% and over 45s have a less than 2% chance of getting pregnant with IVF.  So no matter how fit and healthy you may feel, your chances of IVF success in your mid-forties are very low.

It’s a difficult message, and one that we don’t always want to hear – but the one thing IVF cannot do is turn back the biological clock.

‘Generation IVF’ – does it exist?

You may have heard about the forum organised in New York last month for women struggling to conceive who had experienced unsuccessful IVF. It is an important subject because it is so often ignored but looking at a review of the forum this morning, I was interested to read about an apparent “Generation IVF” of women who “were raised to believe that science can surpass Mother Nature in the tricky dance of conception”.

I know there are women who will leave it until they are approaching 40 to try to get pregnant and hope that fertility treatment will help if they’re too late – but I think most women in this situation are there by circumstance rather than by the assumption that IVF offers miracle solutions to reproductive ageing.  I wonder whether the situation is slightly different in the US where the marketing of fertility treatments does seem to be more aggressive and where there is not the same regulation around clinics and the reporting of success rates.

Here, the HFEA publishes the IVF success rates for each age group nationally, and for each clinic – and so it is quite clear to anyone considering IVF that the success rates for a woman of 43-44 are 5% and for a woman of over 45 drop to just 2%.  The age cut-off for treatment in the NICE guideline also sends a message that IVF is not advised for women who are over the age of 42, and would only be suggested for women aged 40 – 42 who still have a good ovarian reserve.  For women in this age bracket the national success rate is 14%.

So what does drive women who are given very low odds of success to try IVF over and over again? The report says that the women at the forum talked about the pressure to keep trying even when the odds were very low, but where does that pressure come from? Should we blame clinics for agreeing to treat women who have a low chance of success? Or the media for hyped headlines about how fertility treatment can work and stories about celebrities who have had babies in their forties? Or is it something more fundamental to do with human instinct and the desire to reproduce?

Interestingly, the report says that the women of this Generation IVF have grown up with “the reproductive freedom to delay pregnancy” as if this is a given. Of course, women are free to prevent pregnancy, but they certainly don’t have the freedom to confidently delay it. I have never come across a fertility expert who would suggest that fertility treatment gives women the freedom to delay pregnancy either.  Education is obviously key here – we need to work harder to get the message across that IVF cannot turn back the biological clock – but can we lay the blame for hope against the odds at any one door?  I’d be interested in your thoughts..

 

When IVF doesn’t work…

There’s an interesting piece by Zoe Williams in today’s Guardian looking at what happens when IVF doesn’t work, following on from the publicity surrounding a book, Cracked Open: Liberty, Fertility and the Pursuit of High-Tech Babies, written by Miriam Zoll in the States. It’s an important issue as the average success rate of IVF in the UK is still only around 25% and those who have been through unsuccessful treatment are often left feeling isolated and depressed.

That’s why it’s a shame that the Guardian piece got sidetracked at the start by the suggestion that clinics were somehow exploiting lesbians by offering them frozen donor sperm. It was implied that because fresh sperm is more likely to be successful, clinics should be telling women to use this instead. Donor sperm is frozen in order to carry out thorough screening for HIV and other infections, and it would surely be far more alarming if, in order to increase their success rates, clinics were offering women fresh, unscreened sperm with the risk that it might carry an infection or chromosomal abnormality. Yes, those who need donor sperm have the option to find a donor they trust and carry out DIY treatment and to take that risk themselves – but I’m far from convinced that clinics ought to be suggesting this as a better option.

There is a more worrying trend if you are looking to criticise the way clinics deal with people using donor sperm, and that’s around ICSI – a more expensive form of IVF where the sperm is injected directly into the egg which was developed to treat male infertility. Women who have paid for donor sperm – which should be of the highest quality – are sometimes advised that they need to have ICSI when in fact the only real indication for using ICSI is for male fertility problems. ICSI is more expensive for patients and there is no evidence that it increases live birth rates where there is no male fertility problem.

The next issue I have with the piece is around the lying about statistics. The HFEA publishes the success rates for every clinic in the country and these are carefully monitored. Anyone going for treatment is always advised to look at these if they want to know about success rates, and for patients this is one of many reasons it was so important to keep the HFEA. The fact that only 25% of treatment is successful nationally is correct, but that doesn’t mean that 75% of women who have used IVF have not ended up with a baby.  The 25% success rate is for all women and includes those who are having IVF beyond the age of 42 when success rates drop sharply into single figures. The majority of women will have more than one cycle of treatment – and that’s why the NICE guideline recommends three full cycles of treatment (including frozen embryo transfers). Even with fertile couples, natural human reproduction has a success rate of around 25% for the first month of trying to get pregnant, and it is only cumulatively that human reproduction becomes more successful. It is absolutely true that not everyone will get pregnant after IVF – but it is also true that many women are still going into treatment later in life when IVF is less successful as it cannot turn back the biological clock- this is the important message to get across as Fiona Kisby Littleton explains in the article.

The piece also raises the issue of multiple birth, the biggest health risk from IVF, claiming that there are people in the IVF industry “who no longer even see twins as a problem”.  I don’t think there are people who “no longer” see twins as a problem. There are some who have never seen multiple births as a problem who haven’t changed their minds, but there are far more who now understand that this is not a good outcome. When I first had IVF eighteen years ago, three embryos were routinely replaced after IVF treatment but the HFEA has successfully worked with clinics to reduce the multiple birth rate and now more and more women are having just one embryo transfered. While there are some clinicians who are not entirely on board with this, they are a minority. It is now generally accepted that the way to judge a successful clinic is to look for high success rates combined with low multiple birth rates

I absolutely agree that we focus too much on IVF success and don’t give enough time, care and attention to those for whom it doesn’t work. It is true that IVF has become a huge global money-making business, but this is not new. When I wrote my first book about IVF, In Pursuit of Parenthood, in 1998 one of the IVF patients I interviewed said; “Infertility treatment is an industry – an industry that’s founded on hope…. but it’s all fantasy, it’s all hope which is continually shattered”.

When you look at the article online, a list of other related pieces appears in the corner.  One goes to this article, illustrated with an image of a line of pregnant rounded bellies, about a new technique which could “revolutionise” IVF increasing the live birth rate by 50% with claims that it could be the most exciting breakthrough in treatment for 30 years. It is hardly surprising that people with fertility problems are excited by headlines like this – which refers to something that a number of the experts in the piece explain is as yet unproven. Clinics are often blamed for raising false hopes, but in fact most responsible clinicians do tell women when their chances of success are low. When this comes against a steady flow of stories about amazing breakthroughs in treatment and babies born against the odds to perimenopausal women it is often hard to keep expectations in perspective.

 

Single embryo transfer just as successful…

A new study reported in the Guardian shows that putting back just one embryo at a time during IVF doesn’t reduce the chances of having a baby.  It is now policy in the UK to encourage transferring just one embryo whenever appropriate in order to reduce the risks associated with multiple pregnancies and births, but there has been some opposition from those who believe that this will inevitably reduce the chances of having a baby.

The study presented at the British Fertility Society annual meeting in Liverpool focused on live birth rates at the Leicester Fertility Centre during separate periods before a single embryo transfer policy was adopted and afterwards – and found that there was no difference in the number of women who became pregnant, and an increase in the live birth rate – which should be hugely reassuring to anyone who is worried about the single embryo transfer policy.

Of course, when you are going through fertility treatment you want to maximise your chances of success – and some clinics still try to convince patients that this will be done by transferring more than one embryo at a time.  This study shows that it really isn’t the case for all women, and transferring a single embryo for those who are most likely to be successful will not reduce the chances of success but will reduce the chances of a potentially risky multiple pregnancy.

You can read more here