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.