Birds, Bees & IVF: The New Reality

On July 25, the world’s first IVF baby, Englishwoman Louise Brown, will turn 40; on June 23 Australia’s first IVF baby Candice Reed will turn 38. At the time they were dubbed ‘test-tube’ babies and given the scrutiny under which they have lived their lives, its arguable they’ve never left one.

Louise Brown has written a book about being the first person born by assisted reproductive technology (ART), chronicling the support – and condemnation – her parents, Lesley and John, received when she was delivered at Oldham Hospital by registrar John Webster (and a phalanx of specialists including IVF pioneers gynaecologist Prof Patrick Steptoe and biologist and physiologist Prof John Edwards) weighing 2.608kg.

Things have come a long way – just run your eye along some of the most recent statistics in the Australian and New Zealand Assisted Reproduction Database.

The frontier of the science continues to spin heads – the latest being the concept of the three-parent child using mitochondrial transfer – but for the tens of thousands of people having children through ART and the community around them, assisted reproduction is almost next to normal.

Changing community values

But that’s not to say anything goes. The fertility ‘industry’ is tightly controlled by state-based legislation and overseen here in WA by the Reproductive Technology Committee (RTC). The Act was promulgated in 1991 and given the much-expanded boundaries of science and society (in particular the legalisation of same sex marriage) since then, it is somewhat apt that it is now undergoing review in WA by Deakin University health law expert A/Prof Sonia Allen.

Submissions closed in March and she has since been meeting interested parties as well as conducting public forums to gauge where the likely intersection of science and community values lie in our state. A report is expected soon.

Prof Roger Hart

Prof Roger Hart, who is professor of Reproductive Medicine, Division of Obstetrics and Gynaecology at UWA, and medical director of two Perth infertility clinics as well as UWA’s representative on the RTC, spoke to Medical Forum about the medical issues he’d personally like to see addressed in any amendment of the legislation. First and foremost is the number of embryos a woman is permitted to freeze before she is allowed to embark on a further IVF cycle.

“A woman can’t start on another IVF cycle if she has more than two embryos stored, it is a fact of life that age is a factor affecting many women who seek fertility treatment,” he said.

“So a woman of 38 who needs IVF to conceive – perhaps because her egg quality or her partner’s sperm count has deteriorated – goes through a cycle and generates three embryos. However, those have to be used as she’s not permitted to ‘bank’ more with a further IVF cycle.”

“If that woman returns for treatment for a second or even a third child, she has to start her IVF treatment again, and given that she is likely now to be at a minimum nearly 40, the success of that treatment is low. A more pragmatic, and successful approach would be to give her the opportunity to freeze enough healthy embryos at 38 for her to complete her family.”

“This was not the vision of the future when the laws were couched originally, plus back then, the pregnancy rates using frozen embryos was poor. There was a significant chance that at least one embryo would not thaw, so generally more than one freshly generated embryo was placed in the uterus, to avoid freezing embryos. Hence years ago twins and triplets were more common than they are now, and now Australia has one of the lowest multiple pregnancy rates in the world.”

Adding to the case for a greater number of embryos frozen first time round is the issue of genetic testing, to which Roger would add ‘irrespective of a woman’s age’.

Genetic testing needed

“A woman in her late 30s faces an increased risk that her embryos may be chromosomally abnormal and it is the general wisdom to have a critical mass of embryos to test rather than just test one or two or even three, because, unfortunately, they may all be abnormal.” Roger said.

“Batching embryos derived from a couple of IVF cycles would be a good idea to ensure the prospective parents have a reasonable number to undergo testing. This in turn may help to ensure they have a normal embryo to transfer. Unfortunately they will pay a lot of money to test these embryos, so it is pragmatic and emotionally less draining to generate several embryos for testing,” he said.

Roger said the IVF landscape is a rapidly changing place and it is understandable that laws do struggle to keep up.

“Compared with even 10 years ago, when we were routinely transferring embryos after three days, we are now transferring blastocysts after five days of culture, so their potential is much greater and as a result the single embryo transfer rate has improved,” he said.

“Australia has one of the lowest multiple pregnancy rates in the world. We are currently 4.6% where the UK is 22% and its 33% in the US.”

“One in 25 Australians are born from IVF treatment, and by 28 years of age an adult born resulting from IVF treatment becomes financially a net contributor to the State. Medicare is supportive of couples undergoing fertility treatment which in turn helps fertility clinics adopt appropriate and safe practice, to avoid multiple pregnancies, premature deliveries and the attendant social, medical and financial costs that would result.”

“In contrast, in the UK, where there is limited public funding for fertility treatment, patients have to pay the whole cost. Many patients opt to have two or more embryos implanted in one procedure to try to maximise their chance of conceiving because they believe they may not be able to afford another treatment.”

“In Australia, we’re transferring just one embryo with similar pregnancy rates. A singleton pregnancy is not only better for the mother, but it is better for the baby’s long-term health outcomes.”

Something the law can’t change is the increasing trend among couples to delay having children. While it might seem on paper a promising component of a business model, there are not too many fertility specialists who would recommend it.

Counselling essential

For starters, the process, no matter what spin is put on it, is tough on the woman’s physical and mental wellbeing. This psychological component is one of the reasons why WA’s oversight has such a strong emphasis on counselling and support for couples going through treatment.

And ART is not a magic bullet. According to the ANZARD figures for IVF cycles commenced in 2015, of the 77,721 initiated cycles, 22.8% (17,726) resulted in a clinical pregnancy and only 18.1% (14,040) resulted in a live delivery.

Roger said treating medical teams had a significant responsibility to optimise a woman and a man’s health for conception before starting treatment, and in this age of obesity, chronic disease and delayed family planning, that’s easier said than done but essential for both the couple and the community.

“Fertility specialists have been urging women to have children earlier but society is not listening. The common belief is that it is okay to leave it till later. The reality in Australia for children born to women over the age of 37 years or older, one in seven will be IVF babies. A third of IVF cycles in Australia are for women over 40,” Roger said.

“Society needs a discussion about this. The message has been widely disseminated but there is a lot of pressure on women in the workplace because they believe having a family at an earlier age will be detrimental to their careers. That’s not fair.”

“Men throughout all workforces need to be strong advocates for women. After all they all have a mother, and many have wives, daughters or sisters. I strongly believe that we need that dialogue. I certainly urge my junior doctors and medical students to consider this. They shouldn’t feel that they must get the career first and then think about family after.”