In defence of IVF
Dr Raj Mathur
Progress Educational Trust29 October 2018
It is striking how IVF has become part of the national conversation in ways that would have been unthinkable one or two decades ago. Not all news has been good news; in the recent past, reports have revealed examples of unethical practice relating to inducements for donating eggs and sex selection. These are instances of the press doing its job of holding professionals to account, and present an opportunity for the fertility sector as well as its regulator, the Human Fertilisation and Embryology Authority (HFEA).
However, there is also a strain of recent media coverage that I can only describe as 'anti-conventional IVF'. What this seems to be suggesting is that IVF itself, as practised in most clinics in the UK (and for that matter worldwide), is somehow malevolent – both dangerous and inefficient. The coverage is rarely moderate in tone; one much-publicised article used words like 'needless', 'overdose', 'heart attacks and stroke' to create a frightening picture of how IVF is routinely carried out.
As a clinician, I worry about this. This is because I believe that women are not served by being given a skewed, incomplete and inaccurate picture. An obvious point that is often missing from the coverage is that conventional IVF works, and it works more often and for more people than any alternative treatment.
Put another way, it is an effective treatment and other treatments are less effective. Take 'mild' IVF for instance, which is a concept rather hard to pin down. This is because – uniquely – mild IVF is defined not by the actual treatment given but by drug doses relative to an undefined standard and by the intentions of the prescriber.
There appears to be little doubt that conventional IVF gives the woman a significantly better chance of having a baby per cycle started compared with mild IVF. When you take into account the smaller number of embryos generated with mild IVF, the cumulative advantage of conventional IVF over mild IVF is likely to be overwhelming. The significantly lower success rates of IVF in Japan compared with the rest of the world – Japanese clinics have historically been reluctant to use conventional ovarian stimulation – are a cautionary tale.
If we look at the ovarian response rather than the treatment regime or the intentions of the treating physician, large studies show that the live birth rate per cycle increases with increasing egg number, plateauing at between 15 and 20 eggs, while the cumulative live birth rate continues to rise even beyond this.
To achieve some sort of balance in the media coverage of conventional IVF and its risks, an acknowledgement of its superior clinical effectiveness is crucial. So too is an honest presentation of the risks. Otherwise, readers could be forgiven for thinking that fertility clinics are needlessly causing complications when they could be providing an equally effective treatment without these risks. This is clearly not the case.
When we talk about the welfare of women who have IVF, it is important to at least acknowledge the possibility that this may be best served by helping them to achieve their aim: having a baby with the fewest number of treatment cycles. For most women, this aim – the reason they seek fertility treatment – is best achieved by conventional IVF.
Looked at in this light, the question then becomes about properly informed patients making a properly informed treatment choice, taking into account risks and benefits, as in every other area of clinical medicine. Clinicians have a duty to inform patients. But does the media also have a duty to present information accurately?
Take the condition of Ovarian Hyperstimulation Syndrome (OHSS). At various times, I have read in the media that 'thousands' of women develop OHSS each year in the UK and even that it is a leading cause of maternal mortality. This is not a situation that I recognise.
In 2015-2016, NHS data suggested that there were 836 admissions for OHSS, almost certainly an overestimate. Data presented at Fertility 2018 showed that 31 out of 33 hospital admissions coded for OHSS in a major NHS Trust were in fact due to other causes, casting serious doubt on the quality of NHS data and prompting the regulator to revamp the national reporting system. Mortality from OHSS, devastating though it is, remains thankfully rare with no deaths reported in the UK since at least 2006.
We do know that the risk of OHSS increases with the number of eggs collected, and a cut-off of 15 or 20 may be used to judge risk. However, the simple fact that 15 or more eggs are collected in a treatment cycle is not in itself evidence that the woman was 'overdosed' with hormones. Despite modern methods of determining the dose of the hormone, FSH, used in ovarian stimulation, the method remains as much art as science. The ovarian response depends not just on the dose of FSH but also on the sensitivity of the ovaries, and the window between no response and an excessive response can be very narrow.
We should also bear in mind that around a third of cases of severe OHSS occur in women who did not have an excessive response, indicating that OHSS does not follow simplistic rules. In my experience, clinicians who claim never to have had a case of severe OHSS are usually not aware of their patients who develop the condition and are admitted to hospitals remote from their clinic – a common scenario in UK practice.
Of course, fertility professionals and the HFEA have a duty to minimise the incidence of OHSS. Modern techniques, including agonist trigger and elective cryopreservation of all embryos, reduce the risk of significant OHSS in women thought to be at high risk. These are supported by evidence-based guidelines. Professional bodies including the British Fertility Society and the Royal College of Obstetricians and Gynaecologists have produced and disseminated such guidance on the prevention and management of OHSS.
The HFEA mandates every clinic to report cases of severe OHSS and to have in place protocols for managing this condition. Encouragingly, the National Institute of Healthcare Research has recently invited applications for a trial on early active management of OHSS. All of these are indicators of how seriously this condition is being taken, and are reflective of a proper concern for the health and welfare of women who have fertility treatment.
It seems self-evident that this approach of using evidence and persuasion is the most effective and durable way to improve women's welfare, rather than using the blunt tools of the media, or worse, legislation, to effect change. All of us – clinicians, journalists, scientists and patient advocates – have the responsibility to encourage a grown-up conversation in the national media, using verifiable facts and treating women as rational agents capable of informed choice.
Reproduced with permission from BioNews, an email and online sources of news, information and comment on assisted reproduction and genetics.