19 December 2011
ByAppeared in BioNews 638
Following on from the previous sessions where a wealth of eminent researchers gave informative and often provocative talks, Guardian columnist Zoe Williams had the task of chairing what proved to be an entertaining debate.
The session, 'Should Assisted Conception Always Be Evidence Based?', started off with a very pertinent question from the audience – is it possible to obtain evidence-based results for assisted conception technologies? Panel opinion was that many of the difficulties arose due to financing issues, rather than a lack of interest or ability to carry out the research.
Indeed, funding, or a lack thereof, proved to be a common theme, with questions about everything from clinical trials through large-scale collaborations to regulation falling back on the same ground. The verdict was clear: without suitable investment clinics don't have the manpower, resources or time to collect the data or conduct the necessary studies to provide an evidence base.
In terms of clinical trials something I hadn't previously considered were the related benefits. As Professor John Galloway noted, in his own work a major bonus was the fact everyone agreed to work as a group. 'Could you imagine being part of a set up like that?' he asked the panel.
The answer was a resounding 'yes', with Professor Bobbie Farsides saying collaborations are 'excellent' – she thought it would also help even out the 'shocking' differences in success rates between clinics at a basic level. 'We've got to pull the stragglers up to the best practice', she emphasised.
Changing topic slightly, the next two questions had a more ethical aspect – one relating to how to reduce multiple births, and the second to egg freezing.
Dr Virginia Bolton said audience member Professor Brian Lieberman's suggestion that we pay women for fetal reduction or opt for single embryo transfer (SET) was an 'upside down way of saying SET should be on the NHS'. Mr Anthony Rutherford echoed this sentiment, saying he would be 'frustrated if the HFEA [Human Fertilisation and Embryology Authority] take their foot off the gas'. He continued: 'It's about the mindset of the clinicians – this is achievable this if they want to'.
Professor Farsides countered that doctors are only acting in the best interests of patients, and that there needs to be a wider discussion about the risks of multiple births.
'Committed clinics regard SET as the best chance of having a healthy baby and many patients are now accepting that', agreed Ms Jane Denton. '[But] we need more public education'.
It was the ethics of 'social' egg freezing, and the idea of 'banking children' that raised most debate in this section. Dr Maureen Wood thought the idea of women freezing their eggs at 20 as an insurance policy 'a step too far', but Professor André Van Steirteghem believed it was a realistic option worth discussing. 'Having children has changed nowadays, people want to be older. I think it's worth it', he explained.
Professor Daniel Brison said evidence shows that the frozen eggs of a 20-year-old woman have a lower risk of abnormalities than the fresh eggs of a 40-year-old, and Denton pointed out its worth beyond the social – we aren't making enough of the available options for younger women with cancer. I thought a particularly interesting, and often overlooked, point came from Professor Gudrun Moore: 'The best time to have children is when pregnancy is easiest – having a baby at 40 is harder than at 20. We've forgotten all this. We need to invest in making it easier to have babies earlier and protect women's prospects'.
It was noticeable how much discussion there was of randomised control trials throughout the session. A number of panel members raised this as an ideal, although hard to deliver, way to provide the desired evidence base. Dr Joyce Harper, from University College London, asked what the panel thought of previous speaker Dr Simon Fishel's comments at a recent fertility meeting: 'If you waited for randomised control trials we wouldn't get anything done'.
Her own opinion on technological developments? 'There's always something new here and there'. But she was keen to know whether the method was safe and how and such techniques should be implemented in the IVF lab, concluding that 'strange new procedures aren't fair to anybody involved'.
It was Rutherford and Dr Bolton who took on this question, using the example of an embryoscope – an expensive piece of kit, priced, they said, £65,000, which takes automated time-lapse images of the embryos as they are being incubated. However, it can only be used for six patients' embryos at a time, and there isn't enough evidence that it is actively beneficial to the embryos. 'It's a sizeable investment', Rutherford noted. 'If we find the technology doesn't work... someone has to bear the costs'.
The idea that clinicians felt obliged to invest in big money technologies lacking evidence to substantiate their claims again reared its head in the closing remarks from Dr Bolton: 'It's our duty as practitioners to be responsible to patients and the data out there. We need to scrutinize it and not be swayed by the headline-grabbing new technologies'.
Her assertions that they must 'hold fast and behave professionally, being clinicians not charlatans' was met with appreciative applause, and was a fitting end to what had been an informative and thought-provoking day.
PET are grateful to Merck Serono for sponsoring the conference.