28 July 2008
Consultant Obstetrician and Gynaecologist, Chair British Fertility SocietyAppeared in BioNews 468
The media reaction to this survey was interesting yet perhaps predictable. Two powerful messages emerged from the sector, supported by over 80 per cent of respondents: the recognition that the evidence base underpinning clinical practice in our field is weak, and secondly the fact that too many couples throughout Europe are required to resource treatment for themselves.
In respect of the first issue it is clear that there is widespread support for clinical trials to assess efficacy of new procedures in infertility treatment. In recent years questions have been raised about a number of untested and expensive techniques widely offered in IVF clinics including reproductive immune therapy and, more recently, PGS (preimplantation genetic screening). It is understandable that patients, and to some extent clinics, will consider every avenue in an attempt to maximise the chance of realising the dream of having a child. Some respondents expressed anxieties that new clinical and embryological techniques are offered to patients before trials have adequately assessed their efficacy. It is a timely coincidence therefore that a new UK National Reproductive Medicine Clinical Studies Group has been established by the BFS and others with the express intention of co-ordinating funded clinical research trials. The survey results showed that fertility practitioners are committed to this concept and the enthusiasm with which the trials initiative has been embraced by active researchers and clinics in the UK gives us real hope that key questions and uncertainties in our practice can be comprehensively addressed.
The second issue raised by more than 80 per cent of respondents related to the funding of IVF. The continued difficulties experienced by many UK patients in access to resources to assist their aspirations to have a child resonate strongly in the responses to the survey. This contrasts starkly with the easy access to state assistance in avoidance of conception and birth through well-resourced contraceptive and abortion services. This moral inconsistency can surely no longer be tolerated in a society with vast wealth at its disposal and where the demographics indicate that measures to boost the total fertility rate are urgently required to avoid potentially catastrophic social consequences.
Despite these key messages, well reported in some sections of the press, the spin, particularly in television and radio reports emphasised the more sensationalist but perhaps more attractive storyline: 'Almost half of fertility experts say access to IVF should be conditional - and smokers or the obese could be denied treatment' (1).
Much of the next 24 hours was spent addressing questions around this topic rather than the other issues. There is universal acceptance in medicine that lifestyle issues impact on our health to a major degree. In reproductive health these effects are subtle but the evidence base that smoking, obesity and certain recreational drugs including alcohol have an impact on fertility is persuasive. The health for women and babies in pregnancy and families thereafter is also a justifiable concern for those with responsibilities for assisting conception. It was interesting but perhaps not surprising that in the survey there was a spread of opinion on these issues including a minority view seeking to preclude access to state funded treatment in certain circumstances.
The view of the BFS on social criteria and commissioning state funded IVF was set out in a key publication in 2006 (2,3). The important message in this paper ignored by certain sections of the press, then and now, is the need for all patients seeking IVF to be treated equally, no matter where they live. In respect of smoking it is sensible medicine to advise both men and women seeking to have a child to stop and for clinics to provide access to smoking cessation programmes. Where alcohol is taken to excess advice and help is appropriate. Those who struggle to achieve an appropriate weight must be offered assistance to lose or gain weight. It is good medicine to suggest that fertility treatment is deferred if the BMI (body mass index) is in excess of 35 (extremely obese) in the interests of not only effectiveness of treatment but also the safety of pregnancy both for mother and child.
Thirty years on from the birth of the world's first IVF baby born in the UK, a triumph of monumental proportions in the history of medicine, we should surely not be caught up in argument around accusations of denial of access to care. We should be celebrating the revolution in our abilities to help create families.
The State should work with the professions, as it has done in many parts of Europe, to achieve for our patients and their potential children, widespread, uniform and adequate access to care. Political posturing by Ministers and others with responsibility in the UK for the present feeble and inconsistent allocation of resources to assist the infertile is a national embarrassment and an insult to the intelligence of us all.