'Those of us who work in infertility are not going to go out of business anytime soon,' commented Professor Richard Anderson at the Progress Educational Trust (PET)'s latest event 'From Acupuncture to Yoga: Can Lifestyle Choices Improve the Odds of IVF Working for You?'
'Clinics are forming morning, noon and night,' Professor Anderson added as he chaired the lively discussion evening in Glasgow last week.
While IVF is a 'life-changing miracle' for some families, he said, four out of five IVF cycles are unsuccessful. Understandably, the first question returning patients have is 'what can we do differently?'.
The speakers presented a diverse range of backgrounds and expertise. The first speaker, Dr Abha Maheshwari, clinical lead in reproductive medicine at the University of Aberdeen, outlined the evidence for five lifestyle factors believed to affect IVF success.
Weight, or BMI (body mass index), can have an impact on the success of IVF treatment. Consequently, although 50 percent of the population is overweight, NICE recommends excluding female patients with a BMI over 30. Dr Maheshwari said it was 'very disturbing' that there is currently no guidance for male BMI, and that there is a dearth of studies on how male BMI affects sperm quality and male fertility.
Conversely, smoking is known to affect male and female patients differently, given that new sperm are produced every 90 days, while a female smoker's eggs were created while she was in the womb. Smoking lowers the quality of gametes, and for females there is no regeneration if they quit.
There is slightly more ambiguity over how much caffeine, alcohol and diet affect fertility. Dr Maheshwari said five to ten cups of coffee a day are probably not a good idea, neither is binge drinking. One problem with gathering evidence, though, was that studies used patients' recollection of their alcohol consumption, which could be unreliable.
Perhaps this is why one study has said that abstaining from alcohol during treatment doubles the chance of IVF succeeding. Nothing doubles the chance of IVF, said Dr Maheshwari. Equally, she is sceptical of claims the Mediterranean diet can greatly improve conception rates. There is no current evidence to prove this, nor are such effects seen in Mediterranean countries, Dr Maheshwari said.
Lifestyle decisions do not make conception impossible but they can affect it, potentially through both partners. But Dr Maheshwari warned that we should not confuse association with causation.
Next to speak was Isabel Traynor, lead nurse for gynaecology and assisted conception at NHS Greater Glasgow and Clyde. Traynor outlined several of the most popular non-evidence-based alternative therapies – acupuncture, reflexology, yoga and Chinese medicine and homeopathy. She described fertility treatment as an 'emotional rollercoaster', and said these procedures arguably help patients to reduce stress.
While improvements in outcomes are anecdotal, she truly believed that such therapies have a place in IVF clinics. Traynor acknowledged that such approaches could be marketed misleadingly to a vulnerable group of patients.
Yet as she went on to list some increasingly 'alternative' alternative therapies, it seemed relying on anecdotal evidence risked inviting patients to try increasingly bizarre methods. These ranged from mindfulness, crystal therapy and feng shui. She reported that some women had taken to eating McDonalds fries after embryo transfer following what other patients who had had a successful outcome had reported on blogs. She had even had a case where one woman tried cooling her cyclist partner's testicles by blowing air on them.
The third speaker, Dr Jane Jamieson, nutritional therapist at the Natural Fertility Centre, introduced 'the other side of the fence'.
As a practitioner in the complementary therapy sector for 25 years, she outlined her beliefs in the benefits of certain therapies. For instance, she claimed that acupuncture can improve blood flow and modulate the body's hormones and immune system, thereby increasing the chance of conception. She also stated that differing methodologies made it difficult to perform scientific studies of acupuncture.
She finished with anecdotal evidence of a Canadian practitioner who boasted that his fertility centre used nutritional therapy, and claimed that this approach boosted chances of IVF succeeding to 60 percent.
The final speaker was Dr Margaret McCartney, a GP and columnist. She took a forthright view, saying: 'There's no such thing as evidence-based alternative medicine. Only medicine that works, and medicine that doesn't work.'
Her interest was in how patients can get the right, evidence-based medical advice. Poor advice has great potential for harm, she said, referencing examples of overdiagnosis of breast cancer and thousands of deaths historically attributable to poor advice about how infants should sleep.
Dr McCartney warned against cherry-picking isolated studies rather than collating existing evidence to find the scientific consensus, as is done in Cochrane reviews. She also warned against assuming a causative relationship between one of many factors and a result. Her son might believe he was only successful performing handstands when wearing his lucky socks – but in reality, he had performed handstands successfully when his sister had been around to help him.
Modern medicine has a long way to go, she said, particularly when it comes to the fertility industry. 'I don't think we will progress until we are honest about what works and what does not,' she said, lamenting that there is no better regulator than the Advertising Standards Authority for many of the claims made by alternative medicine practitioners. She conceded that people were free to spend their money how they wanted, but said that practitioners should not make false promises.
In the question and answer section, Dr Maheshwari reflected that when the Scottish government decided the BMI cut-off point for funded IVF, it was thought that there would be an increase in people paying for IVF privately. Instead, people changed their lifestyle and lost weight. It's not what we tell them – it's how we tell them, she said.
This opened up discussion about whether fertility clinics needed to provide a more well-rounded service, helping to reduce the stress of patients, and giving them practical steps on how to cope with stressful IVF.
Several alternative therapy practitioners in the audience agreed that their role empowered patients to tend to themselves emotionally and psychologically, and some argued that a distinction should to be drawn between 'complementary' and 'alternative' therapy. Traynor said that the services she worked for did not promote alternative therapies, but that she was nonetheless in favour of patients pursuing such therapies if it gave them a sense of control back.
Professor Anderson reflected that a continuing problem is the frustration caused by unexplained infertility.
Sarah Norcross, director of PET (which publishes BioNews), queried the tendency for some fertility practitioners to imply that feelings of stress during fertility treatment reduced the chances of treatment succeeding. What is the evidence that stress affects the outcome? Dr Maheshwari commented that the problem was how to measure stress scientifically, rather than anecdotally.
Furthermore, Dr Maheshwari linked the lack of rigorous testing for alternative therapies to the patchy NHS funding for fertility treatment. As 60 percent of UK IVF patients are self-funded, it is hard to recruit patients for trials. Meanwhile, this generates a vulnerable group to whom non-evidence-based therapy is offered.
Dr Jamieson said there were very strict rules on what complementary or alternative therapy practitioners could or could not say. Despite this, Dr McCartney remained sceptical, as she read out some of the text from the Natural Fertility Centre's website. 'I wouldn't be able to stay in practice unless I had a positive impact,' Dr Jamieson responded.
As Norcross concluded, while there was little agreement on the panel or among the audience, one element all parties could reach a consensus on was that patients seeking infertility treatment face a difficult and challenging journey.
PET is grateful to the Scottish Government for supporting this event.
PET has plans to organise further events in Scotland this year. Email firstname.lastname@example.org if you would like to be notified when details of these events are announced.