At the start of the IVF industry the players were researchers and academics, and new techniques could be assessed quite easily because 'anything' was better than 'nothing'. Assisted reproduction today is fully established technology with up to three million births over the last 30 years. It has become a real industry and is quite rightly subject to quality regulations and licensing law. Nevertheless, quality control should not, I feel, be interpreted as it sometimes is: as being a boring 'chore', a static tick box system acting only as a shield against comebacks from management, regulators or patients. It should be a process that lets in proven best practice, whilst raising safety standards, for the best interests of the patient.
I would suggest that the clearest picture does not always get through to the patient or the doctor advising the patient, perhaps as a recent commentary piece discusses (2). To make the point generally: is a fraught patient able to understand, for example, the basis for comparing pregnancy success rates? Or whether international best practice is learned from and applied? Or whether the NHS has the actual wherewithal to provide IVF services sufficiently?
Single embryo transfer (SET) has emphasised the importance of freezing efficiency and the use of embryo freezing is increasing. In the US, the number of births following embryo freezing tripled between 1997 and 2006. Shouldn't we look at why some clinics get hugely different success rates to others? One lab in the US freezes approximately 55 per cent of patient's embryos (some more still). It gets day three cleavage embryos showing a 90 per cent survival on thaw cycles. The latest data from the Society for Assisted Reproductive Technology (SART) shows almost a 40 per cent live birth rate per frozen transfer with day three embryos. If I was a patient I would want to know about SET advantages and subsequent choices for freezing my embryos.
Furthermore, controlled rate freezing has thirty five years of practical results and some 350,000 births. By contrast, vitrification in IVF is an interesting new technology with a few dozen results and isolated reports of possible DNA damage. Controlled rate freezing has a capital cost, vitrification has a consumable cost, so they are probably equivalent from that point of view. Vitrification is the 'new kid' and, as such, is of technical interest, but is it in patients' interests?
I am not at completely 'anti-vitrification' - like controlled rate freezing, it is probably good in parts and may eventually prove to be the optimal method, especially for egg freezing. What I am is pro-patient. Patient interests aren't always put first. For example, there is a corollary in the stem cell area, where funds follow the research interest and are channelled into long term projects (possibly of great value) whilst the under-funded National Blood Service attempts to collect and store (probably) more imminently useful cord blood units.
In relation to my third question, a recent article in the Times newspaper (3) discusses the importance of SET and discloses that about a third of NHS trusts do not offer frozen back-up and 85 per cent do not provide the 'three full cycles' recommended by the National Institute of Health and Clinical Excellence (NICE) in 2004. No wonder that Dr Brison of the University of Manchester is reported to be endorsing SET whilst wondering about the reaction it will get because of clinic 'league tables'.
Public and media interest in the morality surrounding the treatment of embryos - for stem technology or IVF work - is high. The same type of concerned interest shown by the public in the debate (for example discarding embryos) should be carried through into private and public practice. I hate the thought of advocating more red tape, all that is needed is to apply the existing rules across the board properly. What I think is needed from the industry is perhaps a way of regaining some of that pioneering spirit. Not so much the gung-ho part - rather, more of that earlier transparency. I would like to rekindle the cooperative early spirit helping to improve techniques amongst all by comparing and sharing information in good practice and then actually implementing it - for the good of all.