IVF: What influences success?

Genea Fertility Specialist Assoc Prof Mark BowmanAs a fertility specialist, I am constantly asked by patients what are my chances of taking home a baby if I have IVF? 1 in 6 couples struggle with infertility at some point in their lives so it is a question that is of interest to many. Will my daughter take home a baby if she has IVF? Will my friend finally get pregnant if she starts infertility treatment? Will we finally have the joy of a baby in our arms if we start this process? 

The answer is complicated but it’s important to explain. It’s ethically responsible to explain.

Two weeks ago, a study was published which looked at the overall chance of having a baby from IVF in Australia and New Zealand. It was heralded as the solution, the success rates all doctors should be sharing with their patients. Many journalists led with headlines such as 'IVF success rates higher for those who go through multiple rounds'. Many stories in the media encouraged women to keep trying for eight cycles. The problem is, once again, these reports and figures are more complicated than they appear and society needs to understand why. 

Many IVF statistics look just at the chance of any one treatment leading to pregnancy, but this study followed individual patients through all of their treatments (this is called the cumulative pregnancy rate). This approach is a much more reliable way of giving patients and society a sense of what an individual woman's overall chance is within IVF and studies like this are very welcome. However there are two lingering questions. Firstly, particularly for younger women, could the results have been better? Second why does it seem to take so long for some women to achieve success in IVF?

Overseas studies have suggested that especially for young women, the ultimate chance of a baby within IVF could be higher than the statistics presented for Australia and New Zealand. It is important to note that the local results are the average of those achieved from all of our IVF units. The national IVF database reported that the chance of a baby from a cycle with fresh embryo transfer amongst different IVF units, for women under 35, in 2014 ranged from 13% to 36%. Is such a variance due to patient differences – are some patients harder to treat than others? Or are there also differences in the medical and laboratory techniques from IVF unit to IVF unit, which positively or negatively influence success? It is an interesting question I discuss with many patients seeking a second opinion when IVF has not led to pregnancy. How much of their difficulties were due to process – the nature of the drugs used, the timing of the procedures and the embryo laboratory system employed – or, how much of the couple's difficulties were independent of process? Were there problems with their bodies or cells that IVF couldn't overcome?

The variability of patients is why the simple publishing of "league tables", comparing the results from one unit to another unit, cannot easily be undertaken. My concern however is that too much emphasis is placed upon patient variables when looking at IVF pregnancy rates and not enough upon the IVF process employed. I don’t accept that all IVF clinics are the same. There is already evidence in the International research to show that sub optimal IVF practices can worsen the genetic health of embryos and obviously this will lower pregnancy rates. Consumers are entitled to know which IVF centres employ optimum practices, research and development which together constantly try to improve outcomes, to get a better sense of how different IVF systems might help them. The Fertility Society of Australia has committed to developing comparison tools that take all of these factors into account. This information would allow consumers to make better choices about their IVF treatment. It is beholden upon our Society to complete this process as at present, patients have no clear means of comparing outcomes from different centres.

What isn't reflected in the statistics that were realised last week is that the patients most likely to achieve success with IVF, will most likely do it within the first few attempts. The best prognosis patients "exit" with a successful pregnancy quickly, leaving a group of unsuccessful couples who might continue to try, but with a lower chance of success. Some of those couples should be actively counselled to stop. It may be appropriate for others to continue (and funding by Medicare should be maintained, to allow for appropriate clinical decisions that aren't influenced by financial circumstances) but those couples continuing, need to understand that the ongoing chance of success is modest. In the study released last week, the authors guesstimated that if patients continued on and on, eventually almost every younger couple could conceive. These "optimal" projected results are better described as "optimistic" - couples should be reminded that cumulative IVF success is not a straight line graph to 100% and if pregnancy is not quickly achieved they should ask "why?".

The best performing IVF centres aim to help a greater percentage of couples and help them in the least possible timeframe. I would argue that this is a better spend of taxpayer (Medicare) dollars and such an approach is more likely in a centre that invests heavily in its systems. Having the best possible laboratory and the best possible scientists results in a more expensive IVF cycle for the patient, but hopes to be more time and cost effective, as well as being psychologically better for the couple because they get pregnant faster. It is false economy, a less effective use of taxpayer dollars and emotionally devastating to undertake multiple "cheaper" IVF cycles for a lower return. As in all areas of medicine, Australians should expect both quality and efficiency in the provision of health services.
 
Posted: 15/08/2017 6:16:43 PM by Karen Sivieng | with 0 comments
Filed under: ANZARD, facts, Information, IVF, Low Cost IVF, Mark Bowman, Statistics, Success Rates, technology
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