It's been an interesting time in the UK discussion of infertility and treatments recently. The HFEA, the body which regulates the fertility industry, is currently carrying out a consultation to see what it should do to try and encourage single embryo transfer. I'm sure you all know this debate. Here is how it goes:
- Multiple births are inherently bad for the mother and bad for the babies. Even with twins the risks of prematurity go way up, and with that, the risks of cerebral palsy, learning difficulties etc. Once you get above twins the picture worsens again
- Current, legislated practice in the UK is that a maximum of two embryos are allowed to be transferred to women under 40. Over 40, three are allowed
- The aim of fertility treatment is to get women pregnant. Studies have shown that pregnancy rates from two sequential single-embryo transfers are as good as from replacing two embryos in the same cycle. Thus the push to limit women, particularly those who are younger and who produce a reasonable number of embryos, to agree to having a single embryo replaced, and thus to limit the risks inherent in getting pregnant with multiples.
- Various studies have shown that infertile couples, and women in particular, are not fully aware of the risks of multiple births. In fact, twin pregnancies after IVF are coveted by many - "the infertile jackpot" is commonly referred to as boy/girl twins. That way women feel relieved that they don't "have to" think about going through treatment again. Their family is pre-made. In a recent study, however, once the risks were fully explained, the percentage of couples who felt positive about having twins dropped dramatically. So it seems that at least part of the problem is awareness of what you're getting into.
However, there are several other factors involved, which don't get quite as much publicity, although I have seen them discussed.
The first is funding. If you have to pay for a subsequent FET after your fresh cycle, you are presumably less likely to take the risk of replacing just one embryo the first time. In a world where a majority of doctors in the UK want to stop funding for all fertility treatment (although other evidence says that fertility treatment is a cost-effective way to deal with the falling pregnancy rate in developed countries, so another example of short-term cost cutting over long term health of the population), it seems unethical to mandate a lower chance of success for any single cycle.
Second, is the stress involved in cycling. I have seen no evidence that the legislators, regulators and doctors in this discussion fully appreciate just how awful a negative cycle makes one feel. At that moment, the thought of a frozen embryo waiting for you is unlikely to be much succour. So in asking us to agree to single embryo transfers, the HFEA is asking us to agree to increase the frequency with which we are likely to go through that kind of trauma.
Third, is that freezing is not yet a perfect science. If you freeze embryos, you run the risk they won't survive the thaw. So this approach would only be reasonable for women with sufficient embryos that they feel able to take a risk on one or more dying before they even get to transfer. How many of us feel we had surplus embryos at that stage of treatment?
So my position? I would be happy for the HFEA to develop a communications programme that adequately explains the risks of multiple births. This should happen much much sooner than it currently does - what happens now, at least at my clinic, is that on transfer day if you transfer more embryos you get a stern talk from the doctor along the lines of "are you aware of the risks of twin pregnancies," and if you say yes, you get dismissed. People need to know way in advance of that stressful moment that there are major risks involved, they need to know the stats for sequential single-embryo transfers, and they need time to decide how they want to play the risks.
I am however strongly opposed to the HFEA legislating a mandatory transfer of single embryos, no matter how many conditions they put on it (e.g., only for women under 35 with more than 6 embryos at day 3, with no more than one previous failure, etc.). I think it's unethical in a situation where most couples are paying a lot of money for this treatment, to mandate a situation which will immediately become more expensive - perhaps unmanageably so. It also takes away the ability of our doctors to consider our individual situations and help us make a reasonable decision based on our individual characateristics. The letter of the law cannot ever get specific enough to cover every situation. Let's put some trust back in doctors and patients to make the right decision, albeit with dramatically improved information over what is available today.
In other news today, poor Natalie Evans has lost her final appeal to use the embryos that were created in 2000 from her eggs and her then-husband's sperm. For those of you who don't know the story, the reason for creating the embryos in the first place was that Natalie was dealing with ovarian cancer, so this move was to preserve her fertility. She and her husband subsequently divorced, and in 2003 he requested that the embryos be destroyed, in line with UK law which says that both parents need to consent to using frozen embryos. She has been fighting ever since. I feel absolutely terrible for her, even though I think that legally this decision is right.
What I find unimaginable is the sheer bloody-mindedness of her ex-husband. How bad could it possibly be for Natalie to raise their genetically joint-children without him? Why cannot he agree that her only chance to raise a family that is biologically related to her is more important than his need to see a complete termination of any biological tie between them? And of course, there is no guarantee that she would actually get pregnant, the whole thing is so damn theoretical. I can only imagine how devastated she must be today. The courts were right, but the case should never have got there. This isn't about legality, it's about basic humanity, empathy and the ability to remember that you once loved someone, and that love is worth something. Easy for me to say, I guess.