The future of IVF remains problematic

Thirty years after the world's first IVF-baby was born commentators and reporters are assessing the gains made by the fertility treatment and the future that lies ahead. Although it seems IVF today has become the established and routine medical procedure its pioneers in 1978 probably hoped it would become, issues of access, funding, success rates, and safety refuse to go away.

To date, around 3.5 million babies have been born through IVF worldwide. Whether it is the sheer rise in numbers or the public's growing familiarity with the technique, newspaper reports over the past two weeks have been keen to stress the progress of public opinion towards IVF. Louise Brown is quoted saying how she was sometimes treated differently at school when she was a child: '...the children used to ask questions like 'how did you fit in a test tube?' and things like that'. The public's unease with a new medical technology at the time was reflected also in alarmist media reporting. Such was the controversy surrounding Louise Brown's birth, her mother, Lesley, had to be placed in hiding away from the media furor for her own and her baby's safety. Louise nevertheless insists her childhood was, 'the same as any other child' (1).

Today IVF is fairly routine - proving or putting aside the 'slippery slope' arguments of the early days. As the Guardian reports (2), some couples now see IVF as a shortcut to pregnancy. 'We are living in a world where we click on things and get them... You want a baby, you click on an IVF unit and hey, look, the baby's crying', said Laurence Shaw, deputy medical director of the Bridge Centre, a fertility clinic based in London. In the US, unconfirmed media reports suggest Angelina Jolie and Brad Pitt had chosen to undergo IVF to increase the chances of giving birth to twins.

The increased prevalence of multiple births amongst IVF patients and the associated risks during pregnancy and birth have given rise to calls for regulation on the number of embryos that can be transferred. In the UK, the Human Fertilisation and Embryology Authority (HFEA) has helped launch a national strategy to reduce the number of multiple births encouraging clinics to adopt an elective single embryo transfer (eSET) policy, although such a policy has not yet been made mandatory. Many patients have expressed distress that SET may reduce their already low chances of conceiving. Recent studies, however, have disproved such a link showing that SET does not have a significant impact on pregnancy rates compared with double embryo transfer.

Safety continues to be a topic of debate with some believing that babies born through IVF are more at risk of complications than those who are not. A recent study published in the Lancet has shown, however, that the increased risk of complications during pregnancy and at birth observed in babies conceived through IVF may in fact be the result of parent's underlying infertility problems rather than the technology itself.

There also remains widespread concern about funding. Infertile couples in the UK will probably receive little solace from knowledge that attitudes towards IVF are changing without more financial support from the state towards the procedure. IVF success rates are often quite poor (at around 25-30 per cent) and many couples require more than one cycle of IVF to become pregnant. At a cost of between £1,000 and £4,000 per treatment cycle, prices can become extremely high for couples undergoing private treatment, but with only nine out of 151 PCTs in England funding the recommended three cycles of IVF for infertile couples, many simply do not have the choice. The latest figures reveal that despite guidance issued over four years ago, four trusts are still offering no IVF treatment at all, and 94 per cent are not providing the full three cycles recommended (3).

New techniques used in conjunction with IVF may improve success rates and reduce the need to fund multiple cycles. Clinical trials have begun on a technique called metabolomic profiling, which is a non-invasive test that can assess an embryo's viability before implantation (4). Another procedure, known as PGS (preimplantation genetic screening), involves removing a single cell from an IVF embryo and testing it for the presence of chromosome aneuploidies - genetic errors that would prevent normal development.

Finally, as IVF has been exported with great success to other countries, most notably the US where around a quarter of a million IVF babies have been born to date, commentators are now addressing the international issue of regulation. Recent reports of 'reproductive tourism' have generated fears that infertile couples are being attracted by lower prices in more permissive regulatory climates, which may put both women and child at risk, as reported recently by Reuters (4). Some commentators are calling for international guidelines to harmonise the way IVF is offered to uphold ethical and safety standards. 'Governments, patient organizations and doctors should organise awareness campaigns to warn citizens for possible dangers of cross-border care and to inform them of the possibilities,' Guido Pennings, an ethicist at Ghent University, Belgium, was quoted as saying.