9
Assisted reproduction technology and in vitro fertilization
Introduction
In humans, most babies are born as a result of in vivo fertilization but 1% (and rising) of all babies in the Western world are born through ART. In some countries, the rate is even higher and in Australia, where infertility patients receive significant government reimbursement, IVF is responsible for approximately 3% of all live births.1 Worldwide, IVF babies are numbered in their millions.
Social commentators have remarked that IVF could separate procreation and sex, in the way that the oral contraceptive pill separated sex and procreation in an earlier generation, a view shared by some IVF researchers who predict that in the future sex will be for fun, and IVF for procreation.2
In many countries, IVF is used more and more frequently by impatient couples who might not have significant fertility issues. One study done on nearly 1400 women between 28 and 36 with unexplained infertility, found that of those who pursued an ART solution, 53% had a baby, but so did 44% of the women who did not use ART.3
IVF Statistics
Countries might report their IVF live birth rates as an overall figure, e.g., the national IVF live birth rate from all IVF cycles in Australia and NZ in 2009 was 17.2% per cycle.4
Or they may report birth rates according to the age range. For example, the national IVF live birth rate per cycle in the USA in 2009 was given as: 41.4% under age 35; 31.7% age 35–37; 22.3% ages 38–40; and 12.6% over age 41 (a significant percentage of these births were twins).5
Comparing individual IVF clinic’s success rates is not always easy because of such inconsistency in methods of reporting. Clinics understandably want their statistics to look good and have found different ways of doing this. Some clinics might include all their IVF patients in their data but will then choose just one particular period of time for analysis. One clinic, for example,6 gathered data on all the women who began IVF over a period of a few months in mid-2009, and reported that 3 years on, 65–70% of those under 38 years and 40–50% of those between 38 and 43 years, had a baby.
Other clinics might report figures for live births for only those women who have blastocysts (5-day old embryos) to transfer and give a cumulative number over a period of 2 years of attempts.7 The birth rate when presented like this was 60–80% for women under 38 years of age, and 50–60% for women 38–43 years.
I am often asked: What is the success rate in treating infertility with traditional Chinese medicine (TCM) and how does it compare to in vitro fertilization (IVF)? This is not an easy question to answer. TCM treatment for infertility is a cumulative process; it is not a discrete monthly program, the success of which can be measured per attempt or per cycle. However, now that some IVF clinics report success rates over a period of years rather than per cycle, we can think about making more meaningful comparisons. Controlled clinical trials are not common because of the difficulty in applying control conditions and statistical analysis to Chinese medicine treatment outcomes and there is a paucity of funding. One review, which presents a meta-analysis of the few trials and cohort studies that have been published, found that Chinese herbal medicine improves pregnancy rates twofold within a 4-month period compared with fertility drug treatment or IVF.8
The Art Clinic
First, we shall examine just what exactly happens in an ART clinic, starting from the most simple to the most complex procedures. Some clinics offer procedures such as ovulation induction, which do not involve manipulation of the eggs and sperm to achieve fertilization without sex, and these are discussed elsewhere (see Ch. 5).
Box 9.1 summarizes the different techniques offered in the reproductive medicine clinic.
Artificial insemination (AI)
Before a couple attempts IVF, some reproductive medicine clinics will suggest less intrusive techniques such as ovulation tracking or ovulation induction accompanied by artificial insemination at the appropriate time. If ovulation is absent or irregular, then there are a number of different drug regimens that can be attempted (discussed in Ch. 5). If the sperm picture is not good, but not hopeless, then washing and sorting the sperm and injecting the best of the bunch into the uterus close to the fallopian tubes at the time an egg is being released increases the chance of conception. Cycles of intrauterine insemination may or may not involve manipulation of the woman’s hormones with drugs similar to those used in an IVF cycle (but in smaller doses) depending on the clinic and the woman’s menstrual cycle history. Progress of follicle development is monitored with blood tests and ultrasounds to predict the day of ovulation. Pregnancy rates with these techniques are lower than with IVF and many patients will progress to IVF if they do not conceive after 3 or 4 rounds of AI.
In vitro fertilization (IVF)
IVF remains the most common protocol offered in an ART clinic.
The way most IVF programs proceed nowadays is explained below (summarized in Box 9.2).
Ovary stimulation
There are a few variations on the IVF theme. They are grouped into long or short cycles (summarized in Box 9.3). Except in the case of the ‘natural’ cycle, drugs are used to achieve what is a called a controlled hyper-stimulation of the ovaries.
Long downregulated (agonist) cycle (± ICSI)
To persuade the ovaries to produce multiple eggs, the menstrual cycle must be manipulated. In the menstrual cycle, prior to IVF being performed, the woman is given ‘downregulating’ drugs. These are gonadotrophin-releasing hormone (GnRH) agonists (called Lucrin/Lupron (Luprorelin) injection or Synarel (Nafarelin) nasal spray), which prevent the pituitary gland from producing hormones and thus interfering with the programed effects of the stimulatory drugs. (See Box 9.4 for other drug names.)
