The IVF revolution

Fertility clinics may be forced to implant only one embryo at a time to cut the number of twin births. By Ian Griggs, Jonathan Owen and Cole Moreton.

Sophia Kyprianou spent five years and £25,000 on private fertility treatment before giving birth to twins last December, after having two embryos implanted as part of her IVF treatment.

For the 36-year-old mother, it was sometimes mental and physical torture, being operated on and pumped with drugs and feeling hope before an IVF attempt, then sometimes suicidal despair when it failed.

Unlike many, she was successful with IVF, giving birth to Lara and Eve. Yet she is bitterly opposed to plans by the fertility watchdog, the Human Fertilisation and Embryology Authority (HFEA), to restrict would-be mothers to having only one egg implanted at a time. New proposals to be published by the HFEA this week will call on clinics to reduce multiple births by allowing women in their mid-30s to have only one of their eggs fertilised and implanted in the womb, instead of the two allowed at present.

“With two embryos there is always the thought that if one perishes the other might survive,” said Sophia Kyprianou. “However they justify this change, to a women desperate to have a baby it feels like they are halving your chances.”

The embryo rationing represents one of the biggest shake-ups in fertility treatment for years and is in response to the rising numbers of IVF twins placing a burden on cash-strapped NHS neonatal wards. Couples desperate for children often view twins as an instant family, but doctors warn of risks including the danger of premature birth, low birth weight and potentially fatal haemorrhage for the mother. However, fertility experts warn that the move will deny some women the chance of having children, particularly as the Government has failed to live up to its promise to fund IVF treatment on the NHS.

“It is going to be a relatively efficient way of reducing multiple pregnancies but you’ll be paying the price for it in some women who will not be able to have babies,” said Professor Ian Craft, a pioneer of IVF in Britain. “I am against the concept that one embryo fits all. It doesn’t.”

The proposals will call on fertility clinics to reduce their twinning rates to less than 10 per cent. But this would mean that thousands of women would be forced to have single embryo transfer (SET). This could compel women to go abroad for treatment, rather than take their chances getting help from the NHS in what campaigners call an IVF postcode lottery.

The “one at a time” approach would not be in the best interest of some patients, according to Professor Craft. “To a large extent, this is motivated by cost to the NHS and costs of treating twins,” he said. “One of the limitations is that very few Primary Care Trusts are offering support for IVF. If you are going to get it you’ll only get one cycle. Why would a couple want to take something with a lower success rate? I don’t think they would.”

A quarter of IVF pregnancies result in multiple births because clinics implant more than one embryo. Twin births have risen by 66 per cent in Britain, from 6,000 a year in 1975 to 10,000 a year today. Mothers’ risk of complications has risen sixfold, and babies’ risk of dying before they are a month old has increased sevenfold.

This is 10 times higher than the multiple birth rate associated with natural pregnancies. Experts hope that, by introducing SET, the number of women bearing twins will drop sharply as it did for the triplet rate when the regulations were last changed.

The Royal College of Nursing said that multiple IVF births had made major demands on special care baby units which are already overstretched. “The fact that a lot of IVF cases are multiple births does put extreme pressure on neonatal units,” said Jane Denton, who helped to found the RCN’s Fertility Nurses Group. “But it is utterly understandable if women are emotional about putting one egg back. What clinics need to do is to get better at identifying which women are at a greater risk of having twins.”

In response to concerns about the numbers of IVF triplets, the HFEA ruled in 2004 that clinics would no longer be allowed to provide three embryos at a time to women under 40. The new proposals to reduce the number from two to one is based on the claim that SET does not significantly reduce pregnancy rates, but even a tiny difference in the chances of success can be massive for some women. Although some research papers have shown little or no difference in success rates, others have shown a lower pregnancy rate for SET.

For a quarter of a century, IVF doctors have replaced more than one embryo at a time to drive up pregnancy rates. Although IVF pregnancy rates are increasing, the chances of getting pregnant after one cycle of treatment are still less than one in three.

Dr Mark Hamilton, the chairman of the British Fertility Society, admits that women could lose out on getting pregnant. “There is a balance between whether we insist on SET or take a more flexible approach,” he said, “If you have a proscriptive approach, it is a possibility that some women may not get pregnant. It is a tricky balance but you have to offset this against the dangers associated with multiple births.”

It is understood that the HFEA consultation paper will insist that hospital trusts must fund at least one free cycle of fertility treatment and freeze spare eggs for free. However, campaigners claim that the proposals are doomed to failure unless the Government implements the guidelines of three cycles of fertility treatment recommended by the National Institute for Clinical Excellence (Nice). Without NHS provision, there will be little incentive for couples to opt for the one-egg-at-a-time approach, argues Claire Brown, chief executive of Infertility Network. “In some areas people have to wait years for treatment,” she said. “Patients are concerned about anything that affects their chances of success. Given that most are having to fund their own treatment they want to maximise their chances.”

A confidential document on the HFEA’s proposals, which has been seen by this paper, says multiple birth is “the single biggest risk to the health and welfare of children born after IVF”. The report goes on to say the goal of all fertility treatments should be “the delivery of a single, healthy child, born at full term”.

An earlier report last October by a range of fertility experts advising the HFEA has already said that professional “guidelines” alone will not be enough to convince fertility doctors to move to SET as a standard. Professor Bill Ledger, a fertility specialist at the University of Sheffield and a member of the expert group which advised the HFEA, claims that younger women would be well advised to go for SET the first couple of tries because the chances of having a baby are almost as good. But he admits that funding is the major obstacle. “If the NHS is prepared to pick up the bill women are more likely to take the longer view.”

Implementing the Nice guidelines could save the NHS up to £8m a year in the costs associated with looking after premature babies, he said. But Dr Simon Fishel, a leading IVF doctor and managing director of the Care fertility clinics, said: “There will be groups of women who will be worse off than before the change to SET,” he said. “Treatment cycles fail. There is not just a financial cost but an emotional cost too.”

The HFEA refused to comment on the details of the consultation. A spokesman said: “Our key priority during the consultation period will be to listen very carefully to what patients and professionals have to say.”

The Department of Health said it would consider the HFEA’s proposals, particularly with regard to the well-being of mothers and babies. But the department refused to commit to forcing hospital trusts to implement the Nice guidelines. “Patients’ groups make the point that patients are likely to want to see greater implementation, by the NHS, of the Nice fertility guideline so that they have more chance of conceiving,” a spokeswoman said. “Infertility Network UK, the leading voluntary organisation in the field, is identifying the areas where IVF provision is good and where it isn’t. We will highlight good practice and help PCTs improve.”

But the Infertility Network points out that it is unaware of a single PCT that offers the three cycles of treatment which women have been promised.

Sophia Kyprianou and her partner Matthew Hickman, from East Sussex, had to go private because they already had a son. Both are teachers, so the cost meant sacrifices. She would have been outraged if the HFEA had let her put only one embryo back.

“After all that pain and suffering, not to mention the money, it would have just felt so wrong. If they are going to do this I think they should offer every woman free one-embryo IVF on the NHS.” she said. “I could accept that. The change as it stands is wrong because the rich will go on trying as many times as they like, whatever the cost, but the poor - who might only be able to scrape the money for one go - will be abandoned.”

‘I wanted three embryos put back’

Helene Torr, 43, and her ex-husband Brian, 64, had IVF treatment three times, all using multiple embryo transfers.

“Our first attempt was unsuccessful so we waited the minimum three months, and then tried again. My second attempt, with two embryos, resulted in me becoming pregnant with twins. But, during the pregnancy, one of the twins failed to thrive and in February 1998 I gave birth to only one healthy baby. It was not till I had the baby that I realised what I had lost.

“The second timeI had a better idea of how IVF worked. That said, the rollercoaster ride of scans, appointments and hoping made reality go out the window. I just wanted to get pregnant. I wanted three embryos put back but my consultant would allow only two. I conceived again with twins. It was an average pregnancy but I gave birth prematurely at 34 weeks. My son was eventually diagnosed with cerebral palsy.

“I paid for my IVF and the only way I would have been happy about a single embryo transfer is if the NHS were offering it free.”

IVF: the facts

3.5m The approximate number of British couples who have trouble conceiving

1% The number of all births in the UK that result from IVF or donor insemination

24% The number of IVF pregnancies that result in twins

1.5% The number of natural pregnancies that result in twins

£3,000 The typical cost of IVF treatment

10,000 The number of twin births in the UK each year

28% The average success rate for IVF treatment in Britain for women aged under 35

20% The number of couples trying to conceive who will succeed within one month

10,242 The number of children born from 2003-04 as a result of IVF

29,668 The number of women who underwent IVF treatment from 2003-04

75% The proportion of patients who have to pay for private fertility treatment

£8m The estimated cost saving to the NHS of implementing free fertility treatment because of saving on premature baby units

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