Assisted reproductive technologies: new guidance for women and doctors is welcome

A new approach better informs women and doctors about what assisted reproductive technologies can achieve in 2017

Since the first Australian conceived by in vitro fertilisation (IVF) was born in 1980, this and other assisted reproductive technologies (ARTs) have come a long way in scope, availability, and success rates. About 4% of all Australian births are now made possible by ART,1 equivalent to one child in every classroom.

There are currently no limits for public funding of IVF in Australia with respect to the number of cycles undertaken or clinical eligibility. Restraining its cost encourages responsible practice, and Australia and New Zealand currently lead the world in the proportion of IVF cycles culminating in single embryo transfers (SET),2 reducing the risks to women and their babies, not least by minimising the probability of a multiple pregnancy.

But IVF and associated ARTs are high profile treatments, and their outcomes are closely scrutinised. In Australia, roughly one couple in six will experience a delay of more than a year in achieving a planned pregnancy.3 As a result of demographic changes and more women delaying pregnancy, infertility has become a significant public health question, and demand for ART has steadily increased. Infertility is difficult to define precisely, so that estimating population levels is challenging; its prevalence in developed countries lies somewhere between 6.6% and 26.4%.2,4 Moreover, not all forms of infertility require IVF, so that establishing the “appropriate” community rate of IVF is difficult.

It is estimated that around 1500 IVF cycles per million people are required each year to meet clinical demand worldwide.5 However, there are large differences between developed countries, and levels of provision are not tightly correlated with clinical need. These differences are largely attributable to the affordability of treatment, particularly policies on public funding of IVF.6

Australian funding arrangements are regarded as exemplary. However, whether IVF treatment represents a good investment of health resources has been debated in Australia for some time.7 Public funding is important for many couples; discontinuation of treatment by older women, in particular, is closely linked with its expense.8 The cost-effectiveness of IVF has been difficult to assess, as it is affected by factors such as age of the woman, the number of cycles required, comparator treatments, and the long term costs of adverse outcomes.

For this reason, the paper by Chambers and colleagues in this issue of the MJA breaks new ground.9 For many people, including doctors, the results of IVF treatment often seem opaque. To improve clarity, the authors quantified the chances of a couple conceiving and taking a baby home by estimating the cumulative live birth rate (CLBR) for best and worst case scenarios, thereby presenting the outcomes of contemporary IVF in Australia and New Zealand to specialists, general practitioners, and women and their partners considering IVF in an understandable manner. Importantly, the concept of linking complete cycles, with all subsequent fresh or frozen/thaw embryo transfers, to the original ovarian stimulation allows women to understand the probability of conceiving during one stimulated IVF cycle.

The authors found that the probability of a live birth for women aged 30–34 years after three full cycles of treatment lay between 64% and 74%, and after six cycles between 69% and 88%. For women aged 40–44, on the other hand, the probability after six cycles was in the range 21–34%. Few women over 44 years of age conceived using their own eggs, with even the optimistic CLBR after five cycles below 4%. It is clear that many women and their families will undergo the emotional and financial strain of treatment without ultimately ever having a baby.

Chambers and her co-authors also emphasise two important aspects of care: freezing embryos for future transfer (cryopreservation), and the policy of transferring only a single embryo whenever possible. The authors do not discuss the probably differing prognoses for different diagnostic groups: a woman without known disease is likely to have a very different prognosis to one with severe endometriosis, lupus, or uterine fibroids. It is extremely difficult to adjust for this level of detail in population studies. Providing prognostic information to women in clinical practice must be carefully tailored to the individual, including information about the likelihood of potential adverse events under particular circumstances. Also worth noting is the rapidly evolving technology of pre-implantation screening for aneuploidy; this should further improve outcomes,10 but was not reflected in the findings reported in this article.

Over the past 25 years, health expenditure in Australia has increased from $50.3 billion to $154.6 billion per year in real terms;11 in a fiscally constrained environment, health economists must ask questions about government funding of IVF.12 Fortunately, Australia has a very good record of achievement in ART, and public funding of IVF has benefited tens of thousands of families. As the study by Chambers and her colleagues shows, most women who commence IVF treatment will eventually take a baby home. However, all those involved in providing ART must repay the trust placed in them by ensuring that treatment is appropriate and meets the highest possible standards.