When they told you about the birds and the bees, they left out the bits about IVF (in vitro fertilisation) and ICSI (intracytoplasmic sperm injection).
If not personally affected, chances are you know a couple faced by fertility challenges. The oft-quoted statistic is that roughly one in six couples will have problems conceiving, yet experts say this could be closer to one in four. These couples will find themselves reluctantly running the gauntlet of the bewildering array of fertility services.
Why is this? It is thought to be due to a mixture of medical and social issues. We know first-time mothers (and fathers) are getting older. Human biology dictates that the ideal age to become pregnant is around 18, yet social norms would suggest a woman waits at least a few years to establish her career and meet the right partner.
Irish women are not oblivious to their ticking biological clocks. Bray GP Dr Deirdre Lundy has a special interest in sexual and reproductive health. In her practice, she says, she regularly sees women who are panicking about their ability to get pregnant when the right time comes for them.
“Most women know that age is not their friend with regard to fertility, but they often have no choice. So many women come into us looking for tests to confirm that they are fertile, but it is a sad truth that there are no such tests readily available,” she says.
Some women like the reassurance of hormone blood tests to confirm ovulation, and this can be done easily and cheaply, but Lundy cautions there are no guarantees with this.
“We tell all our patients that avoidable things like stress, smoking, being too thin or too heavy, or taking recreational drugs will all likely have a negative impact on fertility,” she says.
For those struggling to conceive, help is at hand – if you’ve got the cash. It’s over 40 years since the first ‘test-tube baby’ was born (although the first Irish baby born via IVF didn’t come along until 1986), and the fertility industry is now a mammoth one. Globally, it is estimated it will be worth over $36 billion by 2026. That’s a lot of gametes.
Closer to home, Irish couples are increasingly spending thousands of euro as they endeavour to have that much-loved and wanted baby. It is estimated that between 5,000 and 6,000 IVF cycles take place in Ireland each year, with a significant proportion of couples going abroad for treatment. At an average minimum cost of €4,500 per cycle, they weren’t lying when they warned that babies are expensive.
‘IVF is dinner party conversation now’
Dr John Kennedy is the medical director of the Rotunda and Sims IVF clinics. He agrees that women are now more aware that their fertility could be compromised the later they leave trying to conceive.
“Right now, we think one in five or one in four even could struggle a bit getting pregnant, but that’s not to say one in four couples will need IVF or anything like it. Some couples might just take a little bit longer than they anticipated,” he notes.
The average age of the woman Kennedy and his colleagues see is 38. “That’s obviously after they’ve been trying for a while – they will start on their journey and at some point end up in front of us.” He adds that most patients come via word of mouth: “IVF is dinner party conversation now. It used not to be, but thankfully that has changed.”
Quick biology recap: A baby girl is born with all the eggs she will ever have – around two million. This begins to decrease immediately and by the time she hits puberty just 300,000 are left, and only about 500 will ever be ovulated.
“Egg quantity and egg quality drop as you get older, and you are more likely to have difficulty getting pregnant and holding onto a pregnancy,” explains Kennedy.
The so-called fertility cliff that apparently manifests at the age of 35 isn’t quite an accurate representation – but at 40 your fertility is taking a bit of a nosedive, he admits. “From 34 to 40, the curve drops and then from 40 it drops quite sharply.”
But wait – it takes two to tango. It is now believed that the reasons for infertility are in the ratio 40:40:20 – 40 per cent will be due to an issue on the female side, 40 per cent due to male factor infertility, and 20 per cent unexplained.
“We know sperm counts are decreasing, and that’s a function of diet, Western living, et cetera. Internationally, there is pretty strong data that sperm counts are going down,” says Kennedy.
While there is some help available publicly for certain medical conditions, fertility assistance is largely the preserve of private fertility clinics. In response to criticisms that IVF clinics are too quick to intervene rather than identifying the underlying issues, Kennedy explains the reality is that couples may not have that much time to play with.
“I am guilty of kicking people out and saying, no, we don’t need to go down that route. If someone comes in and they are young and healthy but their cycle is irregular, that’s not someone who needs IVF – they might just need some medication to make their cycle a bit more regular,” he says.
“Now if that someone is 32 years old, we have plenty of time, but if they are 39 years old, I can still do the same thing and I might get them there, but the problem is her months are much more precious than a 32-year-old’s. My job there is to tell someone their chances with each option. It’s seldom as people get older that these situations get better – they generally get worse, so it’s much better to get ahead of it.”
He admits, however, that each case is individual, and in many cases he would prefer to treat a healthy woman in her late 30s than an unhealthy woman in her late 20s.
And while success rates with IVF have steadily risen, Kennedy is quick to acknowledge that this is tempered by the increasing age of the patient population. “That has a big knock-on effect and it will depend on the individual patient,” he says. “The three biggest independent factors when someone asks me if IVF is going to be successful are: firstly, their age; secondly, their ovarian reserve, ie, how many eggs they have left; and thirdly, their weight. Everything else falls way behind.”
Everybody wants to a know a clinic’s success rate, and other countries publish ‘league tables’ comparing their numbers of live births. According to Sims IVF, their success rate ranges from roughly 52 per cent for patients under 39 years to 24 per cent for patients over 40. Chances can be as low as 1 or 2 per cent for a woman in her late 40s, however. Private clinics have also come in for criticism for giving these women false hope.
“I don’t have a problem putting someone into an IVF cycle when there is a relatively low chance of success; I only have a problem when they don’t know that. It is my job to give them all the information they need to make an informed decision,” Kennedy says.
Fertility clinics are now seeing a much broader demographic in response to wider societal change. Single women seeking to become mothers via sperm donors are on the increase, while gay and lesbian couples wishing to have a family are also eagerly seeking assistance.
Kennedy has witnessed a steep increase in the amount of donor egg and donor sperm used in his clinics, which he says is partly due to more same-sex couples wanting to have a baby. “These aren’t patients, they’re more clients. They are looking for a service; the same with single women who are coming through wanting to access donor sperm.”
Dr Michael Harty, a TD and GP from Clare, has offered advice to many of his own patients wishing to go this route.
“It isn’t just couples who fail to conceive naturally. In my experience, the emerging trend is single women having children without a partner,” he says. “This growing number of women who have gone for assisted human reproduction is a relatively recent phenomenon.
“In rural practice here in Clare, I have had several patients who have opted to have a child as a single parent. There is also the wider area of LGBT rights and their right to reproductive assistance.”
Dr Harty chaired the Joint Oireachtas Committee that carried out pre-legislative scrutiny on the Assisted Human Reproduction Bill. Currently, there is no legislation governing the provision of fertility services in Ireland and this long-awaited bill is certain to have significant legal and societal implications. The Bill includes provisions for gamete and embryo donation, surrogacy, pre-implantation genetic diagnosis (PGD), embryo and stem cell research and posthumous assisted reproduction. It also proposed the establishment of a regulatory body, the Assisted Human Reproduction Regulatory Authority (AHRRA).
Following numerous public submissions and several days of hearings over the past 18 months, the Committee recently issued their report to Minister for Health Simon Harris, but Dr Harty is not optimistic that the Bill will become law any time soon. “I know the Minister is anxious that this bill be progressed, but the likelihood of this legislation coming through in the lifetime of this government is small,” he admits.
According to Dr Harty, the bill will have to be a “very comprehensive piece of legislation to cover all the areas that have emerged in the past five to ten years”.
Major sticking points in the draft bill included such issues as donor anonymity, maternal age limits, and recognition of the genetic mother in cases of surrogacy. The ethical and legal conundrums these create make drafting appropriate legislation even more problematic.
“The report is trying to bring together and produce regulations in relation to assisted human reproduction which will satisfy as many people as possible. Unfortunately, I don’t think it is going to satisfy everybody,” he admits.
Technology will not wait as the Bill makes its sluggish journey through the Oireachtas. “There is little or no regulation in the area at the moment and as medicine advances and technology changes year on year it becomes a much more complex not only medical issue but also a moral issue as well,” says Dr Harty.
Yet he believes Ireland has a golden opportunity to produce comprehensive and workable legislation in this area. “Because we are late to the game ourselves, we do have the opportunity to look at legislation that has been introduced in other jurisdictions and learn from that. Legislation produced internationally has had its faults and its flaws, and we can apply best practice here.”
Kennedy sharply objects to the assertion that the industry remains unregulated here. He says there is exceptionally strict regulation around the storage of cells and tissues and the management of sperm, eggs and embryos, with regular inspections carried out.
“What gets said is that we are working in an unregulated field and that is not the case at all,” he says. “What we don’t have regulations around is who we can treat, how many embryos can we put back in, etc. I am looking forward to this coming in because I already know we are doing all that in line with international best practice.”
He adds that he is pleased that some “bizarre” aspects of the draft legislation have been addressed by Harty and colleagues.
“They seem to have taken on board many of the criticisms. There was a lot of nanny-state stuff - for example, the age limit of 47. It made no sense whatsoever. It’s completely paternalistic and these are self-funding patients. It is bizarre.”
The bill was originally supposed to be introduced alongside government funding for fertility treatment. Ireland is one of just three countries in the EU that do not provide state assistance for IVF; the others are Cyprus and Lithuania.
“The government is anxious that this technology should be made available to as many people as possible within reason and within the constraints that our health service can deliver,” says Dr Harty.
“It is an expensive process and, from my own point of view, it should be available to people through our public health service.”
Yet financial aid for IVF was originally flagged by the then Minister for Health Leo Varadkar in 2016. The government then approved the plans in October 2017, and a €1 million funding pot was eventually announced by the Taoiseach last December.
Given the costs of IVF treatment, €1 million will only help a fraction of the couples seeking it every year, says a frustrated Kennedy. “One IVF cycle costs at least €4,500 per person, so if you do the maths, that’s 222 cycles. It’s laughable.”
His cynicism is understandable. “This seems to come up when it may be an election year – the kite always gets flown.”
Kennedy’s understanding is that, on a per capita basis, there is less IVF carried out in Ireland than in other countries where it is funded publicly. But he says those other countries are beginning to tighten their belts; for example, in Britain, there are increasing barriers to entry and some countries operate a “BMI cut-off” when it comes to funding with overweight people unable to avail of it.
The government here had also mentioned the need for couples to meet certain criteria, although what these might be has not yet been stipulated.
Some financial help already exists for couples in Ireland – the government offers a tax rebate of 20 per cent on any fertility services, while the Drugs Payment Scheme covers most of the cost of their medication.
“That represents a substantial sum of money, but while it’s not fair to say the state is doing nothing to support these couples, really they aren’t doing anything close to what’s needed,” says Kennedy. “A proper, well thought-out scheme is what’s needed.”