Doc­tors MUST stop cash­ing in on des­per­a­tion


THE des­per­a­tion and vul­ner­a­bil­ity of in­fer­tile cou­ples leads them to grasp at straws. There are many causes for in­fer­til­ity and just as there are dif­fer­ent causes, so there should be dif­fer­ent treat­ments. Each cou­ple re­quires the most suit­able, cost-ef­fec­tive and safe treat­ment de­pend­ing on the cause for their fail­ure to con­ceive. In­creas­ingly, they are of­fered the treat­ment most con­ve­nient to the doc­tor.

IVF – the most com­plex, ex­pen­sive and de­mand­ing of all in­fer­til­ity ther­a­pies – is seen as the stan­dard pro­ce­dure. It is the treat­ment sug­gested be­fore the spe­cific cause of the in­fer­til­ity is in­ves­ti­gated.

There is no other med­i­cal ther­apy where treat­ment is of­fered be­fore proper at­tempts at di­ag­no­sis are made. Such prac­tice is seen as highly un­eth­i­cal and is likely to be found le­gally neg­li­gent.

To make mat­ters worse, be­cause each cy­cle of IVF has such a high fail­ure rate, there are many emp­ty­handed women left dis­tressed af­ter their IVF has failed. They of­ten find them­selves con­fronted by a doc­tor try­ing to con­sider how their IVF treat­ment might be im­proved.

With­out the un­der­ly­ing cause of fail­ure prop­erly es­tab­lished, they are en­cour­aged to buy one of many add-on treat­ments which mostly have lit­tle or no se­ri­ous ev­i­dence for their ef­fec­tive­ness.

Nearly all, for dif­fer­ent rea­sons, add sub­stan­tially to the costs that a cou­ple has al­ready in­curred.

For ex­am­ple, pre- im­plan­ta­tion ge­netic screen­ing in­volves tak­ing a few cells from the em­bryo dur­ing its first five days and analysing its chro­mo­somes for ab­nor­mal­i­ties.

If they ap­pear nor­mal, the em­bryo is as­sumed to be healthy and is trans­ferred to the uterus. If ab­nor­mal, the em­bryo is dis­carded.

Al­though the ba­sic pro­ce­dure was pi­o­neered in my lab at the Ge­n­e­sis Re­search Trust, it was never in­tended to screen em­bryos and it angers me to see a sci­en­tific study mis­used for com­mer­cial pur­poses.

In spite of the treat­ment hav­ing been in use for nearly 30 years, there are no con­clu­sive, proper stud­ies or good ev­i­dence that it im­proves the chance of a live birth. Some stud­ies even show it re­duces suc­cess rates be­cause healthy em­bryos may be dis­carded.

En­dome­trial scratch­ing at least has the virtue of be­ing cheap. A small wound is de­lib­er­ately made in the womb lin­ing a few days or weeks be­fore em­bryo trans­fer.

Ini­tial re­ports from Is­rael sug­gested im­proved preg­nancy rates, for rea­sons which are still un­clear. More re­cently, Is­raeli sci­en­tists pub­lished con­clu­sions sug­gest­ing no ben­e­fit. Now, 25 years since scratch­ing was in­tro­duced, sci­en­tists from Utrecht in the Nether­lands have ini­ti­ated a huge ran­domised trial.

So far, the ev­i­dence is du­bi­ous. Yet, ac­cord­ing to a re­cent pub­li­ca­tion, up to 83 per cent of pa­tients in New Zealand, Aus­tralia and the UK are ad­vised to have the scratch.

Em­bryo glue is also ad­vo­cated by some clin­ics to help the em­bryo stick to the uterus af­ter it is trans­ferred. It in­volves dip­ping the em­bryo into a spe­cial fluid which may in­ter­act with the womb lin­ing – and some clin­ics in Lon­don only charge £250 for it. The prob­lem is that it prob­a­bly doesn’t work and there are no de­fin­i­tive ran­domised tri­als which show oth­er­wise.

There are also a va­ri­ety of com­plex treat­ments of­fered which are meant to change a pa­tient’s im­mune sys­tem so an em­bryo is less likely to be re­jected af­ter trans­fer.

The treat­ments add sev­eral hun­dred pounds at least to the cost of IVF. There are ex­pen­sive tests on ‘killer cells’ in blood taken from the pa­tient’s arm, but it is doubt­ful whether this gives se­ri­ously use­ful in­for­ma­tion about what is hap­pen­ing in the uterus.

Steroids and drugs which could pre­dis­pose to can­cer are also oc­ca­sion­ally of­fered. A re­cent study from Sheffield and Sheffield Hal­lam Uni­ver­si­ties showed no ben­e­fits to us­ing steroids, and they may be oc­ca­sion­ally as­so­ci­ated with ab­nor­mal­i­ties in the de­vel­op­ing baby.

It is clear these im­muno­log­i­cal treat­ments have not been prop­erly as­sessed by de­tailed ran­domised tri­als, and un­til they are, they should not be sold.

This list of du­bi­ous treat­ments is only a few of those of­fered.

Re­gret­tably, the mar­ket in IVF has led to doubt­ful prac­tice. Even the NHS, in its need for fund­ing, is happy to profit from IVF.

I am not against ex­per­i­men­tal treat­ments, but re­spon­si­ble, eth­i­cal ap­proval is es­sen­tial and cou­ples should not have to pay for un­proven ther­a­pies.

But while the des­per­a­tion of vul­ner­a­ble pa­tients is a fer­tile com­mer­cial op­por­tu­nity, it may not im­prove their chance of a baby.

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