IVF research bears fruit for the childless

NVOLUNTARY CHILDLESSNESS or the inability to have more children (secondary infertility) are devastating for those who want to start a family and, after all, reproduction is a biological imperative. Infertility prevails in about 14 per cent of couples worldwide, which is why IVF has become so prevalent in the decades since I was involved with the team that produced the first IVF baby in 1978. Indeed, for Jewish couples, (be fruitful and multiply) is the first mitzvah of the Torah, in Genesis 1:28.

IVF was developed to bypass blocked, damaged or absent fallopian tubes. Years later, we appreciated that sperm problems were a major cause of infertility too. Today couples access IVF for problems arising in men or women and often both. The causes are abundant, relating to structural (the actual reproductive organs and systems), hormonal and genetic issues, to name a few. Infertility may be unexplained and IVF itself can be diagnostic; observing eggs, sperm and embryos under the microscope often reveals previously unseen problems.

We often see patients who have spent years having investigations but by the time they come for IVF the woman is in her late 30s and the original issue is now less relevant than the fact that she is reproductively older. At age 30, up to 40 per cent of a woman’s eggs carry a chromosome abnormality; by age 40 it is up to 80 per cent. That is why, for example, at 30 the chance of a baby with Down’s syndrome is 1:900 but at 45 it is 1:25.

Yet Down’s syndrome is caused by one chromosome error (an extra copy of chromosome 21) but there are another 23 chromosomes that could cause a problem. And chromosome errors are just part of our DNA. Separately there are genetic errors too (we have 24 chromosomes and these carry the 25,000 or so genes that make us who we are). So I cannot stress enough that the age of the woman seeking treatment is critical.

At 30, in the very best clinics, the chance of a live birth is more than 50 per cent in most cases, whereas at 40 years of age it is less than 15 per cent.

So can we and should we preserve women’s eggs? Traditionally clinics would store eggs only in special medical circumstances. But a new technology, vitrification, enables experienced clinics to achieve great success with frozen eggs, comparable with using “fresh” eggs. We are seeing requests to store eggs from women wishing to preserve their fertility for personal reasons, such as not being ready for marriage, being without a relationship, pursuing a career or hedging against secondary infertility.

There is yet another reason to take notice of this technology. In many western countries the replacement population requirement of 2.5 children is not being met. It is around 1.9 and this is coupled with women starting to try for a child at a later age than at any other time in history. This is a double whammy for social fecundity.

Many access IVF today not only for fertility problems but for other reasons. They may be single women or gay/lesbian couples. They may be seeking surrogacy — especially those who have no womb; they may be involved in egg donation or they may have suffered multiple miscarriages.

The largest single cause of miscarriage is chromosomal anomalies. Technology can now reliably assess all the chromosomes in a cell of the embryo. This gives the potential to transfer only chromosomally normal embryos, improving the chance of a live birth.

Other fertile couples access IVF to avoid passing on a familial genetic disease, using preimplantation genetic diagnosis. More than 4,000 human diseases are caused by a single gene disorder and some ethnic populations are at high risk of specific types. For the Jewish population, this category includes Bloom syndrome, Canavan disease, cystic fibrosis, Gaucher’s disease and Tay-Sachs. By removing a single cell from the embryo a few days after fertilisation, we can tell if it is affected by or a carrier of the disease. Either an embryo that is a carrier or those free of disease can be selected for transfer to the womb.

IVF has developed so fast that we can now help in almost all infertility and fertility-preservation situations. Educating the public about fertility, especially female age and egg preservation and the effects of lifestyle, is very important. Smoking, excessive alcohol, potential harm from some Chinese herbal medicines, toxicity from air quality, oestrogenlike chemicals in food products and cosmetics may all affect fertility.

Judaism has always been supportive of IVF. The first commentary in the western world was biblical Sarah, bitterly resigned to her childlessness and Rebecca in Genesis 30:1, exclaiming “give me a child else I die”. Rashi comments that it signifies that a childless person is accounted as dead. I prefer to consider it a statement on “genetic death”; that without children people do not live on, which was why I started the Rachel Foundation, a fertilityresearch charity.

It is estimated that male-factor infertility accounts for up to 50 per cent of infertility among Jews. Selfhelp organisations such as Chana and Kivisi are vital. Many couples prefer to seek a rabbi’s advice on IVF (it is preferable to consult one who is well versed in Jewish ethics in this area, as opinion varies). Many wish the whole process to be supervised by a trained