20 December 2012

Event: Fertility Treatment: A Life-Changing Event?

The Progress Educational Trust’s annual conference discussed the impact of policy, stress, nutrition, age and ‘bad habits’ on the success of fertility treatment. Jennie Bristow reports.

The conference was held at the Institute for Child Health on 28 November, bringing together clinicians, policymakers and advocacy groups for a day of discussion and reflection on the scientific and cultural issues affecting the provision and success of fertility treatment in Britain today.

Sarah Norcross, director of Progress, opened the conference by noting the ongoing uncertainty about the way fertility treatment would be organised and regulated in the newly-reformed National Health Service. The first session, ‘NICE try: The impact of policy’, was introduced by Peter Taylor, healthcare policy adviser at the cooperation and competition panel for NHS-funded Services. Taylor explained that his presentation was supposed to be about the new published guideline on fertility treatment produced by the National Institute for Health and Clinical Excellence (NICE), but publication of this guideline has been delayed; a factor contributing to the uncertainty surrounding the provision of services.

However, Taylor was able to refer to the draft guidance that has been out for consultation. This makes recommendations about the way treatment should be provided, in terms of defining infertility; unexplained infertility; intrauterine insemination (IUI); the criteria for referral for IVF, including the expansion of access for women aged 40-42; and embryo transfer targets in IVF, where single embryo transfer (SET) is recommended in the first and second cycles for women under 37, but slightly more flexibility is given for the third cycle and for older women.

Taylor explained the way in which the organisation of Britain’s National Health Service (NHS) is set to change, with the replacement of Strategic Health Authorities, Specialist Commissioning Groups, and Primary Care Trusts by the NHS Commissioning Board (NCB) and GP-led Clinical Commissioning Groups (CCGs). Fertility treatment, he said, has always been the ‘poor cousin’, and gaining recognition has been very difficult, leading to very long waiting lists, restrictions on the number of cycles of IVF in some areas, and so on.

‘Big changes are being made in the NHS when costs are very tight,’ explained Taylor, and an argument may need to be made about how fertility treatment fits in with the Health Secretary’s criteria and the national outcome goals. In terms of regulation, there will be specific duties on the NCB to promote equality and tackle inequality of healthcare outcomes, which may help in mediating some of the problems of unequal access to fertility treatment and the current ‘postcode lottery’.

The impact of stress

Tracey Sainsbury, fertility counsellor at number of London clinics, discussed the problem of ‘negative thinking’. One of the issues with negative thinking, she said, is often ‘that you don’t know you’re doing it – there is a myth that you should not be stressed so you believe that you are not’. Those involved in providing fertility treatment, she said, need to have a greater understanding of the emotional journey undergone by patients, who ‘come in with excitement and optimism’ which also triggers ‘a huge pool of fear’.

Zita West, of the Zita West Clinic and the Zita West Assisted Fertility Programme, argued that ‘some things that stop women conceiving lie in the mind’. For example, too many couples ‘run down the IVF route far too quickly’ without considering whether really, they should just be having more sex; for some couples, the issue is ‘not about the inability to conceive but the impatience to conceive’, and once couples are involved in treatment, ‘sex quickly becomes mechanical’, and intimacy needs to be restored. The model of healthcare is very medicalised, said West; and clinicians ‘have to start looking at how mindset has a huge impact on fertility, and at integrating concepts of mind and body’.

Jacky Boivin, head of the fertility research group at Cardiff University, presented the findings of a meta-analysis of studies. Boivin noted that there are many stressors for people with fertility problems, and procedures can become very stressful, compounded by waiting times and other resource issues. These studies suggest that, in fact, stress is unlikely to have a direct effect on women’s ability to become pregnant after fertility treatment. However, stress can have indirect effects on the success of fertility treatment, she suggested, if people drop out before they have a chance to get pregnant, or if they adopt more unhealthy lifestyle behaviours, such as smoking.

From the audience, one clinician argued that the focus on stress tended to imply that if the treatment fails, it’s the patient’s fault; and that he found the balance suggested by Jacky Boivin far more constructive. A delegate from the Infertilty Network argued that ‘sometimes word “stress” is not helpful’, and asked what clinics could do ‘more or less of’ to alleviate emotional distress. In response, Zita West argued that the healthcare model does not look holistically enough at the couple; however, she would hate anyone to delay treatment because they were undergoing complementary therapy. Jacky Boivin suggested that clinics could have a look at where their own practices might be contributing to patients’ stress, for example, through a lack of information.

The impact of weight and nutrition

In a talk on ‘periconceptional nutrition and outcomes’, Nick Macklon, Professor of Obstetrics and Gynaecology at the University of Southampton and Director of the Complete Fertility Centre, described obesity and reproduction as ‘bad synergies’, noting that obesity can cause problems in pregnancy, reduce IVF success, and increase the chance of miscarriage. ‘As clinicians we have a duty to ensure that the embryo is in the optimal environment,’ he said, and went on to talk about the extent to which ‘better diet improves reproductive outcomes’.

Although Macklon stressed the importance of diet, he also cautioned about some of the problems with the food supplements, which – as they are food rather than medicines – are not regulated. There is a ‘huge and lucrative market for preconceptional food supplements’, he said, but care needs to be taken; for example, studies of high levels of omega 3 supplements in pregnancy suggest that this can delay development.

Dietician Fiona Ford spoke to the provocative title ‘Universal panacea or snake oil?’ She started by stating that there is sometimes very good evidence for food supplementation, as in the case of folic acid, to the point where health authorities are considering fortifying everyday food, because ‘a lot of people don’t set out to be pregnant’, and ‘messages get lost along the way’. In Britain, the official recommendations for preconception supplementation are folic acid and Vitamin D. It is recommended that pregnant women only use specially formulated vitamin supplements, to avoid taking the wrong ones; but these are very costly, and Ford suggested it would be better to be very clear on exactly what supplements pregnant women need so that they could buy the pharmacies’ own brands.

Ford went on to talk about the problem of conflicting advice and confused messaging. For example, Vitamin A – ‘there is a lot of talk about not going anywhere near it, but some things, like margarine, contain it in same way that naturally occurs in butter’. Women can be worried and confused by these messages, she said, and ‘a differentiation is not clearly made’. There is a problem with conflicting advice – ‘if the public feel that if health professionals don’t know, what can they follow?’ – and there are also questions about ‘who is giving this information about to the public?’

Ford noted that many people have food issues; indeed in general, ‘women are terrified of food – what they can eat and what they can’t’, so giving them lists of foods to avoid my not be realistic, and also risks ‘imposing guilt on women.’ With regard to what is a healthy weight, Ford stressed that ‘BMI is not the whole story – we also need to look at body composition and body fat, particularly in underweight women’.

Bas Heijmans, Associate Professor of Molecular Epidemiology at Leiden University’s Medical Centre, discussed epigenetics - ‘the way DNA interacts with its environment’ - in the context of a study of the Dutch famine during the Second World War. Exposure to severe hunger is associated with health problems, he explained, but what is interesting is the variety of ways that famine can affect genes in the next generation. The experience of the Dutch famine ‘also showed also how resilient the human body is’; when it comes to nutrition, ‘common sense is a very good guide’. In relation to epigenetics, he argued, ‘there’s a lot to come but don’t expect miracles in the next few years’.

From the audience, there was some discussion about other issues that can get played out through the health agenda, sometimes with problematic consequences. For example, one clinician stated that we know that PCTs use BMI as a rationing tool, with the result that clinics are seeing women who have paid for a gastric band to get weight down and access IVF – ‘the outcomes have been dreadful’. There was also a question about underweight women, who are often not discussed in the focus on obesity, but for whom their weight can be a significant cause of anovulatory infertility. Following Heijmans’s research on the Dutch famine, one audience member noted the number of ‘beautiful healthy babies’ born to women who had been in concentration camps in the Second World War, and asked if anyone had studied their outcomes.

A clinic counsellor noted that women attending clinics for fertility treatment have often already started to abstain completely from alcohol, which adversely affects their social life and relationship, and wondered what the evidence was on the effects of alcohol on fertility treatment. To this, Macklon responded that there is not a great deal of evidence, although ‘of all lifestyle factors, alcohol seems to be the weakest’, and messages should be ‘very careful’ so as not to decrease the chances of conceiving spontaneously.

The impact of alcohol and smoking

Jean Golding, Emeritus Professor of Paediatric and Perinatal Epidemiology at the University of Bristol and Founding Scientific and Executive Director of the Avon Longitudinal Study of Parents and Children (ALSPAC), discussed research into whether the effects of smoking during pregnancy (by the mother or the father) could have an impact on future generations, for example, the grandchildren. Golding argued that the outcomes of smoking in pregnancy included increased risk of miscarriage, stillbirth, low birthweight, and ‘antisocial behaviour’. 

Dr Ellie Lee, Reader in Social Policy and Director of the Centre for Parenting Culture Studies at the University of Kent, discussed the promotion of alcohol abstinence in pregnancy and the ‘politics of risk consciousness’. Lee noted that no distinction is made in advice by the Department of Health between pregnant women and women trying to become pregnant; and in the USA, abstinence advice is targeted at ‘all women who may become pregnant’ – in other words, all women of reproductive age.

In examining ‘the formalisation of tacit and explicit rules’ around drinking in pregnancy, Lee first explained how the public discussion about this issue has shifted considerably in the past 25 years. She contrasted an article in the Guardian in 1991 that dismissed the call for abstinence in pregnancy as a ‘silly’, American idea, with the way that recent reports have endorsed without question the warning that, for example, ‘a tiny amount of alcohol in pregnancy can lower a baby’s IQ’.  But this is not a media panic, she stressed: the message comes from the studies themselves, where the findings are presented in such a way as to ‘contain a proactive approach to a risk-averse position’.

Allan Pacey, Chair of the British Fertility Society and introduced to the conference as ‘the UK face of sperm’, gave a talk titled ‘Balls of Steel: do lifestyle factors affect semen quality?’ He began by explaining that ‘semen quality is very different to male fertility’, and these things often get confused. Pacey noted that, in its advice to males about fertility treatment, NICE guidance warns about smoking, drinking, wearing tight underwear, high BMI, recreational drug use, and occupation. However, examining the evidence base, the studies seem to be quite poor – so Pacey presented the results of an analysis he and colleagues had conducted. From this, there were some interesting results – including that drinking some alcohol and wearing boxer shorts seemed to be beneficial – but the overall conclusion was that ‘few lifestyle factors have a negative effect on sperm motile concentration’.

Neil McClure, Professor of Obstetrics and Gynaecology at Queen’s University Belfast, continued this theme by indicating the complex character of ‘male infertility’, which includes issues to do with ‘volume, concentration, motility, morphology, and antibodies’. He noted that looking at changes to DNA is ‘great in a research context, but not so helpful in clinical context’, and that the problem with many studies is that it is ‘very difficult to control for factors coming together’ – for example, middle-class men are less likely to smoke, more likely to wear boxers, and more likely to be fit and have better diets. In terms of what it is possible to conclude, suggested McClure, ‘smoking is probably bad (though antenatal clinics are full of people who live off fags, Fanta and chips, while infertility clinics are full of couples who eat healthily and don’t smoke or drink’, and the evidence on alcohol is ‘totally unclear’.

The speakers were followed by some discussion about the balance between health factors and social factors in explaining, for example, the decline in male fertility; and questions about what public health messaging should actually be. Allan Pacey suggested that more could be done in school to discuss fertility issues and choices rather than focusing primarily on contraception; Neil McClure suggested that the government should promote moderation rather than abstinence, but it has become ‘scared to say it’s okay to have a glass of wine’; and Ellie Lee argued that the government should stay out of public health messaging in this area, as it is ‘discriminatory’ to single out classes of people (pregnant women, couples seeking fertility treatment) to receive particular messages. Furthermore, she argued, the emphasis on lifestyle behaviour ‘encourages the notions of maternal-fetal conflict, mother blaming, and the obsession with risks facing children’.

The impact of age

Susan Bewley, Professor of Complex Obstetrics at King’s College London, began by noting the trend towards an increasing proportion of older mothers: now, more than half of the women having babies are over 30, and a quarter over 35. This matters, she argued, because there are increasing complications in pregnancies to older women, and pregnancy in middle age can also coincide with the onset of ‘mid-life’ diseases, such as diabetes. Evolutionarily, she argued, pregnancy is ‘a young person’s sport’: the most secure age to have a baby is between 20 and 35, and ‘IVF cannot compensate for delay’. Schools are ‘teaching teenagers to put condoms on a banana and not telling them that they are more likely to be infertile than to have a teenage pregnancy’; and as a society, she suggested, we need to consider whether, if 20-year-olds were well informed, and if they could choose without any other constraints, would they move to later childbearing?

Louise Ghevaert, Partner at Porter Dodson Solicitors and Advisers, talked about the problem of the ‘postcode lottery’ for IVF treatment. Although current NICE guidance states that women aged 23-39 should be eligible for up to three cycles of IVF on the NHS, she explained, PCTs rarely comply with this guidance, and often employ ‘stringent age restrictions as a way of rationing treatment.’ She noted that new legislation bans age discrimination on provision of healthcare services by NHS, including fertility treatment, and that there is also equality legislation, although this is ‘fluffy’ around the question of age.

Dr Gillian Lockwood, Medical Director of Midland Fertility Services, spoke about the fertility implications of deferred motherhood. In relation to the question ‘why are women delaying and deferring?’, she suggested that there are many reasons, but ‘one important one is that the accidental pregnancy is not one seen in educated women’, and another is that ‘women think there will be a technical fix for biological problem’.

So is there a fix? Noting that ’59 per cent of childless women aged 45-39 still want to have a baby’ but that ‘success rates of women in their 40s using their own eggs is absolutely dire’, Lockwood suggested that we think about oocyte freezing. ‘Women today now expect to live until they are 80, but they are biologically infertile by the time they’re 40,’ she said: but more widespread acceptance of egg freezing could offer greater potential for the success of fertility treatment in older mothers. There are, suggested Lockwood, some social consequences of ‘late motherhood’ that should be considered, for example ‘stretching the generation gap’ and the potential increase in
‘lonely, only’ children; but the reality is that we do have the technology, and even though ‘governments have tried bullying, lecturing and hectoring, women are still trying to get pregnant older’.

The session concluded with a discussion about the balance between the advantages of technology for planning fertility and resolving infertility, and the disadvantages of a cultural context in which pregnancies are seen to need to be rigorously planned and intensively monitored. Some of the panellists suggested that it is a good thing that a large proportion of pregnancies continue to happen ‘by accident’, sparing couples the stress and anxiety of worrying about conception.