Is it true that we are over-using Assisted Reproductive Treatments?
It is interesting to try to understand the options for an infertile couple trying to achieve their greatest dream of having a child, in the complex field of infertility
The process which culminates in this joyous event leads to a crossroad, where one road leads towards attempting natural conception, and the other one towards medically (ART).
Of course there are specific clinical cases which lead couples towards the second option, however other circumstance leave room for an alternative solution.
Several studies presented by authoritative scientific journals, such as the one published on BMJ by Kamphuis et. al, demonstrate without much doubt that in many cases, the answer to the question in the title is probably YES.
The growth of Assisted Reproductive Treatments
Since 1978, year of the birth of the first 'test tube' baby, there has been an overwhelming evolution of in vitro procreation. Initially developed to resolve the tube problem, in vitro fertilisation, or ART - sometimes used interchangeably to mean the same process, has been used to treat numerous other causes of infertility.
For example, the treatment of types of subfertility, such as so-called slight male infertility, endometriosis and unexplained female subfertility.
Specifically, subfertility is defined, using a medical-scientific approach, as a form of reduced fertility, associated with a prolonged period of time during which those affected are unable to conceive naturally
However some eminent researchers and doctors have raised doubts:
The use of ART, even in cases of subfertility, may be disproportionate to the probability couples have of conceiving naturally. Would ART be able to guarantee the same probabilities of success in such cases? Lastly, with a growth in the knowledge of cases of adverse effects on the health of children born from ART, would the use of such procedures be justifiable in cases of subfertility?
A group of doctors and researchers from a few important reproductive medical centres, at the University of Amsterdam (the Netherlands), Aberdeen (UK), and Adelaide (Australia), have attempted to provide scientific answers to these and other questions, with clinical evidence.
They provided some "social" motivations which have rendered assisted procreation techniques increasingly widespread.
Age: for women in particular, the age of conception has progressively shifted to over 35, a period in which ovary problems may arise, causing difficulties in natural conception.
Hope: for subfertile couples there is a sharp drop in expectancy after just two years of attempting natural conception, especially in the absence of valid alternatives which often gynaecologists themselves are unable to offer.
Furthermore, researchers underline that with the increase of ART treatments, also due to the fact that they are mostly offered by private centres - in Italy there are 359 ART centres, of which approximately 70% managed by private companies - there has been a loss of focus on the scientific evaluation of single cases: for which couples does ART constitute a true and the only necessity? Said researchers also bemoan how commercial and business requirements overwhelmingly regulate the private nature of this medical service.
Therefore there is an increasing number of cases for which ART is preferred and applied, even for male and female subfertility.
Let us now go back to the point of the aforementioned study, in our search for the answer to the initial question.
ART and unexplained infertility
In cases of blocked tubes or male sterility, based on scientific evidence, it is common opinion that IVF is the only valid opportunity for conceiving a child.
However, in cases of subfertility as well as in cases of unexplained infertility, this certainty wanes somewhat.
On average 30% of cases are affected by unexplained infertility and up to 40% of couples may be affected by subfertility. Researchers compared several international studies and found that in cases of subfertility and unexplained infertility, there is no improvement of pregnancy rate if infertility is tackled with a ART approach. On the contrary, a study conducted on a group of 500 Dutch couples diagnosed as subfertile for over 2 years, demonstrated how 60% were able to achieve a natural pregnancy with their partner.
A second comparative study, comparing two populations of patients with unexplained subfertility, treated with different approached, demonstrated how the percentage of pregnancy rate was the same. The first group was treated with ovarian stimulation and intrauterine insemination (a type of Assisted Reproductive Treatments), the second with an expectant management* programme. In both cases the pregnancy rate was 25% after 6 months and 75% after three years. This demonstrated that Assisted Reproductive Treatments did not produce any effective advantage for couples compared to those who attempted to conceive naturally.
The medical choice is not only about "whether" to intervene in cases of subfertility, but also "when": different economic-clinical studies affirm that in cases of young women affected by subfertility, Assisted Reproductive Treatments are not effective in the first the years of conception.
The duration of a woman's subfertility or infertility appears to be crucial in choosing a particular ART protocol and the evaluation of its effectiveness. It remains unexplained as to why such information does not feature in annual ART surveying carried out by each country.
NB: The UK is the only European country to have adopted ministerial guidelines for the application of ART. Said guidelines recommend that women affected by subfertility or unexplained fertility for under two years are not treated with ART techniques. If said women are under the age of 40, this recommendation changes, initially "not more than 3 years" - without any scientific motivation in support of such decision.
In conclusion, in cases of subfertility and unexplained infertility, medical and clinical evidence has demonstrated the need to consider Assisted Reproductive Treatments as a last resort, although it does not offer a greater probability of success compared to those achievable through an expectant management* path.
* What is it exactly meant by expectant management? We'll discuss this in our next post. Stay tuned.