IVF with the lot may not be the best option

IVF has come a long way since the first baby was born more than 40 years ago. In the early days of IVF doctors waited for the one egg that a woman releases every month to mature before they tried to retrieve it and fertilise it in the laboratory. Needless to say, the chance of a pregnancy was extremely low.

Since then IVF has become much more efficient mainly because hormones are used to stimulate the ovaries to produce multiple eggs, the culture systems in the laboratory have been refined and embryos can be frozen which adds to the chance of a baby.

But, despite these improvements, most IVF cycles still fail. That’s why doctors and scientist are working hard to find ways to improve the chance of success. And this is where so called ‘add-ons’ might be offered, at a cost. ‘Add-ons’ are procedures or drugs given in addition to the normal IVF procedure which are thought to give a bit of an added chance of a positive outcome.

The problem is, most of these ‘add-ons’ are unproven and might even be harmful. Two articles published online today in the journal Fertility and Sterility provide food for thought about ‘add-ons’. The authors of the first article present a summary of the findings from research on several ‘add-ons’ and they conclude that, for most, there is no evidence that they improve chance of success.

They also point out that, in addition to the extra cost for patients, some ‘add-ons’ have unknown risks. They therefore don’t recommend the use of ‘add-ons’ until they are proven to improve the chance of having a baby and to not have unacceptable risks.

The second article points to some of the problems with clinics offering ‘add-ons’. They include that there is no regulation of ‘add-ons’ which means that they can be introduced into practice before they have been shown to improve the chance of success. And, because people who have IVF are pretty desperate and likely to grasp for anything they think might help them have a longed-for baby, the advertising and selling of unproven ‘add-ons’ can be seen as a conflict between the IVF clinic’s profit interests and the best interest of patients.

An added problem is that, anecdotally, patient demand for ‘add-ons’ is high. Patients’ requests for ‘add-ons’ are often based on their own research which mostly is limited to online sources including blogs with personal stories and Facebook groups where the quality of information is variable. When patients ask for a particular ‘add-on’ because they are convinced it is going to help them have a baby, it can be difficult for clinicians to discourage them from using it.

The authors say that ‘Because the effects of a treatment can’t be known until it has been robustly evaluated, we argue that strong evidence should be required before add-ons are introduced to the clinic.’ Until such time, if they are to be offered, clinics need to make sure that patients are given complete information about ‘add-ons’, including that they are experimental, may not improve the chance of a baby and may have unknown side effects for the woman and/or her baby.

The article concludes that encouraging patients to ask the five questions recommended by the Choosing Wisely campaign, before having any test, treatment or procedure, might help them make more informed decisions: ‘Do I really need this test, treatment or procedure?’; ‘What are the risks?’; ‘Are there simpler, safer options?’, ‘What happens if I don’t do anything’; and ‘What are the costs’.

In the context of IVF, the additional question ‘How will this treatment affect my chances of a live birth?’ is likely to help patients make the best decisions for themselves.

Sources:

Kamath M, Mascarenhas M, Franik S, Liu E, Sunkara S, Clinical adjuncts in IVF – a growing list.
Fertility and Sterility
Wilkinson J, Malpas P, Hammarberg K, Mahoney Tsigdinos P, Lensen S, Jackson E, Harper J, Mol B,
Do à la carte menus serve infertility patients? The ethics and regulation of IVF add-ons. Fertility and
Sterility