Funded by the Bupa Foundation
Most people want to plan when they have a baby and, often, fertility control is about trying not to get pregnant. But what happens when conception doesn’t happen as we expect?
Infertility is clinically defined as an inability to fall pregnant after 12 months or more of regular unprotected sex. It is common to believe that conception will happen as soon as contraception is stopped. The reality is that about nine percent of people will experience infertility and that can bring tremendous heartbreak and pain.
Many turn to medicine to help them conceive and, over the last three decades, as medical advances in fertility treatment have been made, the numbers seeking treatment have dramatically increased.
But at what cost?
In the UK, a woman has a just below 22 percent chance of delivering a live baby after undergoing assisted reproductive technology (ART). In Australia, it is 17 percent. Yet, undergoing ART carries health risks, such as maternal postpartum haemorrhaging (excessive bleeding after delivering a baby), and prematurity and low birth weight in the baby.
So, for assisted reproductive treatment, how should we define success?
Researchers at Monash IVF, with funding from the Bupa Foundation, have published the results of several studies that are redefining a clinical definition of success and changing the way IVF is performed globally. This new definition states that success should be defined as a singleton healthy baby born at full term to a healthy mother.
Professor David Healy, Chairman of the Monash University Department of Obstetrics and Gynaecology, Head of the Reproductive Medicine Unit at Monash Medical Centre and President of the International Federation of Fertility Societies, is leading the research and recently published this new clinical definition so that a global standard can be set to monitor IVF clinics around the world on their “success rates”.
In many countries, success is defined as a confirmed pregnancy and, given that ART increases the health risks to mother and baby, Professor Healy believes that this definition falls short of the best possible outcome for both.
“Globally, there are different measures of success,” says Professor Healy. “In Australia, success is one healthy baby born at a healthy weight to a healthy mum. It is dishonest to promote success as anything less than that. It is not necessarily a positive pregnancy test.
”His data demonstrated that transferring more than one embryo was unnecessary and irresponsible because the healthiest mother and baby outcome follow a single embryo transfer.
“We should stop double embryo transfer,” says Professor Healy. “Implanting more than one embryo increases the likelihood of a twin pregnancy, which is an obstetrical complication. A twin birth in Australia costs ten times as much a single birth but the chance of a baby is the same for one embryo as it is with two.
”In addition to redefining IVF outcomes, Professor Healy and his research team have been investigating why some IVF babies are at increased risk of being born early or at a lower birth weight. Prematurity is one of the biggest obstetric risks and the causes have largely been unknown.
In an earlier study, also funded by the Bupa Foundation, Professor Healy discovered that women with ovarian endometriosis were twice as likely to have a premature baby and these babies were small for their gestational age. He reported that subtle changes in the lining of the uterus, called the endometrium, may be to blame.
“The lining of the uterus is thickened – it is more 'luxurious' than turns out is healthy,” says Professor Healy. “Implanting an embryo into a “boggy” uterus produces a pregnancy that is less healthy and produces a higher risk of postpartum haemorrhaging and premature labour. There are massive costs associated with these problems.”
His earlier findings also show that the conditions under which the treatment is carried out can also affect the health of the baby. Professor Healy investigated the different methods for conducting IVF where the embryo can be implanted fresh or frozen, and implanted at the optimal time in a woman’s natural menstrual cycle or a medically stimulated cycle. The results showed that IVF singleton babies conceived from a frozen embryo and implanted into a natural cycle had the best outcome.
In another study funded by a Bupa Foundation grant, they measured an endometrial marker (pregnancy-associated plasma protein-A or PAPP-A), a protein in the blood associated with pregnancy important in embryo implantation, new blood vessel growth and, ultimately, development of the placenta. They found that levels of this protein were significantly lower in IVF pregnancies and that the implantation of fresh embryos as opposed to frozen was lower again.
These findings mean that, for the first time, a blood test early in any woman’s pregnancy could be used to predict the likelihood of complications, such as low birth weight, prematurity and maternal postpartum haemorrhaging, a leading cause of maternal mortality worldwide.
The aim of any fertility treatment should be the birth of a healthy baby. But this new body of evidence shows that the outcomes for mother and baby can be significantly improved with the abandonment of certain IVF practices and recognition that in early pregnancy endometrial function is important. The identification of markers in the blood could drive new obstetric public policy, enabling the triaging of women into high risk groups, marking a dramatic shift towards significantly improving the health of mothers and IVF babies.
“In the 1980s, we focused on the start of the pregnancy,” says Professor Healy. “But now, in 2012, we must focus on the end.”
The Bupa Foundation proudly supports the research of Professor David Healy, Monash University.
References
- Zegers-Hochschild F, Adamson GD, de Mouzon J, Ishihara O, Mansour R, Nygren K, Sullivan E, van der Poel S on behalf of ICMART and WHO 2009. The International Committee for Monitoring Assisted Reproductive Technology (ICMART) and the World Health organisation (WHO) revised glossary on ART terminology. Human Reproduction 24:2683-87.
- Boivin J, Bunting L, Collins JA, & Nygren KG. International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care 2007. Human Reproduction 22:1506-12.
- European Society of Human Reproduction and Embryology (ESHRE). Focus on Reproduction. September 2010. ESHRE. Grimbergen. Belgium. Available here.
- Human Fertilisation and Embryology Association. (2007a) The HFEA guide to infertility 2007/08. HFEA: London.
- Wang YA, Macaldowie A, Hayward I, Chambers GM, & Sullivan EA 2011. Assisted reproductive technology in Australia and New Zealand 2009. Assisted reproduction technology series no. 15. Cat. no. PER 51. Canberra: AIHW.
- Healy DL, Breheny S, Halliday J, Jaques A, Rushford D, Garrett C, Talbot JM, Baker HWG. Prevalence and risk factors for obstetric haemorrhage in 6730 singleton births after assisted reproductive technology. Human Reproduction 2010;25:265-274
- Halliday JL, Ukoumunne OC, Gordon Baker HW, Breheny S, Jaques AM, Garrett C, Healy D, Amor D. Increased risk of blastogenesis birth defects, arising in the first 4 weeks of pregnancy, after assisted reproductive technologies. Human Reproduction 2010;25:59-65
- Jaques AM, Amor DJ, gordon Baker HW, Healy DL, Ukoumunne OC, Breheny S, Garrett C, Halliday JL. Adverse obstetric and perinatal outcomes in subfertile women conceiving without assisted reproductive technologies. Fertility and Sterility 2010;94: 2674-79
- Fernando S, Breheny S, Jaques AM, Halliday JL, Gordon Baker, Healy D. Preterm birth, ovarian endometriomata, and assisted reproduction technologies. Fertility and Sterility 2009;91:325-30
- World Health Organisation. WHO Recommendations for the Prevention of Postpartum Haemorrhage. Geneva, Switzerland: WHO Press, 2007.
