IVF News

The American Society for Reproductive Medicine (ASRM) and the US Society for Assisted Reproductive Technology (SART) have issued new guidelines limiting embryo transfer during IVF procedures to reduce the occurrence of multiple births. Announced at the annual ASRM meeting, held in New Orleans last week, the revised guidelines recommend that no more than two embryos should be transferred to women under 35 during a single cycle of IVF treatment, and that clinics should consider the possibility of transferring only one. For older women the recommended number of embryos increases, but to no more than five. The guidelines state that for women aged between 35 and 37, up to three embryos should be transferred, with up to four recommended for women aged between 37 and 40, and no more than five for women over 40.

The ASRM indicated that its decision to revise US fertility guidelines came as new medical evidence suggested that high pregnancy rates can still be achieved using fewer embryos in the course of IVF. 'The evidence clearly indicates that we can reduce the number of high order multiple gestations and still maintain high pregnancy rates', said Marc Fitz, chair of the ASRM Practice Committee.

In 1999, ASRM issued guidelines recommending that only two embryos be transferred during IVF to women under 35 with a 'healthy' prognosis. This was updated in 2005 suggesting women under 35 should consider implanting only one embryo. What's new in the latest guidelines is that 'no more than two' embryos should be used by women under 35 and limits are also placed on those over 35, who face reduced chances of success. In 2004, researchers at Harvard Medical School published a report which indicated that the occurrence of multiple births following IVF had dropped dramatically since the original ASRM guidelines were issued. However, latest evidence from the March of Dimes, a US organisation committed to preventing birth defects, infant mortality, and premature birth, suggests that over a third of IVF pregnancies in the US still result in multiple births.

In conjunction with the March of Dimes and the American College of Obstetricians and Gynaecologists, the ASRM issued a report highlighting the need to reduce the risk of premature birth for women undergoing IVF. Around 12.5 per cent of US babies are born prematurely and risk long term health problems. Dr Nancy Green, medical director of March of the Dimes, issued a statement saying that 'limiting the number of transferred embryos will mean fewer higher order multiple gestations, defined as three or more foetuses, and reduce the risk of complications for both the mother and the foetus, including preterm birth'. The organisation suggested additional requirements to the ASRM guidelines, including informed consent documents to make explicit the risk of multiple births, and a publishable annual review of clinics' performance and rates of multiple births. Dr Green has said that 'consumers should demand quality assurance in the fertility business'.

In the UK, the Human Fertilisation and Embryology Authority (HFEA) is currently reviewing its policy after commissioning an expert panel looking into multiple births, which reported last week. The report recommends that for patients under the age of 35, the number of embryos that can be transferred should be reduced from two to one. It also states that sanctions should be taken against clinics that exceed a 'cap' placed on the number of twin births allowed. Clinics which routinely exceed a twin birth rate of 5 to 10 per cent, for example, may be placed under further restrictions regarding the number of embryos they can transfer, or may even face problems renewing their licence.

Research presented at the recent annual conference of the American Society for Reproductive Medicine (ASRM) suggests that couples with fertility problems pass on higher health risks to their children than do normally conceiving couples. The findings, given by Professor Mary Croughan from the University of California, US, showed that for children born to parents with fertility complications, the likelihood of developing health problems by the age of six rose by nearly a third, when compared to children conceived without difficulty.

The research indicated that infertility treatments, such as IVF, may influence the increase of risk. But as the phenomenon also occurred in couples who previously underwent infertility treatment but later conceived naturally, Professor Croughan is pointing to the health risks that cause infertility as a 'baseline risk' rather than suggesting that infertility treatments are creating health problems in children. 'What has caused them to be unable to conceive goes on to cause problems', she said. There was also no variance between the different types of fertility treatment and the link to increased health risk of children in the study.

In the study, around 2,000 children whose parents had fertility problems were compared with around the same number of children who were born without difficulty conceiving. Adjustments were made to take into account higher maternal age and the increased incidence of multiple births for infertile couples. The results showed a higher risk of autism, cancer, cerebral palsy, heart disease, and mental retardation in the children whose parents had encountered problems in conceiving. There was a four-fold increase in the incidence of autism. The researchers have stressed that there figures represent relative risks and the actual risks are still very low. For example, a four-fold increase in autism would mean an incidence rate of 1.56 per cent, according to studies of autism conducted by Guy's and St Thomas' Hospital, London, last July.

Stuart Lavery, spokesman for the British Fertility Society, commented that 'there is no doubt that people who have difficulties with their fertility have difficulties conceiving and carrying pregnancies? although it has not been shown that it is the infertility that is causing the problems'. Rather, it seems that it is the health risks that may lead to infertility that are passed on to children. Clare Brown, of Infertility Network UK, called for more research to ensure 'treatment is safe for couples and potential children'.

Meanwhile, an Australian study suggested a link between women who smoke during pregnancy with waist size and the susceptibility to health problems of their daughters. Dr Michael Davies, speaking at the 25th Annual Scientific Meeting of the Fertility Society of Australia, said that the study 'showed that smoking by the daughter was unrelated to the irregularity in weight and reproductive wellbeing, so it appears to be related to maternal smoking in particular'. Over 700 women born between 1973 and 75 were studied, of which 154 had mothers who had smoking during pregnancy.

New research from the University of Chicago in the US suggests that first-born children of young mothers have the best chance of living to 100; statistical results show this to be up to 1.7 times more likely than their siblings. Results were produced by studies from US Census, Social Security and other records, which aided in the reconstruction of family histories of just fewer than 200 centenarians born between the 1870's and 1890's.

The researchers showed that a strong predictor of longevity is having a young mother at the time of birth. These findings, presented at a meeting of the Gerontological Society of America in Dallas, show that children born before their mothers' 25th birthday were nearly twice as likely to live up to and beyond a century.

Dr Natalia Gavrilova, who co-led the research alongside husband Leonid Gavrilova, believes that this could be due to the better quality of eggs that are produced, and because it is less probable that the mother is likely to have acquired infections that might cause long-term damage to the health of the fetus. The team explains this by suggesting that in monthly menstrual cycles, women ovulate their best eggs first, and as they age, their supply of top-quality eggs diminishes and ovulation of lower-quality eggs commences.

Life expectancy for adults has risen sharply in the past 50 years. Average life expectancy in the 1950's for a man was 67 and women 73, this has continued to rise in 2005 to mid-70s for men and early 80s for women. Doctors have attributed this to better healthcare, nutrition and the fact that diseases like tubercolosis and polio have been almost wiped out.

Also reported last week was a study published in Nature suggesting how damaged eggs are weeded out. Scientists have identified 'p63', a protein that helps detect DNA damage in developing eggs. They believe it may play a key role in killing off defective eggs and ensuring only the healthy ones may be fertilised.

The Harvard Medical School research was undertaken on developing mouse eggs where meiotic cell division was studied (which results in a mature egg containing just one set of chromosomes). The research involved exposing egg cells to radiation to cause damage to the DNA. Lead researcher Dr Frank McKeon said: 'p63... is the critical factor for monitoring the level of DNA damage in oocytes...' The researchers say that this work sheds light on the process by which the ovary can quality-control the eggs it contains, to make sure that damaged ones are not ovulated.

Dr Allan Pacey, senior lecturer at the University of Sheffield and secretary of the British Fertility Society says, 'This work might one day allow us to understand why some women have fertility problems because of the poor quality of the eggs they ovulate'.

Doctors are apparently warning women that high doses of drugs taken to stimulate the ovaries in the process of in vitro fertilisation (IVF) may damage eggs and womb lining reducing the woman's chance of conceiving. The reports come in advance of the first annual meeting of the International Society of Natural Cycle Assisted Reproduction (ISNAR). The world's first test-tube baby, Louise Brown, born in 1978, used an IVF procedure which collected the woman's eggs during ovulation making the most of her natural cycle. The use of high dose drugs has increased as older women, with less chance of success, are seeking treatment for infertility. It is believed that one in twenty IVF patients suffer some side effect from the drugs used, this can range from pain and bloating to kidney damage.

One in six British couples suffer from fertility problems, in 2005 around 30,000 women had treatment. Each IVF attempt can cost more than three thousand pounds, if the drugs are not used the cost can be reduced by as much as 1200 pounds. This could enable more NHS funding of the procedure. Professor Robert Winston told the Sunday Telegraph, 'The trend is to get as many eggs as possible, but that may be counterproductive. From the research we've done, the main risk is that doing this produces chromosomal damage in at least half, if not 70 per cent, of eggs. New studies are needed to prove the drugs are causing the damage, but it is my strong suspicion that this is the case'. In a small number of cases women can also have a reaction to the drugs - known as ovarian hyperstimulation syndrome - which may be fatal.

Some specialists are calling for a return to minimal drug regimes which would produce fewer eggs - usually only one egg is released each month at ovulation - but may improve a couple's chance of conceiving by removing the associated damage. The British Fertility Society has defended use of the drugs in the past, saying that doctors are aware of the potential hazards, but that the treatment increases the chances of the treatment working. The chances of successfully conceiving increase from around 10 per cent for each attempt using natural cycle IVF, to 25 to 30 per cent in standard, drug mediated IVF.

IVF News Update 3
Category: News 
Time: 3:44 For your iPod 

FURTHER INFORMATION:

1. Second IVF baby for couple using 19 year-old sperm.

Link: BioNews

2. Report triggers concerns over safety of fertility treatment in UK.

Link: The Independent

3. Now we have the technology that can make a cloned child

Link: The Independent

4. Couples could win right to select deaf baby.

Link: The Telegraph

Sperm Image by Hasan Burjaq ,MT (BGS), TCART, Toronto, Canada

http://www.tcartonline.com/

After a four-year battle, an Israeli court has ruled in favour of a family campaigning for the right to use their dead son's sperm in order to inseminate a women that he never knew. Soldier Keivan Cohen was shot dead in Gaza in 2002. His mother, Rachel, ordered that his sperm be retrieved in order to fulfil his wish to have a family, although he had not given explicit consent before his death to have his sperm used in this way. The hospital refused to give her access to the frozen sperm without court approval, as legally only a spouse can make such a request. The family challenged the hospital's decision in court, claiming that it was their son's deepest wish to have children. The court viewed video material in which Keivan expressed his wish to start a family. The family claimed that it was their duty, as grandparents, to ensure that the insemination was carried out. They also assured the court that, after selecting a woman to have the child, they would restrict their role to that of grandparents. No prior provisions existed in Israeli law regarding the permitted use of sperm extracted from the deceased, therefore this ruling sets a precedent. The move also comes despite a previous ruling three years ago, denying the rights of parents of the dead in such cases. Therefore, the ruling represents the first time that a court has approved the use of a deceased man's sperm to impregnate a woman he has never met. The Cohen family advertised for potential mothers, and subsequently selected a 25-year old woman to be inseminated, from over 40 who came forward with offers of help. The woman wishes to remain anonymous. The family's lawyer, Irit Rosenblum, said that the court ruling meant that family lines could now be continued without the written consent of the male prior to death. Of the Cohen family she commented, 'It's a dream come true, on the one hand [the Cohens] lost a child, on the other hand they got some hope'. In 1997 Diane Blood was denied fertility treatment in the UK in her pursuit to give birth to her husband's children posthumously. Mrs Blood was refused treatment because her husband's sperm had been extracted after he had lapsed into a coma, and therefore he had not given his express consent to its use. However, Mrs Blood travelled to Belgium to have treatment and now has two sons. In September 2003, after a five-year campaign, Mrs Blood won the right to have her late husband's name added to her children's birth certificates.

The Ethics Committee of the American College of Obstetricians and Gynaecologists (ACOG) has said that helping patients to choose the sex of their offspring to avoid serious sex-linked genetic disorders is considered ethical for doctors, but gender testing simply for 'family balancing' is ethically untenable. The opinion of the committee is in line with the views held by the United Nation's International Conference on Population and Development, and the UK's Human Fertilisation and Embryology Authority Code of Practice. The American Society for Reproductive Medicine also opposes the use of preimplantation genetic diagnosis (PGD) for other than medical reasons, although the group issued a statement in 2001saying that if pre-fertilisation techniques such as sperm sorting can be proven to be safe and effective, they would be ethically acceptable. The ACOG committee fears that allowing sex selection for other than medical reasons could be seen as supporting the preference for one gender over another - usually boys - in some cultures. 'The committee opposes meeting requests for sex selection for personal and family reasons, including family balancing, because of the concern that such requests may ultimately support sexist practices', said the report. The authors noted: 'The Committee on Ethics supports the practice of offering patients procedures for the purpose of preventing serious sex-linked genetic diseases'. Such techniques include PGD, which can be used to help parents avoid passing on sex-linked diseases such as Duchenne muscular dystrophy or haemophilia to their children. The committee also considered post-fertilisation sex selection. 'After implantation of a fertilized egg, karyotyping of foetal cells will provide information about foetal sex', the committee members wrote. 'This presents patients with the option of terminating pregnancies for the purpose of sex selection'. ACOG acknowledges that it will sometimes be impossible for physicians to avoid unconscious participation in sex selection because patients are entitled to obtain personal medical information: 'The ACOG's Committee on Ethics maintains that when a medical procedure is done for a purpose other than obtaining information about the sex of a foetus but will reveal the foetus's sex, this information should not be withheld from the pregnant woman who requests it', they wrote. 'This is because this information legally and ethically belongs to the patient. As a consequence, it might be difficult for health care providers to avoid the possibility of unwittingly participating in sex selection'. The Committee pointed out that patients who are planning to abort a foetus of the undesired sex would be likely to hide their intent from physicians if they thought that their request for the procedure for sex selection might be refused. Additionally, 'even when sex selection is requested for non-sexist reasons, the very idea of preferring a child of a particular sex may be interpreted as condoning sexist values and, hence, create a climate in which sex discrimination can more easily flourish', they added.

US patients using fertility services are facing a dilemma over the future of their spare embryos. Legally only the patients themselves are entitled to make the decision concerning the future use of their embryos, which currently comprises of four choices: to have them destroyed, donate them to other couples, continue to store them indefinitely or donate them to medial research. A 2003 study by RAND Corp estimated in 2003 that there were 400,000 embryos stored in 450 US fertility clinics. Lucinda Veeck Gosden, director of embryology at the IVF clinic at Weill-Connell Medical School in New York, says that 54 per cent of the clinic's patients who have finished their families ask to have their embryos destroyed, 43 per cent donate them to basic science unrelated to stem cells, and 3 per cent offer them to other fertile couples. Embryologist Ingrid Jansson and her husband embody the ethical debate that surrounds the future use of redundant embryos. They have had a son through IVF and are now at odds over what to do with their spare embryos. Jansson, who volunteers for the Stem Cell Resource, which helps fertility patients donate their leftover embryos for research, would like to donate her own spare embryos for this purpose. Her husband, Jon Gardner, who is Catholic, disagrees. He believes that dismantling their embryos would amount to the destruction of life. The confusing legal landscape only adds to the difficulty of the decision-making process for such patients. There is currently no federal support for stem cell research, which has slowed developments in an area where scientists believe that these 'master' cells derived from embryos may enable them to develop treatments for diabetes, Alzheimer's and other diseases. Research continues using adult or amniotic stem cells, but scientists argue they are an inadequate substitute for embryonic stem cells, which have the potential to develop into any cell in the body. President Bush approved federal funding for research on 78 existing stem cell lines obtained from destroyed embryos on 9 August 2001, banning the use of funding for lines developed after that date. Evan Snyder, director of stem cell research at the private Burnham Institute in the US, says that most federal stem cell lines are inadequate, because their completion was rushed to meet the President's deadline. There are now just 22 lines remaining in the US that, having been nourished with material from lab mice, cannot be utilised for humans. The Democrat-led Congress initiated a bill in its first week of sitting, which would provide federal funding for stem cell lines derived from fertility clinic embryos. The House of Representatives voted 253-174 to approve the bill, which is likely to be passed by the Senate next month. President Bush has already vetoed a similar bill in July 2006, and has vowed to do the same again. It is doubtful whether Congress could raise the two-thirds majority required to overturn the President's veto.

An AP/Washington Times report has revealed that the market for fertility treatment tourism is booming as a solution to egg donor shortages, high private clinic costs and restrictive donor anonymity laws. More permissive nations are taking a cottage industry approach to promote fertility services that are attracting a growing international clientele. US women travel abroad for cheaper treatment, while women in other nations with stricter donor laws seek access to the US or nations where market-priced competitive donor recruitment is more easily available and donor selection is possible. In the US, where advertisements offer an average of $80,000 for Harvard graduates eggs, donor information is unrestricted and, for the right price, donors can be screened to match particular criteria. An AP/Times survey of about 20 clinics in Spain and Greece revealed that 2,000 women travelled there in 2005, paying between $3,300 and $8,000 for donated eggs. Even including hotel and travel fees, American women can receive treatment in these countries for as little as 10 per cent of US costs. France provides treatment for free but, like many co-signatories of an international cooperative effort to prevent the sale of body parts, it bans payment for egg donation as unethical. The effect of this policy, AP/Times reports, is a 'severe shortage' of donor eggs. In 2004, only 144 women donated eggs in France, according to the regulatory Biomedicine Academy. Patients face five-year waiting lists. Associations now profit from helping these women liase with foreign fertility clinics that better serve their needs, sometimes offering discounts at particular clinics. US residents are now turning to these French associations to help link them with more inexpensive foreign clinics, notably in Spain and Greece. Also, couples in search of eggs from black donors, a generally expensive scarcity, are travelling to clinics in Cameroon and Burkina Faso. Experts warn that without regulatory standards, two-fold deceptions are risked by donor and agency misrepresentations. Arthur Caplan, professor of bioethics at University of Pennsylvania, recommends thorough background checks and cautions, 'We see a wide variability in success rates, which aren't always explained to customers'.

Contrary to some earlier findings, a large Canadian study links an increase in birth defects with babies born through fertility treatments. According to the results of the study, which was presented at a Society for Maternal-Fetal Medicine meeting in San Francisco, the overall risk appears minimal - less than 3 per cent for assisted conception versus less than 2 per cent for natural conception - but the risks for specific birth defects were notably higher. Dr Mark Walker, one of the study's leaders, hoped that people would find the results 'reassuring' because 'the absolute risks are still low'. The study, conducted at the University of Ottawa, is the largest of its kind in North America and it compares the outcomes of 61,208 pregnancies in Ontario during 2005. Five per cent of the total births were a result of fertility treatments. Dr Nancy Green, medical director of the March of Dimes, said the study was an important first because it comprehensively quantified specific birth defects while taking the effects of other potential causal factors such as age, smoking, gender of the babies and birth complications into account when estimating risk rates. The study found that the greater the complexity of the fertility treatment, the higher the risk. Assisted reproductive technologies (ART) like IVF had the highest risk and the administration of ovulation-stimulating medications had the lowest. Babies conceived through ART were almost nine times more likely to have gastrointestinal disorders, such as abdominal wall defects or abnormally located organs. The risk of cardiovascular disorders was more than double and although there was no increased risk for spina bifida and facial defects like cleft palate, the risk of malformed limbs and other deformities was slightly elevated. The study's head researcher, Darine El-Chaar, commented, 'We think this should become part of counselling couples that are infertile, especially that the degree of manipulating the egg and sperm may affect the risk of defects.' It is already known that pregnancies achieved through ART face a higher risk of premature births and complications such as high blood pressure, diabetes and placental problems. Although previous studies found that ART babies are not at any more risk of major health problems than naturally conceived children, some studies have linked IVF to a slightly increased risk of certain rare genetic conditions caused by faulty genetic imprinting, such as Beckwith Wiedmann syndrome.