* Author Topic: Another point of view  (Read 2157 times)

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Offline Lorna

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Another point of view
« on: 17/01/07, 20:15 »
I felt I had to start a new thread, as my post seems to fit under several existing threads, such as: What are the chances of conception for eSET?, IVF children and a point my DH has just made....... and a few others as well!

In the thread “IVF children” Tony says:
> I am trying to hot up this debate.
So let’s hot up this debate. 
eSET raises a huge number of issues, but I am only going to concentrate on two –
The unborn child,
and success rates.

So lets start with the unborn child.  The HFEA seems to be concentrating on the unborn child, probably because under the HFEA Act 1990 http://www.opsi.gov.uk/acts/acts1990/Ukpga_19900037_en_1.htm
Paragraph 13 subsection 5
  (5) A woman shall not be provided with treatment services unless account has been taken of the welfare of any child who may be born as a result of the treatment (including the need of that child for a father), and of any other child who may be affected by the birth.

So the only thing the HFEA has to consider, is the child that may or more likely won’t come into existence.  Existing children, the woman’s partner, grandparents, etc., even the woman herself, is irrelevant to any decisions, that the HFEA make.
But, IMO, Assisted Reproduction is about creating families, and I have not seen *one* paper, about the effect treatment has on families.  It doesn’t mean there aren’t any papers, it just means, I haven’t found any.  So if someone has any information, I would love to hear about it.
So, if the only thing you consider is the unborn child, then SET should have been introduced years ago.  But if you consider anything else then it gets a bit more complicated.

We know that with IVF, more women get a BFN, rather than a BFP.  Does eSET increase the number of BFNs that a woman (her partner, her existing children......) goes through?

Well I can find loads and loads of papers written in Europe, particularly from the Nordic countries, that say the pregnancy rate/live birth rate are (virtually) the same for DET and SET.  A bit like the Titanic was (virtually) unsinkable.  Those small modifying words, like virtually, almost, nearly, etc.. seem to be missing from most reports.  And to me they are very important.

But then I find papers like: “Elective Single-Embryo Transfer versus Double-Embryo Transfer In Vitro Fertilization” http://content.nejm.org/cgi/content/abstract/351/23/2392  which seem to indicate that while pregnancy rates between DET and SET are comparable (DET 44%/SET 40%) live birth rates are not(DET 29%/ SET 19%).  Is this an anomaly?

Well, there is anecdotal evidence, with one poster on this board reporting that their Spanish Embryologist, said you needed the second embryo to make the first one stick.  But, one of my big complaints of policies set by the HFEA, is that they are based on someone’s feeling on a subject, *not* on scientific evidence.  So I don’t think this piece of anecdotal evidence should count.

But the more I dig, the more papers I come up with, that indicate SET lowers the pregnancy/live birth rate.
Papers like: “Number of embryos for transfer following in-vitro fertilisation or intra-cytoplasmic sperm injection”
> The results of this systematic review suggest that live birth and pregnancy rates
> following single embryo transfer are lower than those following double embryo
> transfer

And yet another study “ Guidelines For The number Of Embryos to transfer Following In Vitro Fertilization” http://www.sogc.org/jogc/abstracts/full/200609_SOGCClinicalPracticeGuidelines_1.pdf
showed that:
> Although some studies failed to demonstrate a statistically significant difference, a
> significant review of four of these trials confirmed that DET resulted in a significantly
> higher clinical pregnancy rate and live birth rates per woman than eSET.

So I think the key question is whose right?  Those who say that women going through SET will have the same number of live births as women doing DET, or those who say that SET has a significantly lower live birth rate than DET.  Well as far as I can figure out, believe or not; *BOTH* points of view are correct.

If you rigorously select the women who go through SET, you carefully screen the embryos created, and you have the best cryogenic systems in the world, then SET will have a comparable number of live births as women doing DET.  In the Nordic countries, there are excellent social programmes that encourage women to have children young.  So my feeling is that the countries that produce the best SET results, are the ones that have trials, that use women, that are in the prime of their child bearing years.

But in the UK, women come out of higher education saddled with debts, which they must pay off, before they can afford to buy a tiny house; then add on the cost of childcare, and most women cannot afford to have children, till they are in their 30’s.

Then, when it comes to the UK, the HFEA has a history of introducing a blanket rule.  The one rule fits all, which doesn’t.  The HFEA doesn’t seem to allow doctors to screen women, out of the two embryo only transfer rule.  I mean those younger women, who would benefit from, say, a 3 embryo transfer.

I have no idea, how thorough embryo screening techniques are at clinics.  And lastly the fact that clinics only freeze grade 1 (or2?) embryos, indicates, that many clinics do not have world beating cryogenic procedures.  With SET, the clinic should be able to freeze (virtually, practically, nearly.....) all embryos, and successfully defrost (virtually, practically, nearly.....) all embryos.

We all know, that the UK is 17th out of 23 European countries(there are 26 countries in Europe), probably 25th in the world, and slipping down the tables.  We also know the HFEA, used to inspect UK clinics to the lowest standards in Europe, but has now been forced by Brussels, to make sure clinics meet the much higher European standards.
All this taken together, makes me feel, that the UK tends towards the “SET has a significantly lower live birth rate than DET” end of the spectrum.

Am I right?  I don’t know.  If I am, then the following arguments against SET are valid.  If I am wrong, only the arguments made by the government of Denmark, and the Canadian Health service should be considered.

If I am right, how much lower is live birth rate for SET rather than DET?  I don’t know.  The only paper I have on pregnancy/live rates is the one on “Elective Single-Embryo Transfer versus Double-Embryo Transfer in Vitro Fertilization”.  This indicates that the live birth rate for DET is around 29%, and for SET around 19%.

So what does this mean, for those of you, who just want to hold your baby in your arms?  Well with DET, after 3 cycles of IVF, just over 50% of women age 36 and under will have a live birth, but with SET for women age 36 and under, just under 50% will experience a live birth, after 5 cycles.

In the thread “a point my DH has just made.......”
Tony, you said
> Personally - I wouldn't like to set eSET implemented without full implementation
> of the nice guidelines.

Well after 3 cycles of DET, more than 50% of women in the target group, will experience a live birth.  But when it comes to SET, we are talking about *6* cycles of treatment, before the same number of women, experience a live birth.  Therefore, the NHS needs to offer a minimum of 5 free cycles, if the government insists on SET.

But I stumbled on a report produced by the government of Denmark http://www.sst.dk/publ/Publ2005/CEMTV/IVF_1_2/IVF_1_or_2summary.pdf that said
“from an economical point of view, DET was more cost effective per delivery, and per child than a SET policy.”
And I found a Canadian document that seems to back this up.
http://www.health.gov.on.ca/english/providers/program/mas/tech/reviews/sum_ivf_101906.html  This says
>However, results of an Ontario-based economic analysis shows that cost savings
> associated with a reduction in multiple pregnancies after IVF-SET does not justify
> the cost of universal IVF-SET coverage by the province.

Basically SET costs more than DET!
For SET to be effective, you must have top quality doctors, backed up by superb laboratories to screen the embryos, and world beating cryogenic facilities, then pregnancy rates for SET are almost the same as for DET.  Or, you must pay for, cycle after cycle of treatment in order to achieve a live birth.  Either way, treatment costs, sky rocket.
And in Canada and Denmark, the state pays for treatment for women/couples.

In the UK, patients pay for treatment.  So at the moment with DET it takes on average, 6 cycles for a woman 36 and under to have 2 children.  With SET it will take on average, 11 cycles.  So if the cost of an IVF cycle is 4,000 pounds (please feel free to substitute, what you know to be the correct value), then for DET it costs around 24,000 pounds for the average woman age 36 and under, to have 2 children, but with SET it costs around 44,000 pounds.
The NHS is not paying for SET, patients are.

And there is a further issue, I have not found one paper that talks about the cost of  complications arising from treatment.  The Danish Study, certainly didn’t include the cost of treating complications arising for IVF, and yet they came to the conclusion SET costs more than DET.

Every time we put ourselves through treatment we are exposing ourselves to risks. 
Both short term risks, and long term risks. Around 27,000 women/couples per year, do IVF in the UK, and some will suffer from the following short term complications of treatment:
Ovarian cysts 15% of treatments or 4000 patients.  Usually when a woman develops a cyst treatment is abandoned, and the cysts clear up naturally.......but a small number require treatment in hospital to drain the cyst.
OHSS affects around 5% of patients or 1350 women, of which around 1% require hospital treatment or 270 women per year
Adnexal torsion (Twisting of the ovary) always requires surgery to correct the problem , and occurs in 0.2% of all cases or 54 women per year

Also from http://www.britishfertilitysociety.org.uk/public/factsheets/conceptionrisks.html
there is:
puncturing of the arteries supplying the ovaries, resulting in severe haemorrhage, for 1 in 2,500 or 0.04% of cases or 11 women per year
pelvic infection occurs in 1 in 500 women per year or 1.89% or 54 women per year.  This is usually treated with antibiotics.  Occasionally, though, it is detected so late, that the only option the doctors have, is to do a radical hysterectomy(removal of womb, tubes, and ovaries), and bowel resection, in order to save the woman’s life.
and finally adverse reaction to sedation in 1 in 10,000, or 0.01% of cases or 2.5 women per year.

so that is around 390 women per year, end up in hospital with complications of IVF, and some of them end up with some sort of physical impairment as a result of treatment.
If women can afford to carry on, and that is a big issue, then women will be doing 5 cycles instead of 3, so the number of women who suffer from complication will rise proportionally from 390 to around 650 patients .  That is 390 multiplied by 5 divided by 3.

My understanding is that when a doctor is forced to chose between the life of the mother or life of the child, then the doctor will chose in an extreme situation, to save the mother, and let the baby die.  SET seems to turning this principle on its head.  SET says it is OK for women to become disabled or die, provided we save the life of the unborn child.

And I haven’t even started discussing the long term health implications.  I have suspected for a long time that treatment increase a woman’s chances of contracting Ovarian Cancer – the silent killer.  Why is so called?  Because, in most cases, by the time it is detected, it is too late.  And I have now, finally found, a medical page http://www.britishfertilitysociety.org.uk/public/factsheets/conceptionrisks.html  that shows a link between treatment and ovarian cancer.
But this argument is irrelevant.  The government only cares about saving money now.  Women dying later, doesn’t matter.  Herceptin for breast cancer shows us that.

So women/couples are faced with some really tough choices.  Do I transfer two embryos and risk some of the terrible consequences, posters here have shared, or should a woman keep going through cycle after cycle, and getting a BFN, and risk some of the complications that I have listed?
IMO, the woman/couple in consultation with her doctor should be the one to make these decisions, not the Bishop of Oxford, a dentist, media experts, and the rest of the people that make up the HFEA.


PS Oops! I forgot to look at complications for men.  http://humrep.oxfordjournals.org/cgi/content/full/17/9/2356 or http://cat.inist.fr/?aModele=afficheN&cpsidt=2062677
which suggest 4.8% of men going through ICSI with TESE/MESE, suffer from things like testicular bleeding, and so on.


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    Offline Anthony Reid

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    Re: Another point of view
    « Reply #1 on: 17/01/07, 20:23 »
    Hi Lorna,

    Thanks for digging into this :)

    I am a bit busy to post a responce - but will later.

    Just one note - perhaps 'cycle' is the wrong term to use - but it is suggested by many that a nhs funded eSET cycle would include an FET as well - so 3 cycles is effectively 6.

    Im sure I'll be told off by someone for saying that - but thats from what I have heard.


    Offline Cuthbert

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    Re: Another point of view
    « Reply #2 on: 17/01/07, 20:36 »
    Thank you for all your research, Lorna - you've raised some really interesting points, particularly the points about life birth rates for SET compared with double ET.

    And it's interesting to hear the suggestion about NHS funded eSET, Tony. At the moment my clinic (which is also an NHS provider) will not consider freezing embryos unless there are 5 or more 'spare' top grade embryos and I've never managed to achieve that. So there would need to be changes to clinics' freezing procedures to enable FET to be part of the eSET protocol.


    Offline TC2

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    Re: Another point of view
    « Reply #3 on: 17/01/07, 22:58 »
    Wow Lorna ....  Lots of reading for me to assimilate all that....Thanks