The reproduction revolution
The Irish Times – Saturday, November 19, 2011
Assisted reproduction offers the chance of parenthood to the one in five Irish couples experiencing the heartbreak of infertility. In 21st Century Baby, a three-part series starting today, CARL O’BRIEN explores one of the major technologies of our age, and its social consequences
IT’S JUST AFTER lunchtime and Graham Coull is trying to make a baby.
Inside a dimly lit basement laboratory in Dublin, he peers through a microscope that magnifies sperm by up to 6,000 times. They’re just as you’d expect: hundreds of tiny, tadpole-like creatures darting here and there. The tiny head of each sperm contains a unique genetic blueprint that helps determine everything from hair and eye colour to the sex of a future baby.
Coull is trying to find the best-looking specimen to implant. These are more likely to be healthy and to have normal chromosomes. “This is a poor sample,” he says. “This one, the head is a bit pear-shaped. It should be the shape of an egg. That one over there has two tails. And those ones are swimming around faster than the others, so they’re probably immature.”
Finally, after almost 10 minutes, he selects one. “Here, this looks good,” he says. “See? He has a nice egg-shaped head.” He strikes the tail to immobilise it and prevent it swimming away. Using a pipette 50 times narrower than a human hair, he prepares to implant the sperm.
The sperm is one of the smallest cells in the human body; the egg is the biggest. Under the microscope, it is large, round and grey. It also contains chromosomes that will help provide a unique genetic blueprint for a future baby.
Coull pushes the pipette against the egg’s surface. Its outer membrane stretches and stretches like a giant balloon. And then suddenly – pop! – the point punctures the skin. He shoots the sperm into the core of the egg, and there it is: human life in its very first seconds.
The parents, a married couple in their early 30s, are miles away, waiting anxiously by the phone for news. They’ll find out the next day if the embryo has fertilised and is likely to give them a chance of having their first child. Over the next eight hours or so, the two nuclei will draw together and fuse, forming a pre-embryo. This is the strange and fascinating world of embryology: the hidden science behind IVF.
ON A SUMMER’S NIGHT in 1978, the first live birth following in-vitro fertilisation (IVF) marked the start of a reproductive revolution. It involved fertilising a woman’s eggs with sperm in a Petri dish, then transferring them back into the uterus a few days later.
IVF is a now booming industry driven by two major factors: couples choosing to have children later in life and increasing their possibility of having fertility problems, and new restrictions on international adoption. Fertility problems affect one in six couples, and it’s getting closer to one in five. Experts estimate it will rise to about one in four in the developed world within the decade.
Each year between 2,500 and 3,000 children are born in Ireland as a result of IVF or other high-tech interventions. That number is rising fast and clinics are expanding quickly, despite the economic downturn.
Yet there are no laws to regulate IVF. Ireland is alone in Europe in failing to provide any legislation or proper regulation. This gap leaves families, children and clinicians caught in a complicated web of legal and ethical uncertainty.
At what age should you stop attempting to create human life? Why is almost all donated sperm from Denmark? Why are most donated eggs from Spain or Ukraine? How, in a country where abortion is illegal, do you destroy unwanted embryos? Is it right to sell embryos on the market? What right do children have to know their genetic parents?
IVF is only part of the story of assisted human reproduction. The use of donor sperm or eggs, as well as surrogacy, is allowing forms of family life that were not possible before: single women or men who have decided, in the absence of a partner, to have a child; gay couples coparenting. The very definition of family is changing. What was once considered a fringe and eccentric technology is on course to become possibly the most socially influential technology of the 21st century.
Back in the Sims IVF laboratory in Clonskeagh, there are small hatches to one side that lead to the two operating theatres. Earlier in the morning eggs were taken from several women, examined quickly under a microscope and placed in incubators. These ovens, which look like dishwashers stacked on top of each other, keep the eggs at 37 degrees, with 5 per cent carbon dioxide and 5 per cent oxygen, mimicking conditions in the human body.
Coull, an affable Scotsman and the laboratory’s manager, has been using a procedure called ICSI, or intra-cytoplasmic sperm injection, to implant two sperm in two eggs from the young couple in their 30s. ICSI is one of the greatest but least-heralded medical advances, and it has revolutionised IVF since the 1990s. By enabling the inspection and manipulation of individual sperm, it has almost eliminated male infertility. Now almost any man can become a father if he has a few sperm in his body, even if they are weak or malformed.
But for all the technology, IVF is still a game of chance. Although there’s an 85 per cent likelihood an embryo will form, a child will be born in only 45 per cent of cases. This couple will be told the results the next morning.
Normally, the sperm would have undergone an epic journey through the cervix, into the uterus and along the fallopian tubes. As many as 20 million sperm are deposited in the vagina during ejaculation, only one of which manages to penetrate an egg. It’s a process that requires health, energy and luck on the part of the sperm. In the lab, beneath the lens of a powerful microscope, all of this has been lost, taken over by science. But there isn’t time to sit around philosophising: the longer samples are left in the open, the greater the potential for damage. “We’ve done the hard work for the sperm,” Coull says, putting away the instruments. “It’s now up to Mother Nature.”
The potential for error is frightening. Last year at a clinic in the North, two children were born with darker skin than their parents following a mix-up in donor sperm (instead of using a white donor, as was desired, the mother’s eggs were inseminated with the sperm of a mixed-race man from South Africa).
At Sims IVF, like most other clinics, they can’t be careful enough. Every step has two witnesses who inspect the names and dates of birth of would-be parents. They also use barcodes and scanning equipment as a fail-safe. “There’s full traceability of what we do,” Coull says, calling over an assistant to witness the details of the pre-embryo before it’s placed back in the incubator. There has to be.”
PART OF THE growing demand for fertility services is linked to a rise in maternal age. The average age for a woman giving birth in Ireland has risen from 28 in 1990 to 31.7 in 2010, the oldest in the EU. In addition, the number of women in Ireland aged 45 or older having children has almost doubled in the space of just years. Most experts agree that a woman’s fertility begins to drop from her mid 30s and rapidly deteriorates from 40 onwards.
There are plenty of examples of how IVF and surrogacy are pushing parenthood into old age. A few years ago a Romanian professor revealed she had had a baby at the age of 66. The average age of women undergoing treatment at Sims IVF is about 38. The clinic has set an age limit of 50 years old for women receiving treatment. There is no age limit for men.
“Just because you can do something doesn’t mean you should,” says Dr David Walsh, a founder of the clinic. “Our rule of thumb is that we mimic what happens in the natural world.”
The embryos being created in the lab today have a 50/50 chance of fertilising. For the would-be parents, it can be a tortuous experience of waiting, praying and hoping. When embryos don’t fertilise, it falls to medical staff to tell the clients the procedure has failed. In a counselling room at the clinic, Anne Bracken, a fertility counsellor, helps couples come to terms with what lies ahead.
A box of tissues sits on her desk; the bookshelves are filled with titles such as Beating Anger, Overcoming Anxiety and Counselling Couples in Relationships . The distress, anger and fear associated with infertility come tumbling through Bracken’s door. She sees couples or singles who blame themselves or blame their partners; who become consumed by jealousy when they see mothers with newborn children; who are left with the bombshell of infertility without dealing properly with the grief that comes with it. In short, it affects everyone differently. “For some, you can see couples who have become each other’s best friend. They are really close, because they are facing this challenge together. For others, where they blame themselves or their partners, it really can impact on their relationship,” Bracken says.
For those who can’t conceive, even with the assistance of IVF, there is the option of using donor sperm or eggs. There is little sperm or egg donation in Ireland. Although there’s no law against anonymous donation, it’s uncertain over whether donors can remain anonymous. There is also a lack of screening facilities here. The result is that those looking for donor sperm or eggs generally go abroad.
Most sperm used by Irish couples comes from sperm banks in Denmark. Eggs are typically from Spain and Ukraine. These countries have well-established legal frameworks protecting donor anonymity.
For patients who are lucky enough to have a child, their spare embryos are frozen in what look like stainless-steel milk pails of liquid nitrogen. Some patients will return to use them again. But what if they’re unwanted? Where do they go? And who will pay for the ongoing and often high storage costs?
These embryos present complicated moral and legal difficulties for both patients and doctors. Fears about litigation and the precarious legal position of embryos have led to a reluctance to get rid of unwanted ones. Some facilities destroy them with the consent of patients, but many say they are keeping them in deep-freeze until there is greater legal certainty.
THE NEXT MORNING at the Sims lab, staff open the white doors of the incubator and take out the two Petri dishes. The implanted eggs have spent the night in darkness at precisely 37 degrees. When the embryologist examines the first sample, there’s disappointment. It hasn’t fertilised. There’s just one left.
Under the microscope, the outcome is soon clear: the two nuclei have fused to form an embryo. It’s a success. Later in the week the embryo is transferred to the woman’s uterus. A positive pregnancy test later confirms the result. The couple, staff say, are thrilled. And another life is on its way as a result of this strange, fascinating and complex science.
How much it costs: IVF services in Ireland
Standard IVF typically costs €3,700-€5,000. The State does not subsidise IVF or assisted human reproduction, but you can claim 20 per cent tax relief. The drugs payment scheme, under which a family pays no more than €120 a month for prescriptions, applies to many IVF drugs; most insurers reimburse at least some infertility-investigation costs.
Clane Fertility Clinic Founded in 1985, it started as a joint venture between Clane General Hospital, Co Kildare, and Bourn Hall Clinic in Cambridge. IVF and ICSI are some of its most popular treatments. IVF: €4,160.
Cork Fertility Centre Established in 2002, it says its success rates match favourably with national rates in the US and UK. IVF: About €3,750.
Human Assisted Reproduction Ireland Based at the Rotunda, in Dublin, Hari is a centre of excellence for assisted reproductive technology. IVF: €4,400.
Merrion Fertility Clinic This clinic, linked to the National Maternity Hospital on Holles Street, Dublin, provides IVF and other procedures for the hospital. IVF: €4,100.
NaPro A less well-known form of fertility treatment, “natural procreative technology”, or NaPro, focuses on a woman’s cycle. Its first clinic opened in Galway in 1998. Treatment: About €1,000, excluding surgical intervention and medical treatment.
ReproMed Established in Dublin in 2009, ReproMed works with health professionals, therapists and licensed clinics in Ireland and internationally. IVF: €3,800 (for treatment at its affiliated clinic in Prague).
Sims IVF Founded in 1997, it is one of the biggest fertility clinics in Ireland. Based in Clonskeagh, Dublin. IVF: €4,600.
Costs are a guide only, based on responses from clinics and their websites; prices will vary, particularly if extra services are needed
Living with the private grief of infertility
‘I felt I couldn’t talk to my sisters, my parents – to anyone’
Kate couldn’t speak. She tried to, but nothing came out of her mouth. Her eyes welled up as she grabbed her handbag and rushed out of the specialist’s room. She was 37 years old, just married and had just moved into a newly built family home. And now she’d been told she had “left it too late” to have a baby.
“All I did was cry and cry and cry,” she says. “I felt I couldn’t talk to my sisters, my parents – to anyone. It was just a case of leave me alone.”
The urge to have a child came gradually as Kate got older. She never had any reason to believe she might have fertility problems. Her mother had given birth in her early 40s. Her sisters had all had children. But without warning she had been diagnosed with “premature ovarian failure”.
“I felt so, so alone,” she says. “And I just feel the doctors could have been a little bit more sympathetic or supportive. But, no. That was it.
“To the outside world I was fine, but I’d be crying to myself. I was blaming myself. It was taking over everything. You take it for granted that you can have a child. And then when you realise you can’t, it takes over your every waking thought.”
Infertility is excruciatingly private. It can be a source of acute emotional pain for the one in six couples affected by infertility.
IVF still doesn’t have all the answers. Only about a third of procedures work. No one forgets that in the waiting room. “You sit there and think, It’ll probably work for one of us,” says Kate. “What are the odds it will be me or one of them?”
Often in the waiting rooms at fertility clinics, people build walls around themselves: women sit on their own; men stare at the ground awkwardly. Some people breeze in and out, chatting away loudly on their phones or joking with staff. But these tend to be the exceptions.
Helen Browne founded the National Infertility Support and Information Group. She has seen people who are so desperate for a baby they have remortgaged houses or taken out loans they can barely afford just to give them the chance of having a child through IVF. Few couples are ready for the sometimes gruelling psychological demands of treatment, she says.
The cycles of treatment, the raised expectations, the often shuddering sense of disappointment: it all takes its toll. Some studies compare the stress associated with infertility to those experienced by people with cancer. Patients now are encouraged to explore complementary therapies, such as acupuncture, as well as counselling to help break damaging patterns of thought.
Siobhan Boucher is a specialist in “fertility coaching” (afertilitycoach.com). After having her first child, she was told she had only a 1 per cent chance of having another baby. She’s now using her experience to help others who, through IVF, subject their bodies to invasive tests and procedures, as well as cocktails of drugs. Too often, she says, patients are left to cope on their own after unsuccessful treatment.
“It’s easy to lose sight of ourselves and become single-minded and experience a lack of control over the outcome. That in turn can lead many patients to feel overwhelmed, stressed, anxious and depressed,” she says. “That’s where fertility coaching helps people to regain control and manage stress.”
After being told she couldn’t have a child, Kate decided to try another option. “My sister offered to donate her eggs. I figured we’d nothing to lose.” They each underwent procedures that involved taking fertility drugs, which was tough going. The first attempt failed. So did the second. “That was awful,” says Kate. “It was like we’d been given a little bit of hope, and now it had suddenly been taken away again.”
As a last resort, Kate opted to try a donor egg. She chose a donor from Ukraine over the internet. After the egg was couriered to Ireland, it was fertilised with her husband’s sperm and transferred to her uterus. “I was being told, ‘Stay positive and try to think yourself pregnant.’ And that was so hard; you’re afraid to even move. I took three months off work at the start. In the end, we were lucky. I got pregnant.”
After a stressful nine months, Kate’s son was born by C-section at 33 weeks. He was in an incubator for a few weeks. But, a year on, he is the light of her life. “Now I tend to remember the good things. You try to forget the bad. But it was a very emotional three-year journey.
“People who haven’t been through this don’t understand what it’s like. There needs to be more understanding: from friends, employers, but most especially some professionals. I know it’s a job to them, but this is our future.”
€4,500 Typical cost of IVF treatment
18 in every 1,000 births are now twins, up from 11 per 1,000 20 years ago
1 in 6 Proportion of couples affected by infertility
31.7 Average age of women giving birth in Ireland
500 children born by IVF as a result of sperm or egg donors
2.500 children born via IVF each year in Ireland