Ten Years On – Hope Fades; Infertility

Infertility remains one of society’s most miserable afflictions. Ten years ago the birth of Louise Brown, the world’s first test-tube baby, brought hope to thousands of previously barren marriages. A tidal wave of subsequent advances reinforced the notion that such problems would soon be a thing of the past.

Yet treatment remains patchy, lengthy, costly, and offers a disappointingly low success rate. And of equal importance to most of those concerned it is rarely available on the National Health Service.

Ten per cent of couples fail to conceive after a year of unprotected intercourse. One half of this group may never conceive. The experience of raising a family continues to be a tantalizing dream.

A recent report by the Greater London Association of Community Health Councils highlights the problem. Its questionnaire to the 476 London hospitals showed that, although there are 22 specialist infertility clinics in the capital, the majority of cases are handled by over-stretched general gynaecology departments. Some couples wait a year even for an initial appointment.

The study showed poor co-ordination between GPs, specialists and patients. The quality of routine services eventually received was often poor. Little attempt was made to monitor either the cost of treatment or its outcome.

In today’s cash-conscious NHS, there is little enthusiasm for investing resources to alleviate a condition from which nobody dies (though it has certainly led to a handful of suicides). “We have many demands on our budget, which is already overstretched. There is virtually nothing left over for the new and non-urgent,” one associate general manager said recently.
One of the most common causes of infertility is blocked fallopian tubes, where an in-vitro (or “test-tube”) fertilization is often the only hope of achieving a pregnancy. Of the 30 centers in this country offering IVF, only one hospital, in Manchester, is fully funded by the NHS.

A promising new technique for tackling unexplained infertility known as gamete intra-fallopian transfer, or GIFT, where the egg and sperm are placed in the tubes together is also being developed. But that too is unlikely to be made available quickly or cheaply.

Advanced technology is little use without expert back-up, and that too is in short supply. One center this year had to discontinue its IVF program completely, partly because the hospital’s overburdened laboratory could not guarantee semen analysis facilities.

For many desperate couples, “going private” offers the only realistic hope. But this inevitably means hardship for all but the seriously rich. And then the chances of success are small. For four out of five couples, the arduous road will end in heartbreak.

The Voluntary Licensing Authority for Human In-Vitro Fertilization and Embryology, set up after the Warnock report in 1984, admits that “treatment continues to be determined largely by a couple’s financial resources”. It is hard to accept that, for the majority, finance should rule out even the slimmest chance of having a child.

One third of fertility problems can be traced to the would-be mother, one third to the father and the final third to both partners combined. The treatment of male infertility is even less satisfactory than the female kind. Although research is progressing rapidly, male-factor deficiency most frequently forces the couple to resort to artificial sperm insemination by donor (AID). Although the resulting pregnancy may well produce the child they long for, it may also initiate psychological problems.

Why are the treatment and research resources so stingily rationed? It can’t simply be because the techniques are new. Coronary artery bypass grafting was revolutionary at its inception. Now it is a widely accepted and safe procedure. Will IVF and the newer procedures be as successful in 10 years? The simple answer is: without increased investment, no.

Some might argue that there are already too many babies being born on our planet. Should we be setting aside scarce cash to create even more? It is easy to stand back and say no. But if there is technology available to give even the smallest chance of a yearned-for baby, what right has anyone to deny it?

The problem is not just financing the technology: there are not enough specialists to administer the treatment, and no generally-accepted formula for establishing how many are needed. The best guess, by the Royal College of Obstetricians & Gynaecologists, is that nearly twice as many consultants as are now available would be needed to meet all the needs that arise in childbirth. The government’s current policy is to fund enough “pump priming” posts to expand the number of consultants by 2% a year. But no such posts have yet been established in obstetrics.

“The government is paying lip service to the concepts of consultant expansion,” says James Drice, senior lecturer in obstetrics and gynaecology at Leicester University Medical School. “What does a 2% expansion rate mean to the two or three consultant gynaecologists in a district general hospital who are struggling to cope with their existing work? Absolutely nothing.”

The Department of Health will publish its white paper on the future of the NHS early next year. A consultant gynaecologist recently observed that the service “is supposed to provide care from the cradle to the grave. At the moment, this excludes the infertile, who cannot even get to the cradle-side”.