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AUTHORS of scientific breakthroughs are often referred to as “the father of” whatever new field they usher in, but the term is particularly appropriate for Robert Edwards.
Edwards was awarded the Nobel Prize in Medicine last week for his pioneering work on in vitro fertilisation (IVF), which is estimated to have led to the birth of as many as 4 million babies worldwide in the past 30 years, 100 000 of them in Australia.
The clinicians and scientists involved in what is now a major industry can be justifiably proud of what they have done for couples who might otherwise never have had the experience of being parents.
But the story of IVF isn’t all adoring parents and happy babies. The costs of assisted reproduction — physical, emotional and financial — can be enormous.
Like most people my age, I’ve watched friends ride the IVF rollercoaster. And it isn’t always pretty.
For every treatment cycle that results in the birth of a live baby, there are another four that do not, according to the latest report from the Australian Institute of Health and Welfare. The report presented data from 36 fertility centres in Australia and New Zealand for 2008.
Unsurprisingly, the odds worsen as women age, with the report showing only 6.6% of autologous fresh cycles in women aged 40–44 years resulting in a live birth. For women aged 45 years and older, only 0.3% of such cycles result in a baby.
Despite such odds, women in their 40s have been accessing the technology in steadily increasing numbers over recent years and now represent just over a quarter of all treatment cycles.
Australia has been generous in its public funding of assisted reproduction technology, with often joyous results, and it would be unkind to suggest it should be otherwise.
Opposition Leader Tony Abbott certainly discovered how emotive the issue was when, back in his days as Health Minister, he suggested Medicare funding should be capped based on the number of cycles already undergone, or on maternal age.
Now I wouldn’t want Mr Abbott making decisions about my, or any other woman’s, reproductive options but I have to wonder if there’s a flip side to our generosity in this area.
Although I am sure most women receive an exemplary standard of care, there have always been rumours that some are encouraged to persist with treatment after repeated failures and in the face of apparently insurmountable odds.
In theory at least, the absence of a funding cap could make such outcomes more likely.
And it certainly imposes a burden on the health budget: an Australian study, published in 2008, estimated the cost of autologous assisted reproduction in women aged 45 or older at $1.3 million per live birth.
I have nothing but compassion for couples trying desperately to conceive a child, but maybe, just maybe, we do need to talk about this …
Jane McCredie is a Sydney-based science and medicine writer. She has worked for Melbourne’s The Age and contributed to publications including the BMJ, The Australian and the Sydney Morning Herald. She is also a former news and features editor with Australian Doctor. Her book, Making girls and boys, on the science of sex and gender, will be published by UNSW Press early next year.
Posted 11 October 2010
Thank you Jane for discussing something most prefer not to address. All costs in healthcare include the “opportunity cost” of not spending that money elsewhere and IVF is a particularly costly area. While most will be unable to look at this topic objectively there is no denying that $1.3 million per baby is an incredible expense. For comparison, coronary artery bypass grafting, a complex and expensive but lifesaving operation costs between $10,000 and $20,000. Thus, one could perform up to 130 CABGs for every IVF success. No one likes to make these comparisons but they MUST be made if we are to allocate the dwindling heath dollar effectively (I will expect a tirade of abuse following the comparison). I believe we will have to put more restrictions on access to IVF in the future as we start to feel these opportunity costs take effect. I commend Barry for his forthright examination of the topic and agree that the public purse could be spent better saving lives rather than creating them.
I can understand that a couple may have one child via IVF, but these days it does not stop at that. Two or three IVF children are the norm in some areas (generally the wealthier demographic) and I know of someone who has been criticised by her peers for not trying IVF. While I can identify with infertile couples, having had the problem, the demand is also being driven by other things, not just infertiity itself and a cap may address these issues.
I fully agree with a capped number of cycles. I was one of the unfortunate women who wanted children from as early as I could remember. By 30 years of age when nothing was happening I sought help only to be shocked that I indeed had a problem. I commenced IVF and the failures were shattering. Whether this contributed to the breakdown of my marriage – who really knows, but my life was completely falling apart in my late 30s with no success in having children but also no marriage left after an 18 year relationship.
Then the miracles started. I met a wonderful man who couldn’t care less whether I was fertile or not and we began to pursue a life of a free and easy couple when out of the blue a natural pregnancy occurred despite a very unnatural reproductive system which I was left with after many surgeries. This resulted in a very healthy baby boy. 4 years later another unexpected pregnancy – a baby girl also very healthy. Another 4 years later and now in my mid 40’s another pregnancy occurred which scared me. This pregnancy miscarried and for the first time in my life I had to think about contraception.
I would not have been able to cope with it when I was in the midst of my IVF, but now I am 50 I am so glad that none of the IVF worked. We are a very happy family with 2 beautiful children, now quite grown up and I certainly trust in life. Sure enough, give it a try, but when it’s not meant to be – don’t push. There is a lot more to life that just the kids.
Australian Family Law has as its basis what is best for the child in all decisions.
When a woman of 45 has a baby, and her “partner” is usually older, the child is condemned to look after an ageing, if not geriatric set of parents at an early stage in life.
When that child is aged 30, setting out on life with her/his own plans, career, family, stresses and worries, he/she has a 75+ years set of parents, frail, health failing, replete with worries and concerns.
Any concern for the child should exclude these couples from assisted conception.
I deal with complicated (medical) pregnancies. More than 80% of these pregnancies are to women who already have at least one child. Even worse are those with no partner. My view is that most of them may need psychiatric help, rather than IVF, as their chief problem could be depression and it may not be aided by a pregnancy. Ask the Midwives on the Maternity Wards, not me, they are the ones with much experience caring for these women after delivery.
No, sorry “anonymous” (one of several), in my view, this is not a medical condition and it should not receive any public funding assistance. The money should go where it is essential – Aboriginal health, Mental health, cancer research, etc, this is what Medicine should be doing.
Those who care for children will not assist elderly couples to have IVF, whether they can afford it or not.
As for the few IVF Units that assist women with serious medical problems to conceive, they too play Russian roulette with the wellbeing of any resultant child. Are they better than the overseas units (Russia, Italy, South Africa, USA – to name a few I have seen) who give twins (or singletons) by donor eggs to women aged well over 45? Yes, they are better, but both do the wrong thing, and I have seen many catastrophes.
Pregnancy is not a consumer commodity. Doctors must exercise their ethical judgement, rather than function as robots to be manipulated by people, agreeing automatically to whatever is requested.
Such consultations are very difficult for the Doctor at the human level, but the right thing must be done, even if it means saying “I’m really sorry. I understand your point of view and my heart goes out to you, but I can’t help you in the way you wish me to”.
Aging is not a choice. Smoking is. Would you make health care more expensive for smokers?
We need to separate the moral judgements from the funding issues. From that point of view, it would make sense to restrict public funding to younger patients and/or those with structural or sperm pathology (as opposed to aging eggs). However, if older couples wish to self-fund, why judge them?
It would be great if all therapies were publicly funded accroding to the health benefit produced or objective improvement in outcome. Too difficult and complex to apply across the board, but a good principle for the public funding of healthc care…
Isn’t it time that the social stressors that seem to make infertility an illness or disease rather than a condition be addressed.
Yes it is sad, yes it is difficult, yes it is expensive but also it is an industry, not an altruistic charity.
Thus advertising and other social pressures play a huge part in the perception of parenthood.
We have been through it (ART) and then decided enough is enough, and got on with our life together after 2 failures, with no ongoing regrets.
Perhaps we need to look at funding for donor-egg cycles. Medicare rebates are very low for this I understand, and this is part of the reason that poor-prognosis patients continue to undergo IVF with their own eggs. A donor cycle costs at least twice what an autologous cycle does (but of course success rates are much higher).
As the second poster commented, most IVF clinics would be counselling women over 45 against IVF, unless they had exceptional clinical reasons.
I think rather than imposing an age-related cut-off we also need consider that in terms of ovarian response, women do age differently. Im sure we’ve all encountered women in their early 30s or younger with premature ovarian failure, and those in their 40s (who could have blocked tubes or a partner with MFI) that have the antral follicle count/ AMH level of a much younger woman. Should we be allowing the former group unlimited access but discriminating against the latter? Surely more clinical factors must come into it than age alone.
I also find it hard to understand why there is so much emphasis on women (usually) *choosing* to have children later in life – this group does exist of course, but many only meet a partner later in life. One woman I know was a sole carer for a disabled parent until her mid 30’s – she would have loved to have had a family earlier but circumstances did not allow it …
The economics of healthcare always turns out to be a difficult and often divisive argument without end. While I can empathise with difficulty faced by infertile couples, I find it just as difficult for patients unable to self fund special medications or gain access to transplants due to diseases also not of their making. The particular issue raised in the article is of the low success rates and high economic costs for mature age IVF entrants. I have some objection to the limitless funding in these circumstances where there is a significant component of choice. I am not intending to sound paternalistic, rather stating an objective fact. If you decide to have children later in life, contrary to biology, then the chances are against you, and expecting the public to pay for it doesn’t seem ethically justifiable when there is so much greater utility in other health care options.
It’s all too easy to call for restrictions on IVF when you are not suffering from infertility. Infertility is a medical condition, like any other, which just happens to cause a disproportionate amount of suffering for the person or couple going through it. Sorry, Jane, but ‘watching friends go through the IVF rollercoaster’ is not even remotely the same as being on it yourself. I simply fail to understand how people with naturally conceived children, or people who have never wanted children, cannot empathise with people who desperately want children but are stymied by their medical condition. It’s like expecting ex-smokers with emphysema to put up with a reduced quality of life because lung transplants are expensive. We don’t expect other patients to “put up and shut up”. Why should infertility patients, most of whom are in other ways very healthy, be expected to for the good of the nation’s health budget?
Restrictions on IVF in Australia do exist. Yes, the cycles are generously subsidised, but without the subsidies, it becomes the sole preserve of the wealthy. Is that fair? You also don’t mention donor eggs in your ‘compassionate’ story – how does that change the stats per cycle in older women? As far as I know, most clinics in Australia won’t treat someone over 46.
I can fully appreciate that couples want their own genetic children but if your maths is right the cost might not justify this option. That $1.3 million per live birth could make an enormous difference to health outcomes for the Aboriginal population. I think there does need to be more regulation about who and for how long couples can access public funding for IVF. It’s not reasonable that couples expect to make autonomous decisions about their reproductive options and then expect the government to pay. If we are to have any attempt at equity in our society then the government needs to control how and where public money is spent.