British Fertility Society welcomes NICE publication of Quality Standards report calling for end to IVF postcode lottery

The British Fertility Society (BFS) welcomes the publication of the National Institute for Health and Care Excellence (NICE) Quality Standards report on fertility treatment, which calls for the NHS to make three full cycles of IVF available to all in England who need it.

This is the strongest call yet for commissioners to end the postcode lottery of NHS funding for fertility treatments such as IVF, which results in healthcare inequalities across the country. The BFS urges those making such decisions to take the NICE guidelines on board and do so without invoking other discriminatory exclusion criteria.

The Quality Standards report also identified other areas where improvements in fertility care and services are most needed, such as GPs referring couples for specialist consultation in a more timely manner and the provision of adequate fertility preservation services for those people who are about to undergo treatment for cancer. The BFS calls for all UK commissioners and healthcare providers to follow the new Quality Standards and fully implement the 2013 NICE Fertility Guidelines without delay.

British Fertility Society Chairman Allan Pacey said:

“During my time as the BFS Chairman, it is disappointing to see to see that there has been no improvement in the funding available for assisted conception services in England. Some areas such as Mid Essex are worse off now compared to a few years ago, suffering from reduced or even complete withdrawal of funding. By cherry-picking aspects of guidelines to fund services of their choice, local commissioners fly in the face of what NICE is all about. Their guidelines must be taken as a whole if we are to deliver the best and most cost-effective use of NHS resources.”

British Fertility Society Secretary Jane Stewart added:

"For the inclusion of appropriate and equitable funding as a quality standard, we should applaud NICE for giving the first truly direct national steer to commissioners on this important issue.” 

Artificial fertility treatments create a sex bias

DIFFERENT fertility treatments affect the ratio of boy babies to girls, and this could have serious consequences as artificial fertility treatment becomes more common.
So says Michael Chapman at the University of New South Wales in Sydney, Australia, following a study that compared different kinds of assisted fertility treatment (AFT). His team recorded the sex of all 13,368 babies born in Australia and New Zealand between 2002 and 2006 using AFT.
They compared two types of reproductive technology: IVF, which involves placing an egg on a dish with up to 1000 sperm, and intracytoplasmic sperm injection (ICSI), in which sperm are injected directly into the egg - an approach used for low-quality, immotile sperm. They also compared the stage an embryo was at when transferred to the womb.
IVF raised the proportion of boys to 53 per cent, while with ICSI it fell to 50 per cent. The natural proportion of boys is 51.5 per cent.
The stage at which the embryo was transferred had the greatest effect. The later the transfer, the more likely it would result in a boy (British Journal of Obstetrics and Gynaecology, DOI: 10.1111/j.1471-0528.2010.02731.x).
Chapman suspects the culture medium that is used to grow the embryo is affecting the baby's sex. He is working with clinics to record the type of formula used in the study period.

**Published in "New Scientist"

Success of IVF varies with season of the year

The success of an assisted reproduction procedure may depend on the season. This is the finding of new work presented at the World Congress of Fertility and Sterility, in Munich, Germany.

Scientists have long noted that there are seasonal variations in the number of natural human births. No firm explanation has been put forward for this, but speculation is that human reproduction is linked to temperature and season. Now new research indicates that even Assisted Reproduction may be more effective at certain times of year.

A team led by Dr Daniela Braga (Sao Paolo, Brazil) looked at the cytological and biochemical parameters of 1932 patients undergoing egg retrieval for intracytoplasmic sperm injection (ICSI)*, during different seasons of the year. All patients came from a single fertility center, the Assisted Fertilization Center in Sao Paulo – Brazil.

They looked at 435 patients in winter (representing 22.5% of the total sample), 444 in spring (23.0%), 469 in summer (24.2%), and 584 in autumn (30.3%).

They found that the percentage of developing eggs (MII oocytes), high-quality embryos, implantation, and pregnancy rates did not differ among the groups. Nevertheless the fertilization rate was significantly higher during the spring than during any other season (winter: 67.9; spring: 73.5%, summer: 68.7% and autumn: 69.0%). In fact they report a
1.45-fold increase in the fertilization rate during the spring**.

The team also measured the levels of different hormones, and found that 17-β estradiol*** levels were significantly higher in the spring.

Dr Braga said “This work shows that IVF cycles may have a better outcome during the Spring. Our results show a significant difference in spring fertilization rate, with the fertilization rate in the spring being almost one and a half-times that of other seasons. In practical terms this may mean that if you are having real difficulty in conceiving, it may be better to have an assisted reproduction cycle during this season.

It is possible that what we are seeing is the effect of changing light on neurons in the brain which produce gonadotrophin-releasing hormones (GnRH). These neurons regulate the secretion of gonadotrophin hormones****, which in turn control the secretion of estradiol from the ovaries. We found higher 17-β estradiol levels in the spring; in assisted reproduction, adequate estradiol levels are important for egg maturation and other reproductive processes including fertilization and embryo development.

Our next step is to check if there is any difference in the ICSI outcomes in different regions in Brazil. Brazil of course is a very large country, and we have different day lengths in different regions, so we may see differences from region to region depending on the latitude ”.

Overweight women undertaking ART twice as likely to miscarry as their slimmer counterparts

Being overweight leads to a greater risk of miscarriage for patients undergoing assisted reproductive technology (ART), the 26th annual conference of the European Society of Human Reproduction and Embryology heard today (Monday). Dr. Vivian Rittenberg, a Clinical Fellow in the Assisted Conception Unit, Guy’s and St. Thomas’ Hospital NHS Foundation Trust, London, UK, said that her research provided additional evidence to show that increased body mass index (BMI) was independently associated with a higher miscarriage rate after IVF or ICSI treatment. This information should be included in the counselling given to patients before they undertake ART, she said.
Dr. Rittenberg and colleagues analysed all pregnancies arising after single blastocyst (five-day embryo) transfer (SBT) performed in their clinic over a four year period, between January 2006 and December 2009. The 318 women were divided into two groups according to their BMI at the start of their treatment cycle. One group of 185 women had BMI in the normal range, from 18.5-24.9, and the other group (133 women) was made up of those who had a BMI of 25 or above. Of this group, 19 (14%) were obese, defined as having a BMI of 30 or more.
Overall, 26% of women miscarried before 20 weeks gestation. The researchers found that the miscarriage rate was significantly lower in women with normal weight (22%) compared to women who were overweight (33%). After adjusting for other variables that might have skewed the results such as age, duration of infertility, smoking and a history of previous miscarriage, they were able to show that being overweight or obese more than doubled the risk of miscarriage.
"Although there is evidence that miscarriage rates are higher in overweight women who conceive spontaneously, there were conflicting views about the effect of increased weight on the outcome of pregnancies occurring after IVF and ICSI," Dr. Rittenberg said. "The difficulty of interpreting the studies to date is that they are heterogeneous, their thresholds for defining obesity vary, and they assess the outcome in relation to BMI following the transfer of multiple embryos at various stages of development. Our study differs in that we transferred only one embryo at a specific stage of development, and were therefore able to provide clear evidence of the deleterious effect of being overweight on the chances of miscarriage."
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Being overweight can lead to a number of other pregnancy risks including high blood pressure, pre-eclampsia, diabetes, premature delivery and post-partum bleeding. Besides the inherent medical dangers of these conditions, they can lead to lengthy hospital stays for the pregnant woman. Additionally, babies of obese mothers are more likely to have a high birth weight and thus may face an increased rate of delivery by Caesarean section, which in itself can cause complications for both mother and baby.
"Overweight women wishing to get pregnant by spontaneous conception are already counselled to lose weight before trying for a baby," said Dr. Tarek El-Toukhy, Consultant in Reproductive Medicine at the Assisted Conception Unit, Guy’s and St. Thomas’ Hospital NHS Foundation Trust, London, UK, who led the study. "Our findings have shown clearly that women undertaking ART should be strongly encouraged to heed this advice in order that they can have the best possible chance of obtaining and maintaining a pregnancy."

International fertility clinicians comment on reports linking assisted reproduction with increased risk of congenital malformations.

Press reports yesterday commented on the work of Viot et al*, presented at the European Society for Human Genetics conference. This works indicates an increased risk of congenital malformation posed by the use of Assisted Reproduction Technologies (ART).

The International Federation of Fertility Societies (IFFS), which is the main international body representing national societies working in the fields of fertility and contraception, is issuing the following statement.

“Assisted conception has been responsible for the birth of several million healthy babies born worldwide and is generally a safe process for both mother and baby. There have been previously reported data indicating a small but definite increase in IVF conceptions born with a congenital abnormality. It is unknown if this increase is a consequence of the ART procedures, or of the infertility which is being treated, or both.The IFFS supports continued worldwide surveillance into the outcomes of assisted conception in order to improve our understanding of these concerns. Clinicians are generally aware of this slight risk of congenital abnormalities. The IFFS fully supports clear and comprehensive information being provided to patients to enable them to make informed decisions about treatment”.