Fertility Treatment
What is fertility treatment?
Fertility treatment is the use of medical intervention techniques to aid the natural process of conception.
Most people seeking fertility treatment are not entirely 'infertile', rather one or more parts of their reproductive systems are impaired, and they therefore require medical help to conceive. This is referred to as 'sub fertility' as opposed to 'infertility'.
For men, the most common cause of 'sub fertility' is due to poor sperm quality. For women the matter is more complicated and can be caused by a number of factors.
Fertility treatment is provided in the UK by individual clinics around the UK, specialising in different forms of treatment and providing a variable quality of service and price. High-tech treatments, such as in vitro fertilisation (IVF) and treatments using donor sperm, eggs and embryos, are regulated in the UK by the Human Fertilisation and Embryology Authority (HFEA).
Different causes of infertility or sub fertility require different intervention techniques. The most frequently used treatments are: ovulation induction (hormone treatment); artificial insemination, using the partner's sperm and intra-uterine insemination; surgery to improve blocked or damaged fallopian tubes; gamete intra fallopian transfer; IVF; intra cytoplasmic sperm injection; donor insemination; and surgical sperm recovery.
Background
Fertility treatment has been at the cutting edge of medical science throughout the 20th Century. 1928 saw the first sperm counts taken and the first hormonal induction of ovulation. The first children conceived through Artificial Insemination were born in 1934 in the USA.
In vitro maturation of animal oocytes was proven to be possible in 1939, but it was not until 1979 that the first 'test tube baby', Louise Brown, was born. The first Preimplantation Genetic Diagnosis baby was born in 1990 and the first intra cytoplasmic sperm injection baby was born in 1992.
The Human Fertilisation and Embryology Authority (HFEA) was set up under the 1990 Human Fertilisation and Embryology Authority Act to license those providing fertility treatments and conducting fertility research, including the NHS, and began work in 1991.
Clinics and researchers are obliged to adhere to the HFEA Code of Practice, and are subject to inspection. The Human Fertilisation and Embryology Authority also provides information and guidance for prospective parents seeking to undergo fertility treatment. It is also required to ensure clinics "take account 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".
The Human Fertilisation and Embryology Authority also has an explicit role in promoting public debate about fertility treatment and medical research.
The 1990 Act was amended in 2001 to allow the use of embryos for stem cell research and to provide for its regulation.
February 2004 saw the publication of national guidelines on fertility treatment by the National Institute for Clinical Excellence (NICE), with the aim of providing consistent NHS fertility treatment across the country.
In January 2004, the Government changed the rules for egg and sperm donation, ruling that children conceived through fertility treatment would have the right to know who their biological parents were. But, egg and sperm donors would have no obligation to meet with their biological children, or provide them with financial support. The new rules come into effect in April 2005, and are not retroactive, so children conceived before this date would not be able to access details about egg and sperm donors.
The number of sperm donors has been falling for a number of years, but although this was expected to get worse once donors lost their anonymity, there is no evidence to back this up. The shortage has prompted clinics to look overseas for sperm donors. If the number of sperm and egg donors fails to keep up with demand, there is some concern that couples will travel overseas to receive treatment, where fertility treatment is sometimes not as tightly regulated as in the UK.
Controversies
Fertility treatment is a highly controversial area of medicine: it can be medically risky for participants and is frequently very emotionally exacting; it is expensive; and the development of new techniques raises complex and controversial ethical questions. More widely, it generates debate about the international regulation of medical research and the commodification of human life itself.
Few, however, would question the right of couples to seek medical assistance if they are having difficulties conceiving, and many of the techniques described are widely accepted. Today, IVF treatment is relatively commonplace, but in 1985, a Private Member's Bill sponsored by Enoch Powell was almost successful in outlawing all research on human embryos altogether, mirroring the current debates about stem cell research.
Controversies arising from evolving fertility treatment keep the subject near the top of the media agenda: advancing technology permits older parents to conceive, the sperm of dead fathers to be used, and the precise characteristics of babies to be 'designed'. The heart of the problem is where the line between fertility treatment, cloning and genetic engineering lies.
One scandal arose in 2003 when black twins were born to a white couple at a Leeds IVF clinic - prompting extensive judicial activity to establish their actual legal parenthood. In January 2005 a 66 year-old Romanian woman gave birth to a daughter after fertility treatment, making her the oldest mother in the world. The case provoked controversy, with some terming the woman involved as 'selfish'.
The availability of fertility treatment on the NHS, and its alternatives, is also a matter of controversy. Access to services can be difficult to secure, and many prospective parents have to use expensive private clinics. While the poor do not have this option, the range of services available to the rich outside the UK and its regulatory environment raises questions about the commercialisation of reproduction and the ethics and motivations of 'rogue' doctors.
The National Institute for Clinical Excellence's 2004 guidelines aimed to address availability problems by recommending that every couple has a right to IUI and IVF treatment. However, the Government's response - on cost grounds - that IVF treatments be limited to one course per couple caused widespread disappointment. Many argued that such a situation is actually worse than what preceded it, insofar as the first course is usually unsuccessful and useful for diagnostic purposes only.
The role played by the HFEA in setting ethical boundaries has also caused controversy, particularly in cases involving genetic screening of embryos. When, in November 2004, the HFEA granted the first license to a clinic to screen embryos for diseases they might develop as adults, it was accused of taking a major ethical decision behind closed doors.
The clinic involved in the controversy wanted to test embryos for the genetic mutation that causes familial adenomatous polyposis coli (FAP), which strikes in the early teens. It causes multiple rectal and colon cancers and most people with the condition end up having their colons removed. Although there are strong arguments for embryo selection for this disease, critics worry that if genetic selection is allowed, it will be the beginning of a slippery slope towards outright genetic engineering. Legislation currently going through parliament would allow embryo selection for serious medical disabilities or conditions.
Issues of consent rose to prominence when Natallie Evans lost her court battle to be implanted with embryos created in a former relationship. Her now ex-boyfriend refused to allow Ms Evans to attempt to carry their unborn child to term, despite consenting to the original fertility treatment. The case went all the way to the European Court of Human Rights, which upheld the British courts' original decision that consent can be withdrawn up until the point the embryos are implanted. Ms Evans argued the ruling violated her right to a family life.
The debate over fertility treatment shows no signs of abating, with each new scientific advance heralding a fresh wave of controversy.
In 2007 the government announced plans to overhaul fertility legislation to recognise some of the latest advances, both scientific and social. The human tissues and embryos bill contains a number of proposals.
Among the most controversial proposals is the creation of hybrid human-animal embryos, which scientists claim is necessary to provide sufficient material for research.
The bill also provides something of a response to the Evans case. It allows for a 12-month "cooling off" period before embryos are destroyed if one partner withdraws consent for treatment.
Notably, the bill could abandon the requirement that fertility clinics consider the need for a father when assessing applicants. This would benefit lesbian couples and single mothers and is set to be strongly opposed by conservative pro-family groups.
Statistics
In the UK, about 25 per cent of IVF treatments are provided by the NHS
A treatment cycle of IVF costs between £800 and £3,000
IVF is used by about 27,000 couples a year in Britain, and around 8,000 babies are born each year through IVF
There were 248 sperm donors and 1255 egg donors between 2000 and 2001
Infertility and subfertility affect one in six couples
Statistics 1 to 4: (Source: HFEA, 2004); Statistic 5: (Source: British Infertility Service, 2004)
Quotes
"People who are concerned about their fertility should be informed that about 84 per cent of couples in the general population will conceive within one year if they do not use contraception and have regular sexual intercourse. Of those who do not conceive in the first year, about half will do so in the second year (cumulative pregnancy rate 92 per cent)."
NICE, 'Fertility: assessment and treatment for people with fertility problems', February 2004
"I've never been frightened of the ethical side of things."
Professor Robert Edwards, IVF pioneer, interviewed in 2003