An arm and a leg for a fertilised egg
Doctors have spent decades trying to make IVF more effective. Now they are trying to make it cheaper
LOUISE BROWN was conceived in a Petri dish placed under a dome-shaped glass jar that looks a bit like an old-fashioned cake dish. She was the first baby created by in vitrofertilisation (IVF). Today’s IVF babies are made in fancy laboratories where computers monitor the temperature, sterility and a finely tuned mix of medical-grade gases. Sophisticated techniques, such as testing embryos for genetic diseases, promise hopeful parents a greater chance of a healthy baby.
But the price tag is hefty, ranging from $2,000–3,000 per cycle in India to $12,000–15,000 in America. In England the National Institute for Health and Care Excellence, a government body, says the state should offer infertile couples three cycles of IVF. But tight budgets mean that over half of IVF patients pay out of pocket. In America, where insurers rarely pay for IVF, only a quarter of couples who need it to conceive actually get it, by one estimate. Globally, the figure is less than a tenth.
Can IVF be made cheaper? Experts see two ways to try. The first is to cut the use of drugs, tests or procedures that for many couples are clearly unnecessary. The second is to work out how the cost and effectiveness of simpler methods compare with those of the standard package. For a health problem that affects one in six to seven couples, solid studies on this trade-off are shockingly rare.
A clue about the scale of wasteful over-prescribing comes from new data on the use of intra-cytoplasmic sperm injection (ICSI), a procedure to insert sperm into the egg in cases of male infertility. In 2010 this was used in nearly 70% of IVF cycles globally, though faulty sperm affects only 40% of infertile couples. Other bells and whistles include various tests to find out what causes infertility, such as sperm analysis using expensive machines (inspection under a simple microscope is often enough). Such extras are overused partly because many doctors and patients mistakenly believe that they make a big difference.
Some cost-cutting techniques could make IVF less effective. However, in some cases the trade-off may be worth it, says David Adamson of the International Committee Monitoring Assisted Reproductive Technologies. Lower doses of pricey IVF drugs, for example, reduce the chance of conceiving a baby on each try. But the time it takes to bring home a baby is, on average, similar and the total cost lower under such a regimen, some studies suggest (you simply try the cheaper intervention more often). It also results in fewer complications from the IVF drugs and fewer multiple births. This “mild IVF” approach is increasingly popular in some countries, including Japan, France and the Netherlands.
Two IVF technologies developed in recent years do without the expensive laboratory where embryos are grown before they are placed in the uterus. INVOcell, which was licensed in America last year, is a plastic chamber the size of a champagne cork. The gametes (eggs and sperm) are placed inside and fertilisation occurs when the device is placed in the vagina for three to five days. Some clinics offer IVF with the device at half the price of conventional IVF. One small study showed that pregnancy rates are similar.
Another breakthrough is a shoe-box-sized IVF laboratory. The gametes are placed in a cheap glass tube connected to another tube, in which the carbon dioxide needed for fertilisation is produced using baking soda. So far 51 babies have been born this way in trials in Belgium, with success rates similar to those for conventional IVF. More trials are under way in England, Portugal and Ghana. In Europe this method can cut IVF costs by three-quarters, says Willem Ombelet of the Genk Institute for Fertility Technology in Belgium.
However, many couples desperate for a child will continue to remortgage their houses to pay for conventional IVF until there is enough evidence that these new offerings will give them the same chance of a baby for less money. Even if results from larger trials show that is the case, dispelling the notion that low cost means low quality will be a challenge, says Dr Adamson.
In poor countries only an approach that combines all of these cheaper methods can put IVF within reach of most infertile couples — and government health budgets. Testing low-cost IVF packages in such places is tough, however. One challenge is to persuade health ministries of the need. Infertility is hardly ever on their radar screen. The World Health Organisation had no guidelines on the matter until last year. Western IVF charities struggle to set up low-cost laboratories. A common problem is that the only local expert recruited for such efforts jumps ship to establish a private practice offering conventional IVF to the rich. Some groups are turning to training nurses instead.
Politicians speak with reverence of motherhood (not to mention apple pie), yet infertility research struggles to attract funds. One reason, ironically, is that IVF has grown so much more effective since Louise Brown was born. This has led to complacency, says Geeta Nargund, a campaigner for cheaper IVF.
The recent shift of focus from chasing success at any price to curbing costs is as welcome as it is overdue. If momentum is lost, however, most of the world’s 48m couples longing for a child have only hope on their side.