The Fertility Promise: The Facts Behind in vitro Fertilisation (IVF) - Peter Hollands - E-Book

The Fertility Promise: The Facts Behind in vitro Fertilisation (IVF) E-Book

Peter Hollands

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Beschreibung

The Fertility Promise is a complete guide to the often emotional, expensive and confusing process of fertility treatment. The book offers clear explanations and advice to anyone undergoing fertility treatment (such as in vitro fertilization) or anyone seeking information about relevant treatment options. The information includes advice to both male and female patients, LGBT patients, IVF clinics, the IVF treatment process, the issues surrounding IVF ‘add-ons’, what it is really like to go through fertility treatment and what the future of IVF might look like. Covering every aspect of the topic, the book is an extremely important point of reference for all fertility patients as well as individuals who wish to broaden their perspective on fertility medicine and clinics. The Fertility Promise informs both general readers and empowers fertility patients who are looking for the correct treatment, enabling them to clearly understand the fertility treatment process and to ask appropriate and often revealing questions on the subject.

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Table of Contents
BENTHAM SCIENCE PUBLISHERS LTD.
End User License Agreement (for non-institutional, personal use)
Usage Rules:
Disclaimer:
Limitation of Liability:
General:
PREFACE
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
DEDICATION
A Bit of History
Abstract
Abstract
A Child is Born
Controversy
Other Options for Fertility Patients?
The First Fertility Treatments
The First Technology
Fertility Treatment Today
Global IVF
Money!
‘Breakthroughs’
Nobel Prize
Still Not A Cure
Population Growth
Adoption
Pioneering Times
Black Monday
Inpatients and Regulation
More Recently
Innovation
Profit and ‘Add-Ons’
Stagnation
The Future
Key Points of Chapter 1
The Female Patient
Abstract
Abstract
Introduction
Female Infertility
Blocked Tubes
Endometriosis
Polycystic Ovary Syndrome (PCOS)
Thyroid
Premature Menopause
Surgical Damage and Fibroids
Sterilisation
Medications
Other Causes of Infertility
Idiopathic Infertility
Stress!
‘Back-to-Back’ Treatments
A Final Prayer
Key Points of Chapter 2
The Male Patient
Abstract
Abstract
Introduction
The Male Role in Fertility Treatment
The ‘Men’s Room’ Pornography and Semen Assessment
Hot Pants!
Testicular Damage
Vasectomy
Ejaculation and Psychosexual Disorders
Hormonal and Genetic Disorders
Medicines and Drugs
Life-style Issues
Stress
A Final Prayer
Key Points of Chapter 3
The LGBT Patients
Abstract
Abstract
Introduction
Same Sex Female Patients
Surrogacy for Same Sex Female Patients
Female Partner Providing Eggs for Treatment
Same Sex Male Patients
Egg Donation and Surrogacy
Gender Re-Assignment
Key Points of Chapter 4
IVF Clinics
Abstract
Abstract
Introduction
Money!
Profit (OK, But Not Too Much!)
Public Provision of IVF Services (Difficult to Deliver)
Treatment Cycle Numbers (Size is Not Everything)
‘Famous’ (Or Indeed Infamous) Clinic Staff
IVF Marketing (Caveat Emptor!)
IVF Clinic Statistics (Is That Black Actually White Or Is It Grey?)
Service (Good, Bad or Indifferent)
Fertility Clinic Facilities
Fertility Clinic Staff
Fertility Clinic Technology
Questions to Ask a Fertility Clinic
Key Points of Chapter 5
The Basic Treatment
Abstract
Abstract
Introduction
The Fertility Medications
Follicular Growth Monitoring
Ovarian Hyper-Stimulation Syndrome
The Egg Collection
Semen Production and Insemination
IVF from a Laboratory Viewpoint
The Embryo Replacement (Transfer)
Embryo Freezing and Replacement
The Pregnancy Test and the Day 35 scan
A ‘Precious’ Pregnancy
Donor Gametes (Donor Sperm and Donor Eggs)
Donor Sperm
Donor Sperm in IVF
Donor Eggs in IVF
Key Points of Chapter 6
The ‘Add-Ons’ Scandal
Abstract
Abstract
Introduction
IVF Technologies and Work Practice
The ‘Right’ Patient
‘Wobbly’ Evidence
A ‘Re-Boot’ of IVF
Treatments of Male Infertility
‘Catching Sperm’
‘Add-ons’
Intracytoplasmic Sperm Injection (ICSI) and Related Technologies
Intracytoplasmic Morphologically Selected Sperm Injection (IMSI)
Physiological Intracytoplasmic Sperm Injection (PICSI)
Sperm DNA Fragmentation Testing
Time-Lapse Video Analysis of Embryonic Development
Pre-Implantation Genetic Screening (PGS) and Preimplantation Genetic Diagnosis (PGD)
Pre-Implantation Genetic Screening (Aneuploidy Screening)
Pre-Implantation Genetic Diagnosis (PGD)
Endometrial ‘scratching’ (Endometrial Injury)
Assisted Hatching
Embryo Glue
Elective Freeze All Cycles
Reproductive Immunology
Acupuncture
Conclusions on ‘Add-ons’
Misleading
Counselling and Clinical Trials
Starting from Scratch and ‘Blobs’
Key Points of Chapter 7
The Regulators and Professional Societies
Abstract
Abstract
Introduction
Power Is Not Always a Good Thing
UK Regulation
The Role of a Regulatory Authority
What Does the Regulatory Authority Regulate?
The European Society for Human Reproduction and Embryology (ESHRE)
Key Points of Chapter 8
The Patient ‘Journey’
Abstract
Abstract
The Journey
First Things First
Time is Running Out!
The First Consultation
The Second and Nurse Consultation
At Last! The Treatment is Starting!
The Day of Egg Collection
Fertilisation Day and Onwards
Embryo Replacement (Transfer) Day
It’s Freezing in Here!
Pregnancy Test Day
The Day 35 ‘Heart Beat Scan’
Key Points of Chapter 9
Advice to Fertility Patients
Abstract
Abstract
Introduction
More Advice on Advice
Optimism and Electronic Advice
Clinic Counsellor
Who to Tell?
Family?
Friends?
Should I Tell People At Work?
Smoking, Alcohol, Obesity and Underweight
Smoking
Alcohol
Obesity
Female Obesity
Underweight Patients
Male Obesity
Back-to-Back Treatment Cycles
Egg Freezing: Good Idea, False Hope or Money-Making Machine?
Add-ons
Pregnancy, Birth and Parenthood
Pregnancy
Childbirth (Labour)
Parenthood
A Second Opinion?
Changing Fertility Clinics?
Infertility and Mental Health
IVF Myths
Key points of Chapter 10
The Future of IVF
Abstract
Abstract
Introduction
Future Technology
The Starting Point
Innovations
Profit!
Stagnation
A Promising Future?
Telemedicine
INVOcell-A Possible Cheaper Version of IVF?
Laboratory Automation
Artificial Intelligence
Quantum Biology and Quantum Physics
PRP and Stem Cells
Embryonic Stem Cells and Hybrids
Key Points of Chapter 11
A Final Thought
Abstract
Abstract
Introduction
Fertility Patients
Physicians
Clinical Embryologists
Fertility Nurses
Clinics
Conclusion
Key Points of Chapter 12
Suggested Further Reading
Useful Websites
GLOSSARY
The Fertility Promise: The Facts Behind in vitro Fertilisation (IVF)
Authored by
Peter Hollands
Freelance Consultant Clinical Scientist
Huntingdon, Cambs, PE26 1LB
UK

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PREFACE

Peter Hollands
Freelance Consultant Clinical Scientist
Cambridge, UK

My inspiration to write The Fertility Promise has been my experience in assisted reproduction (or IVF) since it was first introduced to me at Bourn Hall Clinic in the early 1980’s. I was lucky enough to be one of the first Clinical Embryologists in the world. I have seen IVF move from the initial ideas of Bob Edwards, Patrick Steptoe and Jean Purdy, being carried out in a little village in rural Cambridgeshire, to a billion-Dollar (or Pound!) industry being delivered on a global scale. Many things have changed in IVF during that time. IVF technology has moved on to a certain extent (but with no tangible benefit to patients but with definite financial benefits to clinics and manufacturers) and regulation to ensure optimum quality and safety of all fertility treatments is now routine in most countries. Regulation is extremely important in an area such as IVF to protect both patient and societal safety. Patient expectations, in terms of what a fertility clinic can deliver, have undergone an exponential rise. Unfortunately, the technology in IVF and the people working in IVF have not really met these expectations. Without a change in mind-set these patient expectations will never be met.

IVF has, in my opinion, stagnated in the past 25 years to the point where great change is needed to make further progress and improve the service provided to patients. There have been few effective innovations or new ideas and the live birth rate (which, by the way, is the only thing which really matters to all fertility patients) has not really changed since 1978. There are IVF clinics whose sole purpose is to maximise financial profit. There is little or no thought for the well-being of the patients involved or for their hopes, wishes and fears. There are some IVF clinics who deliberately mislead patients to ensure that their profit goals are met. This is not how medicine should be practised and is a very sad reflection on the current practice of IVF.

All physicians and healthcare professionals, in any speciality, have a duty of care to their patients which means that everything which is done to, or for, the patient is in the best interest of the patient. This is sadly not the case in the medical speciality of IVF which is a very sad and depressing reflection on the legacy which was left to us by Bob Edwards, Patrick Steptoe and Jean Purdy. It also means that fertility patients are not getting the care they deserve and need. This is a scandal on a global scale for which everyone involved in these poor practices should be ashamed.

In general terms, the highly vulnerable fertility patient will do anything to make their treatment a success. This is no different to any patient with any sort of problem but over the years I have seen this to be more pronounced in fertility patients. If I told a fertility patient to stand on her head for one hour every day and this will increase her chance of becoming pregnant then I am sure that this patient would do this. If I did this, I would be a very questionable healthcare professional because there is, of course, no evidence that standing on the head will improve fertility treatment outcome and it is therefore not in the best interests of the patient. The combination of vulnerable patients and corporate (sometimes even personal) greed leads us to the present situation in fertility treatment around the globe. There is hype, false promises, deliberately misleading information, false hope, false advice, false science and sometimes even deliberately false claims and marketing. This is destroying the reputation of IVF and seriously inhibiting those who seek to improve the technology with a true focus on patient care.

This book addresses all of these issues using clear, truthful, experienced and unbiased language so that fertility patients can see the true state of IVF. It is not easy reading. You may find some of it shocking. You may find some of it unbelievable but please remember that I only describe what I have seen and know. I have no hidden agenda; my only agenda is to make fertility treatment better for patients. We can repair the damage which has been done to IVF and move forward in an ethical, truthful and professional way. In order to make these changes it will need co-operation from IVF clinics, the IVF equipment and reagent manufacturers, manufacturers of IVF related medication, the IVF regulators and anyone with a financial interest in IVF. These financial interests are often investors or financial giants with a clear vested interest in a fertility clinic or a group of fertility clinics. This is not intrinsically bad until financial interests overtake patient care, then we have a big problem. Staff who work in fertility treatments may well have to change the way in which they currently think to achieve progress. This means everyone in the clinic because if these changes in mind-set are not agreed upon across the clinic, then they will be ineffective. It will also need a clear understanding and critical analysis of IVF by fertility patients. This is a big challenge for fertility patients, because at present, it is very difficult for them to see who to trust. IVF patients need to move from being passive victims to becoming active, well informed people who have the knowledge and courage to challenge or question the activity or promises of their IVF clinic. If this book stimulates further debate and ultimate change, then it will be a success and IVF will become a trusted medical treatment once more. This is what I truly want to see, but at present, this is not where we are heading. We are heading towards more lies and profiteering in the name of IVF. The purpose for which IVF was invented, to give the opportunity of having a baby to infertile patients and not to generate excessive profit, will prosper. If not, IVF will continue to stagnate, patients will continue to be tricked and misled, and profits will continue to rise. I make no apologies for some of the hard truth and criticism of IVF in this book. I believe that the time is right for change and this book is the beginning.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

Peter Hollands Freelance Consultant Clinical Scientist Cambridge, UK

DEDICATION

This book is dedicated to my partner Louise Barrett for her love, dedication and support. I must also thank my cardiac surgeon, Mr Ian Wilson and everyone at Liverpool Heart and Chest Hospital without whom none of this would be possible!.

A Bit of History

Peter Hollands
(An Overview of the Historical Development of IVF from 1978 to the Present Day)

Abstract

History will be kind to me for I intend to write it.Winston. S. Churchill

Abstract

Summary: This chapter introduces the basic history of IVF and fertility treatment and sets the scene for the detailed information presented later in this book. It provides an initial overview of IVF technology from the first birth in 1978 to today and the alternatives to fertility treatment such as adoption. It also considers the growing population of Earth and the possible stagnation of fertility services.

A Child is Born

On July 25th, 1978, a baby girl was born in Oldham General Hospital. This might not seem a terribly important event except, of course, for the parents and family who were welcoming a new baby into the world. This birth was, in fact, the start of a new era in science and medicine because that baby was Louise Joy Brown. Louise was the first ever baby to be born using technology called in vitro fertilisation (IVF).

1978 was an interesting year for other reasons, such as the introduction of the first email system and the first cellular mobile phone (which was the size and weight of a house brick). This communication technology has become pretty dominant in the 21st Century and has thankfully reduced in size and weight! It has also become important in the effective delivery of IVF. It was also the year that ‘Space Invaders’ hit the Earth and took over, Olivia Newton John and John Travolta were strutting their stuff in ‘Grease’ and the Bee Gees were ‘Stayin’ Alive’. On reflection, 1978 was a good year for me; I was studying in Cambridge and on a path which would lead me to being involved in the early days of IVF. I was destined to be involved in IVF for my whole career, along with my work in stem cell technology and regenerative medicine and being an academic in several Universities.

Everything seemed a little more straightforward in 1978 than our complex, information laden lives in 2021, but it is often too easy to look back on the ‘good old days’ with rose coloured glasses. I know that it is important to live in the moment, not in the past. Despite this, we all naturally look back at what used to be, and this is perhaps part of what it is to be human and therefore very important. It is also how Historians make their daily bread!

Controversy

The birth of Louise Brown following IVF resulted in a lot of controversy from many different people and organisations. Some people said it was just a coincidence and that Lesley Brown became pregnant naturally! Others threw their arms up in horror at the thought of ‘test-tube babies’, which was a terrible term invented by the newspapers. This is even more relevant when the importance of newspapers in 1978 is considered. Newspapers were very much more influential than they are today and what and how they wrote about any subject had a considerable impact on everyone. It is important to get one thing very clear from the start: The term ‘test-tube baby’ can and should be dismissed as irrelevant. IVF involves neither babies (these come much later in human development) nor test-tubes, so this term will not arise again in this book.

Controversy about IVF came from many directions, including from religious leaders, scientists, physicians, politicians and of course, some of the media harshly criticised the technology. Some surgeons (you know who you are!) claimed that IVF was nonsense, and that tubal surgery (re-opening of the Fallopian tubes by a surgical procedure) was the answer. It was not; tubal surgery has never worked. Vasectomy reversal is equally ineffective. Nevertheless, there were many people who had praise and admiration for the three pioneers who made this unusual birth possible. These three people were, of course, Bob Edwards, Patrick Steptoe and Jean Purdy. Jean Purdy was a nurse by training and became the second clinical embryologist (research assistant to Bob Edwards) in the world after Bob Edwards. Jean had fantastic attention to detail in her work and was critical in the development of the laboratory technology which enabled IVF to take place both for Louise Brown and in the early days of Bourn Hall Clinic. She worked with Edwards and Steptoe in both Oldham Hospital and Bourn Hall Clinic before her untimely death, resulting from malignant melanoma, in 1985. The ongoing legacy of Edwards, Steptoe and Purdy to the world is IVF and all of the related technologies. This admirable and essential teamwork should be admired and respected by everyone. It has to be said, however, that Jean Purdy has not been recognised for her important role in developing IVF until recently. She was on many of the early research papers as an author but interestingly was not an author on the 1978 paper in the medical journal, The Lancet, which described the first IVF birth. It is easy to speculate about why this happened, but it is clearly another example of women in science not receiving the recognition they truly deserve. This is something which has to change. If someone makes a big contribution to anything, then they should get recognition; their sex and status should be irrelevant.

The basic laboratory research at Cambridge University, which led to the birth of Louise Brown began in the 1960’s and the clinical collaboration between Edwards, Purdy and Steptoe began in 1968. Edwards and Steptoe actually met at a conference where Patrick Steptoe was talking about his new invention called laparoscopy. Edwards realised that this was the perfect technology to use to collect human eggs, and one of the most famous partnerships in science was formed. It took 10 years of research and collaboration to achieve the first IVF birth and from that time, the technology has grown into an industry projected to be worth $37.7 billion by 2027!

The birth of Louise Brown was a moment in history where we can look back and see that this was something very special, perhaps unique, in medical science. It is on par with medical developments, such as vaccination, blood transfusion, antibiotics and organ transplantation.

Other Options for Fertility Patients?

Prior to the birth of Louise Brown, infertility was something which had to be accepted, with patients often adopting a ‘stiff upper lip’ and a ‘get on with it’ philosophy. In previous generations, there were many people who found that they were unable to conceive, and the only real option for these people to have a family was adoption. It is estimated that at present, there are around 153 million orphans around the world. It is very unfortunate and a human tragedy, that because of laws, religion, wars and politics, very few of these orphans will ever find adoptive parents, love and happiness. This is a tragedy on a human scale, and we should all be aware that these children need parents and homes and that we are failing them by making adoption so complex and sometimes impossible. Some fertility patients may choose to adopt if treatment fails, and this is a possible route to happiness not only for the IVF patients but most importantly, for the adopted child. If adoption was easier and more commonplace, I believe that the world would be a better place.

The First Fertility Treatments

In the very early days of IVF at Bourn Hall Clinic, the patients (both male and female) would be inpatients for up to 3 weeks. This often resulted in quite bored patients, especially in bad weather! In the summer, the grounds of Bourn Hall Clinic were beautiful and made a summer treatment cycle much more pleasant. Afternoon tea in the grounds of the clinic in the summer was particularly popular. The male patient would be in the clinic during the day but slept elsewhere usually in the village or in nearby Cambridge. This is in contrast to the situation today where all IVF patients are exclusively treated as outpatients. The reason for the need to use an inpatient approach at Bourn Hall Clinic was because the early technology required daily blood tests, daily urine collections (to exclude the possibility of natural ovulation), daily scans and daily injections. If the urine showed that a patient was about to ovulate naturally, then she would be taken to theatre for egg collection to avoid losing the eggs. This often resulted in the need to get together a full medical and scientific team to carry out egg collections on a 24-hour basis! Laparoscopic egg collections in the middle of the night were a regular event in the early days of IVF. Current fertility staff moaning about high workloads may like to reflect on this!

The First Technology

The early IVF technology was based on a simple and yet ingenious approach. Put very simply, the female patient receives medication to make her ovaries produce more than one egg (the scientific name for an egg is an oocyte but in IVF clinics around the world, the term egg is used). These eggs were initially collected using a surgical technique called laparoscopy. This was the start of a large range of surgical treatments used widely today which are generally known as ‘key-hole’ surgery. The process of laparoscopy was invented by Patrick Steptoe and key-hole surgery is a second legacy that he gave to us which is often forgotten. Today laparoscopy is used for a wide range of surgical procedures from removal of the appendix to gall bladder removal and the basic principle is that developed by Patrick Steptoe. Laparoscopy requires a full surgical team, including an anaesthetist, because the patient has a general anaesthetic and is placed onto a ventilator during the procedure.

Getting back to IVF, the male patient provides semen, by masturbation when it is needed, and the semen is prepared for fertilisation by ‘washing’ it with culture media to concentrate the sperm it contains and to remove some of the unwanted components of semen. The eggs and sperm are then mixed together and placed in an incubator set at body temperature (37°C) overnight. The next morning, the Clinical Embryologist looks at the eggs to see if they have fertilised. A fertilised egg shows two small circular structures called pronuclei. These are the male and female DNA which will combine to make the new individual. When these pronuclei join together, a new human individual is formed with their own, unique DNA. The eggs which have fertilised then develop into embryos over the next few days in culture, forming the familiar 2 cell, 4 cell, 8 cell embryo over the first 2-3 days and then the morula (a compact ball of about 60-80 cells) on day 4 and a blastocyst (a hollow ball of about 120 cells) on day 5 of culture. Embryos can be returned to the mother (replaced or transferrred) at any stage of development from 2 cell to blastocyst. The first ever IVF treatment used an 8 cell embryo and today the there is a trend towards using blastocysts (so called day 5 transfers/replacements) in most clinics in an attempt to select the ‘best’ embryo to replace. In general terms, this is a good philosophy because the embryo which develops best in the laboratory may well be the embryo which has the best potential to form a baby. Please note the use of ‘may’ in the previous sentence because the fact is, even today, that the visual appearance of an embryo has not been shown to have a direct correlation to a positive outcome. Many patients receive embryos which ‘look perfect’ but sadly, a pregnancy does not result. Many patients receive embryos which ‘look bad’ but become pregnant and deliver a healthy baby. This illustrates the complex, multifactorial nature of fertility treatment which we are only just starting to understand.

Fertility Treatment Today

Today, we have moved forward in some areas of IVF technology (and this will be covered in detail in Chapter 6) but there is still a long, long way to go. IVF is now an outpatient only treatment with female patients giving their injections to themselves. Sometimes partners give injections if the female patient cannot bring herself to deal with needles. This situation alone has its pros and cons. This reliance on the patient to deliver her own medication correctly and safely has always been controversial in my mind and I know that some patients dislike it.

The egg collection itself is now carried out under ultrasound guidance (not laparoscopy). This means that the patient only needs to have a light sedation for the procedure, recovers in the clinic in an hour or two and goes home the same day. If serious complications arise following egg collection, then the female patient may need to be admitted to a hospital following egg collection, but this is a very rare occurrence. The laboratory technology has changed out of all recognition since the early days, mostly for the better, but unfortunately, live birth rate has not followed suit. This conundrum of how we optimise treatment to improve live birth rate is the biggest challenge in modern IVF.

Global IVF

When Bourn Hall Clinic opened in the early 1980’s it was the first and only IVF clinic in the world. Patients would come from around the globe to Bourn which is a tiny village in the Cambridgeshire countryside with the biggest attraction (apart from Bourn Hall) being the Golden Lion pub opposite the drive to Bourn Hall. The female patient used to be admitted to Bourn Hall Clinic as an inpatient and the male patient had to do his best to find accommodation in the village, possibly at the Golden Lion, in the surrounding villages or even in Cambridge. The laboratory and operating theatre were portacabins on the front lawn of the Tudor manor house which was Bourn Hall. The original manor house itself was initially used as offices, kitchen, dining room, lounge area, consulting rooms and latterly as accommodation for female patients. By the late 1980’s, a considerable and expensive extension was added to Bourn Hall, using bricks and finishes to match the original Tudor building. This meant that the portacabins could finally go and we had state of the art operating theatres, laboratory and wards for fertility patients. At the same time as this massive expansion of Bourn Hall Clinic, the number of IVF clinics in the UK and in the rest of the world was growing rapidly. This meant that fewer and fewer patients needed to make the journey to the UK for treatment and even those people already in the UK found that there were very often IVF clinics near to their home when needed. The time when Bourn Hall Clinic was the only option for fertility treatment was rapidly and permanently declining.

Money!

When Edwards, Steptoe and Purdy first developed IVF, there were many people who said that they should patent their technology. This was because it was clear that IVF represented a global future industry and that the value of that industry would be enormous. This was not difficult to see even by those who were the most sceptical about the new technology. Edwards, Steptoe and Purdy were true scientists in that they did not really care about patents and money. What they cared about was bringing their safe and effective technology to patients in need and bringing hope to fertility patients. It was, therefore, no surprise that they published the details about the first IVF baby in the medical journal The Lancet (sadly without Jean Purdy as an author), and they even offered to train people in the technology at Bourn Hall Clinic for no fee! I can remember many people coming to Bourn Hall Clinic in the early days, from all around the world, to see exactly what we did and to get ‘hands on’ experience of the whole process of IVF. In those days, we worked on a ‘see one, do one, teach one’ basis. My own training at Bourn Hall Clinic involved watching experienced people carry out procedures, then doing those procedures while being supervised and finally doing everything unsupervised. The emphasis was very much on practical skill and dexterity. Anyone being trained who could not cope with this pace and style was inevitably left behind and often left the clinic. Bob Edwards also kept a very discreet eye on the results created by each Clinical Embryologist and would often offer ‘re-training’ to any Clinical Embryologist who was not meeting his high standards. Once the free knowledge had been accumulated, visitors to Bourn Hall Clinic then took it back home and many of these people set up their own profit-making IVF clinics. This was based on what they had learnt free of charge from a visit to Bourn Hall Clinic. On reflection, it might have been better for everyone involved if this training in the early days had carried some sort of a fee but what is done is done. In later years, Bourn Hall Clinic provided training courses for a fee which were very well attended and generated a welcome small income for Bourn Hall Clinic utilising their skill and experience.

It is estimated that the global IVF industry in 2026 will be worth $27 billion. There are approximately 4000-4500 IVF clinics worldwide. The cost to patients is high in most countries largely because of the technology and skilled staff needed to provide treatment. In addition, the high cost of medications needed to carry out an IVF treatment can easily double the overall cost of treatment. These medication costs are also passed on to the fertility patient. It would be nice if the big pharma producing fertility drugs would reduce their profit to help fertility patients, but this is probably too much to ask! Japan and India currently have the largest numbers of IVF clinics with an estimated 1,100 between them. IVF is now truly a global industry and fertility clinics are commonplace in most countries. Despite this, the quality and effectiveness of the service provided varies considerably.

‘Breakthroughs’

IVF has become a global phenomenon which, when it was first carried out, was headline news throughout the world. This is comparable to things such as the first heart transplant by Christian Barnard which was headline news at the time but is now commonplace. IVF is now routine and most certainly does not reach the news unless a new ‘breakthrough’ is announced (which is usually hype rather than fact). These ‘breakthroughs’ in IVF are sadly usually either unproven or simply a slight variation on what went before with no real benefit to the patient. Journalists take note! The outcome of these ‘breakthroughs’ is usually either small or non-existent and everyone just bumbles along as they have done since 1978. IVF needs a big kick to bring it into the 21st century and to provide a better service to all fertility patients. This will come when new leaders emerge who have the insight, bravery and imagination of Edwards, Steptoe and Purdy to change what in my opinion, has become stagnated technology. Such change will bring new, vibrant and most importantly, more successful technology. This will be the true Fertility Promise.

Nobel Prize

In 2010, Bob Edwards was awarded the Nobel Prize for his work in the development of IVF. Sadly, Patrick Steptoe and Jean Purdy had passed away and could not receive the Nobel Prize posthumously. It is also highly like that Jean Purdy may not have qualified for the Nobel Prize because she was not an author on the first Lancet paper describing IVF. We will sadly never know. Bob Edwards was equally sadly in the grip of senile dementia when the Nobel Prize was awarded to him and so his wife Ruth travelled to Stockholm to receive the award on his behalf. It is sad that the IVF pioneers did not know that their innovative work had been recognised at the highest level. Nevertheless, it gave great reassurance to many fertility patients and immediate colleagues of Patrick, Bob and Jean, like myself that their work was unique and that it has been an enormous benefit to mankind.

Still Not A Cure

It is important to understand that IVF is not a cure for infertility. It is a process by which infertility can be ‘by-passed’ to achieve a pregnancy; the underlying cause of infertility does not change. It is also important to understand that ‘new’ technology such as egg freezing when young does not guarantee a pregnancy later in life, this is discussed in detail in Chapter 10. Fertility patients retain their initial causes of infertility. If they are successful, with live birth, and then want further children in the future, then IVF is still their only option. The only exception to this is that some females suffering from endometriosis find that pregnancy helps to reduce or even remove the endometriosis. Some of these patients may become naturally fertile as a result but certainly not all of them.

In my opinion, this makes infertility a symptom and not a disease. This is a controversial view, especially in N. America where infertility has to be considered a disease to be eligible for support by medical insurers. I propose that it is the various diseases (e.g., tubal damage, endometriosis, male infertility, etc.) which cause the symptom of infertility. This is really an academic argument from the point of view of the fertility patient, but it is an interesting debate and one which no doubt will continue for many years to come.

Population Growth