Tuesday February 23 2010
“An extreme form of IVF that forces individual sperm into eggs is being overused and may pass on infertility to the next generation,” The Daily Telegraph reported. It said ICSI treatment, used in cases where there is poor quality or low numbers of sperm, is being used too widely despite these risks.
Several other newspapers reported this story, based on a presentation at this year’s conference for the Advancing Science Serving Society (AAAS).
What is ICSI?
In 1992 a new technique was developed called intracytoplasmic sperm injection (ICSI), where a single sperm is injected directly into an extracted egg cell. This can be used to help men with fertility problems, such as having a low sperm count, less motile sperm, or sperm that has difficulty fertilising the mother’s egg. This means that as long as some sperm can be obtained (even in very low numbers), fertilisation is possible.
These methods appear to be effective in the treatment of infertility, with experts at a recent conference reporting the practice to be ‘relatively safe’, with only a small risk of abnormalities in the foetus.
As the use of IVF increases and other fertility techniques advance, scientists closely monitor the long-term effects of clinically applying the technique. This clinical monitoring process, which occurs with all medical techniques, is designed to ensure that people are offered the most appropriate treatment possible. As part of this ongoing examination process IVF researchers recently discussed the potential long-term health effects of IVF and the appropriateness of general use of ICSI.
What is the basis for these current reports?
The current reports are based on three presentations at the Advancing Science Serving Society conference in San Diego, USA. These talks were on the health and genetic issues of children born following IVF.
The first speaker, Professor Andre Van Steirteghem from Belgium, talked about studies that had looked at the long-term health of children born following IVF. He said that there may be some difference in birth weight, but that the general growth and health did not differ between children of IVF and those who were conceived naturally.
Professor Van Steirteghem also said that there was no evidence of developmental or motor delay in IVF- or ICSI-conceived children who were born after 32 weeks of pregnancy. Premature babies born at less than 32 weeks are more likely to have health problems compared to a premature baby born between 32 and 37 weeks, regardless of the method of conception.
The second speaker, Dolores J Lamb from Baylor College of Medicine, Houston, discussed that some parents who were infertile may have some defective genes that prevent natural fertilisation. She said that artificially assisting weaker sperm carrying these genes may lead to later health problems in the child. The talk discussed genetic differences that are found in some, but not all, infertile men and hypothesised the potential health outcomes of these effects.
The third speaker, Carmen Sapienza of Temple University Medical School, Philadelphia, discussed research looking at epigenetic differences in children born following IVF or conceived naturally. Epigenetics looks at the way environmental changes interact with genetics, specifically how changes in proteins and chemicals regulate when and how processes encoded in the DNA are ‘switched on’. As these proteins and chemicals can change with environmental stimuli, they can therefore affect how the genes respond to the environment.
The authors of this research measured some of the epigenetic chemicals in the placenta of children born following IVF or natural conception. While they found some differences, there was a high degree of variation in each individual. The research did not follow up the potential health consequences of these differences.
What did the papers say?
The Daily Telegraph said that “an extreme form of IVF that forces individual sperm into eggs is being overused and may pass on infertility to the next generation”, quoting Professor Andre Van Steirteghem on the use of ICSI. He reportedly said: “I don't think it's necessary when you have methods like conventional IVF which is certainly less invasive, and can help couples with female factor or idiopathic (no known cause) infertility when the sperm count is normal. I don't see any reason why ICSI should be used in these situations.”
The newspaper also highlighted the work of Professor Carmen Sapienza that was presented at the conference, calling for long-term research to follow up how IVF may be linked to epigenetic changes that may theoretically affect diabetes or obesity.
The Independent also focused on the potential overuse of ICSI, quoting Allan Pacey, senior lecturer in andrology at the University of Sheffield: “The problem of overusing ICSI is that there is a very small but statistically significant increased risk that some of the babies born from the technique appear to have health problems. As such the sensible thing is to only use ICSI when absolutely necessary.”
The newspaper also quoted Professor Van Steirteghem: “The health of children has to be considered the most important outcome of artificial reproductive technology treatment. It’s fair to say that overall these children do well [but] there a few more problems with these children. It doesn’t mean that when you use ICSI there will be more problems, but it is important that we have to see what comes about in the future, so long-term monitoring is extremely important. ICSI has been overused.”
The Daily Mirror covered the story saying that IVF could be an ‘infertility time bomb’, suggesting that a “generation of children born using fertility treatment are at risk of being infertile themselves”. The newspaper says that “a significant number are likely to inherit problems that made their parents unable to have children”.
Should I still use IVF?
There are many causes of fertility problems and the reasons behind conception difficulties differ from couple to couple. Before treatment options are presented to a couple, a specialist will assess the possible causes of their infertility and draw up a list of the most appropriate techniques for them.
An important point to consider is that IVF regulations, techniques and clinical usage may also vary from country to country. Since the speakers at the conference were from the US and Belgium, their views and opinions may not directly apply to UK practice.
Current UK guidelines from NICE recommend that suitable couples can receive up to three cycles of IVF treatment on the NHS. The practice of fertility clinics is also regulated and licensed by the Human Fertilisation & Embryology Authority (HFEA), which also carries details of organisations that can provide counselling during IVF treatment.
It is also worth remembering that fertility trouble does not necessarily indicate that underlying health problems could be passed on to IVF children, as recent newspaper coverage has implied. Just like any other medical technique there are some risks from IVF but these are mainly associated with other factors, such as the increased chance of multiple pregnancies. In turn, multiple pregnancies increase the chance of low birth weight babies or of the mother developing diabetes or high blood pressure during the pregnancy. For this reason the UK regulations recommend that a maximum of two embryos are introduced into the womb during treatment.
The research presented in the conference also looked at epigenetic changes or DNA defects in infertile men’s sperm, and were not studies designed to assess the long-term health of the children born following IVF. Suggestions that IVF may be associated with diabetes or obesity are presently only hypotheses that still require further research.
While Behind the Headlines has not directly appraised the use of ICSI fertility treatment, the risks are reported to be small and are likely to be outweighed by the opportunity to conceive it would offer some infertile couples. People receiving fertility treatment should receive full counselling on all options suitable to them, and support and monitoring at all stages in the process. As part of this care package fertility specialists can give personalised advice on the benefits and risks of different IVF techniques based on the ongoing research into the effectiveness and safety of all assisted reproduction.