‘Hasty doctors put couples through IVF too soon’

Couples are needlessly having gruelling and expensive fertility treatment because doctors are too hasty in concluding that they are infertile, a study has shown.

Scientists have discovered that most women who fail to conceive after a year of trying to do so –the point at which doctors generally deem a couple to be clinically infertile and recommend IVF therapy — will become pregnant naturally during the next 12 months. Even when a woman is in her late thirties, fewer than one in ten will not conceive after two years provided the partner is aged under 40.

The findings, from research led by David Dunson, of the National Institute of Environmental Health Sciences in North Carolina, suggest that many couples embark on treatment when they could have a baby by natural means.

IVF treatment generally costs about £3,000 per cycle and is emotionally and physically draining for women, who need to have unpleasant hormone injections and undergo invasive and sometimes painful procedures to remove eggs and replace embryos. It also carries a raised risk of dangerous multiple pregnancies, premature birth, low birthweight and birth defects.

In the research, details of which were presented yesterday at the European Society of Human Reproduction and Embryology conference in Vienna, Dr Dunson examined 782 couples taking part in the European Fecundity Study in six countries, including Britain. More than half of all women under 40 who did not conceive in the first year of trying to do so became pregnant after a further 12 months without any medical assistance.

The results indicate that couples worried about their fertility and the doctors who recommend them for treatment are often unnecessarily impatient. When doctors cannot find a clear medical cause for infertility in the man or the woman they would be wise to require that couples try to conceive naturally for two years before turning to IVF, Dr Dunson said. “Many times, couples are recommended for assisted reproduction therapy because of known reproductive problems, but often they just haven’t been able to conceive in a year of trying,” he said. “In these cases, doctors might be overly hasty in recommending couples for treatment.

“We should definitely think about redefining clinical infertility, possibly to two years. It depends on whether there are other clinical indications of infertility, such as a low sperm count in a man or endometriosis in a woman.”

About 27,000 couples have fertility treatment every year in Britain. Of these, 80 per cent have been found to have a specific condition, but the remainder are classified as suffering from “unexplained infertility” after a year of trying unsuccessfully to conceive. IVF is available on the NHS, but waiting-lists are long and eligibility criteria vary regionally.

The study found that 8 per cent of those aged between 19 and 26, 13 to 14 per cent of those between 27 and 34, and 18 per cent of those aged between 35 to 39 fail to conceive within a year. After two years, however, these failure rates had fallen to 3 per cent, 6 per cent and 9 per cent, respectively. For women in their late thirties, the man’s age was also important: among women aged between 35 to 39 the failure rate was 28 per cent after one year, and 16 per cent after two years, if a woman’s partner was aged over 40.

Dr Dunson said that many couples were misinterpreting research, including a recent study by his own team, showing that female fertility began to decline from the late twenties, and fell steeply in the late thirties. This meant only that it would take women longer to conceive, not that it would be impossible without medical assistance, he said.

“On average, the time to pregnancy increases with the age of the woman. But, regardless of age, most of the women who failed to conceive within the first 12 monthly cycles conceived in the next 12. There is a large amount of normal variability in fertility, and many couples having below average but normal fertility may fail to conceive within a year. This is particularly true for older couples, who may fail to conceive within the first year but are successful in the second.”

Doctors should avoid assisted reproductive therapy if at all possible because of its side-effects, he said. “Fertility treatment can result in an increased risk of multiple pregnancies, pregnancy complications, low birthweight, major birth defects and long-term disability among surviving infants. In addition, the chance of success with assisted therapy decreases with age, while the side-effects increase in prevalence.”

Professor Ulrik Kvist, of the Karolinska Institute in Sweden, said that a good solution would be to adopt the Scandinavian practice of testing couples for specific infertility problems after six months of trying. Those with a clear difficulty are treated immediately while the remainder must try natural means of conception for longer. “There is a group of patients who have an obvious fertility problem who will not be helped by waiting and trying normally, so it is good to diagnose them early and start them on treatment,” he said.

In a separate study, scientists in Denmark have found that women who had leukaemia as children maximise their chances of starting a family if they do so when they are in their twenties. This is because chemotherapy used to treat the disease can significantly shorten a woman’s reproductive span, bringing forward the menopause.

“We recommend to all female survivors of childhood cancer with normal ovarian function that they try to have their first child before they are 30,” said Elizabeth Larsen of Copenhagen University Hospital, who led the research.

– Originally written by Mark Henderson for the Times. London.