THE IVF REVOLUTION

LIFE ON ICE | September 22nd 2008
"Soon, IVF may be better than natural conception for many, perhaps most, couples, not just those who can't make babies the usual way", writes Helen Joyce. Your grandchildren may not be conceived the way you were ...

From INTELLIGENT LIFE magazine, Autumn 2008 

It's an unseasonably cold Saturday in July and I'm standing, shivering, in the grounds of Bourn Hall, a Jacobean manor house in Cambridgeshire. All around are happy families, chatting and taking photographs. It feels like a wedding, even down to the disappointing weather, but it is in fact a birthday. The guest of honour, Louise Brown, the world's first "test-tube baby", is about to turn 30. When she was two, Patrick Steptoe and Robert Edwards, the doctors who helped her mother to bypass her blocked Fallopian tubes and conceive, set up the world's first dedicated fertility clinic here. Invitations to the birthday party have gone out to IVF children born every year since. Steptoe died 20 years ago; Bob Edwards, frail but doing well for an 82-year-old, is holding up under the hugs and thanks of his creations. Many of the parents want pictures of Louise Brown with their offspring, and she is graciously obliging. About half the people around me were conceived in vitro.

Who could have predicted the legions that would follow Louise Brown? What her mother, Lesley, went through in pursuit of a baby was no fun: weeks of having her hormone levels monitored round the clock, and then an abdominal operation under general anaesthetic in the hope of removing a ripening egg at just the right moment to be fertilised in a Petri dish by her husband's sperm. And the chances of success were slim to non-existent. Louise was only conceived through ten years of patient collaboration by Steptoe, an obstetrician, and Edwards, a lab scientist--and the willingness of more than 100 other women who subjected themselves to the same procedures as Lesley Brown but got nothing more for their pains than a couple of ectopic pregnancies and a single miscarriage between them. At the time it was thought that the market for such abuse would consist mainly of young, childless, married women: who else would be that desperate?

Yet as IVF has got slicker and more successful, the market has expanded hugely. Those who might quail at the heroic measures taken by Lesley Brown can now fit IVF in around work, with a single day off for egg collection under local anaesthetic. New drugs, and ultrasound, mean that eggs can be harvested at just the right moment with minimal monitoring, and around a quarter of attempts at IVF result in a baby. Male infertility can often be dealt with by injecting sperm directly into the egg. Embryos can be tested for serious genetic illnesses before being put back, and spare embryos can be frozen for later use. Older women, or manless ones, who would once have resigned themselves to childlessness now line up for treatment in their thousands. Altogether, these developments mean there are around 3m laboratory-made humans in the world today, including more than 1% of babies born in Britain and more than 4% in Denmark, the world leader.

And yet I believe the true IVF revolution is still to come. Soon, IVF may be better than natural conception for many, perhaps most, couples, not just those who can't make babies the usual way and the fewer still who know they carry genetic diseases.

The first steps to this reproductive nirvana are already being taken by a few brave, or foolhardy, souls. They are freezing (or, strictly speaking, "vitrifying") their eggs in order to keep them fresh till the right man comes along. Men have been able to freeze and bank their sperm for decades, for example when facing cancer treatment that risks leaving them infertile, and couples can store surplus embryos produced during IVF. But eggs are a tougher challenge. Sperm are small, and of the tens of millions in a single ejaculation plenty will survive freezing and thawing; a couple of days after fertilisation, an embryo will consist of several cells, and even if a few don't survive the trauma, the embryo itself often will. Eggs, though, are single cells--so they have no built-in redundancy--and big (many times larger than the average human cell), so they are full of water that can form ice crystals and destroy the delicate structures inside them.

Until recently, concerns about the effectiveness and safety of egg-freezing meant that it was only offered to women with cancer who were about to embark on treatment that might make them sterile and had no man with whom to make embryos and nothing to lose by trying. But now Bourn Hall and a handful of other clinics in Britain have started offering single women who have no reason to believe they are infertile the chance to go through IVF and stop before the eggs are actually fertilised. Then doctors remove the water from the eggs, replace it with a type of antifreeze, and flash-freeze them in liquid nitrogen, to keep until they are needed.

Bourn Hall has not had much take-up--apparently, by the time women even think of it, they, and their eggs, are already too old for freezing to be much use. But Simon Fishel, the director of the Nottingham-based flagship of care, a chain of fertility clinics in the Midlands, says he gets a handful of enquiries about the technique every week. His clinic and one other, Bridge in London, are actively promoting such social egg-freezing, including an egg-sharing arrangement, where a young woman banks half the eggs for herself and donates the rest to an older, eggless woman--who pays. "My hope is that they bank eggs and never use them," Fishel says. For all his bravura, what he is offering is still an untried technology--"a potential safety net", he tells me, which sounds more like a comfort blanket to me. But then, many people thought Lesley Brown crazy, and Steptoe and Edwards frankly unethical--and look where that led.

In many ways, older women make better mothers--better educated, better paid, more likely to be in a lasting relationship. But biologically, it is a different story. Every day she has lived has been another insult to her eggs, which are as old as she is and will show it even if her face doesn't. It may one day become standard for women barely out of their teens to freeze 20 or 30 young, fresh eggs from a couple of cycles of IVF, to be thawed when child-bearing finally seems like a good idea. Mike MacNamee, Bourn Hall's CEO, tells me that Steptoe used to say: "Sex is for recreation; leave reproduction to the professionals."

The final step would be if a slice of ovarian tissue could be stored and used later to grow as many healthy young eggs as needed. Then we could see healthier babies born to readier mothers, and if pre-implantation testing improved as well, many genetic diseases would become very rare. And it might start to seem irresponsible to make babies any other way, even for those who could. Another Steptoe quote: "One day it may be regarded as unethical to put back an embryo without testing it first."

This is not a prospect to be viewed with equanimity. It's not the unnaturalness that bothers me--Mother Nature is often stupid and always blind, so why shouldn't we improve on what she offers in this area, as in so many others? I am afraid, though, that a technology intended to help make babies will end up achieving the opposite. When will women have children if the clock has stopped ticking? If you have a small daughter, you may be happy to think of her calmly waiting for the right man and the right moment before using the youthful eggs she has wisely stored to make healthy children. But for so many women--and men--there never really is a right time; there is always another promotion to chase, a bigger house to buy, another hurdle to clear. So there's a question for today's youngish parents: will your grandchildren ever be born, and if they are, will you still be alive to see them? 

Picture creditJames Tan Chin Choy/flickr (top); SIRICHAI (illustration)

(Helen Joyce is education correspondent of The Economist. Her sons, aged seven and two, were conceived by IVF with the help of the Hammersmith Hospital in London. Her last article for Intelligent Life, "Mind over matter", was about decision-making.)