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Assisted reproduction: what do midwives need to know?

30 January, 2009

Assisted reproduction: what do midwives need to know?

In this article the impact, if any, infertility treatments have on the work of midwives is discussed. First, some of the social and ethical issues around assisted fertility treatments are outlined.



In this article the impact, if any, infertility treatments have on the work of midwives is discussed. First, some of the social and ethical issues around assisted fertility treatments are outlined.
Midwives magazine: February/March 2009



By Ginny Mounce, midwife at John Radcliffe Hospital, Oxford and a research nurse at Nuffield Department of Obstetrics and Gynaecology, Oxford University



Introduction

The Human Fertilisation and Embryology Authority (HFEA, 2007a) estimates that infertility affects around one in seven couples in the UK. Infertility may be attributed to conditions such as anovulation or endometriosis in women or oligospermia in men, but in around a third of cases it remains ‘unexplained’. Since the birth of Louise Brown in 1978, the world’s first ‘test tube baby’, medical help for these couples has increasingly involved the use of assisted reproductive techniques such as in vitro fertilisation (IVF) (Paulson, 2007). Other users of fertility services are patients wishing to freeze embryos prior to cancer treatments or lesbian couples who would otherwise be unable to spontaneously conceive a pregnancy. In this article the impact, if any, infertility treatments have on the work of midwives is discussed. First, some of the social and ethical issues around assisted fertility treatments are outlined.


Background

Treatments for infertility range from surgery, such as laser or diathermy ablation of endometriosis, and hormone therapy to IVF and intracytoplasmic sperm injection (ICSI). Other techniques such as pre-pregnancy screening and diagnosis are available at some fertility clinics. Associated medical research, sometimes using donated embryos, is concerned with human reproduction and development as well as more ‘futuristic’ ideas. An example is the generation of embryonic stem cell lines, which are believed to have the potential to provide therapy for a range of medical conditions, including some that are currently untreatable (Mountford, 2008).

The development of techniques in assisted conception is controversial due to the complex legal, ethical and religious issues involved in the creation of embryos. Individuals, institutions such as the Roman Catholic Church and other organisations such as CORE (Comment On Reproductive Ethics) have all raised questions about the appropriateness and morality of procedures such as IVF. However, while the issues around assisted fertility continue to be discussed, IVF in particular has become very popular. Already over one million births worldwide have occurred as a result of IVF. In the UK and the USA it accounts for over 1% of live births (Paulson, 2007). This is despite it being an expensive process, costing around £3-4000 per private cycle (Henderson, 2008), and generally ‘unsuccessful’ (the UK overall live birth rate following IVF is 21.6%) (HFEA, 2007a).

IVF is not an easy option, in fact as Leroi (2006) highlights ‘nature has contrived a cheap, easy and enjoyable way to conceive a child; IVF is none of these things.’  For some couples though, it can be a route where no other satisfactory explanation for infertility exists, when other treatments have failed or when the woman is older. It is now a well-known treatment in the UK and, since April 2005, one NHS-funded cycle has been available to all UK women fulfilling local criteria (HFEA, 2007a).

While questions remain as to whether we know enough about the long-term effects of fertility treatment on women or of the babies conceived this way (National Collaborating Centre for Women’s and Children’s Health (NCCWCH), 2004) scientific developments in the assisted fertility sector continue apace. The social and scientific issues of concern to us now were simply not envisaged 18 years ago when the Human Fertilisation and Embryology Act (1990) was first introduced. Examples of techniques now possible include the ability to test or screen embryos for genetic conditions prior to implantation and the ability to select embryos by tissue type, to be ‘saviour siblings’, or by sex, for the purposes of ‘family balancing’.

The existing legislation governing fertility, assisted reproduction and embryo research was reviewed by parliament last year and subsequently updated in the Human Fertilisation and Embryology Act (2008). Key changes include allowing the licensing of some types of inter-species embryos for research purposes and the recognition of same sex partners as legal parents. The Act also bans selection of embryos by sex for non-medical reasons, but allows it in certain cases, for example to screen for diseases, which only affect one sex.

These issues are likely to arouse conflicting feelings in midwives, which resonate in their daily lives and their personal relationships, as well as professionally. Some may require a certain amount of contemplation and reflection to resolve. For example, questions surrounding genetic screening may remind us of the implications of antenatal screening per se, such as the possibility that our society is becoming increasingly eugenic. Midwives should be confident with the role they play in this society. Maintaining our interest and understanding of these subjects is vital if we are to contribute meaningfully to the debate.


Implications for midwives

Some of the issues around assisted fertility treatments and their importance to society at large have been discussed.  However, what impact does fertility treatments have on the work of midwives?

The midwife’s role includes offering pre-conceptual advice to prospective parents, for example, nutrition, lifestyle or screening choices but in the author’s own experience, midwives don’t usually seek details of conception once a pregnancy is confirmed. However, midwives may be aware that a woman in their care has had an ‘IVF pregnancy’ and should know what relevance this has to their practice. In general terms, knowledge of what is involved in fertility treatments may be useful during discussions with clients. Midwives should also be aware of how fertility treatments might affect a pregnancy, both physically and psychologically. For example, pregnancy, and the prospect of parenthood, is obviously joyful for previously infertile couples.


Assisted reproduction techniques

These are treatments which can enable pregnancy without sexual intercourse (NCCWCH, 2004), usually intrauterine insemination (IUI), IVF and IVF with ICSI. Often treatments also require Ovulation Induction (OI) whereby drugs, usually gonadotrophins, are given to stimulate or control ovulation. IUI is a technique where prepared sperm are inserted directly into the uterus at the time of ovulation. IVF involves surgically removing eggs from the ovary, combining them with sperm in a petri dish and, following fertilisation, replacing the resulting embryo(s) in the woman's uterus. ICSI, whereby a single sperm is injected directly into the egg, may be used if the sperm would not otherwise be capable of fertilising an egg. Additionally these techniques may involve donor gametes (eggs or sperm) or embryos.

The donation of eggs, sperm and embryos is subject to strict UK regulations. Donors may be family, friends or strangers. In 2005, the law was changed so that donors can no longer remain anonymous. Now children born as a result of using donor gametes or embryos can, once they reach 18, discover their donor’s identity (HFEA, 2007b). The regulation of donors in other countries is different to that in the UK, for example some countries allow payment of egg donors. As a consequence some UK women travel overseas for treatment where waiting lists may be shorter.


Multiple pregnancy

Assisted reproduction, especially IVF, is considered to be the main cause of the increased number of multiple pregnancies in the UK. In 1978 there were 11,941 babies born in the UK as part of a multiple birth, compared to 20,425 in 2006 (Office for National Statistics, 2007). Currently, almost one in  four births after IVF in the UK results in either twins or triplets, which is approximately ten times higher than in naturally occurring pregnancies. (HFEA, 2007a). 

The risks of multiple pregnancies for maternal and child health are well documented (Expert Group on Multiple Births after IVF, 2006; Elster, 2000). Babies are more likely to be pre-term (Kiely, 1998) and below normal birth weights. Consequently, they are at higher risk of stillbirth, neonatal death (Guyer et al, 1998) and longer-term effects such as cerebral palsy (Topp et al, 2004). Women with multiple pregnancies are at greater risk of obstetric problems such as miscarriage, pre-eclampsia, gestational diabetes, haemorrhage and instrumental delivery (Walker et al, 2004). The risk of maternal mortality is low but is almost doubled in this group (Conde-Agudelo, 2000). Longer-term psychosocial outcomes, such as increased levels of maternal depression and marital or parental stress have all been reported for mothers of multiple birth children (Bryan, 2003). A further consequence is the impact of multiple births on already stretched neonatal NHS services (Ledger, 2006).

The HFEA commissioned report One Child at a Time (Expert Group on Multiple Births after IVF, 2006) concluded that multiple pregnancy is the single biggest risk to health after having IVF. They argued that the numbers of multiple births could be reduced if, in selected cases, single embryos were transferred (currently two is standard). This is likely to be with women who have the highest chance of conceiving, such as younger women with a number of good quality embryos available. The HFEA has now called for the formulation of national guidance in order to implement this strategy. The aim is to reduce the incidence of multiple births following IVF to 10% over the next three years. This policy has been successfully introduced in other countries such as Sweden, Belgium and Finland (HFEA, 2007c) where single embryos are transferred in the majority of IVF cycles.

The HFEA recognises, however, that a reduction in multiple pregnancy rates must be achieved without also adversely affecting pregnancy rates. Transfers of two or more embryos would still be offered to women with lower chances of conceiving which, in the UK, is likely to be around 50% of all treatment cycles. Additionally, there may be some resistance to single embryo transfers from couples wishing to ‘maximise’ their chances, particularly as nearly three-quarters of IVF cycles are privately funded in the UK (HFEA, 2007c). Indeed, while the consensus among fertility groups is that reducing multiple births following IVF is necessary and can be achieved by single embryo replacement in selected patients (Hamilton, 2007), some experts believe that reaching the proposed target levels will only be possible if funding for IVF cycles is improved (Smith, 2008). So, in cases where single embryo transfer is not an option, and for other women with multiple gestations, midwives need to remain vigilant in supporting them and aiming for best possible pregnancy outcomes.
 

Neonatal outcomes

The possibility that children born following assisted reproduction are at greater risk of having major malformations than those conceived naturally has been widely discussed (Hansen et al, 2005; Ludwig, 2005; Paulson, 2007; Van Voorhis, 2006), with particular concern around the invasive ICSI procedure (Sutcliffe, 2002). A recent review by Sutcliffe and Ludwig (2007) estimates this increased risk to be around 30%, but with no apparent difference between IVF and ICSI. However, the authors suggest the reasons for this higher risk may not be wholly attributed to reproductive technologies themselves. They point out various difficulties with studies around this topic including definition of terms and inclusion criteria as well as, in a view shared by Farhi and Fisch (2007), suggesting that underlying problems causing the infertility in the first place may be more significant. Sutcliffe and Ludwig (2007) recommend counselling couples starting treatment that the risk of major malformations is around 1.3 times the normal value, expressed as one in 12 pregnancies compared to one in 15 spontaneously conceived pregnancies. Thus, the absolute risk of having a child with a congenital malformation following assisted reproduction remains low (Paulson, 2007).

Questions remain concerning the use of ICSI. Boys conceived using this technique may inherit Y-chromosome abnormalities from their fathers (which caused or contributed to their infertility) and so may themselves have fertility issues in the future (Sutcliffe and Ludwig, 2007). Additionally, a higher rate of urogenital defects in boys following ICSI has been reported (Bonduelle et al, 2005). Overall further long-term follow up studies of children born following assisted reproduction is required, although existing studies looking at the well-being of children beyond the neonatal period are generally positive (Sutcliffe and Ludwig, 2007).


Maternal health

Assisted reproduction involves the use of ovulation-inducing drugs and there has been speculation as to whether there is an association between this and the incidence of various cancers, but a link has not been proven (Cancer Research UK, 2006). Additionally, the egg retrieval process itself carries a risk to health as it is a surgical procedure (Kennedy, 2005). The most common complication of ovulation stimulation is ovarian hyperstimulation syndrome (OHSS) (Van Voorhis, 2006) a potentially life-threatening condition, caused by an excessive response to the drugs used to stimulate ovulation. Severe OHSS occurs in around 10% of women at particular risk, such as those with polycystic ovaries. This risk is avoided in women undergoing in vitro maturation as they are not required to take hormones to stimulate ovulation. Instead, immature follicles collected from her ovaries are matured in a laboratory. This technique is very new; however, the first UK babies born following the technique occurred in October 2007 (University of Oxford, 2007).

In early pregnancy the main risks are miscarriage and ectopic pregnancies. The rate of spontaneous miscarriage is higher in IVF pregnancies compared to naturally conceived pregnancies, although this is strongly correlated to maternal age (Paulson, 2007). Ectopic pregnancies are far more common after assisted reproduction, but again this is dependent on pre-existing conditions such as tubal pathology (Strandell et al, 1999). In the UK the rate of ectopic pregnancies is 1%, with the risk almost double following IVF (Kennedy, 2005).

Later pregnancy complications associated with assisted reproduction include placenta praevia, abruption, gestational diabetes (Paulson, 2007) hypertension and caesarean section deliveries (Van Voorhis, 2006), mothers with multiple pregnancies being at particular risk (as described earlier). However, as with neonatal outcomes, the absolute risk for these complications is small and it is generally considered that the underlying cause of infertility may have a higher causative affect than assisted reproductive techniques themselves. For example, polycystic ovarian syndrome, which is a common cause of infertility, is linked to insulin resistance and thus the development of gestational diabetes (Paulson, 2007).  Additionally, pregnancy complications including placenta praevia, prolonged labour, hypertension, bleeding and caesarean delivery are associated with older women (complications increase in parallel with advancing maternal age) (Cleary-Goldman et al, 2005; Luke and Brown, 2007). Age may therefore also be a contributing factor to the overall obstetric risks associated with assisted reproduction, since around 50% of treatment cycles are in women over 35 years of age.


Psychological effects

Couples undergoing fertility treatment discover that it is a physically, psychologically and financially demanding process. Many liken it to being on an ‘emotional rollercoaster’ (HFEA, 2007a) and some authors have suggested that midwives should be alert to the potentially increased psychological and emotional needs of these clients (Joels and Wardle, 1994; Morgan, 2004). Certainly women with IVF pregnancies have, unsurprisingly, been shown to be more anxious and scared of losing their baby throughout pregnancy (Hjelmstedt et al, 2003) and may need reassurance that normal symptoms of pregnancy, such as backache, are not something more serious (Bryan, 2000). However, others emphasise that fundamentally such pregnancies are the same as any other (Morgan, 2004) and are no more ‘precious’ than those in the general population (Minkoff and Berkowitz, 2005). The same conclusions were found for couples during their transition to parenthood, with parents of both IVF and naturally conceived pregnancies finding parenthood similarly stressful (Hjelmstedt et al, 2004).

More complex psychological issues may occur for couples using donated sperm, eggs or embryos. This information is not always disclosed to midwives but, although perhaps midwives should be sensitive to its possibility, it is unlikely couples will have entered into the pregnancy without serious consideration of its implications. Additionally, in the UK there is a legal requirement for all couples undergoing treatments using donated gametes or embryos to have counselling. Most can continue to access this service during their pregnancy should issues remain unresolved. Counselling is often available for all couples requiring it, for example, those experiencing negative feelings following unsuccessful treatment cycles.


Pregnancy loss

The death of a baby is always distressing, but it can appear ‘more so’ with IVF pregnancies, particularly when the overall obstetric history of the woman is poor. The perceived unfairness of circumstances which deny parenthood to these women can be especially upsetting to all involved in their care. However, as with all cases of pregnancy loss, midwives need to resolve their own feelings in order to best care for families who are grieving (Burden and Stuart, 2002). Ensuring they receive access to support for themselves and opportunities of debriefing is important to enable them to cope with this demanding aspect of their role.


Conclusion

Assisted reproduction, particularly IVF, is now an accepted part of reproductive science. Small numbers of women will have pregnancies following assisted reproduction treatment and this may be relevant to the midwifery care they receive. By acquiring a basic knowledge of the treatments involved, midwives can demonstrate their understanding of the processes/procedures couples have endured to reach pregnancy. Pregnancies achieved through assisted conception are at increased risk of complications. These risks are mainly those associated with multiple pregnancies, which are significantly more likely after IVF. Currently, around 25% of all UK twins were born to mothers following IVF. New guidelines proposed by the HFEA aim to reduce this to 10% by encouraging clinics to transfer only single embryos in women at most risk of conceiving twins.

Neonatal outcomes and maternal health are also adversely affected following assisted reproduction, but it is unclear whether the fertility treatments themselves or underlying factors contributing to infertility, such as maternal age, are responsible. The psychological effects of fertility treatment vary for individuals, but some couples may be more anxious during pregnancy. More generally, midwives should remain aware of the continuing developments in the field of assisted reproduction. New techniques such as pre-pregnancy screening and the ethical dilemmas around embryo research raise social and legal issues which is likely to affect future midwifery practice.


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