A fact that makes reproductive medicine unique is a specific and quantifiable end point- a healthy baby. Each infertile couple and each and every assisted reproduction technology (ART) program are vitally interested in success rates. The stakes are high. Truly, success breeds success.
Reprinted with permission from American Infertility Association
A fact that makes reproductive medicine unique is a specific and quantifiable end point- a healthy baby. Each infertile couple and each and every assisted reproduction technology (ART) program are vitally interested in success rates. The stakes are high. Truly, success breeds success. A well-placed report of a center's superior success rate can ensure survival in a competitive market and can be translated into substantial financial rewards and acclaim.
At one point in the mid 1980's, over 50% of the over one hundred ART programs had not yet reported a pregnancy. In fact, the high failure rate and the large numbers of attempts generated a sizable financial windfall. Program growth depended on the number of attempts, not pregnancy rate. It was a new technology that offered hope to many, success to few. The low success rates were tolerated. Then, there emerged centers that appeared "to do" IVF better, patients became discriminatory and competition stiffened. Relatively low success rates coupled to the high cost of the procedure led to increased public scrutiny of the IVF procedure and ART programs. In the beginning, if either the cost of ART had been less, or the success rates greater, the need for reporting and regulation would probably never have arisen. Presently, there are many good programs and many more similarities than differences in success rates.
There have been several attempts at "industry" self-regulation. The primary example in the U.S. is the Society for Assisted Reproductive Technology (SART), in conjunction with the American Society of Reproductive Medicine (ASRM) joining forces with the Center for Disease Control (CDC). There are many flaws in the evaluation of ART success rates worldwide and especially, in the US. Make no mistake; a successful pregnancy outcome is still paramount. Perhaps it is the American way of "more is better," and certainly the CDC reporting of center specific results, that has put the stamp of propriety on this approach, but is this the whole story? What is meant by "success"; what is truth in reporting? What is the risk-benefit of ART; its real cost? A fundamental question remains; can medical care be quantified? Is the physician-patient relationship only a Norman Rockwell magazine cover of the past?
The major caveats in the assessment of specific clinic success revolve around outcome reporting and patient management. There are many ways to evaluate, or in some cases obscure, ART success rates.
In conclusion, there remains no doubt about the effectiveness of ART in establishing pregnancies. Often, success is achieved at the end of a long arduous journey, when all other methods have failed. For each individual couple the chances are either 0 or 100%. Of course success is important; it may even be everything. But, there should be a clarity in thought between success and success rate. In some cases, success may be translated as acceptance of infertility, election of childless living or adoption.
Over the last several years, pregnancy rates have significantly improved and most centers and couples are enjoying the benefits of greater chances of success. The two largest obstacles that we now face are not pregnancy rate, but access to therapy and limitation of number of embryos transferred and thus multiple pregnancy rates. Both could be easily solved in a cost-effective way by universal coverage by insurance of infertility and assisted reproduction and by limiting the number of embryos replaced to two.
In reality, there is probably little that separates most ART centers. No center can guarantee a pregnancy. No center can precisely predict chances of success. Should we not start to downplay the business and mechanistic side of ART and concentrate on sound, individualized, cost-effective patient care in well-respected and proven centers? In the final analysis, there can be no substitute for an informed consumer, frank conversation, and a sound doctor-patient relationship.
Sam Thatcher MD, PhD
Center for Applied Reproductive Science
Johnson City, Tennessee