IVF controversy - the facts

A doctor quite unexpectedly rang to congratulate me for successfully helping a patient of his become pregnant through ICSI (Intra Cytoplasmic Sperm Injection). She is now a proud mother-to-be who is carrying twins at her second attempt.

Taken by surprise, I asked why he had called as the patient had self-referred. His honest answer was that he had believed the rumours that we practice cowboy tactics and work in primitive conditions.

Coming from a professional, it jarred. After all, reproductive technology is only carried out at St James Hospital and therefore such rumours and insinuations can only be with malicious intent.

It is incredible how none of those who write and pontificate have ever bothered to ask to supervise what we do, to see what takes place in the theatre and in the laboratory and to observe the protocols we follow. It is downright incomprehensible that our legislators and medical representatives have shown themselves to be equally disinterested.

Since our first successful IVF 17 years ago, the staff at St James have helped hundreds of local and foreign childless couples realise their dream. Unfortunately, not all can be helped but as the years rolled on and we gained experience the success rate grew steadily higher.

St James now boasts of a success rate well above 50 per cent, even going up to 62 per cent and 72 per cent on the last two occasions.

The take-home baby rate is slightly lower since a few will miscarry as is the case with normal conceptions.

When we started, it was customary to transfer all fertilised embryos, on the then accepted notion that the more one transfers the more the chance there is of success. I remember attending a conference where a Japanese fertility specialist said he transferred all the embryos even if there were 15 or more.

It is now a proven fact that the best results are obtained when less than four embryos are transferred. Great progress has been made and overall success rates were yielding multiple pregnancies of four or more.

We recently had the first two cases of quads in 17 years of IVF treatment. In one case, we managed to save one baby, while in the other all four were born healthy and allowed home after a few days.

The other known cases of quads (or more), were not born as a result of In Vitro Fertilisation and related Assisted Reproductive Technology carried out at St James Hospital, but through controlled ovarian hyperstimulation (COHS) which is a process that uses fertility drugs and artificial or natural insemination and is carried out by all gynaecologists and even medical practitioners.

In real terms, this means that in IVF-ICSI cases, even if embryo transfers are limited to one, the possibility of the SCBU at Mater Dei having quads is still higher with COHS since there is no way one can prevent it happening except by strict ultrasound monitoring and avoiding natural intercourse. The other possibility of avoiding multiple pregnancies is to ban all types of fertility treatment.

The real problem we are now facing is the high rate of twin pregnancies. We had about three triplet pregnancies in the last two tries. But while in other countries multiple pregnancies are a complication, here they are a cause for celebration. And I believe it should be the case when everybody is lamenting an ever-declining birth rate.

The question is whether we should go for maximum fertilisation of two oocytes as opposed to three. This will considerably reduce the chance of success for the woman desperately wishing to become a mother. On the other hand, it has to be kept in mind that transferring three embryos very rarely results in having four babies; the same applies to the transfer of two embryos resulting in three babies.

The reason is that if a fertilised transferred embryo divides itself in the first few days, this will result in identical twins. The vast majority of multiple pregnancies are fraternal twins. Another possibility is that in the case of a woman becoming pregnant with triplets or quads, nature, in many instances, reduces this to triplets, twins or even singletons.

I do not object to having our laboratory or system at St James regulated, as long as this does not reduce an infertile woman's chances of becoming pregnant. The reason, however, should not be to appease an under-equipped SCBU unit.

The needs of the occasional premature birth, or of mothers delivering prematurely at the same time, can be met with an increase in the number of incubators. Our specialists are fully capable of dealing with such situations.

We follow a two or three embryo transfer protocol. We do not freeze. Of course, we lose patients who either choose, or are advised, to go for treatment abroad simply because by freezing, women increase the number of chances of success without having to undergo the whole treatment; even if the success rate of transferring frozen embryos is much lower.

The reality is that no law will ever stop women who want to get pregnant from going abroad and using all that is available there. They can easily go to Cyprus, where there are no legal restrictions, and come back carrying quads or quintuplets.

Will the SCBU at Mater Dei refuse to treat these premature babies? The whole question revolves around whether we will go for freezing or not. In Italy, after freezing was prohibited, triplet pregnancies increased above the European average, with a loss rate of 8.3 per cent.

Is Assisted Reproductive Technology going to be made available to the few who can afford to go abroad? Forcing mothers to do that, in order to avoid triplet pregnancies at all costs, will be beyond the pocket of even our average wage-earner. We are always ready to compare ourselves with other countries, but we never quote their average wages.

Doesn't the Hippocratic Oath bind professionals to co-operate in order to help patients whose needs should come first? If it does, what better way is there than to sit around a table to determine the best way to help infertile couples who want to have children? Or is the principle of shared responsibility beyond realisation on our island?

Dr Muscat is chairman of the Saint James Hospitals Group.