william ledger, unsw - medico-legal aspects of reproductive medicine
DESCRIPTION
Professor William Ledger, Head & Professor of Obstetrics & Gynaecology, School of Women’s and Children’s Health, University of New South Wales delivered this presentation at the 2013 Obstetric Malpractice Conference. This is the only national conference for the prevention, management and defence of obstetric negligence claims. For more information, go to http://www.healthcareconferences.com.au/obstetric13TRANSCRIPT
School of Women’s & Children’s Health
William Ledger
Head & Professor of Obstetrics and Gynaecology
University of New South Wales
Medico-legal Aspects of Reproductive Medicine
• Research funding
• Merck Sharp & Dohme
• Merck Serono
• Ipsen Pharma
• Shareholding
– IVF-Australia
• Advisory Board/ lectures
• Merck Sharp & Dohme
• Merck Serono
• Swiss Precision
Diagnostics
• Ferring Pharmaceuticals
• Biopharma
Declaration of interest
The opinions expressed in this lecture are my own.
They do not necessarily agree with those of the University of New South Wales, IVF-Australia
or the National Health and Medical Research Council of Australia
About this talk:
What can we do with IVF?
How it works
Where it can go wrong
Some new innovations
Louise Brown
25 July 1978
102 failed attempts
Natural cycle – one oocyte, one embryo
From 1978 to 2013
6 million IVF children and adults worldwide
Australia 2010 57000 cycles
10500 children
1: 30 births
On average, every primary school class has one
IVF child
IVF in 2013
What happens in an IVF
treatment cycle?
Pre treatment investigations
Informed consent
Counselling
Pituitary downregulation with
GnRH agonist
Superovulation with FSH
‘LH’ surge with hCG
Egg collection 36 hours later
Insemination ‘in vitro’
Check of fertilisation
Embryo culture
Embryo transfer
Freeze ‘spare’ embryos
Luteal support
Pregnancy test
IVF - a complicated affair
Adjuvant Therapies
• Aspirin
• Heparin
• Sildenafil
• Dexamethasone
• Growth hormone
• Testosterone
• DHEA
• Immunoglobulins
• intralipid
• Alternative therapies
‘Soft’ or ‘mild’ IVF
Less patient discomfort
Less complex, shorter stimulation regimes
Less short term complications
Less chance of long term health risks
Less expensive
‘Soft’ or ‘mild’ IVF
Less patient discomfort
Less complex, shorter stimulation regimes
Less short term complications
Less chance of long term health risks
Less expensive
Fewer oocytes
Fewer spare embryos for
cryopreservation
Less programmable IVF
cycles
“Patient friendly”
Superovulation
Baseline USS at start of period
Ovarian cysts, endometrial or myometrial abnormalities, hydrosalpynx, free fluid
Daily injection of FSH plus agonist or antagonist to prevent ovulation
Day 5 onwards, scan and blood test every second day until hCG trigger
hCG when 3 follicles 17mm or greater (antagonist) or 18 – 20mm (long
protocol)
or use agonist trigger (antagonist)
Usually takes 10 – 14 days
Egg collection
Fertilisation
Embryo culture
D5 D3
18h D2 D2
D4
Development to blastocyst
Which culture medium?
How long to culture
– D2 v d3 vs d5
How to assess embryo quality?
– Morphology
– Embryoscope
– Metabolomics
– Biopsy/ PGS
Adjuvants
– Embryoglue
– GM CSF
Controversies in embryology
ICSI
Embryo transfer
Storage of eggs, sperm and embryos
How likely is it to work?
Age 30
First IVF cycle
Male factor/ tubal factor infertility
Single embryo transfer
~ 35% chance of healthy child
Additional 25% with later frozen
embryo transfer
Age 40
First IVF cycle
Male factor/ tubal factor infertility
Single embryo transfer
~ 12% chance of a healthy child
Frozen embryos unlikely
> 45
Less than 1% per cycle
How likely is it to work?
18.8%
8.6%
24.8% 23.2%
34.0%
29.8%
0%
5%
10%
15%
20%
25%
30%
35%
40%
2002 2003 2004 2005 2006 2007 2008
Mu
litp
le B
irth
Ra
te
Australia United Kingdom United States
▼1.6 %pts
▼10.3 %pts
▼4.2 %pts
High
subsidisation
United States
Australia
United Kingdom
Canada Japan
Belgium France
Indonesia
Israel
Sweden
Brazil
Poland Germany
Developing
countries NZ
Low
subsidisation
Thanks to Georgina Chambers, UNSW
Multiple pregnancy rates 2002 - 2008
Funding ART
Cost per cycle $8000 - $12000
With Medicare rebate
– $4420 reimbursement for first cycle
– $4930 for subsequent cycle
Unlimited number of cycles
No age cap
Where can it go wrong?
Potential for error in IVF
Clinical
Ovarian hyperstimulation syndrome
Other physical and psychological sequelae
Risks of the procedures
Risks to the child
(pregnancy complications)
Creation of embryos from the ‘wrong’ gametes
Loss of gametes/ embryos
Failure to survive of fresh or frozen gametes/ embryos
Transfer of the ‘wrong’ gametes/ embryos
Laboratory
Ovarian hyperstimulation syndrome (OHSS)
Severe OHSS in 1 – 2% of cycles Young age
Polycystic ovary syndrome
Excessive doses of gonadotrophin
Multi-system disorder defined by capillary endothelial cell dysfunction
ascites/ pleural effusion, intravascular haemoconcentration
6 direct deaths in UK & Ireland
Unreported cases of permanent handicap
“Severe OHSS should be a thing of the past” Professor Paul Devroey, December 2010
Psychological sequelae of ART
Involuntary infertility can result in levels of psychological distress similar to those seen in patients with cancer
Treatment carries a considerable burden
Many couples do not continue treatment even if there is a good prognosis
Patients may claim for costs of psychological distress when things go badly due to clinical error
Risks of procedures
Side effects of medications
Rarely serious (OHSS)
Can be distressing
Long term risk of malignancy?
Egg collection
Anaesthesia
Pelvic haematoma/ abscess
Damage to viscera
Embryo transfer
Risks of IVF to offspring
• UK MRC Survey
• Australian National data
• Long term follow-up of IVF
offspring
• Major adverse effects on
offspring effects are the result
of multiple pregnancy
• Increased risk of cerebral palsy
– Mainly prematurity related, but
still seen in singleton
pregnancies
(RR 1.3 - 5.8)
• Possible increase in imprinting abnormalities after ICSI (Angelmann, Beckwith)
• Possible increase in risk of birth defects after ICSI using sperm with increased DNA fragmentation
• Possible increase in abnormalities after embryo cryopreservation (large offspring syndrome)
Consent
An embryo is the product of two people’s DNA
Diane Blood
Natalie Evans
Some new challenges
Ovarian aging
So don’t delay!
Delaying IVF from age 35 to age 38 approximately halves the chance of livebirth per cycle
0
50
100
150
200
250
300
20 25 30 35 40 42
miscarriage per 1000births
Down's syndromeper 10000 births
0
5
10
15
20
25
30
35
<25 26 28 30 32 34 36 38 40
Clinical pregnancies
Live births
In 2010, the median age at first
birth for Australian mothers was
30.7 years
Egg freezing
Requires an IVF cycle to superovulate and collect oocytes
Takes 3 - 4 weeks to complete
Does not require a male partner
Vitrification
Fertilise later with ICSI
Over 5000 births reported
Slow freezing
• 2oC/min
• 0.3oC/min
• Ice crystal prevention by
dehydration during
cooling
• Ice crystals can form in
cells.
Vitrification
• 15,000 – 30,000oC/min
• Ice crystal prevention by
dehydration before
cooling
• Glass like state. No
crystallisation (600 times
faster)
Some recent reports of the success of
oocyte vitrification
Survival rate Fertilisation
rate
Implantation
rate
Clinical
pregnancy
rate
Jin et al
2011
88% 75% 37% 50%
Cobo et al
2010
92.5% 58% 39.9% 50.2%
Kim et al
2010
81.0% 73% 80%
Nagy et al
2010
89.1% 87% 55.3%
And the age of the patients was….?
Survival rate Fertilisation
rate
Implantation
rate
Age
<Jin et al
2011
88% 75% 37% <35
Cobo et al
2010
92.5% 58% 39.9% < 35
Kim et al
2010
81.0% 73% < 35
Nagy et al
2010
89.1% 87% 55.3% <35
So what does this mean for social egg
freezing?
If oocyte vitrification is to give > 50% chance of a live birth,
women should
a)Freeze their eggs below age 36
and
b) Aim to freeze at least 12 eggs
But what we see in practice are women over 40 who have little
chance of successful egg freezing
One solution – donor egg
Oocyte donation 2013
Legal in Australia with an altruistic donor
But very few donors
Legal to pay donors in many other countries
USA, Asia Pacific, Spain, Eastern Europe
Results in widespread reproductive tourism
The worst possible outcome?
Daily Telegraph 16 July 2009
Pre implantation genetic diagnosis
(PGD)
and screening (PGS)
Allows screening for known chromosomal and
single gene disorders (PGD)
Allows screening for aneuploidy (PGS)
Allows identification of embryonic sex
Should sex selection be permitted?
Conclusion
Having a family is one of the most fundamental things that most people do
Infertility is deeply distressing
IVF can help but is expensive and has clinical risks
IVF is unpleasant and stressful for the couple
IVF is often unsuccessful
Things can and will go wrong
Thank You