Assisted reproduction to address global infertility – is access a human right?

Most of you may have seen a picture of me with my fraternal / dizygotic twin girls (16 May 2014). To cut a long story short, they were the result of in-vitro fertilisation (IVF), or more specifically intracytoplasmic sperm injection (ICSI). I did my first degree in medical science and was always particularly impressed that one could get pregnant via a ‘test tube’ in the laboratory… and I thought, well that won’t happen to me with my appetite for alpha-males, surely not?! Of course, the term ‘test tube’ isn’t totally accurate; there are lot of drugs you have to self-inject into either buttocks or thigh to regulate your cycle and then to over-stimulate your ovaries, and then there is the whole extraction and return procedure, but I will save that story for another rainy day.

I am now officially a Mum of Multiples (as Tamba, the Twins and Multiple Births Association, refers to us) and as such I seem to surround myself with other twin mums. In fact, we have formed a mini-society in Lichfield and we meet on a Friday in a children’s centre and watch our children cause mischief and havoc, while drinking tea and supporting each other – which mainly consists of telling each other how hard it is and how we are all super mums for having two babies/toddlers simultaneously. However, most of us, I would say at a guess around 80% of us, ‘chose our own destiny’ through the wonder of medical science having had some form of fertility treatment. I do have some interesting stories about same-sex fertility treatment options/decisions after quizzing a few members about how they chose who would carry the child/children and where does one get their sperm from. All totally fascinating I can assure you. Anyway, even though all our journeys here were different, you might say that we are the lucky ones – by hook or by crook our fertility treatment had been a success and our screaming, whining and snotty-nosed pairs were evidence of our victories.

This got me thinking that not everybody was so lucky. I have had friends struggle to get access to fertility treatment provided by our NHS as they did not fulfil certain criteria – they had moderate to high BMIs; they had had ectopic pregnancies within the last two years; they had been pregnant before but they had miscarried and so on. NICE has recently (Feb 2013) updated their guidance on fertility treatment (from previous 2004 guidance) and they still recommend that couples must have been trying to conceive for a total of two years, but that this can now include up to a one year before their fertility investigations commenced. If couples were struggling to gain access to fertility treatment here, what was the situation like further afield?

Data from demographic and health surveys collected by the World Health Organisation from 47 low-income countries, including countries in Sub-Saharan Africa, North Africa, Central and South-eastern Asia and Latin America, showed that more than 180 million couples have infertility problems and are childless involuntarily.[1] Fertility treatment is not available for these groups because they happen to reside in a country that has limited resources, where government strategies seem preoccupied with managing population growth, and where prevention against infectious diseases, sexually-transmitted diseases and malnutrition remain key public health priorities. I had to wonder, is withholding fertility treatment for this group right from an ethical and social-cultural perspective? Indeed, the social consequences of being childless in the developing world appears more problematic, with women being blamed, ostracised and even assaulted by their families.[2]

So what is the answer? We hand back to the medical scientists and ask them to further develop or simplify the current techniques so they are more affordable. Savings can be made by lowering the ‘laboratory costs’ associated with fertilisation and culture of eggs and embryos, for example, by using something called a ‘humidicrib’ – literally a plastic box instead of laminar flow hood.[2] Such developments are supported by the non-profit foundation, the Low-Cost IVF Foundation, established in 2007 with a mandate to bring down the material cost of an IVF cycle to €200.[3] Of course there are many more barriers to implementation of such procedures in the developing world, but at least it is now on the radar – infertility should be considered a global health problem and surely we should all be able to have access to treatments – isn’t it a basic human right to be able to procreate? Otherwise, what’s it all for?

— Nathalie Maillard, CLAHRC WM Head of Programme Delivery

References:

  1. Rutstein SO, Shah IH. Infecundity, infertility, and childlessness in developing countries. DHS Comparative Reports No. 9. Calverton, Maryland: ORC Macro and WHO. 2004.
  2. Ombelet W. Global access to infertility care in developing countries: a case of human rights, equity and social justice. Facts Views Vis Obgyn. 2011; 3(4):257-66.
  3. Vayena E, Peterson HB, Adamson D, Nygren KG. Assisted reproductive technologies in developing countries: are we caring yet? Fertil Steril. 2009; 92(2): 413-6.

 

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One thought on “Assisted reproduction to address global infertility – is access a human right?”

  1. For most of my professional career I was an Obstetrician and Gynaecologist. I supported the establishment of a test tube baby unit in my academic department at St James Hospital, Leeds. I campaigned for resources nationally. In my current role, leading a centre for International Research, I am interested in fecundity and reproductive choice supporting a right to both contraception and fertility treatment. But the latter is a claim right – money spent on infertility has to come from somewhere and has an opportunity cost. So the real question seems to be – what should not be provided in order to make way for assisted conception. This could be put another way – at what level of national wealth (say, per capita GDP) does it become cost effective (in terms of the opportunity cost) to provide tax-funded assisted conception? My disutility function for not being able to have any children would have been 0.15, meaning I would have traded 6 years of my remaining 40 in order to have a family. At societal willingness to pay for one healthy life year at £20k, this means that IVF would have been a good societal buy at any cost up to £120k per first child produced or about £24k per cycle (ignoring discounting and assuming that there was no chance of conceiving without help). However, the cost per cycle would have to be £600 at a societal threshold of £500 per healthy life year, which would be considered high in many really low-income countries. These threshold costs for a cycle of treatment would all have to be about ten times lower if benefits are discounted at 6%. It would be interesting to perform some discrete choice trade-offs in randomly selected groups from different countries.

    — Richard Lilford, Director CLAHRC WM

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