Despair born of baby delay

More New Zealand couples are turning to medical science to help them have children. CARROLL DU CHATEAU asks why and looks at the human and financial cost.

The movie Maybe Baby made fertility treatment look amusing. Hugh Lawrie remained besotted with his gorgeous wife despite her urgent demands for sex at short notice and their private lives seemed to flourish - for a while at least.

But the reality is far less attractive. It is a rare woman who, when propped up on pillows with her legs in the air, looks as good as Joely Richardson. And even the most swashbuckling young husband can be reduced to a quivering wreck when presented with a warm jar, a copy of Ralph and asked to deliver.

But that undignified fate, say Auckland's band of world-class infertility experts, is where many couples are heading as they wait longer and longer to start their families.

Today one in six couples experiences some form of infertility and the problem is growing, says Guy Gudex, the doctor who heads Auckland's public service, Fertility Plus.

Here, in this homely, rather cramped building on the old Green Lane Hospital site, one floor below the Epsom Day Hospital where most of the city's abortions are performed, a team of dedicated doctors, scientists and nurses will this year carry out around 250 in vitro fertilisation (IVF) procedures - half of them paid for by the State.

Down the road at the elegant new Ascot Hospital overlooking the velvet green ribbon of racetrack round Ellerslie racecourse, the hospital's chairman Richard Fisher and his partner Freddie Graham run a second, much swisher, clinic, Fertility Associates.

Fisher and Graham, New Zealand's glamorous pioneers of high-tech infertility services, carried out Auckland's first IVF procedure in 1984. Although they left National Women's Hospital in 1997 their Fertility Associates team still does half the publicly funded and most of the private work in Auckland, carrying out around 400 IVF procedures a year.

Fertility Associates also runs clinics on the North Shore, and in Hamilton and Wellington. At between $5500 and $6000 per IVF cycle, including drugs, Fertility Plus and Fertility Associates' private prices are almost identical and success rates comparable.

Last year government fertility funding doubled to $5.9 million, so allowing all women under 40 who score 65 or more in a complicated points test, to have one course of state-funded IVF or four non-IVF treatments.

Why the surge in infertility? Two main reasons says Gudex. "Each decade the maternal age for reproducing the first child goes up by three years. The average age for a first child in New Zealand is now 30."

While 30 may sound young to start a family and we have all heard stories of 60-year-olds giving birth, from our ovaries' point of view, 30 is getting into amber light territory.

"By 38 women don't have many years of good fertility left," says Gudex. "If a group of women started trying at 20, between 90 and 93 per cent of them would get pregnant in the end ... By 38 that chance drops significantly."

Fisher agrees that women are leaving first pregnancies perilously late. However, as he points out, things are looking up for couples who have trouble conceiving. Assisted reproductive techniques have improved swiftly, particularly over the past two years, mainly because of "subtle" changes in embryology lab and implantation techniques.

"When we started in the mid-80s there was a seven to eight-year waiting list and a 7 per cent chance of having a baby. During the 90s, 15 to 20 per cent was the norm and in the last couple of years the best units (including FA) are doing 25 per cent."

But as Fisher points out, the real trouble starts when women reach 38 and fertility rates fall sharply. By the time women get to 42 even the most brilliant procedures have just a 5 per cent chance of success.

Which is where the controversial Fish method of testing embryos to ensure chromosomes are normal comes in. While the Fish method means discarding embryos before implantation, Fisher says those embryos are not viable in the first place. And by screening for abnormalities at petri dish stage, doctors can drastically cut the incidence of miscarriage.

Sixty per cent of embryos from a woman of 40 will be too abnormal to implant - and only 20 per cent destined for success. As Fisher says, "It's about trying to lessen the grief. Going through something like IVF and then miscarrying is almost worse than not having conceived at all."

For those couples who do become pregnant, advanced fertility techniques are like a gift from God. Take Tracy Lamb and her husband David Joplin who produced healthy triplets 15 months ago.

At 38 Tracy was a senior solicitor (highly stressed lawyers are common at fertility clinics) and David a computer consultant who routinely worked a couple of nights a week. The couple had met and married relatively late then waited until their careers were established before trying for children. And nothing happened.

Their GP advised to let nature take its course - "80 per cent of couples conceive within a year" - before they headed for the Fertility Associates clinic in Newtown, Wellington.

"It was quite harrowing, you really have to be dedicated," says Tracy. First step was to lose five kilos, move into a less stressful job and adopt a relaxed "it doesn't really matter" attitude.

"We went on the AIH (artificial insemination by husband's sperm) programme which meant blood tests almost every second day," she says. "I had patches all over the insides of my elbows and I'd struggle back to work. Then came the DIY injections, which cost $300 a month, that I had to inject into my abdomen at a certain time each day."

Looking back, she says moving on to the full IVF programme, while more expensive, was a relief. "It was a wonderful experience. Unlike the other process, what they try and do is shut down your hormone system so it's actually controlled by drugs."

First came two weeks of follicle stimulating hormones to fool the body into producing extra eggs; second the doctors picked up ripe eggs using a hair-fine needle, microscope and ultrasound guidance. Two days later Hutton returned the fertilised embryos to Tracy's uterus and, after two weeks of careful monitoring they confirmed she was pregnant.

"It's a day I'll never forget," she says. "I finally screwed up the courage to ring them. The nurse didn't tell me at first so I had to ask. 'Yes, you're pregnant,' she said. We were over the moon."

Six weeks later when a scan showed three tiny blips on the screen Tracy and David were still overjoyed. "We were delighted. We saw it as a gift from God - a family all in one."

Despite the joy, as with most multiples, the pregnancy was short and tempestuous. After a second bleeding scare at 14 weeks Tracy left work and 10 weeks later was admitted to Wellington Hospital after Philip, "the lead baby," developed growth problems.

After five weeks of bed-rest the triplets were delivered by caesarean section. All three, Philip 800g, Vanessa 1.5kg and Sarah 1.3kg were small but healthy. Only Philip needed oxygen, but all three needed hospital care and incubators to see them through.

The couple see those eight weeks as a wonderful oasis when they could learn childcare and get to know their babies, but what about the cost, the demand on neo-natal wards and long-term health of the tiniest infants?

According to neo-natologist David Knight of National Women's Newborn Intensive Care Unit, IVF has had only a small impact on multiple birth statistics.

"As far as IVF is concerned we're very lucky in Auckland. All our clinics are very responsible. We do not get the extremes of multiple births they get in the States. Technologically, our fertility experts are at the forefront, but they're very ethical - not trying to push the boundaries ethically and morally like some IVF people overseas."

In 2000 the family-friendly unit with its teacher-supervised sibling playroom admitted six sets of triplets and 26 sets of twins under 32 weeks' gestation. Of those, one set of triplets and four sets of twins were the result of IVF. In all, 11 of the 200 babies born more than two months prematurely, were the result of IVF or Gift (where unfertilised eggs plus sperm are transferred to the fallopian tube for conception to take place).

"So it's a bit more work, the unit's busy when we have two sets of twins, but not enormous."

According to Gladys Billing, president of the New Zealand Multiple Birth Association, the national impact of fertility treatment is higher. "Today one-third of twins, three-quarters of triplets and all quads are the result of fertility treatments."

Certainly New Zealand's incidence of multiples has risen. In 1990 one in 85 births resulted in twins and one in 5000 triplets. By 1998 one in 65 resulted in twins and one in 4600 triplets.

As for cost, one of these tiny 24-week babies will have cost between $50,000 and $100,000 by the time it goes home after about 12 to 14 weeks of nursing. Those with ongoing problems cost more.

Health outcomes for premature babies have, however, improved dramatically with modern paediatric techniques.

"In 1985-86, 20 per cent of babies under 1000 grams had severe disabilities," says Knight. "Now we're probably running at 7-8 per cent. Survival for babies of 24 or 25 weeks' gestation has moved from 50 per cent in the late 80s to 75 per cent.

Bringing up triplets is a difficult and expensive business. All multiple pregnancies are high risk, premature delivery is common and antenatal care and delivery options are virtually taken away.

Tracy and David moved to a larger house, bought as much baby equipment as they could second-hand, and hired a former Karitane nurse to help get the triplets into a workable routine.

"By making sure they slept we were able to cope and get some balance in our lives," says Tracy. "And while they're sleeping they're growing." The couple now have a full-time nanny, Nicola Halstead. Tracy is back at work and life is a joy. "They're very easy babies. We've had no developmental problems, we're very, very blessed."

And Tracy's message to other hopeful parents: "Try conceiving before 35, but if you're over, don't give up. There's a huge misconception that anyone can have a baby well into their mid-40s without difficulty, that you can have it all. We were dumbfounded when we were told that wasn't the case.

"Also, check your weight, adopt a relaxed attitude and have some balance in your work life."

The second major problem, which affects half the couples Gudex sees, relates to a fall in male reproductive health - that is, the proportion of malformed and dead sperm produced by modern men, plus a higher incidence of men with undescended testicles.

The sperm problem is relatively new. Ten years ago a woman was put through a battery of tests before fertility experts even started to look at her husband's sperm quality, now doctors carry out simultaneous sperm quality and blood tests to establish whether the woman is producing eggs.

"We have pretty good evidence that from America and England that [the drop in sperm quality] relates to environmental issues," says Gudex. "That toxins are going to turn out fairly relevant to male fertility."

In other words some scientists say that insecticides, fungicides, chemical oestrogens and PCBs are possibly getting into the male reproductive system, killing and maiming sperm. It is a problem, says Gudex, that when combined with things such as endometriosis, smoking and maturity add up to serious trouble.

But for the high-tech specialists, sperm quality is one of the easiest fertility problems to overcome. Says Fisher, with his typically medical approach, "There's such a big reserve - so many spare in there. Nowadays, as long as a man has as many sperm as his wife has eggs, that's all you need."

It's this kind of "can do" attitude that has kept a young couple we will call Jill and Ben coming back to Fertility Associates year after year, trying for a brother or sister for their 6-year-old daughter.

"I went to Fertility Associates 18 months after Maddy was born and they started me on Clomiphene [to stimulate the ovaries] a year later," says Jill.

Next came a laparoscopy (keyhole surgery to check the uterus and fallopian tubes) which cleared some endometriosis around her uterus, followed by pregnancy - and a miscarriage after 11 weeks.

And then nothing.

"That was four years ago," says Jill, the catch still in her voice "it was really upsetting."

The first IVF treatment tried was six cycles of ovarian stimulation and artificial insemination with Ben's sperm (AIH) which also failed. By then Jill was getting desperate. The couple moved on to IVF but after three cycles she was exhausted emotionally and physically - and still not pregnant.

"I was injecting myself daily for six weeks," she explains. "Then they collect the eggs, fertilise them and return them a few days later."

Even remembering is heart-breaking. "The emotional cost is huge," she says. "Getting negative results is devastating. You get your period and sit on the loo just sobbing. And your family finds it really hard to cope.

"All the drugs you take do make you lose your mind at times. It's dreadful on your sex life, spontaneity goes out the window and even though my husband was quite understanding it's just not the same for men.

"I found the whole thing so isolating, none of my girlfriends really understood. Even worse, I'd look at the embryos dividing under the microscope. It was so exciting - there's so much hope. The doctors would say 'They're perfect embryos, things are looking good, they couldn't be better you've got a really good chance' - and still they didn't take."

Today, a year after her last IVF treatment with her life back in perspective, ("I get my period now and don't cry") Jill is about to have her last embryos, which have been waiting like precious jewels in Fertility Associates' chiller, implanted in her uterus in a final, last-ditch attempt to have a baby.

For the past few months she has been working on her general health, seeing an acupuncturist, taking Chinese herbs, even having another laparoscopy to make sure her fallopian tubes are clear, giving those precious thawed embryos the best-possible chance of survival.

"Ironically now that they've changed the criteria I could have a complete IVF procedure on state funding [rather than simply having the frozen embryos inserted]" she says.

"But I can't go through all that again. Even though the staff at Fertility Associates have been marvellous, the docs so compassionate and I have so much admiration for them, I just can't do it again."

- Additional research by MICHELLE MANN