Saturday 21 January 2017

Ends with a birth issues

I am over 60 years old, so I am nearer the end than the beginning, so you'd expect me to be more focused on end-of-life issues than the other end. And you'd be correct: The Blob is very much more focused on death [the word used 100 times] than birth [used only 22 times]. This is partly because of the math alluded to in the first sentence but it has aspects of parity-of-esteem between the book-ends of life. We congratulate the parents and welcome the young shaver when a birth pops up/out in our circle. We do not congratulate the grown up children on the good death of their parents; this is because death is quite taboo, even in a country like Ireland where the business [wake, tea, ham sandwiches & fairy-cakes, removal, mass, burial, knees-up at the pub] is embedded in the culture.

For us, the children just appeared [nothing to do with me?]: one near the beginning of the normal range for procreation, technically a teenage pregnancy although not a teenage birth; and two towards its end. That was a blessing, especially as other friends and family had a harder, and more expensive, time of it. For one good friend, the 'threat' of IVF was enough to frighten her uterus into action, and others in our circle went round their IVF cycles, round the houses and indeed round the world in the hope of getting with child. Because it's a saga, costs a lot of money, and is an emotional roller-coaster which doesn't always end well, you'd want to go to the best fertility clinic you can find. But which is best? 'What is best?' is an easier question, whose answer is: after much or little tweaking you have a full term pregnancy which delivers one healthy child with the requisite number of limbs and no extra chromosomes.

Jack Wilkinson, a PhD student and medical statistician from Manchester was on the wireless the other day because of his report in British Medical Journal Open Access BMJO. Wilkinson and his co-authors/supervisors, all men, have carried out a statistical analysis of the claims of various medically assisted reproduction MAR centres around Britain. On the radio, Wilkinson was well informed about the Irish MAR territory which has some significant differences from what pertains in our larger neighbour. One aspect is that the UK has a Health Service Ombudsman and a central  Human Fertilisation and Embryology Authority HEFA (which licenses and vets fertility clinics for the whole country) with its own Complaints Inspector. In Ireland it's more of a free-for-all and indeed at least two clinics advertise direct to consumers here on the wireless on a regular basis.

What the BMJO paper reveals is that it is really hard to compare different clinics; so that sub-fertile couples can make an evidence-informed choice about where to start their journey. This is mainly because of the blizzard of slightly different or poorly defined outcomes. What is required is a rate, which needs both a numerator (how many good whatevers] divided by a denominator [total whatevers]. Works also for bad whatevers - ovarian hyperstimulation syndrome; gestational diabetes; maternal death; multiple birth.  Clinics tend to prefer reporting successful pregnancy because the numbers are higher than successful birth which, as indicated about, is the only outcome worth paying for. The excess [pregnancy - birth] is a good case of the medical hubris in the phrase the procedure was successful but the patient died.

The obfuscation results in finding 51 different outcomes being reported by the 53 clinics which have any such data available. This includes 31 different ways of reporting pregnancy rates and 9 different ways to reporting live birth rates. You could calculate the latter by having as a denominator [anyone who has paid us money] but is more likely to be [per cycle started] or [per transfer procedure] which will discount the early failures. If per transfer procedure is used as the headline criterion then you'll get more multiple births - which occur with 25% of UK IVF outcomes -, while per embryo transferred will tend to limit this probably undesirable outcome. In the few cases where a clear comparison was carried out, it looked like competing clinics were using the same data so that their gaff looked better than the other crowd's. That will be familiar to car buyers where almost identical models are both portrayed as being better than the rival brand: this because of alloy wheels, that for the reversing camera. And as with cancer treatment or liver-transplants, you get better "success" rates if you only start with the most promising cases; and regretfully turn away the very old and those with a history of endometriosis.

But do you want to decide on such generic stats as "all births assisted" by this clinic. It might be that each clinic has a particular expertise or experience and one might better suit your particular case:
- are you really old: pushing menopause old ?
- or still young but not conceiving?
- are you obese?
- are there known fertility issues in your family?
- would twins or trips be a disaster?
- is it him?
- is the clinic in Scotland?
According to what I heard on the wireless, it is a sellers market in IVF. Clients come when they are at the end of their tether. They do their research; they find their best clinic is not round the corner from where they live; they take a week off work and stay in a hotel. The very nice woman from the clinic offers them the standard treatment model but also offers 'extras': more tests, screens, procedures and checks which can be added to the bill but maybe don't have demonstrable added value. If your basic IVF package costs £3950, would you begrudge an extra £500 for a year of embryo freezing [backup] or an extra £1000 for ICSI [for lazy sperm that can't get inside the egg and have to be injected]?

Ho hum, the biological imperatives of bearing your own children.
Feel free to get all judgmental about Annegret Raunigk scoring quads in extra time.

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