Bridging the Gap - Health Equity for all

State of the ART: Assisted Conception’s Growing Role in Family Planning

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11 Dec 2023, 1:00 pm

More and more men are joining the 1% (though not the fun kind): the broader umbrella of reproductive issues in men is crawling forward at a rate of around 1% per year in the West, encompassing problems like declining sperm quality and counts, waning testosterone levels, and higher rates of testicular cancer and erectile dysfunction. Rising infertility is alarming scientists over how we’ll be able to sustainably reproduce if the trend continues unabated. In the US, researchers have found that 12%–15% of couples are unable to conceive after 1 year of unprotected sex, and after 2 years, 10% will still not be successful. Couples under 30 who are in generally good health are able to conceive within 3 months at a rate of between 40% and 60%. With increasing frustration comes a growing interest in alternatives, and assisted reproductive technology (ART) is fast becoming a normal part of American family planning: four decades after the first test-tube baby, Louise Brown, was born, one-third of Americans report that they or someone they know has used some kind of ART to help with conceiving a child. That was the finding of a Pew Research study in 2018, and the numbers haven’t slowed down since, with only a minor exception for the pandemic. The American Society of Reproductive Medicine’s report exploring ART uptake during 2020 found that 73,000 babies were born via this technology that year, just a slight dip in the use of these services despite the pressures of a world-changing event. ART includes all fertility treatments in which eggs or embryos are handled. Typically, this involves surgically extracting eggs from a woman’s ovaries, mixing them with sperm in the lab, and then returning the product to the donor’s body (or that of another woman). Around 2% of all babies born in the US every year are conceived using ART, and uptake has doubled in the last decade. Research evaluating the market size of ART suggests it is set for massive growth by 2030, with estimates ranging in value from $41.4–$50.1 billion. Although increasing infertility is the prime reason for this growth, new developments in technology are also promoting uptake. As an example, AI and machine learning capabilities in research and development are expected to deliver superior outcomes for patients in the years to come. For thousands of couples, ART is a near-miracle that helped them to realize their dreams by alleviating the burden of infertility. It’s far from perfect, however, as higher rates of multiple pregnancies (twins), preterm delivery, and low-birth weight are associated with ART. It also doesn’t guarantee success: across different age brackets, the rates of success vary greatly. <figure><img alt="" src="https://cdn.storymd.com/optimized/8okj8MU4A7/thumbnail.png" /> <figcaption>Radiation and Male Fertility. Source: Kesari, K.K., Agarwal, A. & Henkel, R. Radiations and male fertility. Reprod Biol Endocrinol 16, 118 (2018). https://doi.org/10.1186/s12958-018-0431-1 </figcaption> </figure> <h2>Demographics of ART users</h2> The 2018 report by the Pew Research Center contained some interesting findings on what the average ART patient looks like. Folks with higher education were more likely to solicit these services: 43% of those with a bachelor’s degree reported some experience with fertility treatment (either directly or someone close to them), and that figure rises to 56% for those with a postgraduate degree. White women are significantly more likely than black or Hispanic women to have either undergone fertility treatment or know someone who has (37% versus 22% and 26%, respectively). Women aged between 35 and 44 represent the biggest share of patients, and inside this age bracket, white women are again disproportionately higher: 12% said they have directly undergone fertility treatment, compared to 3% black and 5% Hispanic. Around half of people with a family income of $75,000 or higher had at least some form of exposure to the treatment. <h2>Types of ART</h2> <h3>In vitro fertilization (IVF)</h3> Representing around 99% of ART procedures, IVF is undoubtedly the main method for assisted conception. It involves the extraction of eggs and their fertilization in the lab, and following this, specialists perform an embryo transfer to plant the resulting embryo in an individual’s uterus. In terms of success rates of intended egg retrievals that resulted in live-birth deliveries, the CDC’s 2019 data breaks it down in terms of age group: <ul> <li><35: 52.7%</li> <li>35–37: 38%</li> <li>38–40: 24.4%</li> <li>>40: 7.9%</li> </ul> Clearly, there is a steep drop as age creeps in. This is important to be aware of given that an IVF cycle can cost $12,000 or more, and there are potentially additional costs on top that could rack up even more debt. Multiple cycles may be needed to achieve pregnancy, but for some people, the gamble won’t payoff. Figuring out your own odds and whether it’s worth taking the financial and emotional risk of IVF can be daunting. Thankfully, the CDC has put together a useful tool for estimating your odds of success that accounts for your age, weight, history of pregnancies, and more. Google “IVF Success Estimator” to check it out for yourself. IVF carries some possible complications you should know about: <ul> <li>Multiple pregnancies. Because the IVF process often involves the transfer of multiple embryos to boost the chances of a successful pregnancy, there is an increased rate of multiple pregnancies in women who go this route. The Canadian government states that as much as 30% of IVF pregnancies may result in multiples.</li> <li> Ovarian hyperstimulation syndrome (OHSS). Although rare, this syndrome is caused by excessively elevated hormone levels after using medication designed to stimulate the ovaries to produce eggs. OHSS can cause bloating, nausea, and swelling of the abdomen, as well as blood clots or vomiting in its more severe form.</li> <li>Ectopic pregnancy. When the embryo settles outside the womb, where it is unable to survive.</li> </ul> <figure><img alt="" src="https://cdn.storymd.com/optimized/7ogLkZcjdx/thumbnail.jpg" /> <figcaption>In Vitro Fertilization. Source: AliciaKristinaLuboch/Wikimedia</figcaption> </figure> <h3>Other types of ART</h3> There are a number of reasons why someone may go down an alternative ART route. For some, their medical situation is such that they would have a better chance of achieving pregnancy with a niche technique, while for others they opt for one of these methods based on their religious beliefs. Sometimes people’s insurance may only cover a certain type of ART, so they must go pick the one available to them. Some examples include: <ul> <li>Gamete intrafallopian transfer (GIFT). Involves collecting eggs from the ovaries and then putting them in a thin tube along with sperm. Using laparoscopic surgery, this combo of gametes is placed into the fallopian tubes. Since there is no IVF procedure, the patient does not have to pick an embryo to transfer.</li> <li>Zygote Intrafallopian Transfer (ZIFT). A combination of IVF and GIFT. Using IVF methods, eggs are collected, stimulated, and then mixed with sperm in the lab before transfer as zygotes to the fallopian tubes (instead of the uterus). The benefit here is for those with damaged fallopian tubes as it may help them to achieve pregnancy. </li> <li>Pronuclear stage tubal transfer (PROST). Similar to ZIFT except that it involves the transfer of a fertilized egg to the fallopian tube before cell division begins.</li> </ul> <h2>ART’s future and long-term concerns</h2> Since ART came into being, over 8 million babies have been delivered worldwide using this technology, and its use is only increasing. With growing infertility issues and couples delaying the age of conception in industrialized countries, ART use will continue to rise, though it’s debated by just how much. One expert who has thrown her hat into the fray is Shanna Swan, a professor of environmental medicine and public health at Mount Sinai School of Medicine in New York City. Her specialization is fertility trends, and she published a book in 2017 exploring the drop off in sperm concentration in male ejaculate based on the findings of a 2017 paper she authored. The big finding was that concentrations had declined by an average of 1.4% worldwide between 1973 and 2011. “That’s an overall decline of 52% and it shows no sign of tapering off,” said Swan in an interview. “If it continues at this rate, the human race will be unable to reproduce itself and by 2050, many couples will have to turn to technology.” A November 2022 meta-analysis published in Human Reproduction Update produced a similar figure, saying that sperm counts have declined by over 60% since 1972. A 2022 editorial on the future of IVF argued that its growing use “…will transform the way a substantial proportion of the human species procreates”. The authors added that, in the near future, as much as 10% of children will be born via IVF in many parts of the world. The paper listed current figures for global regions on the percentage of newborns delivered via IVF as follows: <ul> <li>5% for European nations where IVF is accessible and/or covered by insurance</li> <li>4.1% for Australia and New Zealand</li> <li>1.9% for the US</li> <li>1.7% for China</li> </ul> As long as barriers to access continue to weaken, growth in use should rise for decades, according to the authors. Advancements in the field that make the process more cost-effective could be the biggest catalyst in this regard, as building, staffing, and operating IVF labs account for a huge proportion of the costs, which in turn leads to unequal access and inconsistent outcomes. Automated technologies could change that, as reliance on trained individuals and their inherent costs could be largely eliminated. For example, microfluidic sperm-sorting devices and automated sperm analyzers have already been introduced into some IVF practices. In the US, there have been calls by experts in the field to mandate insurance coverage for ART in order to lower cost-related barriers. Both private insurers and Medicaid would fall under this idea, but policy shifts would have to go further to assist people with managing work conflicts and family leave. An outlying issue is the long-term health and wellbeing of children born through ART procedures. The first generation of ART kids is now only reaching their forties, so we don’t have the full picture on whether there are long-term effects on their health. There is reason for concern here as there is a wealth of evidence demonstrating that lifelong health can be influenced by poor conditions during development, such as abnormalities in the structure or functioning of the placenta. This is an ongoing area of study, and once ART children start hitting their senior years (>65), it’s possible some consequences may emerge since fetal programming can still have an effect at this age. <h2>More on Assisted Reproductive Technology</h2><ul><li><a href="https://soulivity.storymd.com/journal/qj3584lcam-assisted-reproductive-technology" target="_blank">The Types of Assisted Reproductive Technologies (ART)</a></li><li><a href="https://soulivity.storymd.com/journal/jbrdqadt2w-in-vitro-fertilization" target="_blank">Preparing for In Vitro Fertilization: How It Works and What to Expect</a></li><li><a href="https://soulivity.storymd.com/journal/m8lbzp6cpj-intracytoplasmic-sperm-injection" target="_blank">Intracytoplasmic Sperm Injection (ICSI) to Treat Infertility</a></li></ul>

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