I saw this article in this week's New Scientist, and while superficially it's great that they're helping infertile couples (if you're into touchy-feely human interest stories), I did get a darkly comical vibe from the entire thing, especially the bolded bit.POOR and war-torn, Sudan might be the last place you would expect to find an experiment in cutting-edge fertility treatments. But by the end of October, a clinic at the University of Khartoum plans to offer in vitro fertilisation to couples for less than $300, a fraction of its cost in the west.
The clinic is one of three funded by the Low Cost IVF Foundation (LCIF) of Massagno, Switzerland, the brainchild of IVF pioneer Alan Trounson, who is now president of the California Institute for Regenerative Medicine. The other clinics are in Arusha, Tanzania, and Cape Town, South Africa.
Meanwhile a task force set up by the European Society of Human Reproduction and Embryology (ESHRE) is also set to make IVF affordable for African couples, by vastly simplifying conventional IVF technologies. By the end of the year it plans to begin offering IVF at clinics in Cairo and Alexandria, in Egypt, for around $360.
If successful, such efforts could lower the cost of IVF everywhere. In the US, the price of one round of treatment can be up to $12,000 and is rarely covered by health insurance. In the UK, it costs about £5000 ($8000), which the National Health Service may or may not pay for, depending on where a couple lives.
"Most of what we do in the western world is overkill," says Jonathan Van Blerkom of the University of Colorado at Boulder, a member of the ESHRE team. "If you get these procedures down to a low cost and they are successful, you cannot justify charging $12,000 for an IVF cycle."
It may come as a surprise that the revolution in low-cost IVF is beginning in Africa, given its high birth rate. However, some 10 to 30 per cent of African couples are infertile, often as a result of untreated sexually transmitted diseases, botched abortions and post-delivery pelvic infections. In Sudan, 20 per cent are infertile, double the rate in Europe and the US.
What's more, childless women in many African countries can face public ridicule, accusations of witchcraft, loss of financial support, abandonment and divorce, not to speak of their own shame and depression. "If you are not able to conceive, you are not [considered] normal," says gynaecologist Abdelrahim Obaid Fadl Allah of the University of Khartoum clinic.
So how do the ESHRE group and the LCIF propose to lower the cost of IVF so drastically? "What we did was to say, 'let's take all the complicated high technology out of the process'," says Trounson. "The idea is to provide a service rather than a business."
What we did was to say, 'let's take the complicated high technology out of the process'
He and three other doctors who set up the LCIF opted for government-run clinics whose physicians are paid fixed salaries, and donated $30,000 from their own pockets to each of the three clinics to fit them with basic equipment such as second-hand ultrasound machines. The ESHRE group's approach is similar. "We broke the various procedures in IVF down to their essentials," says Van Blerkom.
For example, to stimulate egg production, many clinics in the west prescribe genetically engineered or "recombinant" forms of follicle-stimulating hormone (FSH) because it can cause women to release a dozen or more eggs per cycle. That means some embryos can be frozen in case the first round of IVF doesn't work. Such drugs have the disadvantage of being enormously expensive, sometimes costing thousands of dollars per round of treatment.
Fewer eggs
In contrast, clomiphene is a generic drug which prompts the pituitary gland to pump out more FSH and costs just $11 for one round of treatment. It was used very successfully in the early years of IVF, inducing maturation of up to four viable eggs per cycle. That's far fewer than with injecting FSH directly, but since low-cost IVF facilities are unlikely to have the equipment or liquid nitrogen for freezing extra embryos, fewer eggs are needed anyway.
Using clomiphene, the ESHRE group plans to transfer no more than two embryos to the woman's uterus, while the LCIF initiative plans to transfer only one.
Combined with not freezing extra eggs, this reduces the chance of a successful pregnancy, but as clomiphene has fewer side effects than recombinant FSH, women may be more likely try further rounds of IVF if earlier attempts fail. The ESHRE group estimates this will achieve a pregnancy rate of 15 to 20 per cent, lower than the European rate of 25 per cent and the US figure of 35 per cent.
Another big cost-saving has come in the use of incubators. Western doctors select the best embryos by allowing them to incubate for up to six days; those that fail to divide, or which show cellular defects, are then weeded out and the best transferred. But certain defects - multiple cell nuclei, for example - can be seen as early as the second day, and some embryos which fail in the artificial environment of a culture dish will develop normally in utero, according to Van Blerkom. On this basis, the ESHRE group plans to transfer the embryo on the first or second day after fertilisation.
Incubators themselves can also be made cheaper. Australian company Cryologic sells portable table-top incubators for less than $1000. These lack the fancy electronics and ability to change temperature of standard incubators, but this is unnecessary for IVF. Van Blerkom has used one to successfully incubate embryos and found that the batteries can be recharged with solar panels, also useful in countries where electricity outages are common. Meanwhile, the LCIF is counting on warm water baths to incubate embryos.
One company argues that incubators can be avoided completely, since a natural one - the woman herself - is already walking around. INVO Bioscience of Beverly, Massachusetts, recently launched the INVOcell, a small plastic capsule into which fertilised eggs are placed together with culture media. The capsule, encased in a protective shell, is then inserted into a woman's vagina for three days, which keeps the embryos at the desired temperature. After removal, doctors select the two best embryos and transfer them to the woman's uterus.
The incubator capsule is inserted into a woman's vagina to keep the embryos at the right temperature
Company spokeswoman Katie Karloff claims that using the device - which costs between $85 in Africa and $185 in Europe - can cut the cost of IVF by half. It is also uniquely suited for places that frequently lose electrical power. Karloff reports that the INVOcell has now been used 85 times around the world, with 20 resulting pregnancies. The device has already reduced the price of IVF in clinics in Africa, South America, Pakistan and parts of the Middle East, she says.
There are other expensive materials that can be eliminated too. For example, in the west, developing embryos are usually placed in a Petri dish in a chamber infused with 5 per cent carbon dioxide. The gas is there to balance a chemical reaction occurring when bicarbonate is used as a buffer to maintain the pH of the culture medium. But cylinders of CO2 are expensive, and unnecessary if an embryo is incubated for only one or two days. Bicarbonate-free media can be used to maintain the pH instead.
Cut-price $900 microscopes for confirming cell division can be easily adapted for minimal-cost clinics, says Van Blerkom, as can portable digital ultrasound machines that sell for less than $5000 - far below the typical $400,000 price tag for machines in western IVF clinics.
The clinic in Khartoum is still in the process of installing its equipment, but already it has changed lives by offering simpler fertility procedures. These include intrauterine insemination (IUI), in which a woman is artificially inseminated with her partner's concentrated sperm. Embryologist Maisa Fathi El Fadil says the clinic has so far administered IUI to more than 500 couples, with about 10 to 15 per cent resulting in a successful pregnancy.
One such couple is Nahla Khidir, aged 34, and her husband Osman Khalid, 38. They married in 2006, and when no baby was born their families pestered them with questions and advice. "My wife was crying all day and my friends told me to marry again," Osman says. Tests showed that Nahla's reproductive system was normal, but his sperm had poor motility. After a course of clomiphene to stimulate egg production and one round of IUI, Nahla became pregnant and is due to give birth in September. "We are very happy," Osman says. "I feel as if I died and got up again to life."
Is it really a wise thing (or morally/ethically justifiable, for that matter) to help people reproduce above and beyond that's already going on in the third world?
The bit about cultural impetus to have kids was interesting to me, and likely has a lot to do with the overpopulation in the first place, as compared to Western nations where people aren't so hung up on having kids.
Rolling out cheap IVF just seems like it will compound an already existing problem.
Thoughts?
. In hindsight, I kinda wish it were IFVs instead.
