IVF science has come a long way, but it still favours the wealthy, writes Julie Robotham.
At this moment, almost 1000 human embryos are growing in test tubes across NSW. Only 40 or 50 will become a baby. Others will simply stop developing while more will be rejected by scientists because their cell division does not follow normal patterns. Some will be put on ice, laid down for the future. Of those returned to a would-be mother, fewer than one in three will result in a live, squalling infant.
But 14,000 Australian and New Zealand children made their way through those long odds to be born in 2009, according to figures released this week - the highest number of in vitro fertilisation (IVF) babies ever, nudging 4 per cent of the total birth rate and up 14 per cent on the previous year.
Techniques that a generation ago were considered outlandish have become unremarkable. Every primary school class is now more likely than not to contain a child conceived in a laboratory.
Australia ranks third in the world, after Denmark and Belgium, in the use of IVF treatments. The rate is roughly double that of Britain, treble New Zealand's and four times that of the United States.
Medicare subsidies for IVF tripled between 2003 and 2007 to $158.7 million, though they have since been restrained by new caps on entitlements last year.
The rise of IVF is also a triumph of medical free enterprise. Assisted reproductive technologies have grown into a hyper-modern industry that employs hundreds and works round the clock.
IVF in Australia is conducted almost entirely in the private sector, by increasingly entrepreneurial groups of doctors backed in many cases by blue-chip private equity companies with an eye to the sector's relentless growth and the federal government's underwriting.
''I came into medicine to care for individual patients, not to be in a competitive marketplace using modern marketing methods to compete against other people,'' says Professor Robert Norman, a South Australian fertility specialist.
And though his view may be coloured by his history - Norman watched the turbulent practitioner buyout and subsequent sale of a University of Adelaide IVF service he helped establish - he still holds it strongly: a conflict of interest may exist, Norman says, when clinics evaluate couples' infertility and also offer IVF treatment for a fee.
''There's a general thread in society that says, 'If I don't get pregnant I'll just go to an IVF company','' he says. ''[But] if you go to a sensible GP or gynaecologist you'll get good advice about things like lifestyle, intercourse frequency … from someone who's not offering an IVF service.''
Professor Michael Chapman is a director of IVF Australia. Along with Queensland Fertility Group and Melbourne IVF, its clinics - in 10 NSW locations - are backed by the Quadrant Private Equity vehicle IVF Holdings, whose website boasts their ''geographic diversification, critical mass and strong organic growth potential [and] integration benefit … with significant savings from sourcing in particular''.
Chapman's version of the benefits is quite different. He says secure finance supports investment in new technologies, such as polarised light microscopy to assess egg quality. ''We can tell you which eggs aren't going to get you a baby - almost 100 per cent [accurately],'' he says. Chapman is excited not by the revenue potential but because the technology helps him look after patients better - letting them down earlier in a treatment cycle doomed to fail. He concedes money has the potential to influence the type and intensity of treatment patients receive, but says that is no different to cardiology or orthopaedics.
''Any time there's a fee for service, a doctor's going to have some eye on what's going to be [gained] financially,'' Chapman says. ''But the goal is treating patients well.''
Doctors win kudos from their peers if they achieve pregnancies without turning on the big guns. ''IVF is a last resort,'' he says.
The per-patient payments clinic bosses make to doctors for the procedures they perform may subtly or less subtly favour IVF over milder treatments, such as intrauterine insemination (IUI), regardless of the reason for the couple's infertility.
Dr Mark Bowman is impatient with suggestions the rise in IVF might signify an unseemly rush to treatment. ''What research has progressively shown over two decades is that IVF, done properly, is for many people the most appropriate medical pathway,'' says the medical director of Genea, formerly Sydney IVF, still largely owned by doctors and other staff.
''The reality is, that treatment approach has the best chance of getting the person pregnant.''
But ethical fertility treatment, says Bowman, is ''not about mucking about with the simple stuff endlessly … Our society has decided infertility's an illness. This treatment happens to work very well.'' In an era of openness about illness, in which everything from cancer to depression is disclosed and sympathetically discussed, involuntary childlessness remains deeply stigmatising.
Sandra Dill, director of patient group Access Australia, says: ''Heirlooms aren't given to women who don't have children. It's not big things like real estate, which are distributed fairly. It's things like china tea-sets.''
A woman's inability to bring forth a child will ripple throughout her life, Dill says. Arguably that stigma is now riding higher than ever; IVF's public success may suggest that people who have no children have simply not tried or spent enough.
Dayna Smith, 44, had two embryos frozen three years ago, but she cannot afford to use them. She and her partner have cut expenses and are saving $50 to $100 a week from their modest income, in the hope they will be able to afford the procedure by April. ''Since the last transfer in January, I've been struggling with the reality that it may not happen and it's a pretty big thing to deal with,'' Smith says.
Caps introduced in 2010 to the Extended Medicare Safety Net scheme mean patients like Smith no longer receive automatic higher rebates beyond an annual threshold of healthcare usage.
For the government, the change ends a perverse incentive to accelerate treatment and reduces spending.
For Smith, it prolongs the agony. ''I have absolutely no idea what I'm going to do from here,'' she says.
In Australia, the opportunity to use reproductive technologies is skewed towards the wealthy. A Herald analysis of Medicare data shows 71 per cent of all IVF treatment cycles last year were performed on people who lived in areas rated among the most advantaged 40 per cent by the Australian Bureau of Statistics. People in the least advantaged 40 per cent of areas received only 13 per cent of IVF treatment. Those proportions have not budged in almost a decade.
In every other area of medicine in which the private sector is active - hip and knee replacements and childbirth, for example - a public hospital equivalent exists.
Generously, compared with other states, NSW funds one public unit, at Royal Prince Alfred Hospital, staffed by Genea's doctors. There are out-of-pocket costs but they are lower.
Tara Er has been on its waiting list since February. Her first appointment was in May. With luck, she may start an IVF cycle this month. If not, she will have to wait until next year as the service closes over Christmas.
But at 39, Er is racing the clock. She had two failed IVF attempts three years ago, through a private clinic. ''I'd have liked to keep going a couple of years ago but financially that was impossible,'' she says.
Since IVF is an accepted treatment for a recognised condition, should it not be offered routinely in public hospitals? The NSW Health Minister, Jillian Skinner, says: ''While I empathise with the issues faced by those experiencing infertility, I do ask that [hospital administrators] take into account the scarcity of our health dollars when determining priorities.''
At Michael Chapman's Kogarah clinic, one morning last month, a couple in their 30s sat across the desk with their toddler daughter. They have had two cycles of intrauterine insemination, but further attempts offer ''a declining return'', Chapman explains. IVF means a 35 to 40 per cent chance.
''We've already decided,'' said the woman. ''We're going for IVF.''
It is a happy transaction, with every chance of another baby.
But the 2009 figures show 851 women aged 45 or older attempted a pregnancy with their own eggs. Only four delivered a live baby. In each case, a doctor consented to a costly, invasive and almost certainly futile procedure.
Those everyday negotiations between fertility doctors and patients are the next ethical frontier for IVF, Norman says.