Assisted reproduction: step by step through an obstacle course

BarcelonaOne in six people suffers from infertility problems, according to the World Health Organization (WHO), and one in 10 children are now born through assisted reproduction techniques in Spain—in 2022, there were 39,546 babies, according to the Spanish Fertility Society (SEF), out of 16,719 born. in vitro (IVF) and 31,635 artificial inseminations (AI). Although the success of these techniques is indisputable, the figures already show that going through an assisted reproduction process is not a piece of cake. The success rates, which depend on age and other factors, are 13.7% in the case of artificial insemination, and 43.8% in each cycle ofin vitro which reaches embryo transfer (when the embryo is placed in the uterus), which occurs in 60% of the cycles initiated.

Francesc Fàbregues, a specialist in gynecology and obstetrics at Hospital Clínic, takes responsibility. "There have been important advances, access to the techniques is easy, there has been a lot of innovation. Perhaps that's why, in some ways, we've conveyed that it was easier than it really was," he explains. "We've trivialized it a bit, and it's not. It has a brutal emotional toll, terrible uncertainties, and everything." The doctor is in favor of explaining the process very well from the beginning because it can bring "frustration and disillusionment." Behind the doctor, in the office, there are a pile of photographs of babies born thanks to assisted reproduction techniques. Although there are many, Fàbregues concludes: "If we hung the failures on a wall, it would perhaps take up much more space than what you see there." Each stimulation is, he says, "like a game of cards": "There are new eggs; sometimes they fertilize, sometimes they implant, and sometimes they don't."

"It's a false myth to think that nothing happens if I postpone motherhood; I turn 40 and have IVF," adds Ana Polo, head of the reproductive medicine service at the Hospital de Sant Pau and the Fundació Puigvert, who points out that at childbearing age, between 20 and 25 years old, the fertility rate is unchanged without any impact on fertility. Although assisted reproduction is improving results a lot, delaying motherhood causes these rates to drop, which at 40 years old are close to 20% per transfer with a in vitroEven if the target is met, abortions still occur in 22% of cases, a figure similar to that of natural pregnancies.

An obstacle course

The emotional impact of ovarian stimulation—up to three simultaneous hormone injections over a period of 10-12 days on a regular schedule—the discomfort and incapacity for 24 to 48 hours after ovarian puncture (an operation under anesthetic sedation) and the anxiety of taking the so-called beta5 pregnancy test—are surely the most difficult phases of IVF. It's a process that Polo describes as "an obstacle course" (see infographic) and that can have a psychological impact on patients. Fàbregues also states that it puts couples "in a hostile situation that is very difficult to manage," and "some separate during the procedure."

To this is added the economic cost if it is done through private healthcare, in which a process ofin vitro It can cost approximately €8,000 per cycle, including the cost of the medication. Patients who have exhausted both attempts in the public health system, those over 40 years old, or those who have already had a child through a natural pregnancy are required to be on the waiting list. Also on the waiting list are those who cannot afford the public health system, which currently lasts approximately 6 to 12 months, awaiting a single list that serves as an entry point for all assisted reproduction services in Catalan hospitals.

A social problem

Since "the biological clock doesn't coincide with the social clock," Polo believes it's necessary to promote sexual education so that women "know when they will begin to lose fertility and can plan their children." However, social reality cannot be ignored, she points out: "We will increasingly have older women. Spain is the country with the highest number of pregnant women over 40 who are having children in Europe."

And experts agree that assisted reproduction would barely exist if there weren't an increasingly exacerbated delay in childbearing. The reasons, according to the latest fertility survey by the National Institute of Statistics (INE), are the combination of work-related reasons, work-life balance, and economic reasons, in 30% of cases; in addition to not having a stable partner. "We are solving a social problem, not a doctor," says Fàbregues.