Don't dismiss conflict-of-interest concerns in IVF, they have a basis

It’s estimated over 5 million children have been born worldwide as a result of assisted reproductive technology treatments. Assisted reproductive technology, an umbrella term that includes in vitro fertilisation (IVF), is a highly profitable global industry, and fertility clinics are increasingly regarded as an attractive investment option.

In 2014, two major IVF clinics - Virtus and Monash IVF — floated on the stock exchange. Excited financial analysts observed at the time that:

people will pay almost anything to have a baby.

Over the past 12 months, there have been numerous critical media analyses of the IVF industry in Australia, including Monday night’s ABC Four Corners program, The Baby Business. The episode suggested IVF doctors are recommending treatments that are expensive, unsafe and likely to be futile.

The following morning the Fertility Society of Australia rejected these assertions, saying:

Four Corners presented no evidence to support these claims.

One of the claims made in the program was that IVF doctors have a financial incentive to treat women with the more invasive practice of IVF. The program suggested this financial incentive conflicts with the doctor’s duty of care towards the patient.

Four Corners highlighted the conflicted nature of commercialised IVF, where some IVF doctors are more concerned about their own interests (making money for themselves or their clinics) than they are about their patients.

Not surprisingly, the Fertility Society of Australia strongly denied such conflicts of interest exist. It argued that the profession is both highly ethical and highly regulated.

While it is certainly a big call to claim some IVF doctors may not be sufficiently committed to their patients, the possibility that practice is being shaped — at least in part — by conflict of interest cannot simply be dismissed. There are three key reasons individuals working in the IVF industry, and the industry more broadly, may be perceived to be conflicted.

First, every time a doctor advises patients to consider IVF treatment, he or she profits financially from the recommendation. While all Australian doctors receive fees for their services, many IVF doctors also own shares in assisted reproductive technology companies, so they receive passive income that reflects the amount of assisted reproductive technology the company sells.

It is also worth noting that, as employees of publicly listed companies, doctors at clinics such as Monash IVF, according to their code of conduct, must:

recognise that (their) primary responsibility is to the Company and its shareholders as a whole.

It is therefore not unreasonable for people to be concerned some clinicians may be motivated (perhaps unconsciously) by financial conflicts of interest to make decisions that may not be in the best interests of their patients.

Second, there appears to be a lack of transparency about IVF success rates. Success, as measured by a live birth, is very dependent on age and the reason for seeking assistance.

In the youngest age bracket in Australia and New Zealand in 2013, the live birth per cycle rate was 27%. In the oldest it was between 1% and 5%, depending on whether a fresh or frozen egg was used. It is more likely that a cycle will result in failure than not, and some argue there is a lack of transparency about the likelihood of a live birth.

A striking example of this was seen on Four Corners when Dr Gab Kovacs, ex-medical director of Monash IVF, claimed:

I know that if you hang in there you get pregnant, because one of my patients got pregnant after 37 cycles. And, ah, so I encourage people to stay on.

While it is quite possible this woman made a fully informed decision to undergo this number of cycles, Dr Kovacs’ subsequent claim that he couldn’t say “no” and had no choice but to continue to offer the woman what she wanted inevitably makes one wonder what she knew about her real chances of success.

A third reason for concern about conflicts of interest, and one that might distinguish conflicts of interest in IVF from those in other medical settings, is the potential for exploitation of strong personal and social values associated with reproduction.

A strong discourse of hope runs through the IVF industry, and people seeking assisted reproductive technology are often very vulnerable. The profit motive of these companies has the potential to exploit these cultural norms and social pressures for ends that are not necessarily in the best interest of patients.

There are now two positions being taken: by those who consider some IVF practices are exploitative and unethical, and by those who consider that conflicts of interest are inherent in medical practice and are sufficiently well managed.

Rather than simply dismissing concerns about conflicts of interest, as the Fertility Society of Australia has just done, IVF specialists, ethicists and other stakeholders need to create a forum in which these concerns can be discussed openly and constructively.