Doctors and patient advocates are calling for changes to “discriminatory” criteria that restrict access to IVF.
When New Zealand’s first test-tube baby was born 40 years ago this month, such was the secrecy surrounding the historic event that the birth was induced so it would happen on a quiet Sunday. The announcement was delayed for 10 days and members of the IVF team did not even visit the new mum on the ward for fear her identity would leak.
Although these were momentous times for New Zealand in other ways – the end of Muldoonism at a snap election in July; the arrival of David Lange and Rogernomics – the birth still created national headlines and reporters clamoured to know more about the history-making family. As a young medical reporter for the now-defunct Auckland Star, I waited for hours at the hospital to collect the first supplied photo of the instantly famous, but anonymous, baby.
For 25 years, Felicity and Stephen Bell and their daughter Amelia kept their secret, revealing their identity finally in 2009. It was no surprise that at a recent function at Auckland City Hospital to mark the June 24 anniversary of Amelia’s birth, the trio remained in the audience rather than taking the stage as organisers had hoped.
But now they have agreed to speak once again, to express their gratitude to the team that forged ahead with the IVF programme at National Women’s Hospital despite orders from the then Auckland Hospital Board that the treatment – which had begun without official sanction – should stop.
At 27, Felicity Bell had been trying for three years for a second baby before her specialist, Celia Liggins, wife of obstetric researcher Graham “Mont” Liggins, referred her to fertility doctor Freddie Graham and the IVF team.
Until IVF technologies arrived in New Zealand – the first “test-tube baby” was born in the UK in 1978 – there was no way for women with blocked or missing fallopian tubes to conceive. Adoption was the only alternative. Fertility aids were limited to ovulation-boosting treatments such as hormone injections and, later, oral clomiphene tablets, used for women who did not release eggs and did not have periods.
“Freddie would say, ‘Come at this time and don’t let anybody see you,’” says Bell. “When I was doing egg retrievals, they’d line you up in theatre, and he said, ‘If anyone talks to you, just say you’ve got women’s problems.’”
At least the secrecy meant she always had a room to herself.
Although she had about a 6% chance of having a baby with the new technique, Bell conceived on just her second cycle of treatment when just one egg was retrieved, fertilised and re-implanted. “I thought Freddie was the most amazing thing that walked the Earth. Because look what he did.”
The Bells told only a few trusted friends about the IVF treatment and did not raise Amelia to feel her conception made her special. They told her about it on her 10th birthday when the family was on their way to a party at National Women’s Hospital to mark the event. “We didn’t want to put her up there to make her different,” says Felicity. How she started her life was neither here nor there.”
Placards in protest
News that IVF had begun at National Women’s sparked protests from the Catholic Church, which regarded the treatment as “morally unacceptable” – and still does – and some feminists, who believed it was experimentation on women. Placard-waving protesters gathered outside the homes of Graham and his colleague Richard Fisher, and Fisher’s letterbox was blown up. Fisher says a neighbour squirted the demonstrators with her garden hose and told them to “fuck off back to Mt Roskill”. In those days, Mt Roskill was known as Auckland’s Bible Belt: conservative, white, working-class. “It was the biggest insult she could imagine,” he says.
“IVF got conflated with abortion. We were creating embryos and we were putting them back and they weren’t implanting [attaching to the wall of the uterus]. Therefore, we were killing babies.” On the contrary, he says, when the work started, they were unable to freeze embryos and were forbidden not to replace them in the mother.
The team would fertilise only the eggs the couple wanted implanted, so as success rates increased, so did multiple births. “Two good embryos meant a reasonable chance of two babies,” says Fisher. “I got really sick of being asked, ‘Have you ever thought about one thing or another, which would usually be an ethical issue, when we lived every day of our lives thinking about ethical issues. We never made a decision without talking about it.”
Before IVF began here, infertile couples had no options apart from adoption if their problems could not be medically or surgically treated. “Celia [Liggins] had the biggest fertility practice in Auckland and hated the fact that there was nothing you could do [for infertile couples].”
It made the team determined to proceed with the programme, despite the hospital board’s efforts to derail it. It helped that the treatment was launched not by hospital staff, but doctors employed by the University of Auckland’s postgraduate school of obstetrics and gynaecology, allowing its then head professor, Dennis Bonham, to ignore the edict.
The turning point in their ability to launch IVF came in early 1983 with the arrival from California of primate embryologist Pam Binkerd to work with Mont Liggins during a sabbatical year. Embryologists, who isolate and fertilise eggs and culture the embryos, are critical to the procedure and when Binkerd wrote to Liggins asking to work with him in Auckland, he knew she was the missing link they needed.
Liggins had been involved in the fertility treatment of Ann Lawson before the birth of her famous quins in 1965 but Graham says Liggins was not that enthused about the prospect of the test-tube baby service Graham had been advocating for about a year. “He didn’t get excited about many things but he knew I was. He handed me Pam’s letter and said, ‘Here’s a way of starting IVF, Freddie.’”
The first test-tube babies were conceived within a few months of Binkerd’s arrival. “We were very lucky,” says Graham. They were lucky, too, that when Binkerd returned to the US, they were able to replace her with a talented young scientist, John Peek.
Graham and Fisher, who was acting superintendent of National Women’s when Amelia Bell was born, became poster boys for public IVF – a Metro magazine story published in June 1984 was headlined “The glamorous gynaecologists”. It said the remarkable deeds of the hospital’s history, which included Sir William Liley’s first fetal blood transfusions and Liggins’ discovery that cortisol injections could mature the fetal heart before premature deliveries, “have barely prepared us for Doctors Graham, Bonham and Fisher, a trio whose combined brilliance, audacity and political nous is truly extraordinary”.
Fisher describes Graham and himself as “the prima donnas” of IVF, who benefited publicly from the unheralded expertise of the likes of Binkerd and Peek. “John was the entire corps de ballet. He could turn his hand to anything.”
But behind the scenes at National Women’s, the pair were becoming increasingly frustrated and disenchanted with the Auckland Hospital Board’s antagonism towards their work and the fear it would withdraw funding. “It was a constant threat,” Fisher recalls. “Every time we said we have a waiting list of X, we need more money, the board would reply saying there was ‘unlikely to be any increase in funding and the possibility we will cancel it’.”
The pressure led Graham and Fisher to mortgage their homes to establish the country’s first private IVF service, Fertility Associates, in 1987. By that time, the waiting list for public treatment had already stretched to seven years. The company now holds the contracts for the provision of all public IVF south of the Auckland area – 40% of IVF treatment nationally is private.
Around 2000 IVF babies are now born every year in New Zealand and about half a million worldwide, with the technology enlisted for almost all types of infertility. Success rates have risen dramatically since Felicity Bell conceived. Now, in women under 34 who have two egg cycles (the maximum number that can be publicly funded), the success rate is 70%. The fact she had already had a child, and was not yet 30, probably made Bell an ideal candidate for treatment.
Tight criteria
But under scrutiny now are the criteria for access to public treatment, which sets the maximum BMI for women at 32 and men at less than 40, and forces couples with unexplained fertility to try for five years before being treated. Doctors and patient representatives are calling for wider access.
University of Auckland professor of obstetrics and gynaecology Cindy Farquhar is the medical director of Fertility Plus, which provides mainly public but some private fertility treatment. She believes the BMI requirement discriminates against ethnicities with higher BMIs, such as Māori and Pasifika. Obesity is defined as a BMI over 30, but the average BMI of Pacific women is nearly 32.
“The criteria took the emotion out of it and the terrible judgment thing,” she says. “It weighted the system in a way that made a lot of sense. But I would like to see the criteria reviewed and be a bit more nuanced.
“It’s not that I want to go open slather on anyone having it, because as your BMI increases, your pregnancy complications increase. You’ll use more drugs, it’s more expensive and there are more complications.”
Obesity is associated with a greater incidence of gestational hypertension, diabetes and the delivery of babies who are large for their gestational age and at higher risk of breathing problems. Other exclusion criteria are smoking, alcohol abuse and vaping.
Farquhar says the number of publicly funded IVF cycles has been static since about 2005, despite population growth, but clinics are also using non-IVF fertility treatments as much as possible. These include sperm washing and intrauterine insemination, during which sperm is placed directly into the uterus.
Clinicians and community representatives lobbied the Ministry of Health to update the guidelines about five years ago, says John Peek, who helped devise the criteria which were introduced in 2000 and who also supports a review. He says the group wanted to “tweak” the eligible BMI to 36 and reduce the length of time couples with unexplained infertility had to wait for treatment. But the attempts failed, largely because expanding the criteria without increasing the funding meant some couples currently eligible would miss out on treatment.
Peek, who joined Graham and Fisher at Fertility Associates and became group operations manager before his retirement last September, says advances in IVF technology mean the BMI restriction and five-year wait for treatment for those with unexplained infertility are now outdated. “Better drugs and drug regimes for IVF stimulation in the past 10 years mean that people with a BMI at least up to 36 have the same chance of a baby as those with normal or lower BMI.”
At the time the criteria were formulated, people with three or four years of unexplained infertility still had about a 20% chance of having a baby each year – about the same chance as an IVF cycle, so it made sense to spend the money on people who had no chance of conceiving without it, he says. But now, couples have a 50% chance of conceiving from just one cycle if the woman is “relatively young” – say in her mid-30s. About 30% of couples have unexplained infertility when they begin IVF treatment.
Delayed start
Fertility New Zealand CEO Lydia Hemingway is one of the women who waited five years for IVF treatment after conceiving her first child naturally. She was 39 by the time she was treated and 40 when she had her second daughter – the cut-off age for public treatment is 40.
Hemingway says she and her husband lost their Bexley home in the Christchurch earthquakes, which delayed their plans to start a family earlier.
She says the BMI rule is “particularly challenging” for Māori and Pacific patients. “It’s harder for them to meet that criteria because of genetics.
“There might be an underlying issue that is causing the infertility [that could be relatively easily treated] but people are just declined on their weight and don’t have the capacity to have their treatment privately.”
She has heard of women losing 20 or 30kg to qualify. “Obviously, there are many health benefits of doing that but you don’t want them to do it too quickly either, because that’s not healthy.”
Peek says per capita when compared with Australia, New Zealand has “1000 missing IVF babies” annually. Across the Tasman, couples can have six cycles of public treatment; here, the limit is two. Medical insurance plans here do not cover IVF, unlike in Australia.
Te Whatu Ora figures do not break out IVF funding from its public contracts for fertility treatment in general. The total for publicly funded fertility treatment (including testing for genetic abnormalities, egg and sperm storage) from private fertility providers in 2018-19 was $10.9 million, rising 10.5% to $12m in 2023-24, but those figures exclude Fertility Plus’s public clinic.
Peek says by his estimate, the population has increased 17% in the past decade, inflation has jumped 30% but public funding has risen only 16%.
Private treatment can cost $12,000-$20,000 – amounts vary widely, in part because of different medication costs.
Farquhar says the Fertility Plus private service, which operates from the Greenlane Clinical Centre, is at the lower end of pricing because couples are treated by a team rather than having a specialist of their own. “The price is better and the results are the same.”
The access difficulties for couples who cannot afford private care have prompted entrepreneur Jaimee Lupton, who with billionaire partner Nick Mowbray welcomed her first IVF baby this year, to launch a drive to raise $1 million to help fund the treatment. The couple will match donations dollar for dollar up to $500,000. Grant applications opened on June 1.
Less burdensome process
Much has changed in every stage of in vitro fertilisation over the four decades since Amelia Bell was born, from the way ovulation is stimulated to the process by which eggs are taken from the mother, as well as the cultures used to incubate the embryos and the length of time before implantation. It means the process is a lot less arduous for women, says Fertility Plus scientific director Jeanette MacKenzie.
“The IVF landscape has undergone a remarkable transformation. From safer methods of ovulation stimulation to less intrusive egg retrieval procedures [no longer by invasive laparoscopies], the journey of IVF for women today is undeniably smoother and less burdensome. That reflects not only scientific progress but a profound shift towards a more compassionate and empowering approach to fertility treatment.”
Intriguingly, research at the Liggins Institute about 15 years ago concluded the biology of IVF babies was different from those naturally conceived. The work, led by paediatric endocrinologist Wayne Cutfield, now the institute’s co-director, found IVF-lings tended to be taller, slimmer and have better blood lipids (think cholesterol) than their peers.
Cutfield called for a register to be established to follow the children’s long-term health, but he says although that has been discussed in many countries, it has never been set up. He says lack of funding has precluded long-term studies of IVF babies here.
Knowing the lengths her mother went to for her birth, it’s an irony for Amelia Bell that at 40, she has all but given up on the possibility of motherhood herself. She says that although she had always thought she would become a mum, life had other plans – her former husband already had children and so does her current partner. “I feel like I’m a bit old and tired for it now!”
Bell, an office administrator, thanked the IVF team and her parents, calling infertility treatment in those days an “incredible journey”. “I’m so grateful to my parents who dared to embark on that uncertain path of treatment and the pioneering doctors whose expertise and dedication made my existence possible.”
‘Grateful every day’
Olympian Dame Valerie Adams is the mother of two children, daughter Kimoana and son Tava, thanks to IVF she paid for privately. The world champion shot-putter would not have qualified for publicly funded treatment because of her BMI.
Public criteria restrict IVF to women with a BMI of 32 or less. Despite her obvious fitness and athleticism, Adams’ BMI has always been higher than that. “I have been classified as morbidly obese throughout my life based on this scale,” she says. Part of the problem is that BMI calculations do not differentiate between weight from muscle and that from fat and it has long been recognised that the tool can be inaccurate in muscular athletes.
Kimoana was six months old when Adams won silver at the 2018 Commonwealth Games and Tava was born in 2019, using a frozen embryo from the first procedure.
She says she “wholeheartedly agrees” that the current criteria are discriminatory and wants to see “significant changes”. “It’s imperative to have more comprehensive screening and get a deeper understanding of the genetic make-up and backgrounds of individuals. The reliance on BMI as a determining factor should be eliminated as it sets many up for failure.”
She says the measurement does not accurately reflect the diversity of society today and may lead to unjust outcomes.
“There are countless reasons why individuals face difficulties in conceiving, and it is essential to make well-informed decisions. I was fortunate enough to have the financial means to pursue private IVF treatment, although it required careful budgeting and planning, not to mention enduring some setbacks along the journey.
“The emotional toll and heartache experienced by those struggling to conceive are truly incomprehensible unless you have gone through it. I am grateful every day for the opportunity to be a mother to Tava and Kimoana.”
