Poland is finally facing up to legislation ntil recently, there were just three countries Parliament. And only then, after three readings, legislation for IVF: Ireland, Croatia, and There’s still a long way to go, and some say that 2010 is too politically busy (with a presidential professional guidelines endorsed by its health election) for something as delicate as IVF to find ministry, while the Croat Parliament at the end of its proper place in the agenda. Maybe 2011 . . . October did finally pass an amended law on IVF But whether this year or next, no-one is doubting making it easier for couples to receive treatment. The that IVF will, in one shape or another, be brought new Croat law, however, despite strong criticism, under legal control in Poland - though not without now bans the freezing of embryos, which had thus a battle of deep-rooted principles at whose heart far been excluded from legal restraint. Thus, as this lie the place and ideologies of the Catholic church.
new decade begins, only Poland among the 27 What’s worrying to those practising IVF is how member states of the EU is without any formal restrictive that legal control will be.
regulation for IVF. And that too is about to change.
After a year of political debate, intense lobbying legislative options which at one extreme would and the ideological intervention of pseudo science, apply restraints on IVF not unlike those of Italy’s the draft texts of four legislative proposals on IVF ‘Law 40’ legislation of 2004. At another end lies a now lie with the leader of Poland’s Parliament; when more reasonable approach which recognises IVF - and if - implemented as law, the legislation (from as a legitimate treatment for infertility, and with it whichever proposal) would finally bring IVF in the basics of good ART practice as defined in Poland under statutory control. But before then, the Speaker of the Parliament may send the proposals One proposal, however, put forward by Poland’s back to their sponsors for legal clarification, he may opposition right-wing Law and Justice party, calls reject them outright, or he may pass them on to the for an outright ban on IVF, taking as its lead the Health Commission before formal readings in Catholic church’s position that human life begins with conception and that IVF - according to an with total treatment cycles (fresh + frozen) at open letter from Polish bishops - is ‘a refined form around 8000 and a population of 40 million, the of abortion’. But even this initiative, extreme as it availability of IVF stands at around 200 per million, appears, seems positively liberal in comparison with a very low rate and far below the 2000+ per million a ‘citizen’ proposal made possible by the collection of more than 100,000 signatures that the practice However, Poland’s success rates are comparable of IVF should be punishable by a prison term of up with the rest of Europe, with an overall delivery to three years. This ‘Contra In Vitro’ proposal, rate of 23% per cycle reported from 15 clinics - and which was again supported by the Catholic church of 35% per cycle from the country’s biggest, where (with links on pro-life websites to send supportive almost 2000 fresh and frozen cycles are now e-mail ‘opinions’ to Polish parliamentarians and undertaken in state-of-the art conditions each year.
Prime Minister Donald Tusk) was rejected by the The cost of treatment, says the clinic’s director Dr lower house of Poland’s Parliament earlier last year Piotr Lewandowski, is around 1600 euro plus the (despite support of the Law and Justice party).
cost of drugs - and all fertilisations are by ICSI.
Elsewhere, treatments can be as little as 1100 euro Although unregulated, IVF has not been a wild Cost (and a lack of reimbursement), in a country which suffered such huge deprivation under a devastation in World War II, must surely be one reason for the relatively low uptake of IVF, but another will certainly be the ideology of the Catholic church and the proscription of IVF by its hierarchy. Such feelings run deep, says Radwan, and the influence of the local priest, as well as the revered memory of Pope John Paul II, carry enormous weight. Indeed, Professor Waldemar consortium suggest that almost 4000 cycles were Kuczynski, a member of the group in the eastern started in 2005 in 16 clinics, representing around city of Bialystok which recorded Poland’s first IVF 70% of the country’s activity. Poland’s clinical birth in 1987, recalls that in 1998, when his clinic member of ESHRE’s Committee of National was looking to move to new premises just 300 Representatives, Dr Pawel Radwan, estimates that, metres from the city’s cathedral, the first signature ‘NaPro technology’ the church’s alternative to IVF
Treatment (see http://www.infertility. ‘I hear The four draft proposals now before Poland’s Parliament
From former gynaecologist Boleslaw Piecha for the Law and Justice party, which would completely ban IVF in Poland.
From Civic Platform MP Jaroslaw Gowin, which emerged from a narrow majority of the Bioethics Commission and would restrictfertilisation to two oocytes and ban embryo freezing - the ‘Italianmodel’ - and IVF in women over 40 and unmarried couples.
From MP Marek Balicki for the Social Democrats, which has the support of consumer groups, represents the minority opinion of theBioethics Commission, and will allow embryo storage.
From MP Malgorzata-Kidwa Blonska and the ruling Civic Platform party, which identifies IVF as legitimate treatment and applies the EUtissue and cell directives to human gametes. PGD would be allowedfor couples at risk of genetic disease, and IVF in all heterosexualcouples.
on the church’s petition of protest was that of his expertise in IVF) to look at the whole question of own mother. ‘The bishop had more influence than fertility treatment, and determine how Poland in this explosively emotive field could bring itself into But despite the prevalent opposition - even from line with its fellow members of the EU. And it was many gynaecologist colleagues - IVF stumbled out of the keenly divided deliberations of this bioethics commission that one of Tusk’s parliamentary lieutenants in the ruling Civic experimental embryology by Andrzej Tarkowski, Platform party, Jaroslav Gowin, decided to push whose zoology lab at the University of Warsaw forward his own version of an IVF bill - which, say found many world-leading embryologists passing critics, represented just a narrow majority of the through on their way to greater fame - and whose commission’s opinion. The proposal, which seeks to one-man reports in Nature remain to this day the outlaw IVF in unmarried couples and prohibit most cited scientific papers in reproduction from embryo freezing, would also set a limit of Poland. So those like Kuczynski who turned to IVF fertilisation in just two oocytes, both of which had also to turn their hand to everything it involved would require transfer. To those in the IVF sector, - the investigation, work-up, stimulation, egg collection, and the laboratory. ‘So we were ready Again, there was an uproar of protest, not least for ICSI from the very beginning,’ says Kuczynski, from many of Gowin’s colleagues in the Civic ‘but it still means that from 1995 when we had our Platform party and from the ‘unrepresented’ first ICSI birth I’ve done around 17,000 ICSI members of the bioethics commission. As a result, injections. I could even strip down and service the former Health Minister Marek Balicki and a Social Democrat MP, set about his own alternative And IVF may well have continued its unsteady proposal with the support of patient organisations and unregulated progress had Poland not joined the (including Poland’s consumer fertility group Nasz EU in 2004 nor its Health Minister Ewa Kopacz Bocian (Our Stork)). ‘Gowin’s was a proposal which declared in November 2008 that IVF should be took no account of the minority in the ethics funded from the public purse. Reaction, particularly commission,’ says Balicki, whose draft bill, which from the opposition Law and Justice party, was would allow IVF in unmarried couples and embryo immediate, and IVF was suddenly on the front page freezing, appeared to have wide support in and the focus of a public debate which Kopacz had Parliament (and even in the ruling Civic Platform never intended. It was out of this melee of opinion party, thus leaving Gowin somewhat exposed and and dogma that Prime Minister Tusk sought consultation proposals from the main political Thus, in a bid to unite the warring factions and parties, and why the Catholic church, under the develop a proposal more representative of the Civic banner of ‘Contra In Vitro’, collected its 100,000 Platform party as well as the divergent views of other vested interests, Civic Platform formed Tusk had also asked a newly formed bioethics another working group - to which both Kuczynski commission (many of whose 18 members were and Professor Rafal Kurzawa representing the associated with the Catholic church and had no Polish Gynaecological Society were advisors - to No-one is predicting which of the four proposals will finally make the statute book in Poland.
Despite his involvement with the Civic Platform proposal, Rafal Kurzawa fears that the Gowin bill on a two embryo limit and no freezing may well bepresented as the ‘compromise’ proposal (in muchthe same way as restrictive laws on abortion wereintroduced in 2007). If introduced - as many fear -the Gowin legislation will make IVF in Poland themost restricted in the world. According toKozlowska-Rajewicz, 30% of parliamentariansfrom the Civic Platform party (and most of the Lawand Justice MPs) support the Gowin proposal. But whichever way Parliament turns, it will not be without acrimony and high emotion. ‘We can’teven mention embryo selection,’ says Kurzawa, take a look. Many of the hopes of the IVF mindful of the bitter memories of Poland’s history, community in Poland now rest on this proposal, ‘but at the same time Poland can’t be an ideological which is set out in a brand new bioethics bill and in island. We’re in the EU now, and we have to have amendments to two others. The new bill firmly legislation - but it must be good legislation.’ For his establishes the legitimacy of IVF as a treatment for part, Pawel Radwan simply wants to see far greater infertility, but also requires that all couples access to ART in Poland, and a reliance on treatment which is evidence-based and effective.
supernumerary embryos should be stored or ‘Because IVF is not reimbursed,’ he says, ‘we’re in donated. ‘This means that embryos may not be the ridiculous situation that infertility patients are discarded,’ says MP Agnieszka Kozlowska-Rajewicz overtreated with time-wasting and ineffective from the parliamentary Health Commission. ‘We treatments - just because these are reimbursed or Similarly, such emotive issues as embryo selection Many of those behind the more liberal political or the number of embryos for transfer are not proposals - such as Marek Balicki - believe that no- referred to, the draft leaving such matters to the one dare grasp the nettle of legislation until this better judgement of clinicians. ‘We’re not specifying year’s parliamentary elections are over, and anyway therapies, but specifying quality assurance,’ says they believe that a delay may well allow opinions to Kozlowska-Rajewicz. One of the two amendments settle and judgements to mature. Indeed, an opinion will provide a legal framework for the welfare of poll reported in March last year found that 77% of the child, while the second will give rights at the age Poles accept IVF as a fertility treatment - though of 18 to any child conceived with donor gametes to only 52% thought that supernumerary embryos were acceptable. So right now, says Kurzawa, ART The draft will also apply the EU’s directives on remains more a political football than a medical tissues and cells to human gametes - the directives discipline, with little understanding at the public or so far in Poland have only been implemented for parliamentary level of what it actually is or what it transplantation. The EU directives, insists can achieve. But fears among the experts - that such Kozlowska-Rajewicz, provide a legal framework for basics as embryo freezing might be banned - are the cryopreservation of embryos, despite misgivings real. And it will take politics as much as good from many Parliamentary colleagues that embryos clinical practice to remove those fears.
are now given the same legal status as transplant organs. The proposal would allow IVF in all Simon Brown is a freelance medical writer and in that heterosexual couples and require that all treatment capacity is editor of Focus on Reproduction for ESHRE 1. This simple statement may not be as simple as it reads. Research carried out by ESHRE for the EuropeanCommission’s Directorate General for Health and Consumer Affairs (DG SANCO), much of which is posted on theESHRE website, suggests that no specific ART legislation exists in Cyprus, Latvia, Lithuania, Malta, Romania andSlovakia - as well as in Ireland and Poland. However, in some countries - such as Romania - legislation is in place basedon the Tissues and Cells Directives, and in others - such as Malta - legislation is under discussion. As far as ESHRE cantell, regulation in many of these countries is of a very limited nature and confined to limited procedures.


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