In the latest of the Masters of Medicine series, June Shannon speaks to Prof Robert Harrison, who was responsible for Ireland’s first ever couples-oriented fertility service
The father of IVF in Ireland, Professor Robert (Robbie) Harrison was born in 1940 in Mansfield, Nottinghamshire in the North of England. He was brought up in Liverpool where his father worked as GP.
As a child, Prof Harrison wanted to be either a doctor or an airline pilot. Luckily for the one in six Irish couples who suffer from infertility, medicine won out over the airline industry. Prof Harrison qualified from the RCSI in 1967 and trained in obstetrics and gynaecology at the Mater and Rotunda Hospitals in Dublin.
In 1972, he returned to the UK where he worked at the Queen Charlotte's and Chelsea Hospital for Women, and the Royal Postgraduate Medical School in London where he was appointed Honourary Senior Registrar and Lecturer.
It was during his time at the Chelsea that the young Prof Harrison developed an interest in infertility which, as part of the burgeoning subspecialisation of medicine that was developing in the UK at the time, was emerging as a distinct speciality within obstetrics and gynaecology.
This interest in infertility was to lead to a hugely successful career spanning almost 40 years, during which Prof Harrison pioneered the development of a modern infertility service for couples in Ireland.
This included the introduction of assisted human reproduction (AHR) techniques such as IVF, which he carried out for very first time in Ireland in 1985.
Prof Harrison founded the Human Assisted Reproduction Ireland (HARI) Unit at the Rotunda in 1989, where he also worked as Professor and Head of the Department of Obstetrics and Gynaecology at the RCSI.
He chaired the WHO Taskforce on Infertility from 1984 to 1988, and in 1983 was appointed Secretary General of the International Federation of Fertility Societies (IFFS), an international organisation encompassing the national fertility societies of almost 50 countries.
In 1998, he was appointed President of the organisation, a position he held until 2001. He also served as Chair of the IFFS Scientific Committee from 2001 to 2004, during which time he was instrumental in organising the 2004 IFFS World Congress in Montreal.
He was also awarded an Honorary Membership of the IFFS, an honour bestowed by the organisation on individuals of outstanding merit.
In 1992, he was given the Andres Bello First Class Award by the President of Venezuela and in 2008, he became the Irish Fertility Society's first Honorary Fellow. Since its establishment in 1989, the Rotunda HARI Unit has gained a worldwide reputation for excellence in all areas of infertility services, research and training, and is one of the leading providers of assisted human reproduction services in Ireland today.
Prof Harrison returned to Dublin in 1976 as Consultant/ Senior Lecturer in Obstetrics and Gynaecology at the Rotunda and TCD, and was later appointed Associate Professor.
Immediately on his return, he set about providing Ireland's first couples-orientated infertility clinic at the Rotunda, and together with Consultant Urologist Prof Michael Butler (former President of the RCSI), he also established one of the first joint gynae/urology infertility clinics in Ireland and the UK at St James's Hospital.
New clinics
Prof Harrison credits the support and forward thinking of clinicians like Dr Edward Lillie, Master of the Rotunda (1967-73) and family planning pioneer Dr Michael Solomons, Consultant Obstetrician and Gynaecologist at the Rotunda, for permitting him to set up the new clinics.
While people like Dr Solomons and Dr Raymond Crosbie were already providing infertility investigations at the Rotunda before Prof Harrison arrived, these were mainly focused on women and did not routinely involve men.
"They allowed me to convert my gynaecological clinic into an infertility clinic for couples ... Michael Solomons was on the board of the hospital at that stage and that was a great help," Prof Harrison explained.
"It was having a hospital board, a Master who allowed me to do these things, that was the great thing...I have huge positives about that. They could have said ‘no you have got to do your general like everybody else'."
The clinics at the Rotunda and St James's Hospital (which at the time also had a busy obstetrics unit that delivered approximately 3,000 babies a year) were the first in Ireland to look at infertility as a couple's problem.
"We started proper full investigation of infertility as a couples' problem not just a female problem, which is what most people felt," Prof Harrison commented.
"When I came back in 1976, having trained in this area in the Chelsea Hospital for Women, it was obvious that this was a couple's problem, why ignore the male? So being allowed to set up a fertility clinic in the Rotunda and one in St James's which would deal with infertility as a couple's problem, and being able to offer all the treatments and investigations that were current at the time, was very important," Prof Harrison stated.
The relationship between emotional stress and some forms of infertility have long been recognised and the clinics established by Prof Harrison at the Rotunda and St James's were also the first to offer de-stressing techniques such as meditation to affected couples in the early 1980s.
Together with Dr Mona O'Moore and Dr Rory O'Moore, St James's Hospital, and TCD and researchers from the Department of Clinical Pathology at the Maudsley Hospital in London, Prof Harrison published a research paper on psychosomatic aspects in idiopathic infertility, which found that stress hormones were much higher in people with infertility difficulties.
To help with this, couples were advised to practise de-stressing techniques such as transcendental meditation and autogenic training, a stress management technique, which Prof Harrison said for some, resulted in natural pregnancies. Pre-IVF, Prof Harrison explained that "first of all you investigated people; if there was an ovulation problem you could give them ovulation induction therapy. Scans weren't in then either. If the guy had a problem, such as a varicocele, you could operate on that."
Boost
According to Prof Harrison, Ireland's burgeoning infertility service received an enormous boost when Irish microsurgeon Dr Mark Darling returned from the UK. Dr Darling's expertise meant that the clinic was able to offer microsurgery for the first time to women who suffered from tubal damage.
Additional advances in investigative techniques were a further boost to the service, he added.
We could investigate somebody before treatment. I think that was the main thing, Prof Harrison said.
"Forty-eight per cent of our patients got pregnant without us doing anything because you told them what was wrong; that is a huge placebo effect. I can still tell a junior doctor who is going to be good because they get patients pregnant without doing anything ... It's a placebo effect ... that is so important ... Up to 10 per cent, I reckon, got pregnant before we even saw them.
"Of those that are going to get pregnant, 48 per cent will get pregnant within two years without you doing anything. Twenty-one per cent of people who have had IVF will get pregnant a second time without you doing anything, so there is a huge placebo effect ... In those days we would investigate people properly and if we could offer therapy, we would."
Demand
The birth of the world's first IVF baby, Louise Brown in the UK on July 25th 1978, stimulated huge interest worldwide and increased demand from infertile couples who felt it could finally offer them the chance of parenthood.
This momentous medical breakthrough achieved by Dr Patrick Steptoe and Dr Robert Edwards resulted in the development of fledging IVF services in countries worldwide.
Ireland was to have its own IVF service just eight short years later.
On November 20th 1982, Dr Patrick Steptoe was invited to speak at the AGM of the Institute of Obstetricians and Gynaecologists of the RCPI.
On June 21st 1985 the Institute published policy guidelines for the practice of IVF in Ireland, which were devised by Prof William Thompson, Professor of Obstetrics and Gynaecology, Queen's University, Royal Maternity Hospital in Belfast.
The Institute then set up an IVF subcommittee to monitor the situation. In the summer of 1985, Prof Harrison and his team carried out three attempts at IVF at Sir Patrick Dun's Hospital in Dublin, which resulted in one early miscarriage.
News of Prof Harrison's pioneering IVF work was leaked to the medical press and a voluntary moratorium was introduced while the situation was discussed at a contentious conference in Maynooth on August 30th that same year.
Despite the controversy, Prof Harrison received agreement from the relevant authorities including the Medical Council, St James's Hospital and the Institute of Obstetricians and Gynaecologists at the RCPI, to recommence the service.
In January 1986, he was granted permission by the Board of St James's Hospital to start Ireland's first Assisted Human Reproduction Service at the hospital.
(Meanwhile Sir Patrick Dun's Hospital had closed).
Pioneers
Prof Harrison said that when he came to start IVF in Ireland, life was made somewhat easy for him thanks to the amount of published literature on the subject by pioneers like Prof Alan Trounson and Prof Carl Wood in Australia.
It was their research in the late 1970s that established IVF as a method for the treatment of human infertility worldwide. The Wood/Trounson team achieved Australia's first successful IVF birth in 1980.
"When I came to start I was able to say this is not an experimental technique; there are papers all over the place now which show that this is routine therapy, that is how I was able to start," the Professor stated.
The fact that the Institute of Obstetrics and Gynaecology of the RCPI had guidelines in place around the exact same time as Prof Harrison trialled the procedure was also very important, he added.
"There were rules in place exactly at the same time as I started and that was what we played by."
Ireland in the late 80s was a very different place to today, with the sting of the controversial and hugely divisive 1983 abortion referendum still in the air.
Despite this, however, Prof Harrison said that his clinic never attracted any controversy. From October 1986 to February 1989, Prof Harrison ran an NHS-style IVF and gamete intrafallopian transfer (GIFT) service at St James's Hospital in Dublin.
Prof Harrison explained that egg collection for IVF was carried out at St James's late at night, as this was the only time theatre space could be accessed. The regular nursing and theatre staff volunteered to assist, having first received the go-ahead from their individual religious bodies.
Prof Harrison's wife Caroline was also on hand in the early days to incubate the collected eggs in her cleavage so as to maintain them at body temperature.
HARI unit
In April 1989, Prof Harrison was appointed Professor and Head the Department of Obstetrics and Gynaecology at the RCSI and the Rotunda Hospital. With the transfer of the St James's fertility service to the Rotunda, he established the HARI Unit at the maternity hospital that same year.
"I was thrilled. I had always been a Rotunda person because I was a student there and was delighted to come back to the Rotunda. Also there was something a bit special about coming back as Professor and Head of Department in a place where you were a student because that doesn't happen to many people. I felt fantastic."
Today in Ireland, IVF is carried out at up to 10 clinics around the country. Despite being the most common form of infertility treatment, it does not receive any Government funding and is not available to public patients. A cycle of IVF can cost several thousand Euro and patients who cannot meet these costs have limited access to fertility treatment.
According to Prof Harrison, an actuarial study was carried out at St James's, which formed the basis for a funding submission to the Government of the day. However, the Government fell in 1987 before a decision on funding could be made.
To this day, no IVF service in Ireland receives any funding from the Government and couples are forced to pay out huge amounts of money (up to €4,500 for one IVF cycle) to access treatment.
The fertility drugs which are commonly used with these procedures can cost up to €3,000, depending on how a woman responds to treatment. The Drugs Payment Scheme pays for the fertility drugs, with couples having to pay the first €120 (January 2010).
This was something that Prof Harrison negotiated while he was still at St James's. Couples can claim tax relief on medical expenses associated with IVF, however this was halved in 2008 from 40 per cent to 20 per cent.
The HARI unit at the Rotunda treats medical card patients for free every year.
Influx
"The HARI Unit at the Rotunda Hospital treats medical card holders free ... as many as come and they are done on the backs of other patients ... That may be changing now because of the huge influx of medical card holders but certainly up to the end of June that was absolutely true and that is very important ... Of course it should be free to medical card holders ... It is not experimental any more. It is just a treatment like anything else ... Why should they pay for my hip or knee to be done when they won't pay for IVF?"
The HARI unit also provides a number of additional altruistic services such as egg and sperm freezing for cancer patients, which again was pioneered by Prof Harrison. In 1998 he started freezing male sperm and in 2003 the freezing of female eggs began at the unit. The HARI Unit now receives some funding from the Government for this service under the National Cancer Strategy, Prof Harrison explained.
"There was no money at the beginning when we originally started and I never received one penny out of HARI. It had its advantages because it meant I could be truthful ... If somebody came who you didn't think was suitable, instead of just putting them through because you were looking for the money for yourself and the shareholders, you could ... say ‘no, it is not for you; it is not going to work'."
Despite having a presence in the country since the late 1980s, Ireland still has no official body or legislation for the regulation and licensing of IVF or other assisted reproduction services.
In 1999, Senator Dr Mary Henry introduced a private members bill in the Seanad aimed at putting a regulatory framework in place to govern fertility clinics. Called the Regulation of Assisted Human Reproduction Bill, it led to the establishment of the Commission on Assisted Human Reproduction (CAHR) in 2000.
CAHR published its report five years ago in 2005 and one of its main recommendations was for a regulatory body to be established by an Act of the Oireachtas to regulate AHR services in Ireland.
Ethical guidelines
Five years later the situation remains unchanged. Last year the Women's Health Council (WHC) published two reports on the issue and also called on the Government to regulate infertility treatments in Ireland and to implement the 2005 CAHR report.
The Medical Council's Ethical guidelines contain advice for medical professionals on fertility and assisted reproduction treatments.
According to the WHC reports, the most recent data shows that in Ireland in 2005 there were 301 babies delivered following IVF using fresh embryos, 217 deliveries following ICSI using fresh embryos, and 59 deliveries following either ICSI or IVF using frozen embryos (Nyboe Andersen et al, 2009).
The number of deliveries following IVF and ICSI with fresh embryos and IVF and ICSI with frozen embryos has generally been increasing in Ireland.
Asked why he thought that the area had not been regulated to date, Prof Harrison said that firstly, he thought there were currently, perhaps, more important issues to deal with such as the recession and secondly, that it was a difficult and divisive issue to regulate for.
The Irish Supreme Court recently judged that frozen human embryos are not among the "unborn" referred to in the Constitution. The judges also called on the Oireachtas to introduce legislation to regulate assisted human reproduction.
The Minister for Health, Mary Harney, has long promised to introduce new legislation on this issue.
In a statement to the Medical Independent, a spokesperson for the Department of Health said that the Minister "intends to bring forward proposals to Government later this year with a view to drafting legislation to govern the area of assisted human reproduction and related practices. The work involved in developing these proposals will examine and consider, among other things, the issues arising from the frozen embryos Supreme Court judgment."
Asked what has been the single biggest development for the Irish fertility services in the 40 years of his career, Prof Harrison said it was technical advances such as the use of laparoscopy, hormone and semen assays, and ultrasound, which have allowed for proper investigation and treatment of couples.
Book
Prof Harrison retired from active practice in 2005 and three years later he tragically lost the love of his life, Caroline, to ovarian cancer.
Caroline was a psychotherapist who specialised in sex and relationship therapy and at the point of her untimely death, had contributed hugely to the field of IVF, including being a member of the Government's CAHR.
Caroline also contributed to and illustrated Prof Harrison's book The Smart Guide To Infertility, which was published in September 2009.
Commenting on the highlights of his 38 years in practice in Ireland, Prof Harrison said that the natural arrival of all four of his children was a major highlight.
"Having your own kids and then realising how lucky you are that you didn't have to have any of these treatments, those were the positives."
Prof Harrison said another highlight was meeting patients years later and being introduced to their children.
He recalled the words of one of his patients who, on the birth of his new baby daughter, pronounced that it was "like scoring a goal in the cup final".
"That is what it is, it is like scoring a goal in the cup final," Prof Harrison smiled.
Professor Robert Harrison at a glance
- Professor Robert (Robbie) Harrison was born in 1940 in Mansfield, Nottinghamshire in the North of England.
- In 1967, he qualified in medicine at the RCSI and trained in obstetrics and gynaecology at the Mater and Rotunda Hospitals in Dublin.
- In 1972, he went to the UK to work at the Queen Charlotte's and Chelsea Hospital for Women and the Royal Postgraduate Medical School in London where he was appointed Honorary Senior Registrar and Lecturer.
- In 1976, he returned to Ireland and was appointed Consultant/Senior Lecturer in Obstetrics and Gynaecology at the Rotunda and TCD. He was later appointed Associate Professor. He also established Ireland's first couple orientated infertility clinics at the Rotunda and St James's Hospital.
- In 1983, he was appointed Secretary General of the International Federation of Fertility Societies (IFFS).
- He chaired the WHO Taskforce on Infertility from 1984 to 1988.
- In 1985, he became the first person to carry out IVF in Ireland.
- In 1989, he was appointed Professor and Head of the Department of Obstetrics and Gynaecology at the RCSI and established the Human Assisted Reproduction Ireland (HARI) Unit at the Rotunda.
- In 1992, he was given the Andres Bello First Class Award by the President of Venezuela.
- In 1998, he was appointed President of the IFFS.
- From 2001 to 2004, he served as Chair of the IFFS Scientific Committee, during which time he was instrumental in organising the 2004 IFFS World Congress in Montreal.
- In 2008, Prof Harrison became the Irish Fertility Society's first Honourary Fellow.
- In September 2009, Prof Harrison's book The Smart Guide To Infertility was published by Hammersmith Press.