IVF News

Women with fertility problems would rather take the risks associated with multiple pregnancies than risk not becoming pregnant at all, reveals research published in BJOG: An International Journal of Obstetrics and Gynaecology (BJOG) this month. Researchers from the University of Aberdeen surveyed a total of 74 women who were awaiting IVF treatment to find out their preference for having children with the severe disabilities associated with multiple births, including physical impairments, mental impairments, visual impairments, stillbirth or death in early infancy and premature birth, compared to not becoming pregnant at all.

'Today a growing proportion of women conceive via assisted reproduction, yet there is limited appreciation amongst the general population regarding the risks involved with multiple births for both mother and child', said Professor Philip Steer, BJOG editor-in-chief. He added: 'This study reveals that a significant number of prospective parents value the experience of parenthood ahead of the risk of significant disability to their child'.

The UK 'postcode lottery' for heath care extends into fertility treatment. While UK guidelines recommend funding three cycles of IVF for women younger than 40, limited resources mean that many women are only offered a single try. 'A more appropriate way to minimise risks without risking poor outcomes would be to encourage uptake of single embryo transfer in a climate which permits a greater number of funded treatments to couples', suggests lead researcher Graham Scotland, Research Fellow of the University of Aberdeen. However, he admits that limited resources may make this recommendation hard to put into practice.

Two or more embryos are transferred into some women undergoing IVF, depending on guidelines issued under the HFEA's existing Code of Practice. However, the Authority launched a consultation in April this year aimed at finding the best way to reduce problems experienced by IVF children arising from multiple births and is expected to make a policy decision on the basis of the evidence and the consultation responses sometime in autumn 2007.

The HFEA last reviewed its guidelines on how many embryos can be transferred during IVF treatments in July 2005. At the time, over 90 per cent of IVF cycles in the UK involved the transfer of two or three embryos. Current guidelines say that clinics can transfer up to two embryos per cycle for women under 40 and up to three for women over 40. Transferring multiple embryos means women are 20 times more likely to have twins and 400 times more likely to have triplets, compared to natural conception. As well as representing a significant risk of mortality to mother and child, this pronounced increased in multiple births puts added pressure on an already stretched National Health Service.

Preliminary results from European research suggests that transferring single embryos may be as effective as transferring of two or more embryos, raising the question of whether this decision should be made by the doctor or by the patient. Regardless of who decides, good information is the key, say the researchers. 'Our results suggest that, at the present time, information on the risks associated with twin pregnancy may not be enough to deter some women in the UK from choosing double embryo transfer, given their perception that it will improve their chances of a live birth', said Scotland.
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According to the UK's Sunday Times newspaper last week, clinics in the UK are offering couples the chance to choose the sex of their child, a practice that is illegal in Britain unless done to avoid a serious genetic disorder in the resulting child, by referring them to clinics abroad. An undercover reporter from the newspaper approached a leading fertility specialist in London and was offered IVF with preimplantation genetic diagnosis (PGD) to choose the gender of a resulting baby - despite having no fertility problems - for the price of ?12,000.

The sex selection procedure was to be carried out at a clinic in Limassol, Cyprus. The reporter was told that the procedure was legal there - however sex selection has been banned in Cyprus since 2001. More than one British clinic offered to send the couple to Cyprus for 'treatment'. One of the Cypriot clinics - Repromed - is run by controversial fertility expert Dr Panos Zavos, who claimed to the reporters that social sex selection was allowed in the countries in which they operate and no local laws would be broken.

PGD is a technique developed in order to allow embryos to be tested for serious inheritable diseases, some of which may be related to the embryo's gender. A cell is removed from the early embryo, tested in the laboratory and, if the embryo is free of the disorder, or the desired sex, it is then implanted into the mother's womb. Sex selection for 'social' or 'family balancing' reasons is not illegal in the United States but has never been allowed in the UK, and a recent survey suggests that only a small minority of the British public would support its use.

The Cypriot health minister, Charis Charalambous, responded to the Sunday Times report by ordering the attorney-general to initiate an immediate criminal investigation. He told the newspaper that 'we are very concerned about this' and added that 'prosecutions may follow'.

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The American Society for Reproductive Medicine (ASRM) and the US Society for Assisted Reproductive Technology (SART) have issued new guidelines limiting embryo transfer during IVF procedures to reduce the occurrence of multiple births. Announced at the annual ASRM meeting, held in New Orleans last week, the revised guidelines recommend that no more than two embryos should be transferred to women under 35 during a single cycle of IVF treatment, and that clinics should consider the possibility of transferring only one. For older women the recommended number of embryos increases, but to no more than five. The guidelines state that for women aged between 35 and 37, up to three embryos should be transferred, with up to four recommended for women aged between 37 and 40, and no more than five for women over 40.

The ASRM indicated that its decision to revise US fertility guidelines came as new medical evidence suggested that high pregnancy rates can still be achieved using fewer embryos in the course of IVF. 'The evidence clearly indicates that we can reduce the number of high order multiple gestations and still maintain high pregnancy rates', said Marc Fitz, chair of the ASRM Practice Committee.

In 1999, ASRM issued guidelines recommending that only two embryos be transferred during IVF to women under 35 with a 'healthy' prognosis. This was updated in 2005 suggesting women under 35 should consider implanting only one embryo. What's new in the latest guidelines is that 'no more than two' embryos should be used by women under 35 and limits are also placed on those over 35, who face reduced chances of success. In 2004, researchers at Harvard Medical School published a report which indicated that the occurrence of multiple births following IVF had dropped dramatically since the original ASRM guidelines were issued. However, latest evidence from the March of Dimes, a US organisation committed to preventing birth defects, infant mortality, and premature birth, suggests that over a third of IVF pregnancies in the US still result in multiple births.

In conjunction with the March of Dimes and the American College of Obstetricians and Gynaecologists, the ASRM issued a report highlighting the need to reduce the risk of premature birth for women undergoing IVF. Around 12.5 per cent of US babies are born prematurely and risk long term health problems. Dr Nancy Green, medical director of March of the Dimes, issued a statement saying that 'limiting the number of transferred embryos will mean fewer higher order multiple gestations, defined as three or more foetuses, and reduce the risk of complications for both the mother and the foetus, including preterm birth'. The organisation suggested additional requirements to the ASRM guidelines, including informed consent documents to make explicit the risk of multiple births, and a publishable annual review of clinics' performance and rates of multiple births. Dr Green has said that 'consumers should demand quality assurance in the fertility business'.

In the UK, the Human Fertilisation and Embryology Authority (HFEA) is currently reviewing its policy after commissioning an expert panel looking into multiple births, which reported last week. The report recommends that for patients under the age of 35, the number of embryos that can be transferred should be reduced from two to one. It also states that sanctions should be taken against clinics that exceed a 'cap' placed on the number of twin births allowed. Clinics which routinely exceed a twin birth rate of 5 to 10 per cent, for example, may be placed under further restrictions regarding the number of embryos they can transfer, or may even face problems renewing their licence.

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Institute of Bio-Medical Research (DSIR Recognized) in association with SRM University (India's No.1 Private University) invites applications to pursue PhD Programme in the fields of Clinical Embryology, Reproductive Genetics, Stem Cell Biology and Regenerative Medicine. 

Kanmani Fertility Centre Pvt Ltd is one of the leading and pioneer fertility centres in Tamilnadu.  It was established in the year 1996 by Dr. S.S. Muthiah, an Eminent Embryologist with 25 yrs of experience in the field of Human Embryology.  Now the centre  has successfully completed its 18 years of service with excellence in the field of human reproduction. 

To proceed with academic and research activities, Kanmani Fertility Centre Pvt Ltd has established a separate R&D wing ‘Institute of Biomedical Research’ in the year 2010 at T. Nagar, Chennai. ‘Institute of Biomedical Research’ has been recognized by the Department of Scientific and Industrial Research (DSIR), Ministry of Science and Technology, Government of India to carry out research in the emerging fields of biomedical sciences with special reference to human reproduction.  In addition, the institute is also recognized and enrolled under National Registry of ART Clinics and Banks in India by Indian Council of Medical Research. 

Essential Educational Qualification

MD - Obs&Gyn/Microbiology/

          Biochemistry 

MS - Urology

M Tech - Biotechnology

M Sc - Life Sciences

Desirable

Candidates with Fellowship from CSIR / ICMR 

Resumes should be sent to

[email protected]

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Clinical   Fellowship in Andrology and Reproductive Medicine.

 

Objectives: 

Train postgraduate students to establish and run an efficient, cost effective and ethical reproductive medicine unit.

At the end of the course, candidates will

1.be able to handle reproductive medical problems both in the male and female.

2.have good working knowledge in the field of infertility and reproductive laboratory services

Eligibility:

Postgraduate Degree or Diploma in Obstetrics and Gynecology, General surgery,urology and general medicine.

Duration:

1 year

Mode of Teaching:

Lectures, Power point presentations and interactive sessions

Practical demonstrations

Hands on – wherever applicable

Journal club every month

Frequent examinations conducted throughout the course. MCQ’s, Short notes and Essay type Questions.

The students will not receive any stipend or any other form of financial support from the institution. However they may utilize the existing infrastructure in the department and institution. Fellows enrolled will not be on call in the hospital in any other department.

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Scientists from the University of California in San Francisco have identified the mechanism by which sperm start swimming towards the egg when they enter the female reproductive system. The discovery could lead to drugs that boost male fertility and new forms of contraceptives. The finding was reported in Cell.

It has been known for a while that a sperm's level of activity is affected by a change in internal pH, but the exact mechanism that regulates swimming was unknown. To investigate, Dr Yuriy Kirichok and his team used a technique called patch clamping to record proton movement across the cell membrane of sperm.

They discovered that there was an abundance of Hv1 proton channels in the tails of the sperm. These act as a pore in the outer membrane of the sperm cell, extrude protons and are responsive to changes in the levels of zinc and pH outside of the cell. The uterus has a pH concentration one thousand times higher than semen, and this triggers the Hv1 channels to open. Extrusion of protons makes the environment within the sperm more alkaline and this, in turn, causes the sperm to start swimming.

High concentrations of zinc, as found in semen, inhibit the Hv1 channels, preventing them from opening too soon. The levels of zinc are lower in the fallopian tubes and this may trigger an extra spurt of swimming power as the sperm nears the egg. Dr Kirichok said: 'What we're very excited about is that we've found the molecule that elevates sperm intracellular pH and we've found how that molecule is activated'.

The researchers found that a compound called anandamide, which is found in high levels near the egg, also causes the channels to open. The compound is similar to the active ingredient in cannabis and it is possible the drug may mimic the effect. This could explain the link between cannabis use and poor fertility in males.

The finding could lead to new forms of contraception. Dr Kirichok said the channel could be exploited by a drug which hampers proton release, leaving the sperm unable to swim. He said: 'All of these events are essential to fertilisation - you can imagine now that we know the molecule responsible we could block it to prevent activation and fertilisation as a kind of male contraception'.

It may now also be possible to find a way to improve the sperm mobility of men who have fertility problems.

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More than 100,000 young women in the US have been recruited to become egg donors (1) with the offer of large sums of money, typically $8-15,000 per egg retrieval cycle, but at times up to $100,000. The US is also a destination for European women seeking to sell their eggs. Additionally, many couples seeking egg donors are from Europe, where paying for such services is illegal and waits can stretch for years (2).

In the US egg donation is a virtually unregulated industry. After egg retrieval, donors are discharged from the IVF clinic but are rarely contacted afterwards. Consequently, there has been a dearth of studies of both short and long-term adverse consequences of ovarian stimulation and egg donation. In addition, only a few published studies have considered the emotional and psychological effects of egg donation on donors.

We conducted a retrospective study of egg donors, up to 22 years after egg donation; 155 of them completed a survey on the website of Donor Sibling Registry (DSR), a US- based worldwide registry that helps donor-conceived individuals search for and contact their donor and/or their half siblings, as well as supplies support, news, and education for parents and former donors. The survey asked about medical complications and subsequent health problems, contact with IVF clinic, willingness to have contact with recipient families, donors' satisfaction with the donation process, and current feelings. Our results highlight the inattention by US IVF centres to the health and needs of egg donors and their genetic offspring.

Regarding early medical complications, we found a high prevalence of ovarian hyperstimulation syndrome (OHSS), now recognized as a common adverse effect - 14 per cent required hospitalization and/or paracentesis, a procedure to remove fluid that has accumulated in the abdominal cavity. One-quarter reported infertility and/or menstrual problems. As for late medical complications, several women developed various cancers, but in the absence of large long-term studies, it is uncertain whether the hormonal regimen they received to hyperstimulate their ovaries increased their cancer risk. Earlier studies of infertile women undergoing IVF suggest this is possible (1).

In the US, most egg donations are anonymous. In many IVF centres, this not only means that donors and recipients do not know each other's identities, but that the IVF centre does not follow up the donors. In our study, 96 per cent of the donors were never contacted by the IVF center for medical updates, so there is no opportunity for reproductive specialists to learn about potential long-term adverse effects on the donors. 

Moreover, there is no effort to learn about medical developments in the donors that it might benefit their genetic offspring to know. In our study, one-third described medical changes they thought would be of interest to donor children (including a diagnosis of breast cancer in a donor and cystic fibrosis in a donor's child); half had attempted to report these changes to the clinic, with variable results, such as being told their chart was missing or destroyed, the clinic that had gone out of business or had relocated and couldn't be found, or that the clinic declined to notify the recipients on the basis of anonymity. Donors who did not attempt to report these changes did not recognize the value of this information to recipients, or else confused anonymity with confidentiality, believing that 'anonymity' meant they were not to contact the clinic and/or that the clinic could not contact the recipients.

In recruiting potential egg donors, IVF clinics in the US tend to understate the medical risks. Even when known risks are fully discussed, the prospective donor is informed that long-term risks are unknown; young women may not clearly understand the difference between 'there are no risks' and 'there are no known risks'. The results of our survey make it clear that communication between egg donor and IVF clinic is often not encouraged. 

IVF clinics need to give anonymous egg donors clearer guidelines about asking for outcome information or giving the clinic medical updates to benefit their biologic children. Additional long-term studies are needed to ascertain egg donors' risks of infertility or cancer. In order to make this possible, a national egg donor registry is highly desirable so that researchers can regularly contact donors. Given the reluctance of the US IVF industry to maintain such a registry, it may require passage of a law mandating a national egg-donor registry. Several groups in the US are working toward this goal.

We also found that pre-donation counseling often neglects the potential emotional impact on donors, which may change with time, and the emotional impact on the donors' children as well as the donor-conceived offspring. We learned that as egg donors get older, many want to know the outcome of the pregnancy. Those who initially prize anonymity may want to have more information and contact with their biological children. Donors need to be offered adequate opportunities to think about the long-term impact that donating might have on them, their family, the recipient family, and the genetic offspring. 

We recommend that IVF clinics: 

1. Maintain donor records indefinitely.

2. Develop protocols to contact the donors regularly to update medical information on the donor's health and information of interest to recipients. 

3. Educate the egg donors about the importance of contacting the IVF clinic, even years later, to provide such information 

4. Contact recipient families with relevant information provided by the egg donor.

5. Notify donors if any IVF-conceived children are born with genetic abnormalities or potentially inherited diseases as the woman may already have or someday want to have children of her own. 

6. Make egg donors as well as recipients, and eventually egg donor children aware of resources for updating and sharing medical information. Until there is a mandatory record keeping system, the Donor Sibling Registry is successfully allowing thousands of families formed via donor conception to establish mutual consent contact and share important genetic, ancestral and medical information. 

Currently the primary focus of fertility clinics is to serve the needs of infertile women by maximizing the likelihood of a successful pregnancy. The results of this study reinforce the need to broaden the concerns of IVF clinics include the short- and long-term health and safety of the egg donors and also to recognize the needs of donor-conceived children.

References:

(1) Schneider, JP 2008. Fatal colon cancer in a young egg donor: A physician mother's call for follow-up and research on the long-term risks of ovarian stimulation. Fertility and Sterility 90:2016. Online: .e1-2016.e5. 

(2) 'Ova time: Women line up to Donate Eggs', Wall Street Journal, 9 December 2008, Online at: http://online.wsj.com/article/SB122878524586490129.html

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A divorced couple have applied to the Texas Supreme Court for rights over frozen embryos, created using each of their gametes whilst they were still married. Randy and Augusta Roman underwent fertility treatment together before they separated in 2002. On the eve of the day the embryos were due to be implanted, Randy is reported to have withdrawn his consent to the procedure. The couple subsequently divorced and they have been fighting for 'custody' of the embryos ever since.

Initially, the district court ruled that Augusta had a constitutional right to the use of the embryos. The decision was later reversed by the Texas first Court of Appeal that ruled that the couple had made a contractual and binding agreement to destroy the embryos if they divorced. The case has now been referred to the Texas Supreme Court; which is not expected to decide whether it will hear the case until later this year.

The case has ignited debate in America because of its potential implications for the legal status of the embryo. The ability to store embryos has created new legal questions over rights to these embryos in the event of subsequent disagreement between couples. There is currently no federal precedent and this is the first time such a case has come before the Texas Supreme Court. Similar cases have gone to the Supreme Courts in six states in America and the general trend has been to prevent implantation on the basis that one spouses' right not to implant the embryos overrules the other spouses right for them to be implanted.

Some fear that if the case ends up in the Federal Supreme court, then the increasing conservative Court may use it as a vehicle for reconsidering the legal status of the embryo. In the landmark Roe v Wade ruling, which effectively made abortion legal in America, the Court ruled that because the unborn do not have constitutional rights, the woman's rights over her own body take precedent. If the unborn are considered to have a constitutional right to life, the legality of abortion will be thrown into question.

A similar case has recently gone through the European Court of Human Rights (ECHR). Natallie Evans fought for the right to use frozen embryos, created with her former partner, after he had withdrawn his consent to their use. The Court's final ruling was that Evan's right to become a parent should not be afforded more weight than her ex-partner's right not to become a parent.
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A Harvard Medical school study involving 18,000 women has shown that taking multivitamins, particularly folic acid, can improve chances of pregnancy in couples having difficulty conceiving.

Around 150,000 couples in the UK suffer from infertility problems due to the woman's inability to ovulate, which is about 1 in 10 of all women affected by infertility. The study, which followed nurses who hoped to become pregnant for an eight year period, showed that women who took multivitamin supplements six times a week were 40 per cent less likely to fail to ovulate than women who took none.

In the UK, women are advised to take 400 micrograms of folic acid (one of several different B vitamins) every day while trying to conceive, and during the first 12 weeks of pregnancy. 1000 micrograms of folic acid daily is the safe upper limit. The Food Standards Agency (FSA) has proposed adding folic acid to the nutrients currently used to fortify white flour, as has happened in the US since 1988.

Dr. Jorge Chavarro who led the US study told the annual American Society for Reproductive Medicine conference in New Orleans that the beneficial benefits seem to derive from folic acid, which helps prevent birth defects, 'The beneficial effect on fertility continued to increase as women consumed higher amounts of folic acid', he said. Folic acid is found in green leafy vegetables and liver.

Other recent research presented at the 25th annual scientific meeting of the Fertility Society of Australia has shown that daughters of people who smoke during pregnancy are more prone to reproductive health problems. The conference organiser, Professor Geoff Driscoll, said it was important the public understood that lifestyle affected fertility. He noted that starting a family younger, controlling obesity, exercising regularly and not smoking all improve chances of conceiving.

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A study in the Netherlands has shown that lying down following artificial insemination, also known as intrauterine insemination (IUI), increases the chances of pregnancy by 50 per cent.

The findings, published in the British Medical Journal (BMJ) last week, revealed that 27 per cent of women who remained in a supine position following treatment for 15 minutes achieved a live birth, compared with only 17 per cent of those who got up and moved around. In total, 391 couples aged between 18 and 43 took part in the study, which took place across several hospitals in the Netherlands. Each couple received up to three cycles of insemination and were split into two groups - one remained immobilised immediately after treatment and the other, the control group, were asked to walk around.

Lead author Dr Inge Custers, from the Academic Medical Center in Amsterdam, said that the pregnancy rate for the immobilised group was 'significantly higher'. He explained that 'immediate mobilisation might cause leakage [of the sperm]', which may take longer to reach the fallopian tubes if the woman is moving around. 'As immobilisation is easily done and carries very little cost, we suggest incorporating immobilisation as a standard procedure in intrauterine insemination treatment', said Custers, adding that clinics in the Netherlands were already adopting the method. However, there is concern that extending the period each bed is used in clinics could mean that clinics treat fewer patients. Custers said that improving the success rate of IUI will be more economical for patients. 'Although immobilisation takes more time and occupies more space in busy rooms, the intervention will be economic in the long run, as pregnant patients will not return in subsequent cycles,' he said.

In an editorial piece which accompanied Custer's publication in the BMJ, Professor William Ledger, from the Academic Unit of Reproductive and Developmental Medicine at the University of Sheffield, said that there remain many unexplained factors that need to be explored, such as the optimal length of time a woman should remain immobile following treatment to achieve pregnancy. He also noted that it was not clear what proportion of women in the study were given drugs to stimulate their ovaries to produce eggs and expressed some doubt over the benefits of remaining immobile. 'Such postcoital positioning was advocated in the United States many years ago but did not seem to improve conception rates after sex,' he said. He also warned that the overall pregnancy rate achieved in the study is somewhat lower than can be expected in Britain.

Ledger said that clinics should perform their own studies in the 'real world' to test Custers' findings. If further studies confirm the findings of the Netherlands team then he agreed that some couples will be spared the cost of IVF (in-vitro fertilisation). Artificial insemination is cheaper than IVF and requires minimal drug treatment. It is often used prior to IVF and success rates vary from 5-70 per cent, according to Ledger.

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