IVF News

Transferring only one embryo during IVF (in vitro fertilisation) treatment significantly reduces the risk of multiple births without considerably altering a woman's chances of conceiving and having a baby, report Swedish researchers.

In a study published in the New England Journal of Medicine, comparing single with double embryo transfer, 53 per cent of the women who had a single embryo implanted had a live baby, compared with 57 per cent of women who were implanted with two embryos.

The study involved 660 women, 330 of whom were implanted with a single fresh embryo. If that treatment cycle failed, a second embryo was implanted which had been frozen then thawed before use. The remaining 330 women were implanted with two fresh embryos.

Dr William Gibbons, the president of the American Society for Reproductive Medicine, said that these findings 'should provide comfort for those who want to perform single-embryo transfers that the pregnancy rates are equivalent'.

The study also showed that the rate of multiple births among women first implanted with a single fresh embryo was significantly lower, at just 2.3 per cent. Of the women implanted with two fresh embryos, 27.5 per cent gave birth to more than one baby.

IVF treatment has routinely involved the implantation of multiple embryos in order to increase a woman's chances of having a child, but as IVF procedures have become more advanced, doctors have been able to implant fewer embryos, with equally successful results. However, multiple births are a common result, and incur health risks for both the mother and baby. Gestational diabetes, bleeding and pre-eclampsia, are all a risk for the mother, and the baby is at increased risk of cerebral palsy, birth defects and developmental delays.

The costs of IVF often prohibit more people choosing single embryo transfer, particularly in countries such as the US where treatment is not covered by national healthcare providers or insurance.

Moreover, 'the stress and disappointment of a failed cycle is hard to put a value on' says Dr Laurel Stadtmauer, an associate professor of obstetrics and gynecology at the Jones Institute for Reproductive Medicine in Norfolk, Virginia, US. 'This research adds further evidence confirming the value of elective single embryo transfer in assisted reproductive technologies,' said Richard Kennedy, a spokesman for the International Federation of Fertility Services.

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An article published recently in the New Scientist alerted readers to ongoing developments in the creation of 'female' sperm and 'male' eggs (1). If - and it is a big if - this technological breakthrough ever comes about, it is suggested that such artificial gametes could offer the possibility of genetic reproduction to people in same sex relationships. In fact artificial gametes offer huge breadth of scope for people to have genetically related offspring regardless of age, gender, relationship status or sexuality. Women could use the technique to produce eggs even after having gone though the menopause. Individuals who cannot find reproductive partners could even use artificial gamete technology to create complementary gametes from their own bodies to fertilise their 'natural' sperm or eggs. 

Because of this, it has been reported that artificial gametes would 'democratise reproduction' (2) and even 'end infertility' (3). This makes for some difficult regulatory decisions. How can we determine who should have access to artificial gametes? The New Scientist article quotes MP Evan Harris, who suggests that the provision of artificial gametes to same sex couples is likely to remain illegal in the UK. Instead, they would be made available only in cases of authentic infertility - something which would be far more acceptable to parliament, and perhaps also to the general public.

The underlying assumption here is that some people have a genuine medical need for artificial gametes, while others do not. But is there really a clear clinical rationale for providing treatment to those who are infertile, while excluding those who are homosexual? Already, fertility treatments are routinely sought by - and provided for -individuals who have no specific clinical problem with conceiving. NICE guidelines recommend that men who have very poor semen quality or azoospermia should be offered ICSI, a procedure which involves ovarian stimulation, egg harvesting, IVF and implantation for the man's partner. The fact that women in this situation are given access to IVF is imbued with social meaning and choice and cannot be encompassed or explained purely with reference to biological or medical facts. That is, the woman is infertile by virtue of the partner she has chosen. 

For this reason, a woman in perfect reproductive health may be deemed to have a clinical need for IVF. But can the kind of quasi-clinical justification that supports a woman's access to IVF on the grounds of her partner's infertility really support the restriction of these services to heterosexual couples? Imagine two patients seeking treatment, woman A and woman B. Both have chosen partners with whom they cannot reproduce. A's partner is an infertile man. B's partner is a woman. In the current system these women would be treated differently not because of any intrinsic physiological, biological, clinical or medical difference between the women themselves, but because one has a male partner, while the other's partner is female. 

Is this a system that could be extended to artificial gametes? I think its arbitrary and unsatisfactory nature is self-evident. If the choice of partner is what generates a clinical need for treatment, it seems highly unjust that same sex couples, who are also infertile by virtue of their choice of partner, are excluded. These problems arise largely from the fact that clinical need has been very broadly interpreted in the case of IVF and related treatments. Intuitively, it may seem right that IVF is perceived to meet a medical need when it is used to help heterosexual couples to have a baby. Yet specifying exactly how it meets this need is conceptually difficult, especially when the treatment is provided to a person who is not physiologically infertile. Because of this, it is not convincing to suppose that some people have a clear clinical need, while others do not. 

Artificial gametes have the capacity to put huge strain on a regulatory framework that is already struggling to maintain coherence. The connection between biological malfunction and the need for treatment is extremely tenuous in this context. There is a common assumption that technology, especially medical technology, must inevitably better the human lot, and reduce human suffering. But new technologies cannot overcome social problems, and medical terminology is no longer sufficient to demonstrate who 'needs' fertility treatment. When we talk of reproduction, or of infertility, it is no longer clear to what we are referring in the light of new reproductive technologies which could enable anyone to reproduce. As the philosopher Quine points out, there is no use in reaching for the dictionary in this situation. Those who compile dictionaries have no greater philosophical access to the truth than anyone else, even if they are well versed in etymology and usage (4).

This might not matter if it were not that these definitions impact on our healthcare resources and regulatory environment. But because they do, it is imperative that lazy generalisations and hazy assumptions are challenged. The belief that there are simple medical or biological answers to how technology should be used pre-empts the possibility of reaching an openly-negotiated solution to these ethical and social questions. It is the recognition of this need for renegotiation which is lacking from current legal and bio-ethical debates on the issues raised by new technologies such as artificial gametes. 

The advent of a marvellous new technology is of little comfort to people whose reproductive desires could perhaps already be remedied with existing technologies, but to whom access is denied, whether on social or clinical grounds. Artificial gametes could in some respects exacerbate the misery that already exists in the context of reproductive technologies in the UK. Current restrictions are variously regarded as arbitrary, unfair, and unjustly discriminatory (5). In this environment it is utterly misguided to suppose that any new technology, however ingenious, will either end infertility or democratise reproduction.

References:

1. Aldhous P. Are male eggs and female sperm on the horizon? New Scientist. 2nd February 2008. Available at http://www.newscientist.com/channel/sex/mg19726414.000-are-male-eggs-and-female-sperm-on-the-horizon.html

2. Testa G, Harris J. Ethics and synthetic gametes. Bioethics. Volume 19 Issue 2 Page 146-166, April 2005 (p165)

3. Bhattacharya S. Stem cells can end infertility, say IVF pioneers. New Scientist.com News Service, 24 July 2004. Available at http://www.newscientist.com/news/news.jsp?id=ns99993980 (accessed 14 Dec 2004).

4. Quine W. From a logical point of view. Harvard University Press. 1980. p 24.

5. Peterson MM. Assisted reproductive technologies and equity of access issues. Journal of Medical Ethics. 31; 280-285. 2005.

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The role of the clinical embryologist has changed in many significant ways since the profession began. In the early days at Bourn Hall Clinic the embryologists? role was confined to the laboratory. The scientists there carried out excellent work in an environment they knew and loved. They often worked very long hours (no change there then!) especially in the days before down regulation. I was often still at the clinic at midnight to do the insemination for an LH surge egg collection carried out at 8.00pm. These were pioneering days and the embryologists involved accepted the work gladly. Their 21st century colleagues have very different demands on them including ICSI licensing, never ending rules and regulations and ever changing technologies.

Probably the most significant change is the amount of legislation and documentation related to the work. In the UK and in many other countries there are now very specific laws governing the practice of IVF clinics and the embryologists often find themselves responsible for this paperwork. This can place enormous pressures on embryologists, especially those working in small teams. Failure to comply with these regulations will result in closure of the clinic and possible personal prosecution. Clinics should seriously consider administrative back-up for this increasing amount of red-tape. It is unfair to expect already stretched scientific staff to complete this paperwork.

A second very significant change is the amount of patient contact most embryologists are expected to carry out. In the early days of IVF the most patient contact I ever got was at embryo replacement (transfer) when I was expected to say:
?Hello Mrs Bloggs, you have got three embryos to replace now and six to freeze?.
Today many embryologists find themselves in long involved discussions with very well informed patients (thanks to the internet!). There is very often little or no training for this new role and many embryologists can find it very daunting. I do agree that some patient contact does enable the scientist to put his role into context but I also believe that this should be in moderation!

Another point of hot debate is the salary available to clinical embryologists. In the UK there are two types of clinic: National Health Service (NHS) government run clinics and privately run clinics. In the NHS clinical embryologists come under the clinical scientist grade. In this system a very experienced clinical embryologist very often earns the same as a new graduate going into the computer science business! This offers very little encouragement to clinical embryologists who are, after all, working with human life with an enormous responsibility. In the private sector the situation is slightly better but the embryologist still receives much less reward than his clinical colleagues. I would dearly like to work full-time in clinical embryology but unless I can get the job of scientific director in a private clinic (about as likely as me needing to muck out my little boys? rocking horse) I could not even match my meager academics? salary. There is clearly an enormous divide between clinical and scientific salaries within IVF clinics, something which the professional bodies representing clinical embryologists could well spend some time and effort addressing.

I am sure that we would all agree that the best IVF clinics are those at which there is a team effort and a good team spirit. At the clinics where I have worked there has always been a very good team spirit but this is apparently not always the case. There can be a tendency for ?the lab? to be undervalued and for scientists to be down-trodden by clinical staff. This will result in very poor co-operation between team members which almost always reflects in the overall performance of the clinic. These concepts are illustrated perfectly when some clinicians decide that they will ?learn embryology? and then do without an embryologist. I understand that this often happens because of lack of money but what kind of message does this send to embryologists? Would these clinicians attempt to do the nursing, the portering, the maintenance or the cleaning to save money? Probably not!

Many of my colleagues are also involved in ground-breaking clinical research including the development of the full potential of embryonic stem cells, a subject which I laid the foundations for in animal studies in the 1980?s. These researchers often work in their own time (after a long day of clinical work) and very rarely work with the financial support of their host laboratory. The profession must recognise the importance of these researchers if the field is to progress.

Clinical embryology is a satisfying job. It is a pleasure to serve the patients we treat and especially to see their joy when the outcome is positive. Nevertheless, we as a profession must ensure that we are respected in our work and that we are given the appropriate professional status and salary. At present this is often not the case.

Dr Peter Hollands
Anglia Polytechnic University, East Road, Cambridge, UK, CB1 1PT
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Dr. Jacques Cohen discusses methods of embryo selection.

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A UK woman left brain-damaged after a stroke caused by a rare side effect of IVF treatment is set to receive 'very substantial' agreed damages. The 34-year-old patient, who cannot be identified for legal reasons, became pregnant but then developed ovarian hyperstimulation syndrome (OHSS). Fertility doctor Paul Rainsbury, of the Bupa Roding Hospital in Ilford, Essex, agreed last week in the High Court to pay her an undisclosed amount of compensation.



OHSS is caused by the drugs used in IVF to make the ovaries produce more eggs than usual. Mild symptoms of the syndrome, such as swelling and breathlessness, apparently affect up to 20 per cent of women undergoing treatment. However, very rarely, the symptoms are more severe and potentially fatal. Only one death from OHSS has been reported by the UK media to date, that of 33-year-old Temilola Akinbolagbe earlier this year. The total number of fatalities in the 30 years that IVF has been available in the UK is unknown, but it is believed to be less than five.



In the latest case, the woman became pregnant after receiving IVF treatment in 2000. She then developed symptoms of OHSS, which Mr Rainsbury identified on 7 August 2000, but diagnosed as 'mild'. Crucially, on 11 August, she telephoned Mr Rainsbury to say she felt very unwell. She claimed he told her not to worry, but she then later miscarried, the court heard. The next day, she suffered a stroke, and now has great difficulty with her speech, mobility, reasoning and decision-making. But Rainsbury's QC, John Grace, told the judge that if the case had gone to trial, the woman's evidence would have been contradicted by her medical notes - which show that many of her symptoms were still mild when she was admitted to hospital on 12 August.



Mr Rainsbury did not admit liability, but the woman is now set to receive a 'seven-figure' sum, according to the Daily Mail. Her barrister, James Badenoch, said the award meant that she could retain care of her only son and have some freedom from the constraints upon her. The judge, Mr Justice Nelson, approved the settlement.

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Regularly eating processed meats such as bacon may have a detrimental effect on sperm quality, a small US study suggests.

Study leader Dr Myriam Afeiche, from the Harvard School of Public Health in the USA, said: 'We found that processed meat intake was associated with lower semen quality and fish was to higher semen quality'.

Researchers examined sperm samples from 156 men in couples who were undergoing fertility treatment at Massachusetts General Hospital. The men were also questioned about their eating habits including how often they ate processed meats and fish.

Men who regularly consumed bacon and other processed meats had lower sperm quality than those who ate smaller amounts. The study also found that those who ate white fish at least every other day had significantly more normally-shaped sperm cells. Added to this, sperm counts were significantly higher for men who regularly ate dark meat fish such as salmon and tuna. Dr Afeiche said that it is still unclear how these foods might affect sperm count and morphology.

Dr Allan Pacey, chairman of the British Fertility Society and senior lecturer in andrology at the University of Sheffield warned that the results should not be over-interpreted. 'This may be a real effect, but the study is small and we know that accurately measuring sperm size and shape in the laboratory is fraught with error', he said.

Dr Mark Bowman, president of the Fertility Society of Australia also noted that sperm morphology is a complicated area. 'Not all different looking sperm are actually abnormal sperm', he told ABC News.

The findings were presented this week at the annual meeting of American Society for Reproductive Medicine in Boston. The study should be considered as provisional as the results have not yet been published in a peer-reviewed journal

Dr Pacey said that it is well-established that a healthy diet could improve male fertility but it is still unclear if specific foods could lead to reduced sperm quality. 'It is already known that high intake of processed meat is linked to other health issues and so advising men to limit their intake of processed food may improve their health generally as well as possibly be good for their fertility', he added.

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BioNews reporting from ESHRE conference, Berlin:

A chemical that occurs naturally in the leaves of an African plant could help couples conceive, UK scientists say. The research, carried out at King's College London, shows that chemicals released into the blood after chewing khat leaves may improve the ability of sperm to fertilise an egg. The same chemicals could also help keep the sperm 'switched on' and ready for fertilisation for longer than usual, according to team member Lynn Fraser. The study suggests that treatments based on the chemical cathinone, the active ingredient of khat, could help couples trying to conceive, especially if the man and woman both take it.

Many people living in East Africa, where the khat plant grows, chew its leaves to produce feelings of euphoria. There is also a long-held belief that chewing khat can improve a man's sex drive and ability to maintain an erection. But until now, there have been no scientific studies on the effect of khat on the male reproductive system.

The King's College team studied the effects of chemicals derived from cathinone on human and mouse sperm. They found that these chemicals, called phenylpropanolamines (PPAs), trigger the final stage of sperm maturation, when sperm develop the ability to fertilise an egg. And as well as helping prepare the sperm for fertilisation, it seems that PPAs can also keep the sperm in a state of readiness for longer.

Fraser says that the concentrations of PPAs used in the experiments are similar to those found in the blood after chewing khat leaves, and which are still present up to 80 hours later. This raises the possibility that PPA-based treatments, perhaps in tablet form, could soon be available to couples who want to boost their fertility during attempts to conceive, and also as an aid to couples undergoing IVF. 'We could give it to men to improve sperm production, and to women because it is in the female reproductive tract that the sperm go through this process to become fertile', she said.
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Research presented at the annual conference of the European Society of Human Reproduction and Embryology (ESHRE) in Madrid shows that women who act as surrogates suffer no severe emotional problems during pregnancy or after giving up the child. In what the researchers say is the largest and most representative study of surrogates undertaken so far, 34 surrogates were interviewed. They were asked about their reasons for becoming a surrogate, their relationship with the commissioning parents, how they felt about handing over the child and the reactions of others.

The researchers, from the Family and Child Psychology Research Centre at City University, London, interviewed the surrogates approximately one year after they had given birth. Five of the women had acted as a surrogate on a previous occasion. Seven of them were known to the couple before the surrogacy arrangement was entered into, and the others had been introduced to the couple through a surrogacy agency. None of the women said that they had had doubts about handing over the baby to the commissioning parents. Most of the women said that their main reason for becoming a surrogate was 'to help a childless couple', while other reasons given were 'enjoyment of pregnancy' and 'self fulfilment'. Only one woman said she had become a surrogate for the money as well. Only half of the women had experienced a negative reaction to their being a surrogate from their family and friends, but this changed over time, becoming more positive toward the end of the pregnancy.

All of the women said that they had enjoyed a good relationship with the commissioning couple before the pregnancy and, although some of the relationships had sometimes become slightly strained, this was rectified by the end of the pregnancy. The biggest problem was encountered by a woman who became pregnant with twins, said Vasanti Jadva, the lead researcher. 'None of the women experienced any doubts or difficulties whilst handing over the baby', said Ms Jadva, adding 'one woman said that she never viewed it as handing over the child; instead she considered she was handing back the child'.

In the few weeks after giving up the child, 11 of the women experienced 'mild difficulties' and one had 'moderate difficulties'. After a few months, 29 of the women had no difficulties at all, and after a year, this figure was 32. The other two women reported feeling 'occasionally upset'. Eight of the women had had no contact with the child at all since it was handed over, but the majority of the surrogates had maintained some level of contact with the child and the couple. However, only two of the women expressed a desire for more contact than they had. Ms Jadva said that the research, which is ongoing, shows that 'surrogacy appears to be a positive experience for surrogate mothers'. Professor Susan Golombok, director of the centre, said that the study 'does not support many of the claims commonly made about surrogacy. There was no evidence of difficulties with respect to those aspects of surrogacy that have been the greatest cause for concern'.
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Announcement:Addition Clinical Fellowship in Andrology and Reproductive Medicine
Clinical Fellowship in Andrology and Reproductive Medicine for medical postgraduates in gynaecolgy, general surgery, urology and general medicine Objectives: Train postgraduate students to establish and run an efficient, cost effective and ethical reproductive medicine unit.

Duration: 1 year.

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.
For details contact: Dr.N.Pandiyan,
Chief Consultant in Andrology and Reproductive Medicine and Head of the department, Department of Reproductive Medicine,
Chettinad Health City,

E mail: <[email protected]>

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