The early days of IVF outside the UK

Infertility and risk of postmenopausal breast cancer in the women's health initiative

PURPOSE

Although infertility (i.e., failure to conceive after ≥ 12 months of trying) is strongly correlated with established breast cancer risk factors (e.g., nulliparity, number of pregnancies, and age at first pregnancy), its association with breast cancer incidence is not fully understood. Previous studies were primarily small clinic-based or registry studies with short follow-up and predominantly focused on premenopausal breast cancer. The objective of this study was to assess the relationship between infertility and postmenopausal breast cancer risk among participants in the Women's Health Initiative (analytic sample = 131,784; > 25 years of follow-up).

METHODS

At study entry, participants were asked about their pregnancy history, infertility history, and diagnosed reasons for infertility. Incident breast cancers were self-reported with adjudication by trained physicians reviewing medical records. Cox proportional hazards models were used to estimate risk of incident postmenopausal breast cancer for women with infertility (overall and specific infertility diagnoses) compared to parous women with no history of infertility. We examined mediation of these associations by parity, age at first term pregnancy, postmenopausal hormone therapy use at baseline, age at menopause, breastfeeding, and oophorectomy.

RESULTS

We observed a modest association between infertility (n = 23,406) and risk of postmenopausal breast cancer (HR = 1.07; 95% CI 1.02-1.13). The association was largely mediated by age at first term pregnancy (natural indirect effect: 46.4% mediated, CI 12.2-84.3%).

CONCLUSION

These findings suggest that infertility may be modestly associated with future risk of postmenopausal breast cancer due to age at first pregnancy and highlight the importance of incorporating reproductive history across the life course into breast cancer analyses.

Mammalian embryo culture media: now and into the future

For over 70years, since the culture of the first mammalian embryo in vitro , scientists have undertaken studies to devise and optimise media to support the manipulation and culture of gametes and embryos. This area of research became especially active in the late 1970s onwards following the successful birth of the first human in vitro fertilised embryo. This review summarises some of the key advances in mammalian embryo culture media over time based on a greater understanding of the biochemical milieu of the reproductive tract. It highlights how learnings from studies in mice and agricultural species have informed human culture media compositions, in particular the inclusion of albumin, growth factors, cytokines, and antioxidants into contemporary culture media formulations, and how these advances may then in turn help to inform and guide development of in vitro culture systems used in other arenas, in particular agriculture. Additionally, it will highlight how the introduction of new technologies, such as timelapse, can influence current trends in media composition and usage that may see a return to a single step medium.

Long-Term Effects of ART on the Health of the Offspring

Assisted reproductive technologies (ART) significantly increase the chance of successful pregnancy and live birth in infertile couples. The different procedures for ART, including in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), intrauterine insemination (IUI), and gamete intrafallopian tube transfer (GIFT), are widely used to overcome infertility-related problems. In spite of its inarguable usefulness, concerns about the health consequences of ART-conceived babies have been raised. There are reports about the association of ART with birth defects and health complications, e.g., malignancies, high blood pressure, generalized vascular functional disorders, asthma and metabolic disorders in later life. It has been suggested that hormonal treatment of the mother, and the artificial environment during the manipulation of gametes and embryos may cause genomic and epigenetic alterations and subsequent complications in the health status of ART-conceived babies. In the current study, we aimed to review the possible long-term consequences of different ART procedures on the subsequent health status of ART-conceived offspring, considering the confounding factors that might account for/contribute to the long-term consequences.

The history and future of in vitro fertilization in the United States: the complex interrelationships among basic science, human medicine, and politics

Although much of the foundational basic scientific and clinical research was conducted in the United States, the first in vitro fertilization (IVF) birth occurred in the United Kingdom. Why? For centuries, all research surrounding the field of "reproduction" has elicited bipolar passionate responses by the American public, and the issue of "test tube babies" has been no different. The history of conception in the United States is defined by complex interrelationships among scientists, clinicians, and politically charged decisions by various branches of the US government. With a focus on research in the United States, this review summarizes the early scientific and clinical advances important to the development of IVF and then addresses the potential future developments in IVF. We also consider what future advances are possible in the United States given the current regulations, laws, and funding.

The Lack of Ireland’s Assisted Human Reproduction (AHR) Regulation Viewed under the Lens of the Patient’s Experience

Assisted Human Reproduction (AHR) treatment is unregulated in Ireland, although it is practised there. Within Europe, Ireland is one of the only European countries without any form of AHR-specific regulation. This study aims to investigate the experiences and viewpoints of Irish women undergoing AHR treatments and establish if the lack of legislation is affecting these experiences. A quantitative survey was carried out on women undergoing AHR treatment in Irish clinics. Patients highlighted a lack of information in terms of end-to-end care and poor information around treatments and success rates. Key issues highlighted included unanticipated high treatment costs and add-on treatment costs, lack of financial support from the government, no redress process in the event of dissatisfaction, and generally an overall feeling of a lack of support both from the AHR clinics and the Irish government. This study offers a real-time view of the Irish AHR system from the patient’s experience of AHR and under the lens of the lack of a legislative system. In early 2022, the Irish government announced that it would adopt its bill around AHR treatment and that subsidies for AHR treatment are to come into effect, which will alleviate some financial pressures on patients. Further studies of the legislation carried out post implementation will provide more information about the impact of having a legislated AHR process on the patients.

Association of infertility with atherosclerotic cardiovascular disease among postmenopausal participants in the Women's Health Initiative

OBJECTIVE

To investigate the association of infertility with atherosclerotic cardiovascular disease (ASCVD) among postmenopausal participants in the Women's Health Initiative (WHI). We hypothesized that nulliparity and pregnancy loss may reveal more extreme phenotypes of infertility, enabling further understanding of the association of infertility with ASCVD.

DESIGN

Prospective cohort study.

SETTING

Forty clinical centers in the United States.

PATIENT(S)

A total of 158,787 postmenopausal participants in the Women's Health Initiative cohort.

INTERVENTION(S)

Infertility, parity, and pregnancy loss.

MAIN OUTCOME MEASURE(S)

The primary outcome was risk of ASCVD among women with and without a history of infertility, stratified by history of live birth and pregnancy loss. Cox proportional-hazards models were adjusted for demographics and risk factors for ASCVD.

RESULT(S)

Among 158,787 women, 25,933 (16.3%) reported a history of infertility; 20,427 (80%) had at least 1 live birth; and 9,062 (35%) had at least 1 pregnancy loss. There was a moderate overall association between infertility and ASCVD (adjusted hazard ratio, 1.02; 95% confidence interval [CI], 0.99-1.06) over 19 years of follow-up. Among nulliparous women, infertility was associated with a 13% higher risk of ASCVD (95% CI, 1.04-1.23). Among nulliparous women who had a pregnancy loss, infertility was associated with a 36% higher risk of ASCVD (95% CI, 1.09-1.71).

CONCLUSION(S)

Women with a history of infertility overall had a moderately higher risk of ASCVD compared with women without a history of infertility. Atherosclerotic cardiovascular disease risk was much higher among nulliparous infertile women and among nulliparous infertile women who also had a pregnancy loss, suggesting that in these more extreme phenotypes, infertility may be associated with ASCVD risk.

Interplay of Oxidants and Antioxidants in Mammalian Embryo Culture System

One principal purpose of assisted reproductive technology (ART) is to produce viable and good quality embryos. However, a variety of environmental factors may induce epigenetic changes in the embryo. Moreover, laboratory conditions including the culture media may also affect embryo development. Therefore, media change is an important factor in maintaining proper oxidant/antioxidant balance during embryo culture. Alterations in the oxidant/antioxidant balance are related to various cellular responses such as an increase in the level of reactive oxygen species (ROS) and consequent lipid peroxidation (LPO), DNA damage, and apoptosis. The current study focuses on the role of external factors on embryo culture and the ability of antioxidants to enhance in vitro fertilization (IVF) outcomes. Indeed, an optimization of media culture by the addition of enzymatic and nonenzymatic antioxidants in animal models and human embryos in ART has been updated in this study, with an emphasis on comparing the available results and their possible reasons.

Three ways of knowing: the integration of clinical expertise, evidence-based medicine, and artificial intelligence in assisted reproductive technologies

Decision-making in fertility care is on the cusp of a significant frameshift. Online tools to integrate artificial intelligence into the decision-making process across all aspects of ART are rapidly emerging. These tools have the potential to improve outcomes and transition decision-making from one based on traditional provider centric assessments toward a hybrid triad of expertise, evidence, and algorithmic data analytics using AI. We can look forward to a time when AI will be the third part of a provider's tool box to complement expertise and medical literature to enable ever more accurate predictions and outcomes in ART. In their fully integrated format, these tools will be part of a digital fertility ecosystem of analytics embedded within an EMR. To date, the impact of AI on ART outcomes is inconclusive. No prospective studies have shown clear cut benefit or cost reductions over current practices, but we are very early in the process of developing and evaluating these tools. We owe it to ourselves to begin to examine these AI-driven analytics and develop a very clear idea about where we can and should go before we roll these tools into clinical care. Thoughtful scrutiny is essential lest we find ourselves in a position of trying to modulate and modify after entry of these tools into our clinics and patient care. The purpose of this commentary is to highlight the evolution and impact AI has had in other fields relevant to the fertility sector and describe a vision for applications within ART that could improve outcomes, reduce costs, and positively impact clinical care.

Founding Pioneers of IVF: Independent innovative researchers generating livebirths within 4 years of the first birth

In this 40th anniversary year of the first IVF live birth, it is pertinent to look at all those teams endeavouring to generate live births from this unique technology and who succeeded within 4 years of the first. There were 9 teams who achieved this and a further 3 who were successful soon after, by the end of 1982. This historical review is compiled by 2 authors who were actively engaged in the field of IVF at the time of the first birth and who have remained active in Reproductive Medicine throughout their professional lives. They bring intimate and relevant knowledge of those pioneer researchers from the early years who can be classified as the "Founding Pioneers" of IVF.

Mortality in Women Treated With Assisted Reproductive Technology-Addressing the Healthy Patient Effect

In previous studies, investigators have reported reduced mortality among women undergoing assisted reproductive technology (ART) treatment, possibly related to selection of healthy women into ART treatment. Our aim in this study was to explore the impact of relevant selection factors on the association between ART treatment and mortality and to explore effect modification by parity. Women treated with ART in fertility clinics in Denmark during 1994-2009 (n = 42,897) were age-matched with untreated women from the background population (n = 204,514) and followed until December 31, 2010. With adjustment for relevant confounders, the risk of death was lower among ART-treated women during the first 2 years after ART treatment (hazard ratio (HR) = 0.68, 95% confidence interval (CI): 0.63, 0.74), but there was no apparent difference after 10 years (HR = 0.92, 95% CI: 0.79, 1.07). Having children prior to ART treatment was associated with markedly reduced mortality (HR = 0.45, 95% CI: 0.38, 0.53), possibly due to better health among fertile women. While the frequencies of previous medical and psychiatric diagnoses among ART-treated and untreated women were similar, differences in disease severity could explain the reduced mortality among ART-treated women, as poor prognosis would make initiation of ART treatment unlikely. The survival advantage among ART-treated women is likely a selection phenomenon rather than a biological phenomenon.

Resolved Parental Infertility and Children's Educational Achievement

Although difficulty conceiving a child has long been a major medical and social preoccupation, it has not been considered as a predictor of long-term outcomes in children ultimately conceived. This is consistent with a broader gap in knowledge regarding the consequences of parental health for educational performance in offspring. Here we address that omission, asking how resolved parental infertility relates to children's academic achievement. In a sample of all Swedish births between 1988 and 1995, we find that involuntary childlessness prior to either a first or a second birth is associated with lower academic achievement (both test scores and GPA) in children at age 16, even if the period of infertility was prior to a sibling's birth rather than the child's own. Our results support a conceptualization of infertility as a cumulative physical and social experience with effects extending well beyond the point at which a child is born, and emphasize the need to better understand how specific parental health conditions constrain children's educational outcomes.

Well-informed by national registers? A comparison of national ART registers in Germany, France and the United Kingdom

OBJECTIVES

National registers which document assisted reproductive technology (ART) treatments are important for a range of stakeholders. Their websites and reports are a source of information for ART practitioners, (future) patients and the public. The aim of our study was to compare national ART registers in the three European countries with the largest populations and evaluate whether ART registers currently meet the information needs of the different groups.

METHODS

We compared the publications of national registers in three European countries (the United Kingdom, France and Germany) with diverse regulatory approaches. Our analysis focused on two criteria: data quality and patient orientation.

RESULTS

Our findings suggest that the German and French registers' publications fulfil the criteria to a lesser degree than the British register publications, by collecting data that are likely to be less accurate and publishing less information specifically targeted at patients.

CONCLUSIONS

Differences in the publications and the data collection methods of the three registers impact the opportunities of various stakeholders to access information about ART from their respective national registers.

Impact of the IVF laboratory environment on human preimplantation embryo phenotype

The phenotype of the human embryo conceived through in vitro fertilization (IVF), that is its morphology, developmental kinetics, physiology and metabolism, can be affected by numerous components of the laboratory and embryo culture system (which comprise the laboratory environment). The culture media formulation is important in determining embryo phenotype, but this exists within a culture system that includes oxygen, temperature, pH and whether an embryo is cultured individually or in a group, all of which can influence embryo development. Significantly, exposure of an embryo to one suboptimal component of the culture system of laboratory typically predisposes the embryo to become more vulnerable to a second stressor, as has been well documented for atmospheric oxygen and individual culture, as well as for oxygen and ammonium. Furthermore, the inherent viability of the human embryo is derived from the quality of the gametes from which it is created. Patient age, aetiology, genetics, lifestyle (as well as ovarian stimulation in women) are all known to affect the developmental potential of gametes and hence the embryo. Thus, as well as considering the impact of the IVF laboratory environment, one needs to be aware of the status of the infertile couple, as this impacts how their gametes and embryos will respond to an in vitro environment. Although far from straight forward, analysing the interactions that exist between the human embryo and its environment will facilitate the creation of more effective and safer treatments for the infertile couple.

The impact of atosiban on pregnancy outcomes in women undergoing in vitro fertilization-embryo transfer: A meta-analysis

Background

Atosiban is administered to women undergoing in vitro fertilization-embryo transfer (IVF-ET) to improve pregnancy outcomes. However, the results of this treatment were controversial. We conducted this meta-analysis to investigate whether atosiban improves pregnancy outcomes in the women undergoing in vitro fertilization (IVF).

Methods

Databases of PubMed, EMBASE, Web of Science, China BioMedicine, and Google Scholar were systematically searched. Meta-analyses were performed to investigate whether atosiban improves pregnancy outcomes in the women undergoing IVF.

Results

Our results showed that atosiban was associated with higher implantation (OR = 1.63, 95% CI: 1.17–2.27; P = 0.004) and clinical pregnancy (OR = 1.84, 95% CI: 1.31–2.57; P < 0.001) rates. However, atosiban showed no significant association with the miscarriage, live birth, multiple pregnancy or ectopic pregnancy rates. When a further subgroup analysis was performed in the women undergoing repeated implantation failure (RIF), implantation (OR = 1.93, 95% CI: 1.45–2.57; P < 0.001), clinical pregnancy (OR = 2.48, 95% CI: 1.70–3.64; P <0.001) and the live birth (OR = 2.89, 95% CI: 1.78–4.67; P < 0.001) rates were significantly higher in the case group. Nevertheless, no significant difference was detected in the miscarriage and multiple pregnancy rates between the case and control groups.

Conclusion

Atosiban may be more appropriate for women undergoing RIF and play only a limited role in improving pregnancy outcomes in the general population of women undergoing IVF. These conclusions should be verified in large and well-designed studies.

A global perspective on assisted reproductive technology fertility treatment: an 8-country fertility specialist survey

BACKGROUND

Procedures that may optimize success in achieving live births from assisted reproductive technology (ART) continue to be examined. Not yet considered are the perspectives of fertility specialists regarding important developments in the fertility treatment field, current unmet needs, and anticipated future advances. In the current study, an 8-country survey of fertility specialists was conducted to provide a comprehensive, global depiction of fertility treatments across different regions.

METHODS

Fertility specialists from France, Germany, Italy, Spain, the United Kingdom (UK), the United States (US), China, and Japan were invited to participate in an online survey. Participants were eligible if they personally managed ≥25 patients/month who were experiencing difficulty conceiving, and if they had performed ART fertility treatment with ≥1 patient in the previous month. Quantitative questions addressed the number of patients seen, main infertility causes, number of cycles performed, ART procedure type, and ART outcomes. Qualitative questions covered diagnostic trends, unmet needs, important advances, and expected future developments.

RESULTS

The number of fertility specialists who completed the survey included 29 in France, 33 in Germany, 23 in Italy, 38 in Spain, 34 in the UK, 91 in the US, 50 in China, and 65 in Japan. Patient volume increased over the prior 2 years according to 67 % (242/363) of the fertility specialists. As expected, ART outcomes all declined with age in all countries. ART outcomes varied by country, with the highest implantation, pregnancy, and live birth rates reported by fertility specialists in the US and China and the lowest rates reported in France and Italy. The most frequently reported unmet needs in fertility treatment were financial coverage, improved implantation rate, and egg donation. Most frequently named future advancements expected to change the fertility treatment field included improved embryo selection through imaging and/or metabolomics, improved embryo implantation rate, and use of preimplantation genetic diagnosis.

CONCLUSIONS

This study, which follows a rigorous survey methodology, elucidates the current state of fertility specialists' practices and perspectives on the global fertility treatment field, which highlights differences and similarities among countries. This research may inform further studies and procedural developments that might better improve and standardize ART.

The Oldham Notebooks: an analysis of the development of IVF 1969-1978. II. The treatment cycles and their outcomes

This paper reports on the numbers of treatment cycles involved in the development of IVF (1969-1978) and their outcomes. We show that between 1969 and 1978: (i) a minimum of 282 women were involved in 495 cycles of potential laparoscopic oocyte retrieval (LOR); (ii) of these cycles, 457/495 proceeded to LOR to attempt egg collection; (iii) of which an outcome was recorded in 436/457; (iv) eggs were recovered in 388/436 of these; (v) inseminations were recorded in 331/388; (vi) embryos were recorded in at least 167; (vii) a total of 112 embryo transfers were attempted; and (viii) a maximum of 11 possible biochemical/preclinical pregnancies plus five clinical pregnancies were observed; (ix) from which two healthy live births resulted.

IVF culture media: past, present and future

BACKGROUND

The advances in the world of IVF during the last decades have been rapid and impressive and culture media play a major role in this success. Until the 1980s fertility centers made their media in house. Nowadays, there are numerous commercially available culture media that contain various components including nutrients, vitamins and growth factors. This review goes through the past, present and future of IVF culture media and explores their composition and quality assessment.

METHODS

A computerized search was performed in PubMed regarding IVF culture media including results from 1929 until March 2014. Information was gathered from the websites of companies who market culture media, advertising material, instructions for use and certificates of analysis. The regulation regarding IVF media mainly in the European Union (EU) but also in non-European countries was explored.

RESULTS

The keyword 'IVF culture media' gave 923 results in PubMed and 'embryo culture media' 12 068 results dating from 1912 until March 2014, depicting the increased scientific activity in this field. The commercialization of IVF culture media has increased the standards bringing a great variety of options into clinical practice. However, it has led to reduced transparency and comparisons of brand names that do not facilitate the scientific dialogue. Furthermore, there is some evidence suggesting that suboptimal culture conditions could cause long-term reprogramming in the embryo as the periconception period is particularly susceptible to epigenetic alterations. IVF media are now classified as class III medical devices and only CE (Conformité Européene)-marked media should be used in the EU.

CONCLUSION

The CE marking of IVF culture media is a significant development in the field. However, the quality and efficiency of culture media should be monitored closely. Well-designed randomized controlled trials, large epidemiological studies and full transparency should be the next steps. Reliable, standardized models assessing multiple end-points and post-implantation development should replace the mouse embryo assay. Structured long-term follow-up of children conceived by assisted reproduction technologies and traceability are of paramount importance.

Proposed legislative change mandating retrospective release of identifying information: consultation with donors and Government response

STUDY QUESTION

How do gamete donors who presumed they could remain anonymous respond to proposed legislation to retrospectively remove anonymity?

SUMMARY ANSWER

A little more than half of the donors opposed the recommendation to introduce legislation to remove donor anonymity with retrospective effect.

WHAT IS KNOWN ALREADY

An increasing proportion of parents disclose their origins to their donor-conceived children and growing numbers of donor-conceived adults are aware of how they were conceived. Research indicates that access to information about the donor is important to donor-conceived people. However, worldwide most donor-conceived people are unable to find any identifying information about the donor because of the practice of anonymous gamete donation.

STUDY DESIGN, SIZE, DURATION

This study adopted a qualitative research model using semi-structured interviews with gamete donors that included open questions. Interviews with 42 volunteers were conducted between December 2012 and February 2013.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Before 1998 gamete donors in Victoria, Australia, were able to remain anonymous. Pre-1998 donors were invited through an advertising campaign to be interviewed about their views on a recommendation that legislation mandating retrospective release of identifying information be introduced.

MAIN RESULTS AND THE ROLE OF CHANCE

Donors were almost evenly split between those who supported and those who rejected the recommendation to introduce legislation to remove donor anonymity with retrospective effect. About half of the donors who rejected the recommendation suggested the compromise of persuading donors voluntarily to release information (whether identifying or non-identifying) to donor-conceived people. These donors were themselves willing to supply information to their donor offspring. The findings of this study informed the Victorian Government's response to the proposed legislative change. While acknowledging donor-conceived people's right of access to information about their donors, the Government decided that identifying information should be released only with the consent of donors and that donors should be encouraged to allow themselves to be identifiable to their donor offspring.

LIMITATIONS, REASONS FOR CAUTION

There is no way of knowing whether participants were representative of all pre-1998 donors.

WIDER IMPLICATIONS OF THE FINDINGS

The balancing of donors' and donor-conceived people's rights requires utmost sensitivity. All over the world, increasing numbers of donor-conceived people are reaching adulthood; of those who are aware of their mode of conception, some are likely to have a strong wish to know the identity of their donors. Legislators and policy-makers in jurisdictions permitting anonymous gamete donations will need to respond when these desires are expressed, and may choose to be guided by the model of consultation described in this paper.

STUDY FUNDING/COMPETING INTERESTS

The study was funded by the Victorian Department of Health. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

The Alpha Stem Cell Clinic: a model for evaluating and delivering stem cell-based therapies

Cellular therapies require the careful preparation, expansion, characterization, and delivery of cells in a clinical environment. There are major challenges associated with the delivery of cell therapies and high costs that will limit the companies available to fully evaluate their merit in clinical trials, and will handicap their application at the present financial environment. Cells will be manufactured in good manufacturing practice or near-equivalent facilities with prerequisite safety practices in place, and cell delivery systems will be specialized and require well-trained medical and nursing staff, technicians or nurses trained to handle cells once delivered, patient counselors, as well as statisticians and database managers who will oversee the monitoring of patients in relatively long-term follow-up studies. The model proposed for Alpha Stem Cell Clinics will initially use the capacities and infrastructure that exist in the most advanced tertiary medical clinics for delivery of established bone marrow stem cell therapies. As the research evolves, they will incorporate improved procedures and cell preparations. This model enables commercialization of medical devices, reagents, and other products required for cell therapies. A carefully constructed cell therapy clinical infrastructure with the requisite scientific, technical, and medical expertise and operational efficiencies will have the capabilities to address three fundamental and critical functions: 1) fostering clinical trials; 2) evaluating and establishing safe and effective therapies, and 3) developing and maintaining the delivery of therapies approved by the Food and Drug Administration, or other regulatory agencies.

The politics of human embryo research and the motivation to achieve PGD

This article reports a historical study of factors influencing the achievement of clinical preimplantation genetic diagnosis (PGD) in 1990, 22 years after its first demonstration in animals. During the 1970s, research on PGD continued in large farm animals, but serious interest in human PGD was not evident until 1986. First, interest in PGD during the 1970s waned with the advent of prenatal testing, which for gynaecologists was clinically more familiar, technically simpler and ethically less challenging than IVF. Indeed, IVF was viewed with widespread suspicion until the first IVF births in 1978. Second, interest in clinical PGD was stimulated by the UK Parliamentary reaction against human embryo research that greeted the Warnock Report in 1984. This hostility led scientists to initiate a pro-research campaign, further galvanized in 1985 by MP Enoch Powell’s bid to ban such research. However, while Powell abhorred embryo research, he approved of PGD, a stance that divided the anti-research lobby. Accordingly, the campaigners for research emphasized that it was needed to achieve PGD. Powell demanded evidence of such projects and PGD research increased from 1986. It is concluded that UK political debates on embryo research played a critical role in stimulating the achievement of clinical PGD.

Human pregnancies following preimplantation genetic diagnosis (PGD) for embryo sex were announced in 1990, 22 years after the technique was pioneered in animals. PGD in humans required not only technological advances, such as IVF and sensitive diagnostic tests, but also the motivation to develop and apply them. Our historical analysis shows that, although research on PGD continued in large farm animals during the 1970s, and techniques of the required sensitivity were developed on mouse embryo models, interest in clinical PGD was not evident until 1986. Two factors stimulated this sudden change in motivation. First, interest in PGD was depressed during the 1970s by the advent of prenatal diagnostic techniques, which for gynaecologists were clinically, technically and ethically less challenging than IVF. IVF was then regarded with a suspicion that only started to wane in the early 1980s following the first IVF births. Second, the UK Parliamentary reaction against human embryo research that greeted the Warnock Report in 1984 provided a positive stimulus to clinical PGD by prompting scientists to form a pro-research lobby, which was further galvanized in early 1985 by MP Enoch Powell’s almost-successful bid to ban human embryo research. We show that while Powell abhorred embryo research, he approved of PGD, a stance that fractured the unity of the anti-research lobby. Accordingly, the pro-research lobby emphasized that embryo research was needed to achieve PGD. Powell demanded evidence of such projects, thereby, we argue, stimulating PGD research from 1986. Our evidence shows that UK political debates about PGD played a critical role in stimulating the achievement of PGD clinically.

Infertility in Australia circa 1980: an historical population perspective on the uptake of fertility treatment by Australian women born in 1946-51

OBJECTIVE

To estimate the prevalence of lifetime infertility in Australian women born in 1946-51 and examine their uptake of treatment.

METHODS

Participants in the Australian Longitudinal Study on Women's Health born in 1946-51 (n=13,715) completed up to four mailed surveys from 1996 to 2004. The odds of infertility were estimated using logistic regression with adjustment for socio-demographic and reproductive factors.

RESULTS

Among participants, 92.1% had been pregnant. For women who had been pregnant (n=12738): 56.5% had at least one birth but no pregnancy loss (miscarriage and/or termination); 39.9% experienced both birth and loss; and 3.6% had a loss only. The lifetime prevalence of infertility was 11.0%. Among women who reported infertility (n=1511), 41.7% used treatment. Women had higher odds of infertility when they had reproductive histories of losses only (OR range 9.0-43.5) or had never been pregnant (OR=15.7, 95%CI 11.8-20.8); and higher odds for treatment: losses only (OR range 2.5-9.8); or never pregnant (1.96, 1.28-3.00). Women who delayed their first birth until aged 30+ years had higher odds of treatment (OR range 3.2-4.3).

CONCLUSIONS

About one in ten women experienced infertility and almost half used some form of treatment, especially those attempting pregnancy after 1980. Older first time mothers had an increased uptake of treatment as assisted reproductive technologies (ART) developed.

IMPLICATIONS

This study provided evidence of the early uptake of treatment prior to 1979 when the national register of invasive ART was developed and later uptake prior to 1998 when data on non-invasive ART were first collected.

Pluripotent stem cell-derived gametes: truth and (potential) consequences

An emerging body of data suggests that pluripotent stem cells may be able to differentiate to form eggs and sperm. We discuss the state of the science and the potential social implications and offer recommendations for addressing some of the ethical and policy issues that would be raised by the availability of stem cell-derived gametes.

Clinical biochemistry of assisted conception

Assisted reproductive technology has shown rapid advancement since the birth of the first 'test-tube' baby in Oldham, UK, in 1978. Since April 2005, women between the ages of 23 and 39, who meet the described eligibility criteria, are able to get one free in vitro fertilization cycle funded by the National Health Service. Private treatment costs anything from pound4000 to pound8000 for a single cycle of treatment. Almost 15% of the couples in UK are affected by fertility problems and undergo detailed investigations before being offered assisted conception. Assisted reproduction is the collective name for treatments designed to lead to conception by means other than sexual intercourse. These include intrauterine insemination, in vitro fertilization, intracytoplasmic sperm injection and gamete donation. This review is intended to summarize the principles of assisted conception and examine the role of the biochemistry laboratory in: (A) the diagnosis and subsequent management of ovulatory disorders; (B) assessing ovarian reserve before initiating fertility treatment and (C) monitoring fertility treatment. It touches on the screening of potential gamete donors and follow-up of children born after assisted conception. This article was prepared at the invitation of the Clinical Sciences Reviews Committee of the Association of Clinical Biochemistry.

Mild ovarian stimulation for IVF

BACKGROUND

Mild ovarian stimulation for in vitro fertilization (IVF) aims to achieve cost-effective, patient-friendly regimens which optimize the balance between outcomes and risks of treatment.

METHODS

Pubmed and Medline were searched up to end of January 2008 for papers on ovarian stimulation protocols for IVF. Additionally, references to related studies were selected wherever possible.

RESULTS

Studies show that mild interference with the decrease in follicle-stimulating hormone levels in the mid-follicular phase was sufficient to override the selection of a single dominant follicle. Gonadotrophin-releasing hormone antagonists compared with agonists reduce length and dosage of gonadotrophin treatment without a significant reduction in the probability of live birth (OR 0.86, 95% CI 0.72-1.02). Mild ovarian stimulation may be achieved with limited gonadotrophins or with alternatives such as anti-estrogens or aromatase inhibitors. Another option is luteinizing hormone or human chorionic gonadotrophin administration during the late follicular phase. Studies regarding these approaches are discussed individually; small sample size of single studies along with heterogeneity in patient inclusion criteria as well as outcomes analysed does not allow a meta-analysis to be performed. Additionally, the implications of mild ovarian stimulation for embryo quality, endometrial receptivity, cost and the psychological impact of IVF treatment are discussed.

CONCLUSIONS

Evidence in favour of mild ovarian stimulation for IVF is accumulating in recent literature. However, further, sufficiently powered prospective studies applying novel mild treatment regimens are required and structured reporting of the incidence and severity of complications, the number of treatment days, medication used, cost, patient discomfort and number of patient drop-outs in studies on IVF is encouraged.

Two-year outcome after recurrent implantation failure: prognostic factors and additional interventions

Objectives

After recurrent implantation failure (RIF), empirical figures on further prospects are essential for counselling but difficult to estimate within single IVF centres due to high drop-out rates. Alternatively, couples referred to a tertiary unit for RIF were evaluated.

Materials and methods

Multi-centre 2-year observational trial of 1,174 eligible couples treated consecutively with adjuvant lymphocyte immunotherapy (LIT) in a university immunological department from 1999 to 2002 after three or more unsuccessful fresh embryo transfers. Acquisition of data was completed in 2005.

Results

With another 1.5 oocyte retrievals, delivery rate per couple depended on age (39.3% at <30 years, 16.9% at >39 years, P < 0.005). Prognosis was favourable when frozen embryo transfers had been conducted before (34.4 vs. 25.8%, P < 0.005). The outcome was slightly better in ICSI couples as compared to conventional IVF (31.0 vs. 24.8%, P < 0.05). Birth rates per fresh embryo transfer from the fourth to eighth retrieval were 17.4–18.3–15.0–12.9–12.9% (decline not significant). Apart from LIT, further additional interventions were given more often to couples who had had frozen embryo transfers before (49 vs. 40%, P < 0.005).

Conclusions

Female age and ovarian response are crucial for further IVF prognosis. Previous frozen embryo transfers indicate better chances. Couples with male factor infertility may benefit from intracytoplasmatic sperm injection (ICSI) because underlying female factors are less prevalent. Cycle rank had comparatively little impact. Additional interventions are preferentially offered to couples who have a favourable prognosis anyway. Their multiple use is common practice in RIF, but its value should be considered limited.

SmARTest regulation? Comparing the regulatory structures for ART in the UK and Australia

Assisted reproductive technologies are regulated in both the UK and Australia, thereby curtailing both reproductive and professional autonomy. Different regulatory models have developed in each jurisdiction, despite the similar legal, scientific and cultural histories of the two jurisdictions. In the UK the regulatory structures are under review, largely in the absence of empirical research on the costs and benefits of regulation. The regulatory structures in each jurisdiction are compared and some key differences identified. The UK regulatory structure governing assisted reproductive technologies is currently simpler, more accountable and more transparent than that in Australia. On the other hand, despite administrative and legislative restrictions (particularly in Victoria), the medical scientists and clinicians in Australia generally have more control than their British counterparts over the technical aspects of their work in the provision of IVF and other treatment services, and to a lesser extent in embryo research. Recent proposals appear to move the UK regulatory structure towards a less accountable and less transparent model, but with no evident increase in reproductive or professional autonomy. It is suggested that this change is not in the interests of patients, doctors and the public, and a different model is outlined for devolution of both authority and accountability to the professions.

Escaping the tyranny of the embryo? A new approach to ART regulation based on UK and Australian experiences

The early legislative responses to fertilization of human oocytes in vitro exaggerated the protection of the embryo at the expense of the interests of other parties. Although more recent legislative changes have lessened this embryonic grip, it nonetheless still distorts legal thinking and is fundamentally in conflict with biological understanding. Drawing largely on experiences in the UK and Australia, a proposal is explored that reframes the legislative approach to the regulation of assisted reproductive technology (ART) with the following objectives: (i) to align more closely the legal and biological understandings of the earliest stages of human development; (ii) to place the legislative focus on objective, intent and outcome; and in the process (iii) to disentangle legally and conceptually the status of the embryo from that of the potential child. Experiences in the UK and Australia are drawn on, because these two jurisdictions have a common legal heritage and were among the earliest players both scientifically and legally but have pursued very different legal routes to their current legislative practices.