Over 2 decades ago, ICSI (intracytoplasmic sperm injection) revolutionized the treatment of male infertility. The ICSI procedure involves injection of a single sperm into each egg at the time of IVF (in vitro fertlization). Before the development of ICSI, couples with sperm issues, what we call "male factor," had very low fertilization and pregnancy rates, even when undergoing IVF. Now a days, because of the use of ICSI, poor sperm quality is a very unusual reason for an IVF cycle to be unsuccessful or to blame for poor fertilization. Over concerns about potentially poor fertilization, many fertility centers have chosen to use ICSI routinely to ensure optimal fertilization even when the male partner's sperm is perfectly normal. At Princeton IVF, our philosophy has always been to allow fertilization to happen "naturally" in the dish when there is no history of sperm issues or poor fertilization. While ICSI had been shown to be quite safe, we feel that a more natural selection process makes more sense and research in the past has suggested that ICSI is only beneficial in male factor patients. A recent large-scale study recently published in the Journal of the American Medical Association has borne this out. ICSI when used in IVF cycles used in couples without sperm issues had lower fertilization and lower implantation rates than non ICSI cycles.
Think going through fertility treatment today is stressful ? Imagine in a world in which everyone suffers from infertility, everyone needs donor embryos in order to get pregnant and there are not nearly enough embryos to around. Lifetime network plans to release a trailer for a series called the Lottery with just that story line. In the show, mankind faces extinction as no one is able to conceive and no babies are born. The only hope is in a small batch of embryos, the fate of which, and of mankind's survival is left up to a lottery.
With government agencies in the US and UK, considering allowing the use "cloning" technologies to prevent the transmission of mitochondrial disease, nuclear transfer has become a hot topic in Reproductive Medicine. As discussed in our prior blog post, IVF is used to obtain eggs from both the intended mother and an egg donor, and the nucleus of the egg (which contain the mother's genetic material) is transferred into the donor egg (which contains healthy unaffected mitochondria). British authorities have now issued a draft guidance document recommending letting research proceed on mitochondria donation. What will the USFDA recommend and will this type of research to help couples with mitochondrial diseases move forward? Only time will tell.
The use of Preimplantation Genetic Testing (PGD) enables fertility doctors to screen embryos for genetic diseases such as Cystic Fibrosis or Sickle Cell Anemia, permitting couples at high risk to avoid transmitting these diseases onto their children. PGD is done as part of an IVF cycle. A biopsy is taken when the embryo reaches the 8 cell or the blastocyst stage, and tested for the specific gene we are concerned about. This same technology can also be used to test for genes that do not necessarily cause a disease but put an individual at risk for other serious diseases. One such genetic mutation, called the BRCA 1 and 2 gene, puts affected women at very high risk for developing breast and ovarian cancer. The risk of developing these cancers in affected women is so high that many women (such as Angelina Jolie) chose to have their breasts and/or ovaries surgically removed just to prevent cancer. Since we know the genetic sequence of the BRCA mutation, it is possible to screen embryos for it, and prevent transmitting the gene onto one's daughters. This article in the Wall Street Journal tells the story of a family who decided to go that route.
In Reproductive Medicine we are comfortable in offering our IVF patients Preimplantatation Genetic Testing (PGD) and Screening (PGS) to prevent the transmission of genetic diseases and reduce miscarriages. Many of us in the field are concerned that there is also a slippery slope, and that advances in genomics may make it too easy to cross that line. Researchers in China are now trying to use these new tools to help couples select smarter babies. To many of us in the west this sounds like Brave New World, the novel by Aldous Huxley, but in China this idea is not so controversial. If their project is ultimately successful, it should raise enormous ethical concerns for all of us, and more importantly is the potential that our patients will insist on access to this technology regardless our ethical concerns.
Coenzyme Q-10 is a naturally occurring chemical found in the parts of the cells (mainly the mitochondria) that produce energy, and is thought by some to be helpful for certain diseases such as cancer, heart disease and some neurologic diseases. A recent study suggests that using Coenzyme Q-10 as part of IVF (In vitro fertilization) may increase the percentage of embryos that are genetically normal. We know that genetically abnormal embryos (which is actually most embryos transferred) explain most IVF failures and miscarriages, so anything that might increase the number of generically normal embryos may improve a couple's odds for success. A word of caution: this study is too small to draw any conclusions. Further research is needed to determine if Coenzyme Q10 is effective or not.
Assisted reproduction and particularly advances in fertility preservation procedures such as egg freezing has made it more likely than ever that men and women will have offspring born after they are deceased. A woman who freezes her eggs (or a husband his sperm) before chemotherapy may not survive the cancer. So what happens when those eggs or sperm are used to help the surviving partner or some one else conceive? This article in the NY Times explores the legal and financial issues that might arise.