Recent advances in assisted reproductive technology in Nigeria by Prof Oladapo Ashiru
Sub-fertility or infertility may be the most painful problem in the lives of those who are unable to bear children. Infertility has a social stigma and it leads to social, mental and physical problems, especially in women.
In 1978, the world witnessed the birth of Louis Brown, which was achieved via In Vitro Fertilisation of one oocyte collected through a natural cycle. Since then, there have been explosive advances in assisted reproductive technology.
Indeed, what was perceived in those days as controversial in medical practice is now fully employed in IVF to bring hope to infertile people who are desirous of bearing children.
Initially, the methods used in IVF were unrefined and they often resulted in poor pregnancy outcomes. However, some current practices that have enhanced these developments and growth include the ability to understand the physiological processes of ovulation and to mimic these processes artificially with ovulation induction drugs, which are capable of stimulating a woman’s ovaries to yield multiple eggs; luteal phase support and the use of transvaginal ultrasound scan.
Low-cost IVF is a new and trending topic of discussion among medical experts and efforts are being made to ensure that more people have access to the treatment of infertility, despite its financial implication.
In some instances, there is what is called dual stimulation. This occurs when a patient is mildly stimulated in a series of stimulation processes where a fewer number of eggs are retrieved per cycle, but a series of stimulation to get enough eggs for fertilisation. There are instances where a patient that has been diagnosed with cancer requires immediate stimulation to preserve their eggs before chemotherapy commences.
For poor responders, there are pre-treatment therapies available in the form of vitamins and antioxidants to help in improving the quality of the available eggs before stimulation commences. Currently, there is ongoing research to improve the thin lining of the womb, but there is no effective, easy solution yet. However, Coenzyme Q10, resveratrol and alpha-lipoic acid have been proving beneficial in terms of reducing aneuploidy rate, delaying oocyte reserve depletion, improving mitochondrial activity and reducing intracellular oxidative stress. There is a need to target drug delivery and action.
There is a new trend of Freeze All” now, where the lining of the womb is prepared to receive the embryos at a later time to maximise the implantation rate. This alludes to the fact that the excessive exposure of the endometrial lining to oestrogen may limit the implantation window, which can be better timed during a frozen embryo transfer cycle.
The available evidence from randomised controlled trials and systematic reviews and meta-analyses indicates that overall live birth rates were significantly higher after FET as compared to fresh ET in the hyper responders, with a significantly lower risk for ovarian hyperstimulation in the groups.
The World Health Organisation has now recognised infertility as a disease. WHO has been working closely with teams of experts to identify ways that fertility treatment success rates can be improved globally as the success rate is still approximately in the range of 45 per cent.
One of the limiting factors to fertility success has been identified as the environmental toxins that include but not limited to cosmetics, insecticides, fuel fumes, heavy metals, food allergies, to mention a few. These toxins have frequently been exposed to us on a day to day basis, and it affects our reproductive capability as well. Mayr therapy is one of the new ways of detoxifying the body in preparation for IVF treatment, especially for the couple that had suffered repeated failed IVF cycles and unexplained implantation failure.
New modifications are done in an embryology laboratory in terms of embryo culture, kind of culture media used and most importantly, quality assurance being employed in IVF labs has escalated the recent successes in assisted reproductive technology.
Perfecting the embryo culture media has significantly increased the pregnancy rates. One of such modifications in the lab is research on optimal oxygen levels in incubators and optimal PH in the embryology media. Other advances, such as the use of intracytoplasmic sperm injection, assisted hatching, embryo glue and ultrasound-guided embryo transfer.
In the IVF laboratory, the ability to mature oocytes called In Vitro Maturation is one of the recent techniques employed in the embryology lab and this is the process of retrieving immature follicles, less than 18mm in diameter, and then completing the maturation in vitro.
The major reason for IVM of oocytes is to reduce the adverse effect of ovarian stimulation in polycystic ovarian patients which is ovarian hyperstimulation syndrome, which can be critical and life-threatening if not well managed. Although IVM is beneficial, it has a lower pregnancy outcome than standard IVF/ICSI.
Another new introduction in the field of Assisted Reproductive Techniques is the use of Pre- implantation Genetic Testing. This technique is used to detect abnormal embryos or genetically affected embryos like sickle cell affected embryos. The test is applied on blastocyst embryos to give a more detailed analysis of embryos cultured in the laboratory.
For a regular IVF process, the morphological grading system is utilised to grade embryos before transfer. This method does not have the capacity to detect aneuploidy in an embryo, but now, pre-implantation genetic screening is available to couples who are at risk of having babies with chromosomal abnormalities, single genetic diseases like sickle cell disease, advanced age couples at risk of Downs syndrome and sex selection.
PGT using recent advances in technology can detect aneuploidy in embryos that are genetic diseases that may not be compatible with life. This screening has helped in taking a quick decision about the treatment of infertile women, as well as increasing the pregnancy outcome and shortening time to pregnancy.