18 ways to make a baby
The good news for infertile couples is that modern technology makes it possible for almost any couple to have a baby. There are atleast 18 ways to sucessful conception and more are under development.
There is no doubt that IVF and the newer assisted reproductive technologies ( ART) represent one of modern medicine's success stories. Today, there is practically no couple whom we cannot help to make a baby. This can be best exemplified by the following story of one of our patients.
Mrs DF was a 35 year old woman who first came to us for a second opinion regarding her primary infertility in 1991. She had been married for 3 years, but had failed to conceive. Her family doctor had referred her to a gynecologist, who promptly did a laparoscopy and confirmed she was normal. She was asked to then get her husband's semen analysis done. After a lot of persuasion, she finally managed his to get his semen tested - and much to her dismay, the report came back as azoospermia. The husband flatly refused to believe the report - how can my sperm count be zero when I can have sex thrice a night ? However, when repeated testing confirmed the report, he finally agreed to visit the doctor. The gynecologist then referred them to a urologist, who advised him to get a testis biopsy done, to find out if he had a block so they could repair it surgically, if possible. He was so worried about the prospect of surgery on his testes, that he refused to visit any doctor for further treatment. His wife got increasingly desperate as time went by, because she had to suffer the taunts and barbs of friend and relatives for her "barrenness" - and to protect her husband's ego, she couldn't tell them about his problem.
I asked her to come back for a consultation with her husband, explaining to her that infertility is always a couple's problem, and we need to see both the partners together. I then requested him to repeat the semen analysis from a reliable lab, and evaluated the report carefully. This confirmed he had azoospermia; and also showed his seminal volume was normal; the fructose was positive; and the pH was alkaline . The analysis also showed that there were sperm precursor cells present in the ejaculate. I then requested him to perform a sequential ejaculate - two semen samples, ejaculated after a one hour interval. In order to help him produce a second sample, we gave him 100 mg of Viagra. The first sample again showed no sperm. A preliminary examination of the second ejaculate also showed no sperm, but when the sample was centrifuged and the pellet examined carefully, we saw occasional motile sperm per high power field. This confirmed he had cryptozoopsermia, and that his problem was partial testicular failure ( non-obstructive azoospermia). We had to explain to him that there was no treatment for this problem ( remember this was in 1991) and the only treatment option we could offer him would be donor insemination.
He flatly refused this option, and would not consider adoption either. He was very intelligent and highly motivated. He asked - "Doctor, why can't you inject my sperm into my wife's eggs in the test tube baby lab. After all, you only need one sperm to fertile one egg, don't you ?"
We had to explain to him that this was not possible, and that for IVF, we needed at least 1,00,000 sperm. Since he refused to consider the option of donor sperm, he went back home disappointed.
In 1994, he came back to us again, excitedly holding a newspaper report of an article about how doctors in Belgium had invented a new technique, in which they could fertilise a single egg with a single sperm. He wanted us to do this new treatment called intracytoplasmic sperm injection or ICSI for him. We learnt about this major new advance in IVF technology, which allowed us to ensure that 1 sperm plus 1 egg = 1 embryo, and since this was the only method by which he could have a baby with his own sperm, they agreed to go ahead.
We performed an ICSI cycle in July 1995. Since his wife was now 39, we were worried about her ability to produce eggs, so we superovulated her aggressively.She was superovulated with 6 ampuoles of HMG ( Human Menopausal Gonadotropins, Menogon, 450 IU daily) from Day 3, after downregulation with Suprefact ( Buserelin , GnRH analog, 0.5 ml sc daily from Day 1, short protocol). However, her ovarian response was poor, because of her advanced age, and we were forced to abandon the cycle. They were very disappointed, but now wanted to explore the alternative of using donor egg ICSI. They accepted this option readily, and we then did a donor egg ICSI cycle for her in October 1995.
We synchronised the cycles of the donor and the wife by treating them with birth control pills. The egg donor was superovulated with 3 ampuoles of HMG ( Human Menopausal Gonadotropins, Menogon, 225 IU daily) from Day 3, after downregulation with Suprefact ( Buserelin , GnRH analog, 0.5 ml sc daily from Day 1, short protocol). At the same time, the wife's endometrium was primed by treating her with 6 mg estradiol valerate daily, after downregulation with Suprefact.
12 oocyte cumulus complexes were recovered under vaginal ultrasound guidance on 11 Oct 1995. The oocyte complexes were stripped using hyaluronidase, and 11 eggs were found to be mature ( metaphase II). Two sequential semen sample were washed with culture medium containing HEPES ( IVF flushing medium, Medicult), and then centrifuged. 2 ul of the pellet was then added to a 10 ul droplet of PVP ( Medicult, Denmark) and overlaid with mineral oil ( Vitrolife, Scandinavia). Motile sperm were then identified and immobilized; and ICSI performed using Narishige micromanipulators mounted on an Olympus IX-70 inverted microscope, equipped with Hoffman contrast modulation optics, in which a single sperm was injected into each egg. The injected eggs were then cultured in IVF medium ( Vitrofile) in a CO2 incubator for 48 hours. Of the 11 injected eggs, 10 fertilised and a non-contact diode laser ( Cronus, Research Instruments, UK) was then used to drill a hole in the zona to perform assisted hatching for 3 4-cell Grade A embryos , which were then transferred into the wife's uterine cavity using a Rocket embryo transfer catheter on 13 October 1995. The supernumerary 7 embryos were cryopreserved in liquid nitrogen. Luteal phase support was provided with daily Progynova and vaginal progesterone suppositories.
She conceived in this cycle as documented by rising beta HCG levels and serial ultrasound scans which revealed a healthy twin pregnancy with growth appropriate for dates . She required a caesarean section, and now has 2 healthy babies - one son and a daughter.
This story highlights a number of issues. Firstly, the key importance of having a reliable laboratory to perform the semen analysis. Since a semen analysis is no inexpensive, it is often performed badly, and the results are very unreliable. An incorrect report can mislead the doctor, leading to inappropriate treatment. Doctors must insist that the semen analysis be performed at a trustworthy lab, which specializes in semen analysis. The need for close cooperation between the lab and the doctor is also critical. Your doctor must let the lab know what he is suspecting, so they can intelligently process the semen sample.
It is important also that the infertile couple be treated as a unit. Unfortunately, most gynecologists just refer the infertile man to a urologist, with the result that care becomes fragmented and incomplete. It is essential that your specialist be well-informed about male fertility . He should be knowledgeable about interpreting a semen analysis report ; and also know how to examine the infertile man .
This story also emphasizes the dramatic advances which assisted reproductive technology can offer today in helping infertile couples to start their own family.
A TV program produced in the USA in 2002 described 18 ways to make a baby.These included:
- Natural sex
- Artificial insemination -- of mother with father's sperm
- Artificial insemination -- of mother with donor sperm
- Artificial insemination -- with egg and sperm donors, using surrogate mother
- In vitro fertilization (IVF) -- using egg and sperm of parents
- IVF -- with Intra-Cytoplasmic Sperm Injection (ICSI)
- IVF -- with frozen embryos
- IVF -- with Preimplantation Genetic Diagnosis (PGD)
- IVF -- with egg donor
- IVF -- with sperm donor
- IVF -- with egg and sperm donor
- IVF -- with surrogate using parents' egg and sperm
- IVF -- with surrogate and egg donor
- IVF -- with surrogate and sperm donor
- IVF -- with surrogate using her egg, sperm from baby's father
- IVF -- with surrogate using egg and sperm donors
- Cytoplasmic transfer
- Nuclear transfer and cloning
If you now add additional options such as TESA ( testicular sperm aspiration) and PESA ( percutaneous epididymal sperm aspiration);assisted hatching and embryo fragment removal, the list becomes even longer !
The bottom line is that today there is a solution for every infertility problem - and doctors and patients need to apply their mind, so they can decide what's best for each individual couple !Top