The ART of Fertility Treatment
L to R: Dr Kim Matthews; Ann Tolman, Registered Nurse; Dianne Mann, NUM Day Surgery; and Anita Stewart, Registered Nurse.
L to R: Dr Kim Matthews and Ann Tolman, Registered Nurse.
By Dr Kim Matthews
The science of Assisted Reproductive Technologies (ART) is an incredibly important part of the process. Over the years the science has expanded and to keep up with it requires a very large team of dedicated personnel.
In the time I have been practising fertility and reproductive medicine we have gone from transferring three embryos at the day two cleavage stage with no better than a 20 per cent pregnancy rate per transfer, to single embryo transfers at the day five blastocyst stage with a 40-50 per cent pregnancy rate in women less than 38 years of age, depending on the medical reasons required for fertility treatment. This resulted in the large number of twin pregnancies that were seen in the late 1990s and early 2000 but thankfully this is no longer the case and single embryo transfer has been the normal practice in Australia for many years. These advances were largely achieved with attention to the components of the media in which the embryos develop, strict temperature control with the use of individual small incubators for each patient and minimising the manipulation and checking of the embryos during their development in vitro by only looking at their progress at certain limited times. Add to this the facility to be able to test the genetics of the embryo prior to transfer (preimplantation genetic screening or PGS) and this has further reduced the miscarriage rate and increased success rates per embryo transfer, particularly in the older age group where aneuploidy is more frequently seen in the embryo cohort, although this is not a necessary tool for everyone undergoing treatment.
There have been many other scientific tools that have come and gone during the 30 years that IVF has been available and it behoves the team to assess and evaluate those which prove to be beneficial and those which should be abandoned. One such tool was the use of assisted hatching, which was thought to help the older women’s embryos hatch by using a laser to make a small hole in the zona pellucida on day three, but was then shown to adversely effect frozen embryo outcomes. However, a modified technique is still used to enable embryo biopsy on day five for PGS and currently the role of sperm selection for microinjection is being reassessed as to its role and validity.
We are now able to achieve pregnancies with very few sperm present due to advances in microsurgery allowing our colleagues who specialise in this area to pinpoint the seminiferous tubules most likely to be producing sperm, thereby giving our scientists access to these sperm for the process of microinjection into the oocyte. Even when sperm is plentiful, changes have also been made to how and where we ask our patients to collect to ensure we have the sperm processed quickly to allow for maximal fertilisation rates. Originally, we used to ask our partners to abstain for about seven days prior to oocyte collection but we have more recently reduced the number of days of abstinence so that sperm is not sitting in the genital tract for too long and is therefore not exposed to oxidative stresses for too long. Indeed when increased DNA fragmentation is seen we increase the frequency of ejaculation to minimise this issue and this can help to improve embryo quality and reduce miscarriage risk.
However, it has also been my experience that there is an ART to fertility management that requires more than the science. The importance of teamwork and caring for the couple as they embark on a fertility journey is paramount. We are aware that every interaction can have an impact on the couples experience and that this can influence both the outcome and the persistence of a couple in order to achieve their much desired pregnancy. This starts from the first phone call to the pregnancy scan and every interaction in between. The role of the team including administration staff, clinicians, fertility nurses, scientists, operating staff, managerial staff, donor coordinators and counsellors cannot be underestimated.
As a clinician, I am always discussing options with my patients and prefer them to feel part of the decision making process. Our couples are as individual as we are and require many differing pathways. Numerous treatment options are possible from simply helping time intercourse, inducing ovulation with tablets or injections or intrauterine insemination, through to the complex process of In Vitro Fertilisation (IVF). Even then there are several different types of IVF, including IVF, microinjection (ICSI), surgical sperm collection and preimplantation genetic screening (PGS) and preimplantation genetic diagnosis (PGD) for single gene disorders.
Tailoring the treatment protocols to try and achieve the best response from the ovary and development of the oocytes is an art form like no other and requires careful thought and management of each cycle. Even then, the quality of the oocytes can vary from cycle to cycle even with the same message being given to the ovaries. The use of donor gametes is another possible treatment option and we have a team dedicated to this service due to its complex nature and legal requirements. Surrogacy is considered alongside donor gametes as a complex process and requires a lot of time and effort to support but is another important treatment option for a few select indications.
A pregnancy is not always possible and so it is equally important that these couples are well supported and this outcome is also recognised as a possibility.
Indeed, there are many ways to create a family and it takes a village to raise a child. The art of fertility treatment aims to help as many couples as possible. Whilst recognising that it is not always achievable and nothing in the fertility world (as with much of medicine) is 100 per cent, the Lakeview Private Hospital and Monash IVF teams always strive to do their best.
This article is dedicated to Prof Geoffrey Driscoll.
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