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CHANGES IN PRACTICE IN ASSISTED REPRODUCTIVE

TECHNOLOGY (ART) IN THE PAST 30 YEARS

Mr Naim Abusheikha, MB;Bch, D. Obst. (RCPI), FRCOG (London)

Consultant in Reproductive Medicine
Al-Essra Hospital, Amman
abusheikha@doctors.org.uk

The birth of Louise Brown on 25th July 1978 after an In Vitro Fertilization (IVF)
treatment was the climax of ten years of collaborative research between Mr
Patrick Steptoe, a Gynecologist, and Dr Robert Edwards, a Scientist. Their
achievement is considered by many to be one of the most significant
achievements in medicine and science in the 20th Century.

IVF was originally developed for the treatment of intractable female tubal
factor infertility. Since then however, a number of different treatment options
have evolved from the original IVF, and many other causes of infertility can
now successfully be treated. These specialist treatments have arisen out of
the original concept of IVF.

In the earliest IVF cycles no ovarian stimulation was used and Louise Brown
was conceived in a natural cycle, with the timely collection of a single oocyte
(egg). Thereafter, ovarian stimulation was considered to be appropriate and
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many protocols evolved. With these protocols, a larger number of better
quality oocytes were produced in controlled circumstances and pregnancy
rates improved.

The reason Patrick Steptoe originally became involved with ART was as a
result of his pioneering work with laparoscopy. He was able to directly
visualise ovaries and see developing follicles and later he developed
techniques to retrieve oocytes from these follicles. However, with the major
advances that were made in ultrasound imaging techniques in the early
1980’s, methods of retrieving oocytes under ultrasound guidance were
developed. Initially these involved passing a needle directly through the
abdominal wall and the bladder into the ovary; a later similar technique
involved going transurethral through the bladder, and later still, the trans-
vaginal ultrasound technique of oocyte recovery was developed. This
remains the method used by the large majority of ART units worldwide. It has
an overwhelming advantage over laparoscopy in that it is less traumatic for
patients, more oocytes are retrieved by the vaginal ultrasound technique,
there are fewer potential complications and the procedure can be done under
sedation or local anesthesia.

From the time that follicular stimulation was first introduced into ART, surplus
embryos have been generated. I feel it is ethically unacceptable to dispose of
any of these spare embryos and methods to freeze and store were developed
from the first day and have been always up to date. The chance of achieving
a pregnancy with these embryos is almost as good as with fresh embryo
transfer.

The introduction of freezing techniques to ART has allowed the freezing of

other tissues in special circumstances. Freezing of human sperm has been
successful since the mid 1950’s and has been used for many purposes.
Since the late 1970’s the technique has also been used for helping young
men who have cancer or other malignancies who are about to undergo
chemotherapy or radiotherapy and who are likely to be made infertile. By
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freezing samples of semen before treatment, they have been able to conserve
their fertility potential and have successfully had babies when they have
recovered. However, it has been less easy to help young women with
malignancies, since, until recently, freezing ova for future use has not been
very successful. However, in the last five years it has become possible to
achieve pregnancies with frozen/thawed human oocytes. .

In the early 1980’s, couples of whom the male partner had severe sperm
dysfunction were largely excluded from treatment by IVF. However in the late
1980’s it became apparent that with careful sperm preparation and
concentration, IVF treatment became successful and in the early 1990’s,
sperm microinjection techniques evolved. Initially a few spermatozoa were
injected into the subzonal space of the oocyte and from this technology arose
the current and very successful technique of intracytoplasmic sperm injection
(ICSI), which has now become the standard treatment for the most severe
forms of male factor infertility.

It is now possible also to help men who are entirely azoospermic but who
have spermatozoa in their testes or epididymes. It is possible to retrieve
small numbers of spermatozoa by fine needle aspiration of the testes or
epididymis, prepare the sperm samples obtained and microinject single
spermatozoa into oocytes. The results of this treatment are now very good
and it has offered the chance of having families to men who would never
previously have been able to do so.

Another small group of infertile couples whom specifically been treated during
the last fifteen years are those in whom the male partner has suffered a spinal
cord injury and has been left paralysed. These men are generally unable to
ejaculate semen but they can be helped to do so by techniques, such as the
use of a penile vibrator or rectal electro ejaculation (REE). The semen
obtained is invariably of very poor quality, however, with careful preparation in
the laboratory, it can be used for IVF or ICSI of his partners oocytes. The
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results achieved have been very satisfactory, with many paralysed young men
now having their own genetic children, when they would never normally have
been able to do so.

There are still more developments that will occur over the next two decades.
The major hope is that there will continue to be improvements in pregnancy
rates. At present, the average live birth rate per treatment cycle started is in
the region of 50% - 60%. It is expected that live birth rates of up to 80% may
be achieved in the future. .

One of the most exciting developments at present is the use of embryonic

stem cells derived from human embryos which may be used to repair
damaged or diseased tissues in the future. The concept of cloning individuals
is not one that will be acceptable, but tissue cloning for medical purposes will
almost certainly happen in the next decade. Other interesting developments
are the possible use of in vivo and in vitro techniques for the development of
mature oocytes from primordial follicles; also the culture of testicular tissue in
vitro, or in animal species in vivo which is now possible and may become
routine practice in the future.

In conclusion, the practice of ART has undergone major changes over the
past two decades. Many infertile couples now have the chance of achieving a
much wanted baby, when only a few years ago they had no hope at all.

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 ‫عقم الرجال الى اين؟‬

‫د‪.‬نعيم احمد أبو شيخه‬

‫استشاري الجراحة النسائية والتوليد والعقم‬
‫رئيس وحدة علج العقم و أمراض الذكورة و أطفال النابيب بمستشفى السراء‬

‫تكون الحيوانات المنوية غائبه عند رجل واحد من بين كل عشرين رجل و‬
‫الحقيقة انه قبل اقل من عقدين من الزمن لم يكن إل المل الضئيل لتمكين بعض‬
‫هؤلء من النجاب وذلك بان يقوم جراح متخصص باستئصال الجزء المسدود‬
‫وتوصيل بقية القنوات ببعض ويكفي لتصور صعوبة هذه المهمة أن نعرف آن‬
‫قطر تلك القنوات هو ‪ 0.2‬من المليمتر – أي بسماكة شعرة الرأس – ومخاطي‬
‫‪.‬الملمس مما يزيد من صعوبة الجراحة فيها‬

‫ثم تقدم علج عقم الرجال فأصبح بالمكان و في مراكز محدودة في العالم ‪،‬‬
‫سحب الحيوانات من الوعاء الناقل مباشرة واستعمالها لتلقيح البويضات في عملية‬
‫أطفال النابيب‪ ،‬ولكن هذه العملية طويلة وتحتاج إلي وقت طويل لتخليص‬
‫الحيوانات المنوية من الدم ‪ ،‬ولهذا لم تكن النتائج على القدر الذي كان يأمل لها ‪،‬‬
‫وفرص الحمل وقتها لم تكن تتعدى العشرة بالمئة‪ .‬وبقي المركذلك الى ان‬
‫حصلت نقلة نوعية عام ‪ 1992‬حينما اكتشفت تقنية حقن الحيوان المنوي داخل‬
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‫وهذه كانت وبل )‪ ( ICSI‬سيتوبلزم االبويضة اي ما يعرف بتقنية الحقن المجهري‬
‫شك اهم التطورات في علج عقم الرجال اذ صار بالمكان اذا ما وجد حيوان منوي‬
‫واحد ان يستعمل هذا الحيوان للحقن المجهري بل انه لم يعد هناك حاجة لن يكون‬
‫الحيوان متحرك و واكب هذا التقدم ايضا تقدم في طريقة الحصول على الحيوان اذ‬
‫صار بالمكان احيانا الحصول عليه عن طريق إبرة تغرز في البربخ بعملية سهلة‬
‫ودون الحاجة آلي إدخال المريض الى المستشفى وهذا ينجح في الغالب في‬
‫الحصول على حيوانات كافية للحقن المجهري وقد يكون هناك فائضا للتخزين‬
‫للستعمال في دورات علجية أخرى ال اننا نحتاج احيانا الى السحب من‬
‫الخصية مباشرة او الى فتح الخصية لخذ الحيوانات ثم حضانتها لمدة قد تصل إلى‬
‫‪.‬يومين لتستعمل بعد ذلك في الحقن المجهري مع فرص طيبة للحمل‬
‫و هنا ل بد من التنويه الى انه و قبل تعريض المريض لهذه العملية (مع بساطتها‬
‫النسبية) ل بد من تقييم حالته بشكل مفصل و مراجعة اية تحاليل سابقة لن هذا‬
‫يوفر عليه الكثير من الجهد و المال و من ثم حين يتم التاكد من وجود و صلحية‬
‫الحيوانات فانه يتم ايضا تقييم وضع الزوجة والتأكد من مخزون المبيضين للدخول‬
‫ببرنامج الخصاب باستعمال الحيوانات المنوية الموجودة‬

‫وبهذا ا صبح بو سعنا ب عد هذا التقدم العل مي المذ هل علج الكث ير من حالت ع قم‬
‫الرجال ‪ ،‬ولكن وبل شك أن هناك بقية من الحالت ل تزال يد الطب قاصرة عن‬
‫علجها‪ .‬ولكن من المتوقع ان ما ل يمكن علجه اليوم سيمكن علجه غدا ‪ ،‬فقد‬
‫تساعد تقنية الخليا الجذعية مستقبل في علج الكثير من الحالت التي لم نتمكن‬
‫من علجها حتى الن كما انه وربما في سنوات قريبة قادمة سيمكننا زراعة خليا‬
‫الخ صية غ ير الناض جة في المخ تبر والح صول على حيوانات ناض جة قادرة على‬
‫أحداث حممل او ممن يدري فقمد يصمبح بالمكان برمجمة الخصمية لنتاج حيوانات‬
‫منوية سليمة‪.‬‬
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‫وعليمه يكون لزاما علينما أن نسمتمر فمي السمتعداد للمسمتقبل باحثيمن عمن‬
‫أسرار ال في خلقه مدركين أن لكل شئ حكمه وانه فوق كل ذي علم عليم‪.‬‬

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