Fer­til­ity treat­ment espe­cially assisted repro­duc­tive technology-IVF enabled many women to achieve preg­nancy even those with the most dif­fi­cult cases of infer­til­ity. Advances include ICSI-injection of a sin­gle sperm into an egg ‚  PGD-biopsy of embryos and polar bod­ies for genetic diag­no­sis, of spe­cific genetic dis­eases, pro­longed cul­ture of embryos to blas­to­cyst stage-day 5 to 7 and TESE-surgical sperm retrieval.

Mean­while, a new host of fer­til­ity treat­ments emerged in the past 10 or so years that were not thor­oughly stud­ied includ­ing egg freez­ing, ovar­ian tis­sue freez­ing and trans­plan­ta­tion, IVM-in vitro mat­u­ra­tion of oocytes, PGS-preimplantation genetic screen­ing for chro­mo­so­mal abnor­mal­i­ties in the emryo or oocyte and gen­er­a­tion of ‘arti­fi­cial’ eggs or sperm. These pro­ce­dures carry great promise to advance repro­duc­tive options for men and women and can be tai­lored to their med­ical or social circumstances.

Poten­tial issues with new repro­duc­tive tech­nolo­gies include effi­cacy, short and long term risks to the mother and chil­dren. The Amer­i­can Soci­ety for Repro­duc­tive Medicine-ASRM states that “pro­ce­dures for the diag­no­sis or treat­ment of infer­til­ity will be con­sid­ered exper­i­men­tal or inves­ti­ga­tional until the pub­lished med­ical evi­dence regard­ing their risks, ben­e­fits and over­all safety and effi­cacy is suf­fi­cient to regard them as estab­lished med­ical practice”

Infor­ma­tion dis­sem­i­nated about fer­til­ity pro­ce­dures online and in lay press are some­times inac­cu­rate or con­vey unre­al­is­tic expec­ta­tions. Recently, a same sex cou­ple curb­side me to rec­om­mend a physi­cian to har­vest one part­ner bone mar­row to pro­duce arti­fi­cial gametes that can then be used with the other part­ner gametes. When I explained to them that this exper­i­men­tal and was never accom­plished in humans, they were very  dis­mayed and dis­ap­pointed, con­firm­ing that they read about the pro­ce­dure  online.

Look­ing at pub­lished stud­ies dis­cussing new repro­duc­tive tech­nolo­gies one can infer

Egg freez­ing

Still con­sid­ered inves­ti­ga­tional by the Amer­i­can Soci­ety for Repro­duc­tive Med­i­cine. Not suit­able for all patients based on their ovar­ian reserve. No large stud­ies com­par­ing the effi­ciency of egg freez­ing in com­par­i­son to the estab­lished tech­nol­ogy of embryo freez­ing. No long term fol­low up data for chil­dren con­ceived using thawed oocytes.

Ovar­ian stim­u­la­tion in estro­gen sen­si­tive cancers

Using con­ven­tional pro­to­cols for ovar­ian stim­u­la­tion in breast can­cer and other estro­gen sen­si­tive can­cers was not stud­ied in terms of its effects on can­cer recur­rence. Using spe­cial pro­to­cols to reduce estro­gen expo­sure dur­ing stim­u­la­tion was not stud­ied long enough. In short and inter­me­di­ate terms, how­ever, it does not appear to increase recurrence.

Ovar­ian Tis­sue Freezing

This is the most inves­ti­ga­tional tech­nique for fer­til­ity preser­va­tion. Ovar­ian tis­sue is har­vested and frozen for later trans­plan­ta­tion. Only spo­radic case reports were pub­lished. It is con­sid­ered in women with very high risk for ovar­ian fail­ure e.g. after chemother­apy. There is also the risk for trans­mis­sion of malig­nant cells within the graft at the time of trans­plan­ta­tion. The out­comes of chil­dren con­ceived after trans­plan­ta­tion is unknown.

In vitro maturation

Imma­ture eggs are not suit­able for fer­til­iza­tion with sperm. Imma­ture eggs can be har­vested, matured in the lab then fer­til­ized or frozen. ‘Cul­ti­vat­ing’ very imma­ture eggs from pri­mor­dial fol­li­cles in the lab is exper­i­men­tal and was not done in humans yet. Imma­ture eggs obtained after short period of ovar­ian stim­u­la­tion can pro­duce a viable chil­dren.  This pro­ce­dure is more applic­a­ble to women with very good ovar­ian reserve. The long term safety of the pro­ce­dure is not known yet.

Pre-implantation genetic screen­ing for aneuploidy

Many eggs in every woman are not chro­mo­so­ma­lly normal-having an extra or miss­ing chromosome-egg qual­ity. Fer­til­iza­tion of these eggs result in chro­mo­so­ma­lly abnor­mal embryos. The major­ity of abnor­mal embryos do not implant or are mis­car­ried. Test­ing of embryos to select the nor­mal ones was sug­gested as a method to increase the preg­nancy rate. This is yet to be proven in a peer-reviewed sci­en­tific pub­li­ca­tion. The exact embryo stage to test and the method of test­ing are still debated.

Arti­fi­cial gametes

The con­cept that eggs and sperm can be gen­er­ated from human embry­onic stem cells was shown in mice. The func­tion of the result­ing gametes is unknown. This was never accom­plished in humans. If func­tional gametes can be pro­duced from other cells, likely apply­ing this tech­nol­ogy in med­i­cine will require another decade or more.

Beware of what you read

Many new repro­duc­tive tech­nolo­gies are avail­able to address one or more med­ical or social issues related to repro­duc­tion. Some of these tech­nolo­gies are exper­i­men­tal, not effi­cient or their out­comes not stud­ied long enough to ensure its safety. They may be applied in lim­ited or mon­i­tored set­tings e.g research or for those that at risk for loos­ing their fer­til­ity and have no other options. Detailed dis­cus­sion with woman / cou­ple is essen­tial to ensure that the they have real­is­tic expec­ta­tions con­cern­ing their out­comes and that uncer­tainty about their safety is clearly explained.

Read more at http://nycivf.org