Monitoring In Vitro Fertilization Outcome ppt

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Monitoring In Vitro

Fertilization Outcome

Alastair G. Sutcliffe

Department of Community Child Health,

Royal Free and University College Medical School, and

University College London, London, U.K.

INTRODUCTION

In this chapter, I will provide insights into the following areas of in vitro fer￾tilization outcome. First, why we monitor in vitro fertilization (IVF)

outcome. Second, why monitoring IVF outcome is not well done. Third,

a brief overview of the known IVF literature. Fourth, how to do monitoring

in an ideal world, and what outstanding questions have not been addressed

which are of concern to families, fertility practitioners, the broader scientific

community, and general public.

WHY MONITOR IVF OUTCOME?

The first generation of assisted reproductive technology (ART)-conceived

children are now growing up and ART practice has changed much during

this period. The initial method of IVF has been supplemented by embryo

cryopreservation and more recently by intracytoplasmic sperm injection

(ICSI). Following on from these procedures, trans epididimal sperm

aspiration (TESA) and testicular biopsy have resulted in a less naturally

selective form of reproduction. These developments and also such things

as extended culture, blastocyst transfers, etc., are often used without explicit

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consideration of the risks for the child. However, several positive practice devel￾opments are underway now, including a genuine effort (underpinned by legis￾lation) to reduce the risk of higher-order births (still the main risk to children

born after ART), and efforts to consider the well-being of the child more for￾mally from the start of new therapies. For example, I have been involved recently

as an advisor on a (confidential) trial which investigates the efficacy of a treat￾ment to enhance embryo implantation. The study designers, from the outset,

asked advice on how to assess the health of any children born after successful

pregnancies, both at birth and one year, with possibly longer-term plans.

Subfertile parents who conceived by IVF in its various forms are per se

a skewed population of individuals whose offspring may well be at risk of

problems via their parents’ genetic natures, rather than the procedural-based

aspects of their treatment for subfertility. This is not to trivialize the treat￾ment-related aspects that are a topic of some concern, particularly at the

present time when animal experiments seem to be backed up by recent

human-related literature that suggests, e.g., imprinting disorders are some￾times a higher risk for children conceived after assisted reproductive therapies

(see below). Families who are going to have assisted conception in its various

forms, will often ask what the risks are to potential offspring as well as

regarding the more immediate risk to themselves as patients undergoing what

are often invasive and unpleasant procedures in order to conceive.

Crude epidemiological data have shown some striking phenomena as a

result of ART, the most obvious of those is the birth of higher-order birth

children such as triplets or quadruplets. These children themselves are at risk

of problems as a direct consequence of having to share the fetal environment

with their siblings and being born early.

Whenever a new form of ART is introduced (it seems that we are

constantly, with the innovative nature of the development of fertility treat￾ments, using seemingly more and more invasive methods of helping couples

to conceive), there should be monitoring in place to look at the consequences

for any births and pregnancies. Systematic follow-up is always better and if

the processes are not in place to do that from the beginning, then attempting

to ‘‘pick up the pieces’’ often leads to erroneous interpretation. A good

example of monitoring resulting in changing a practice in the literature was

the first child or groups of children born after round spermatid conception (1).

Fortunately, these cases were reported, and as they had congenital anomalies,

the procedure was suddenly banned by the Human Fertilization and Embry￾ology Authority. Another example concerns the work of Eppig and

O’Brien (2) in the United States, whose laboratory managed to persuade

the primordial follicle of a mouse to be progressed through developmental

stages to a mature follicle that then was inseminated, and subsequently the

mouse which he called Eggbert was born. This mouse had an allegedly happy

life but unfortunately developed a midlife crisis and dropped dead from obes￾ity, diabetes, and sarcoma. Had this mouse’s growth not been monitored,

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