Textbook of Assisted Reproductive Technologies: Laboratory and Clinical Perspectives

d ir on Th iti Ed

Gardner Weissman Howles

Textbook of Assisted Reproductive Technologies

Shoham

Laboratory and Clinical Perspectives

From reviews of previous editions: ‘Sampling liberally from the wealth of knowledge contained between its covers will be rewarded by affirming knowledge already garnered from experience or, better, augmenting knowledge to improve one’s understanding and practice through exposure to a fresh perspective’ Fertility and Sterility ‘The book’s real value is that it is standing on our shelf in the clinic. We discuss a day-to-day problem in the unit and immediately know where to look’ OBGYN Contains sections on: Establishing and Maintaining an IVF Laboratory • Gamete Collection, Preparation and Selection • Micromanipulation • Culture, Selection and Transfer of the Human Embryo • Cryopreservation • Diagnosis of Genetic Disease in Preimplantation Embryos • Implantation • Quality Management Systems • Patient Investigation and the Use of Drugs • Stimulation Protocols • Technical Procedures and Outcomes • Special Medical Conditions • Complications of Treatment • Egg Donation and Surrogate Motherhood • Future Directions and Clinical Applications • The Support Team • Ethics and Legislation

With over 300 color and black-and-white illustrations

David K Gardner DPhil is Chair of Zoology at the University of Melbourne, Australia, and Scientific Director at the Colorado Center for Reproductive Medicine, USA

Ariel Weissman MD is a senior physician at the IVF Unit, Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, and Sackler Faculty of Medicine, Tel Aviv University, Israel

Colin M Howles PhD, FRSM

is Vice President, Scientific Affairs Fertility, Global Medical Affairs, Merck Serono International SA, Geneva, Switzerland

Textbook of Assisted Reproductive Technologies

A truly comprehensive manual for the whole team at the IVF clinic, this covers both laboratory aspects and their clinical application. Methods, protocols and techniques of choice are presented by eminent international experts. The third edition has been extensively revised, with the addition of important new chapters on developing techniques.

Textbook of Assisted Reproductive Technologies Laboratory and Clinical Perspectives

Third Edition

Edited by

David K Gardner Ariel Weissman Colin M Howles Zeev Shoham

Zeev Shoham MD is Director, Reproductive Medicine and Infertility Unit, Department of Obstetrics and Gynecology, at Kaplan Medical Center, Rehovot, Israel

Third Edition

ISBN 978-0-415-44894-9

Special Edition

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Textbook of Assisted Reproductive Technologies

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The editors (from left to right: David K Gardner, Colin M Howles, Zeev Shoham and Ariel Weissman) at the annual meeting of ESHRE, Barcelona, 2008 The editors would like to make a special acknowledgment to their respective children, who are a constant reminder of the joy and happiness that working in this field of medicine can bring to families, friends, and communities

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Textbook of Assisted Reproductive Technologies Laboratory and Clinical Perspectives Third Edition

Edited by David K Gardner DPhil Chair of Zoology, University of Melbourne, Victoria, Australia and Scientific Director, Colorado Center for Reproductive Medicine, USA Ariel Weissman MD Senior Physician, IVF Unit, Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon and Sackler Faculty of Medicine, Tel Aviv University Tel Aviv, Israel Colin M Howles PhD, FRSM Vice President, Scientific Affairs Fertility, Global Medical Affairs, Merck Serono International SA, Geneva, Switzerland

Zeev Shoham MD Director, Reproductive Medicine and Infertility Unit, Department of Obstetrics and Gynecology, Kaplan Medical Center, Rehovot, Israel

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© 2009 Informa UK Ltd First published in the United Kingdom in 2004 Third edition published in the United Kingdom in 2009 by Informa Healthcare, Telephone House, 69–77 Paul Street, London, EC2A 4LQ. Informa Healthcare is a trading division of Informa UK Ltd. Registered Office: 37/41 Mortimer Street, London W1T 3JH. Registered in England and Wales number 1072954 Tel: +44 (0)20 7017 5000 Fax: +44 (0)20 7017 6699 Website: www.informahealthcare.com All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of the publisher or in accordance with the provisions of the Copyright, Designs and Patents Act 1988 or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P 0LP. Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be glad to acknowledge in subsequent reprints or editions any omissions brought to our attention. The Authors have asserted their rights under the Copyright, Designs and Patents Act 1988 to be identified as the Authors of this Work. A CIP record for this book is available from the British Library. Library of Congress Cataloging-in-Publication Data Data available on application ISBN 978-0-415-44894-9 Distributed in North and South America by Taylor & Francis 6000 Broken Sound Parkway, NW, (Suite 300) Boca Raton, FL 33487, USA Within Continental USA Tel: 1 (800) 272 7737; Fax: 1 (800) 374 3401 Outside Continental USA Tel: (561) 994 0555; Fax: (561) 361 6018 Email: [email protected] Book orders in the rest of the world Paul Abrahams Tel: +44 (0) 207 017 6917 Email: [email protected] Composition by C&M Digitals (P) Ltd, Chennai, India Printed and bound in India by Replika Press Pvt. Ltd

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Contents List of Contributors Introduction Robert G Edwards

ix xvii

Establishing and Maintaining an IVF Laboratory 1. Setting up an ART laboratory Jacques Cohen, Antonia Gilligan and John Garrisi 2. Quality control: maintaining stability in the laboratory David H McCulloh 3. The ART laboratory in the era of ISO 1000 and GLP Cecelia Sjöblom and Christoph Keck

1 9 25

Gamete Collection, Preparation and Selection 4. Evaluation of sperm Kaylen Silverberg and Tom Turner 5. Sperm preparation techniques Harold Bourne, Janell Archer, David H Edgar and HW Gordon Baker 6. Sperm chromatin assessment Ashok Agarwal, Juris Erenpreiss and Rakesh Sharma 7. Oocyte retrieval and selection Laura F Rienzi and Filippo M Ubaldi 8. Preparation and evaluation of oocytes for ICSI Irit Granot and Nava Dekel 9. Oocyte in vitro maturation Daniela Nogueira, Sergio Romero, Leen Vanhoutte, Daniel G de Matos and Johan Smitz 10. Use of in vitro maturation in a clinical setting Anne-Maria Suikkari

39 53 67 85 103 111 155

Micromanipulation 11. Equipment and general technical aspects of micromanipulation of gametes and embryos Frank L Barnes 12. Intracytoplasmic sperm injection: technical aspects Gianpiero D Palermo, Queenie V Neri, Takumi Takeuchi, Simon J Hong and Zev Rosenwaks 13. Assisted hatching Anna Veiga, Irene Boiso and Itziar Belil 14. Human embryo biopsy procedures Alan R Thornhill and Alan H Handyside

163 171 181 191

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Culture, Selection and Transfer of the Human Embryo 15. Analysis of fertilization Lynette Scott 16. Culture systems for the human embryo David K Gardner and Michelle Lane 17. Evaluation of embryo quality: new strategies to facilitate single embryo transfer Denny Sakkas and David K Gardner

207 219 241

Cryopreservation 18. The human oocyte: controlled rate cooling Andrea Borini and Giovanni Coticchio 19. The human oocyte: vitrification Masashige Kuwayama 20. The human embryo: slow freezing Lucinda L Veeck Gosden, Rosemary Berrios, Richard Bodine, Robert N Clarke and Nikica Zaninovic 21. The human embryo: vitrification Zsolt Peter Nagy, Gábor Vajta, Ching-Chien Chang and Hilton Kort 22. Managing the cryopreserved embryo bank Phillip Matson 23. Cryopreservation and storage of spermatozoa Eileen A McLaughlin and Allan A Pacey 24. Handling and cryopreservation of testicular sperm Joseph P Alukal, Dolores J Lamb and Larry I Lipshultz 25. Ovarian tissue cryopreservation and other fertility preservation strategies Erkan Buyuk, Ozgur Oktem, Murat Sonmezer and Kutluk H Oktay

255 267 275 289 305 311 323 327

Diagnosis of Genetic Disease in Preimplantation Embryos 26. Severe male factor: genetic consequences and recommendations for genetic testing Inge Liebaers, André Van Steirteghem and Willy Lissens 27. Polar body biopsy Markus Montag, Katrin van der Ven and Hans van der Ven 28. Clinical application of polar body biopsy Yury Verlinsky and Anver Kuliev 29. Preimplantation genetic diagnosis for infertility Santiago Munné 30. Genetic analysis of the embryo Yural Yaron, Veronica Gold, Ronni Gamzu and Mira Malcov 31. Proteomic analysis of the embryo Mandy Katz-Jaffe

343 357 371 381 403 417

Implantation 32. Embryonic and maternal dialogue and the analysis of uterine receptivity Francisco Domínguez, Jose Antonio Horcajadas and Carlos Simón

427

Quality Management Systems 33. Quality management in reproductive medicine Christoph Keck, Cecelia Sjöblom, Robert Fischer, Vera Baukloh and Michael Alper

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Patient Investigation and the Use of Drugs 34. Indications for IVF treatment: from diagnosis to prognosis Nick S Macklon, Frank J Broekmans and Bart CJM Fauser 35. Initial investigation of the patient (female and male) Bulent Gulekli, Tim J Child and Seang Lin Tan 36. Drugs used for controlled ovarian stimulation: clomiphene citrate, aromatase inhibitors, metformin, gonadotropins, gonadotropin-releasing hormone analogs, and recombinant gonadotropins Zeev Shoham and Colin M Howles 37. The role of FSH and LH in ovulation induction: current concepts Juan Balasch

447 459

469 489

Stimulation Protocols 38. Endocrine characteristics of ART cycles Jean-Noël Hugues and Isabelle Cédrin-Durnerin 39. The use of GnRH agonists Judith AF Huirne and Roel Schats 40. GnRH antagonists Michael Ludwig 41. Monitoring IVF cycles Matts Wikland and Torbjörn Hilljensjö 42. Oocyte collection Gab Kovacs 43. The luteal phase: luteal support protocols James P Toner 44. Treatment strategies in assisted reproduction for the low responder patient Ariel Weissman and Colin M Howles 45. Repeated implantation failure: the preferred therapeutic approach Mark A Damario and Zev Rosenwaks

511 529 539 553 559 565 577 617

Technical Procedures and Outcomes 46. Ultrasound in ART Marinko M Biljan 47. Sperm-recovery techniques: clinical aspects Herman Tournaye and Patricio Donoso 48. Gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT) Machelle M Seibel and Ariel Weissman 49. Embryo transfer Leif Bungum and Mona Bungum 50. Anesthesia and in-vitro fertilization Ethan E Harow 51. Medical considerations of single embryo transfer Outi Hovatta

635 657 673 693 701 707

Special Medical Conditions 52. Endometriosis and ART Andy Huang, Mark Hunter and Alan H DeCherney 53. Polycystic ovaries and ART Thomas H Tang and Adam H Balen

711 721

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54. Prognostic testing for ovarian reserve Frank J Broekmans, Bart CJM Fauser and Nick S Macklon 55. Management of hydrosalpinx Annika Strandell

737 547

Complications of Treatment 56. Severe ovarian hyperstimulation syndrome Zalman Levine and Daniel Navot 57. The environment and reproduction Kenneth Barron and Machelle M Seibel 58. Bleeding, severe pelvic infection, and ectopic pregnancy Raoul Orvieto and Zion Ben-Rafael 59. Iatrogenic multiple pregnancy: the risk of ART Isaac Blickstein

759 773 787 795

Egg Donation and Surrogate Motherhood 60. Egg and embryo donation Mark V Sauer and Matthew A Cohen 61. Gestational surrogacy Peter R Brinsden

807 817

Future Directions and Clinical Applications 62. Human embryonic stem cells Rachel Eiges and Benjamin Reubinoff 63. Microfluidics in ART: current progress and future directions Jason E Swain, Thomas B Pool, Shuichi Takyama and Gary D Smith

827 843

The Support Team 64. The evolving role of the ART nurse: a contemporary review Joanne L Libraro 65. Patient support in the ART program Sharon N Covington 66. The relationship between stress and in vitro fertilization outcome Andrea Mechanick Braverman

859 867 877

Ethics and Legislation 67. The impact of legislation and socioeconomic factors in the access to and global practice of ART Fernando Zegers-Hochschild and Karl G Nygren 68. Recent ethical dilemmas in ART Françoise Shenfield Index

885 895

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List of Contributors Ashok Agarwal Center for Reproductive Medicine, Glickman Urological and Kidney Institute and Obstetrics–Gynecology and Women’s Health Institute Cleveland Clinic Cleveland, Ohio, USA Michael Alper Boston IVF Waltham, Massachusetts, USA Joseph P Alukal Scott Department of Urology Baylor College of Medicine Houston, Texas, USA Janell Archer Reproductive Services The Royal Women’s Hospital and Melbourne IVF Melbourne, Victoria, Australia HW Gordon Baker University of Melbourne Department of Obstetrics and Gynaecology The Royal Women’s Hospital and Melbourne IVF Melbourne, Victoria, Australia Juan Balasch Department of Obstetrics and Gynecology Faculty of Medicine Hospital Clinic University of Barcelona Barcelona, Spain Adam H Balen Reproductive Medicine and Surgery Leeds General Infirmary Leeds, UK Frank L Barnes IVF Labs, LLC Salt Lake City, Utah, USA

Kenneth Barron Department of Obstetrics and Gynecology University of Massachusetts School of Medicine Worcester, Massachusetts, USA Vera Baukloh Fertility Center Hamburg Hamburg, Germany Itziar Belil Reproductive Medicine Service Institut Universitari Dexeus Barcelona, Spain Zion Ben-Rafael Department of Obstetrics and Gynecology Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine Tel Aviv University Tel Aviv, Israel Rosemary Berrios The Center for Reproductive Medicine and Infertility Weill Medical College of Cornell University New York, New York, USA †Marinko M Biljan Isaac Blickstein Department of Obstetrics and Gynecology Kaplan Medical Center Rehovot, Israel Richard Bodine The Center for Reproductive Medicine and Infertility Weill Medical College of Cornell University New York, New York, USA Irene Boiso Centre de Reproducció Assistida Clinica Sagrada Familia Barcelona, Spain

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Andrea Borini Tecnobios Procreazione Centre for Reproductive Health Bologna, Italy

Robert N Clarke The Center for Reproductive Medicine and Infertility Weill Medical College of Cornell University New York, New York, USA

Harold Bourne Reproductive Services and Melbourne IVF The Royal Women’s Hospital Carlton, Victoria, Australia

Jacques Cohen Galileo Research Laboratories Ansonia Station New York, New York, USA

Andrea Mechanick Braverman Psychological and Complementary Care Reproductive Medicine Associates of New Jersey Morristown, New Jersey, USA

Matthew A Cohen Department of Obstetrics and Gynecology College of Physicians & Surgeons Columbia University New York, New York, USA

Peter R Brinsden Bourn Hall Clinic Bourn, Cambridge, UK Frank J Broekmans Department of Reproduction and Gynaecology University Medical Centre Utrecht Utrecht, The Netherlands Leif Bungum Reproductive Medicine Centre Malmo University Hospital Malmo, Sweden Mona Bungum Reproductive Medicine Centre Malmo University Hospital Malmo, Sweden Erkan Buyuk Department of Obstetrics and Gynecology Albert Einstein College of Medicine of Yeshiva University New York, New York, USA

Giovanni Coticchio Tecnobios Procreazione Bologna, Italy Sharon N Covington Psychological Support Services Shady Grove Fertility Reproductive Science Center Rockville, Maryland, USA Mark A Damario Department of Obstetrics, Gynecology and Women’s Health University of Minnesota Minneapolis, Minnesota, USA Alan H DeCherney Department of Obstetrics and Gynecology David Geffen School of Medicine Los Angeles, California, USA Nava Dekel Department of Biological Regulation The Weizmann Institute of Science Rehovot, Israel

Isabelle Cédrin-Durnerin University of Paris XIII Division of Reproductive Medicine Hôpital Jean Verdier Bondy, France

Daniel G de Matos EMD Serono Reproductive Biology Institute Rockland, Massachusetts, USA

Ching-Chien Chang Reproductive Biology Associates Atlanta, Georgia, USA

Francisco Domínguez Fundación Instituto Valenciano de Infertilidad Instituto Universitario IVI Valencia University Valencia, Spain

Tim J Child Oxford Fertility Unit Nuffield Department of Obstetrics and Gynaecology University of Oxford John Radcliffe Hospital Oxford, UK

Patricio Domoso Centre for Reproductive Medicine Clinica Alemana de Santiago Santiago, Chile

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David H Edgar Reproductive Services The Royal Women’s Hospital and Melbourne IVF Melbourne, Victoria, Australia

Irit Granot IVF Unit, Department of Obstetrics and Gynecology Kaplan Medical Center Rehovot, Israel

Robert G Edwards Duck End Farm Dry Drayton Cambridge, UK

Bulent Gulekli Dokuz Eylul Universitesi Tip Fakultesi Kadin Hastaliklari ve Dogum ABD Balcova-Izmir, Turkey

Rachel Eiges IVF Unit, Department of Obstetrics and Gynecology and Goldyne Savad Institute of Gene Therapy Hadassah University Hospital Jerusalem, Israel Juris Erenpreiss Andrology Laboratory Riga Stradins University Riga, Latvia Bart CJM Fauser Department of Reproductive Medicine University Medical Center Utrecht Utrecht, The Netherlands Robert Fischer Fertility Center Hamburg Hamburg, Germany Ronni Gamzu Department of Obstetrics and Gynecology Lis Maternity Hospital Tel Aviv Sourasky Medical Center Tel Aviv, Israel David K Gardner Department of Zoology University of Melbourne, Victoria, Australia John Garrisi Galileo Research Laboratories LLC New York, New York, USA Antonia Gilligan Alpha Environmental, Inc. Jersey City, New Jersey, USA Veronica Gold Sara Racine In Vitro Fertilization Unit Tel Aviv Sourasky Medical Center Tel Aviv, Israel

Alan H Handyside The London Bridge Fertility, Gynaecology and Genetics Centre London, UK Ethan E Harow Outpatient Surgical Center Edith Wolfson Medical Center Holon, Israel Torbjörn Hillensjö Fertility Centre Scandinavia Carlander’s Hospital Göteborg, Sweden Simon J Hong Andrology and Assisted Fertilization Cornell Institute for Reproductive Medicine New York, New York, USA Jose Antonio Horcajadas Fundación Instituto Valenciano de Infertilidad Instituto Universitario IVI Valencia University Valencia, Spain Outi Hovatta Karolinska Institute Karolinska University Hospital Huddinge Stockholm, Sweden Colin M Howles Global Medical Affairs Merck Serono International SA Geneva, Switzerland Andy Huang Department of Obstetrics and Gynecology David Geffen School of Medicine Los Angeles, California, USA Jean-Noël Hugues University of Paris XIII Division of Reproductive Medicine Hôpital Jean Verdier Bondy, France

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Judith AF Huirne Department of Obstetrics and Gynecology Division of Reproduction and Fertility Investigation IVF Center Vrije Universiteit Medical Center Amsterdam, The Netherlands Mark Hunter Department of Obstetrics and Gynecology David Geffen School of Medicine Los Angeles, California, USA

Joanne L Libraro Center for Reproductive Medicine and Infertility Weill Medical College New York, New York, USA Inge Liebaers Center for Medical Genetics University Hospital VUB Brussels, Belgium

Mandy Katz-Jaffe Colorado Center for Reproductive Medicine Lone Tree, Colorado, USA

Larry I Lipshultz Division of Male Reproductive Medicine and Surgery Baylor College of Medicine Scott Department of Urology Houston, Texas, USA

Christoph Keck Department of Obstetrics and Gynecology University of Freiburg Freiburg, Germany

Willy Lissens Center for Medical Genetics University Hospital VUB Brussels, Belgium

Hilton Kort Reproductive Biology Associates Atlanta, Georgia, USA

Michael Ludwig Centre for Reproductive Medicine and Gynaecological Endocrinology Endokrinologikum Hamburg Hamburg, Germany

Gab Kovacs Monash IVF Richmond, Victoria, Australia Anver Kuliev Reproductive Genetics Institute Chicago, Illinois, USA

Nick S Macklon Division of Reproductive Medicine Department of Obstetrics and Gynecology Erasmus Medical Center Rotterdam, The Netherlands

Masashige Kuwayama Kato Ladies’ Clinic Shinjuku Tokyo, Japan

Mira Malcov Sara Racine In Vitro Fertilization Unit Tel Aviv Sourasky Medical Center Tel Aviv, Israel

Dolores J Lamb Scott Department of Urology Baylor College of Medicine Houston, Texas, USA

Phillip Matson Hollywood Fertility Centre Hollywood Private Hospital Monash Avenue Nedlands, Western Australia, Australia

Michelle Lane Department of Obstetrics and Gynecology University of Adelaide Adelaide, South Australia and Repromed Dulwich, South Australia, Australia Zalman Levine Division of Reproductive Endocrinology and Infertility New York Medical College Fertility Institute of New Jersey and New York Westwood, New Jersey, USA

David H McCulloh University Reproductive Associates, PC Hasbrouck Heights, New Jersey, USA Eileen A McLaughlin ARC Centre of Excellence in Biotechnology and Development School of Environmental and Life Sciences University of Newcastle Callaghan, New South Wales, Australia

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Markus Montag Department of Gynaecological Endocrinology and Reproductive Medicine University Clinics Bonn Bonn, Germany

Allan A Pacey Academic Unit of Reproductive and Developmental Medicine University of Sheffield Sheffield, UK

Santiago Munné Institute for Reproductive Medicine and Science of Saint Barnabus Reprogenetics Livingston, New Jersey, USA

Gianpiero D Palermo Andrology and Assisted Fertilization Cornell Institute for Reproductive Medicine New York, New York, USA

Zsolt Peter Nagy Reproductive Biology Associates Atlanta, Georgia, USA

Thomas B Pool Fertility Center of San Antonio San Antonio, Texas, USA

Daniel Navot Division of Reproductive Endocrinology and Infertility New York Medical College Fertility Institute of New Jersey and New York Westwood, New Jersey, USA

Benjamin Reubinoff IVF Unit, Department of Obstetrics and Gynecology and Goldyne Savad Institute of Gene Therapy Hadassah University Hospital Jerusalem, Israel

Queenie V Neri Andrology and Assisted Fertilization Cornell Institute for Reproductive Medicine New York, New York, USA

Laura F Rienzi Centre for Reproductive Medicine Clinica Valle Giulia Rome, Italy

Daniela Nogueira Follicle Biology Laboratory Center for Reproductive Medicine Vrije Universiteit Brussel Brussels, Belgium

Sergio Romero Follicle Biology Laboratory Center for Reproductive Medicine Vrije Universiteit Brussel Brussels, Belgium

Karl G Nygren Fertility and IVF Unit Sophiahemmet Hospital Stockholm, Sweden

Zev Rosenwaks The Center for Reproductive Medicine and Infertility Weill Medical College of Cornell University New York, New York, USA

Kutluk H Oktay Department of Obstetrics & Gynecology New York Medical College, Valhalla and Institute for Fertility Preservation Center for Human Reproduction and Memorial Sloan Kettering Cancer Center New York, New York, USA Ozgur Oktem The Center for Reproductive Medicine and Infertility Weill Medical College of Cornell University New York, New York, USA Raoul Orvieto Department of Obstetrics and Gynecology Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine Tel Aviv University Tel Aviv, Israel

Denny Sakkas Department of Obstetrics and Gynecology Yale University School of Medicine New Haven, Connecticut, USA Mark V Sauer Department of Obstetrics and Gynecology College of Physicians & Surgeons Columbia University New York, New York, USA Roel Schats Department of Obstetrics and Gynecology Division of Reproduction and Fertility Investigation IVF Center Vrije Universiteit Medical Center Amsterdam, The Netherlands

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Lynette Scott Fertility Center of New England Reading, Massachusetts, USA Machelle M Seibel Department of Obstetrics and Gynecology University of Massachusetts School of Medicine Worcester, Massachusetts, USA Rakesh Sharma Center for Reproductive Medicine, Glickman Urological and Kidney Institute and Obstetrics–Gynecology and Women’s Health Institute Cleveland Clinic Cleveland, Ohio, USA Françoise Shenfield Reproductive Medicine Unit University College Hospital and Medical School London, UK Zeev Shoham Department of Obstetrics and Gynecology Kaplan Medical Center Rehovot, Israel Kaylen Silverberg Texas Fertility Center Austin IVF Austin, Texas, USA Carlos Simón Fundación Instituto Valenciano de Infertilidad Instituto Universitario IVI Valencia University and Centro de Investigación Príncipe Felipe Valencia, Spain Cecilia Sjöblom NURTURE University of Nottingham Queen’s Medical Centre Nottingham, UK Gary D Smith Department of Obstetrics and Gynecology and Reproductive Medicine Program University of Michigan Ann Arbor, Michigan, USA Johan Smitz Radioimmunology and Reproductive Biology Center for Reproductive Medicine University Hospital VUB Brussels, Belgium

Murat Sonmezer Department of Obstetrics and Gynecology School of Medicine Ankara University Ankara, Turkey Annika Strandell Reproductive Medicine Department of Obstetrics and Gynecology Sahlgrenska University Hospital Göteborg, Sweden Anne-Maria Suikkari Väestöliitto Fertility Clinics Helsinki, Finland Jason E Swain Fertility Center of San Antonio San Antonio, Texas, USA Takumi Takeuchi Andrology and Assisted Fertilization Cornell Institute for Reproductive Medicine New York, New York, USA Shuichi Takyama Department of Obstetrics and Gynecology University of Michigan Ann Arbor, Michigan, USA Seang Lin Tan McGill Reproductive Center Royal Victoria Hospital Department of Obstetrics and Gynecology McGill University Montreal, Quebec, Canada Thomas H Tang Reproductive Medicine and Surgery Leeds General Infirmary Leeds, UK Alan R Thornhill The London Bridge Fertility, Gynaecology and Genetics Centre and Department of Obstetrics and Gynecology University College London London, UK James P Toner Atlanta Center for Reproductive Medicine Woodstock, Georgia, USA

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Herman Tournaye Center for Reproductive Medicine University Hospital of the Dutch Speaking Brussels Free University Brussels, Belgium Tom Turner Texas Fertility Center Austin IVF Austin, Texas, USA

Lucinda L Veeck Gosden The Center for Reproductive Medicine and Infertility Weill Medical College of Cornell University New York, New York, USA Anna Veiga Reproductive Medicine Service Institut Universitari Dexeus Banc de Linies Cellulars Centre de Medicina Regenerativa de Barcelona Barcelona, Spain

Filippo M Ubaldi Centre for Reproductive Medicine Clinica Valle Giulia Rome, Italy

Yury Verlinsky Reproductive Genetics Institute Chicago, Illinois, USA

Gábor Vajta Academic Director PIVET Medical Centre Perth, Western Australia Australia

Ariel Weissman IVF Unit Department of Obstetrics and Gynecology Edith Wolfson Medical Center Holon, Israel

Hans van der Ven Department of Gynaecological Endocrinology and Reproductive Medicine University of Bonn Bonn, Germany

Matts Wikland Fertility Centre Scandinavia Carlander’s Hospital Göteborg, Sweden

Katrin van der Ven Department of Gynaecological Endocrinology and Reproductive Medicine University of Bonn Bonn, Germany Leen Vanhoutte Follicle Biology Laboratory Center for Reproductive Medicine Vrije Universiteit Brussel Brussels, Belgium André Van Steirteghem Center for Medical Genetics University Hospital VUB Brussels, Belgium

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Yural Yaron Prenatal Genetic Diagnosis Division Genetic Institute Tel Aviv Sourasky Medical Center Tel Aviv, Israel Nikica Zaninovic The Center for Reproductive Medicine and Infertility Weill Medical College of Cornell University New York, New York, USA Fernando Zegers-Hochschild Unit of Reproductive Medicine Clínica las Condes Santiago, Chile

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Introduction: the beginnings of human in vitro fertilization Robert G Edwards

In vitro fertilization (IVF) and its derivatives in preimplantation diagnosis, stem cells, and the ethics of assisted reproduction continue to attract immense attention scientifically and socially. All these topics were introduced by 1970. Hardly a day passes without some public recognition of events related to this study, and clinics spread ever further worldwide. Now we must be approaching 1.5 million IVF births, it is time to celebrate what has been achieved by so many investigators, clinical, scientific, and ethical. While much of this Introduction covers the massive accumulation of events between 1960 and 2000, it also briefly discusses new perspectives emerging in the 21st century. Fresh advances also increase curiosity about how these fields of study began and how their ethical implications were addressed in earlier days. As for me, I am still stirred by recollections of those early days. Foundations were laid in Edinburgh, London, and Glasgow in the 1950s and early 1960s. Discoveries made then led to later days in Cambridge, working there with many PhD students. It also resulted in my working with Patrick Steptoe in Oldham. Our joint opening of Bourn Hall in 1980, which became the largest IVF clinic of its kind at the time, signified the end of the beginning of assisted human conception and the onset of dedicated applied studies.

Introduction First of all, I must express in limited space my tributes to my teachers, even if inadequately. These include investigators from far-off days when the fundamental facts of reproductive cycles, surgical techniques, endocrinology, and genetics were elicited by many investigators. These fields began to move in the 20th century, and if one pioneer of these times should be saluted, it must be Gregory Pincus. Famous for the contraceptive pill, he was a distinguished embryologist, and part of his work dealt with the maturation of mammalian oocytes in vitro. He was the first to show how oocytes aspirated from their follicles would begin their maturation in vitro, and how a number

matured and expelled a first polar body. I believe his major work was done in rabbits, where he found that the 10–11-hour timings of maturation in vitro accorded exactly with those occurring in vivo after an ovulatory stimulus to the female rabbit. Pincus et al also studied human oocytes.1 Extracting oocytes from excised ovaries, they identified chromosomes in a large number of oocytes and interpreted this as evidence of the completion of maturation in vitro. Many oocytes possessed chromosomes after 12 hours, the proportion remaining constant over the next 30 hours and longer. Twelve hours was taken as the period of maturation. Unfortunately, chromosomes were not classified for their meiotic stage. Maturing oocytes would be expected to display diakinesis or metaphase-I chromosome pairs. Fully mature oocytes would display metaphase-II chromosomes, signifying they were fully ripe and ready for fertilization. Nevertheless, it is well known that oocytes can undergo atresia in the ovary involving the formation of metaphase-II chromosomes in many of them. These oocytes complicated Pincus’ estimates, even in controls, and were the source of his error which led later workers to inseminate human oocytes 12 hours after collection and culture in vitro.2,3 Work on human fertilization in vitro, and indeed comparable studies in animals, remained in abeyance from then and for many years. Progress in animal IVF had also been slow. After many relatively unsuccessful attempts in several species in the 1950s and 1960s, a virtual dogma arose that spermatozoa had to spend several hours in the female reproductive tract before acquiring the potential to bind to the zona pellucida and achieve fertilization. In the late 1960s Austin and Chang independently identified the need for sperm capacitation, identified by a delay in fertilization after spermatozoa had entered the female reproductive tract.4,5 This discovery was taken by many investigators as the reason for the failure to achieve fertilization in vitro, and why spermatozoa had to be exposed to secretions of the female reproductive tract. At the same time, Chang

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reported that rabbit eggs that had fully matured in vitro failed to produce normal blastocysts, none of them implanting normally.6

Modern beginnings of human IVF, preimplantation genetic diagnosis, and embryo stem cells My PhD began at the Institute of Animal Genetics, Edinburgh University, in 1952, encouraged by Professor Conrad Waddington, the inventor of epigenesis, and supervised by Dr Alan Beatty. At the time, capacitation was gaining in significance. My chosen topic was the genetic control of early mammalian embryology, specifically the growth of preimplantation mouse embryos with altered chromosome complements. Achieving these aims included a need to expose mouse spermatozoa to X-rays, ultraviolet light, and various chemicals in vitro. This would destroy their chromatin and prevent them from making any genetic contribution to the embryo, hopefully without impairing their capacity to fertilize eggs in vivo. Resulting embryos would become gynogenetic haploids. Later, my work changed to exposing ovulated mouse oocytes to colchicine in vivo, in order to destroy their second meiotic spindle in vivo. This treatment freed all chromosomes from their attachment to the meiotic spindle, and they then became extruded from the egg into tiny artificial polar bodies. The fertilizing spermatozoon thus entered an empty egg, which resulted in the formation of androgenetic haploid embryos with no genetic contribution from the maternal side. For three years, my work was concentrated in the mouse house, working at midnight to identify mouse females in estrus by vaginal smears, collecting epididymal spermatozoa from males, and practising artificial insemination with samples of treated spermatozoa. This research was successful, as mouse embryos were identified with haploid, triploid, tetraploid, and aneuploid chromosomes. Moreover, the wide scientific talent in the Institute was a perfect place for fresh collaborative studies. For example, Julio Sirlin and I applied the use of radioactive DNA and RNA precursors to the study of spermatogenesis, spermiogenesis, fertilization, and embryogenesis, and gained knowledge unavailable elsewhere. An even greater fortune beckoned. Allen Gates, newly arrived from the United States, brought commercial samples of Organon’s pregnant mares’ serum (PMS) rich in follicle-stimulating hormone (FSH), and human chorionic gonadotropin (hCG) with its strong luteinizing hormone (LH) activity to induce estrus and ovulation in immature female mice. Working with Mervyn Runner,7 he had used low doses of each hormone at an interval of 48 hours to induce oocyte maturation, mating, and ovulation in immature mouse females. He now wished to measure the viability of 3-day embryos from immature mice by transferring them to an adult host to grow to term.8 I was more

interested in stimulating adult mice with these gonadotropins to induce estrus and ovulation at predictable times of day. This would help my research, and I was by now weary of taking mouse vaginal smears at midnight. My future wife, Ruth Fowler, and I teamed up to test this new approach to superovulating adult mice. We chose pregnant mares’ serum to induce multifolliculation and hCG to trigger ovulation, varying doses and times from those utilized by Allen Gates. PMS became obsolete for human studies some time later, but its impact has stayed with me from that moment, even until today. Opinion in those days was that exogenous hormones such as PMS and hCG would stimulate follicle growth and ovulation in immature female mammals, but not in adults because they would interact badly with an adult’s reproductive cycles. In fact, they worked wonderfully well. Doses of 1–3 IU of PMS induced the growth of numerous follicles, and similar doses of hCG 42 hours later invoked estrus and ovulation a further 6 hours later in almost all of them. Often, 70 or more ovulated oocytes crowded the ampulla, most of them being fertilized and developing to blastocysts.9 Oocyte maturation, ovulation, mating, and fertilization were each closely timed in all adults, another highly unusual aspect of stimulation.10 Diakinesis was identified as the germinal vesicle regressed, with metaphase I a little later and metaphase II, expulsion of the first polar body, and ovulation at 11.5–12 hours after hCG. Multiple fertilization led to multiple implantation and fetal growth to full term, just as similar treatments in anovulatory women resulted in quintuplets and other high-order multiple pregnancies a few years later. Years afterwards, germinal vesicle breakdown and diakinesis were to prove equally decisive in identifying meiosis and ovulation in human oocytes in vivo and in vitro. Even as these results were gained, Ruth and I departed in 1957 from Edinburgh to the California Institute of Technology, where I switched into immunology and reproduction, a topic that was to dominate my life for five or six years on my return to the UK. The Institute at Edinburgh had given me an excellent basis in genetics, but equally in reproduction. I had gained considerable knowledge about the endocrine control of estrus cycles, ovulation, spermatozoa, and the male reproductive tract, artificial insemination, and the stages of embryo growth in the oviduct and uterus, superovulation and its consequences, and the use of radiolabeled compounds. Waddington had also been deeply interested in ethics and in relationships between science and religion, and instilled these topics in his students. I had been essentially trained in reproduction, genetics, and scientific ethics, and all of this knowledge was to prove of immense value in my later career. A visit to the California Institute of Technology widened my horizons into the molecular biology of DNA and the gene, a field then in its infancy.

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After a year in California, London beckoned me, to the National Institute for Medical Research working with Drs Alan Parkes and Colin (Bunny) Austin. I was fortunate indeed to have two such excellent colleagues. After two intense years in immunology, my curiosity returned to maturating oocytes and fertilization in vitro. Since they matured so regularly and easily in vivo, it should be easy to stimulate maturation in mouse oocytes in vitro by using gonadotropins. In fact, to my immense surprise, when liberated from their follicles into culture medium, oocytes matured immediately in vast numbers in all groups, with exactly the same timing as those maturing in vivo following an injection of hCG. Adding hormones made no difference. Rabbit, hamster, and rat oocytes also matured within 12 hours, each at their own speciesspecific rates. But to my surprise, oocytes from cows, sheep, and rhesus monkeys, and the occasional baboon, did not mature in vitro within 12 hours. Their germinal vesicles persisted unmoved, arrested in the stage known as diffuse diplotene. Why had they not responded like those of rats, mice, and rabbits? How would human oocytes respond? A unique opportunity emerged to collect pieces of human ovary, and to aspirate human oocytes from their occasional follicles. I grasped it with alacrity.

Moving to human studies Molly Rose was a local gynecologist in the Edgware and District Hospital who delivered two of our daughters. She agreed to send me slithers or wedges of ovaries such as those removed from patients with polycystic disease, as recommended by Stein and Leventhal, or with myomata or other disorders demanding surgery. Stein–Leventhal wedges were the best source of oocytes, with their numerous small graafian follicles lined up in a continuous rim just below the ovarian surface. Though samples were rare, they provided enough oocytes to start with. These oocytes responded just as the oocytes from cows, sheep, and pigs, their germinal vesicles persisting and diakinesis being absent after 12 hours in vitro. This was disappointing, and especially so for me, since Tjio and Levan, and Ford, had identified 46 diploid chromosomes in humans, while studies by teams in Edinburgh (Scotland) and France had made it clear that many human beings were heteroploid. This was my subject, because chromosomal variations mostly arose during meiosis and this would be easily assessed in maturing oocytes at diakinesis. Various groups also discovered monosomy or disomy in many men and women. Some women were XO or XXX; some men were XYY and XYYY. Trisomy 21 proved to be the most common cause of Down’s syndrome, and other trisomies were detected. All this new information reminded me of my chromosome studies in the Edinburgh mice. For human studies, I would have to obtain diakinesis and metaphase I in human oocytes, and then continue this analysis to metaphase II when the oocytes would

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be fully mature, ready for fertilization. Despite being disappointed at current failure with human oocytes, it was time to write my findings for Nature in 1962.11 There was so much to write regarding the animal work, and describing the new ideas then taking shape in my mind. I had heard Institute lectures on infertility, and realized that fertilizing human oocytes in vitro and replacing embryos into the mother could help to alleviate this condition. It could also be possible to type embryos for genetic diseases when a familial disposition was identified. Pieces of tissue, or one or two blastomeres, would have to be excised from blastocysts or cleaving embryos, but this did not seem to be too difficult. There were few genetic markers available for this purpose in the early 1960s, but it might be possible to sex embryos by their XX or XY chromosome complement by assessing mitoses in cells excised from morulae or blastocysts. Choosing female embryos for transfer would avert the birth of boys with various sex-linked disorders such as hemophilia. Clearly, I was becoming totally committed to human IVF and embryo transfer. While looking in the library for any newly published papers relevant to my proposed Nature manuscript, I discovered those earlier papers of Pincus and his colleagues described above. They had apparently succeeded 30 years earlier in maturing human oocytes cultured for 12 hours, where I had failed. My Nature paper11 became very different from that originally intended, even though it retained enough for publication. Those results of Pincus et al had to be repeated. After trying hard, I failed completely to repeat them, despite infusing intact ovaries in vitro with gonadotropin solutions, using different culture media to induce maturation, and using joint cultures of maturing mouse oocytes and newly released human oocytes. Adding hormones to culture media also failed. It began to seem that menstrual cycles had affected oocyte physiology in a different manner than in nonmenstruating mammalian species. Finally, another line of inquiry emerged after two years of fruitless research on the precious few human oocytes available. Perhaps the timing of maturation in mice and rabbits differed from that of those oocytes obtained from cows, baboons, and humans. Even as my days in London were ending, Molly Rose sent a slither of human ovary. The few oocytes were placed in culture just as before. Their germinal vesicles remained static for 12 hours as I already knew, and then after 20 hours in vitro. Three oocytes remained, and I waited to examine them until they had been in vitro for 24 hours. The first contained a germinal vesicle, so did the second. There was one left and one only. Its image under the microscope was electrifying. I gazed down at chromosomes in diakinesis, and at a regressing germinal vesicle. The chromosomes were superb examples of human diakinesis with their classical chiasmata. At last, I was on the way to human IVF, to completion of the maturation program and the onset of studies on fertilization in vitro. This was the step I had waited for, a marker that Pincus had missed. He never checked for diakinesis,

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and apparently confused atretic oocytes, which contained chromosomes, with maturing oocytes. Endless human studies were opening. It was easy now, even on the basis of one oocyte in diakinesis, to calculate the timing of the final stages of maturation because the post-diakinesis stages of maturation were not too different from normal mitotic cycles in somatic cells. This calculation provided me with an estimate of about 36 hours for full maturation, which would be the moment for insemination. All these gaps in knowledge had to be filled. But now, my research program was stretching far into the future. At this wonderful moment, John Paul, an outstanding cell biologist, invited me to join him and Robin Cole at Glasgow University to study differentiation in early mammalian embryos. This was exciting, to work in biochemistry with a leading cell biologist. He had heard that I was experimenting with very early embryos, trying to grow cell lines from them. He also wanted to grow stem cells from mammalian embryos and study them in vitro. This began one of my most memorable 12 months of research. John’s laboratory had facilities unknown outside, with CO2 incubators, numerous cell lines in constant cultivation, cryopreservation facilities, and the use of media droplets held under liquid paraffin. We decided to start with rabbits. Cell lines did not grow easily from cleaving rabbit embryos. In contrast, stem cells migrated out in massive numbers from cultures of rabbit blastocysts, forming muscle, nerves, phagocytes, blood islands, and other tissues in vitro.12 Stem cells were differentiating in vitro into virtually all the tissues of the body. In contrast, dissecting the inner cell mass from blastocysts and culturing it intact or as disaggregated cells produced lines of cells which divided and divided, without ever differentiating. One line of these embryonic stem cells expressed specific enzymes, diploid chromosomes, and a fibroblastic structure as it grew over 200 and more generations. Another was epithelioid and had different enzymes but was similar in other respects. The ability to make whole-embryo cultures producing differentiating cells was now combined with everlasting lines of undifferentiated stem cells which replicated over many years without changing. Ideas of using stem cells for grafting to overcome organ damage in recipients began to emerge. My thoughts returned constantly to growing stem cells from human embryos to repair defects in tissues of children and adults. Almost at my last moment in Glasgow, with this new set of ideas in my mind, a piece of excised ovary yielded several oocytes. Being placed in vitro, two of them had reached metaphase II and expelled a polar body at 37 hours. This showed that another target on the road to human IVF had been achieved as the whole pattern of oocyte maturation continued to emerge but with increasing clarity. Cambridge University, my next and final habitation, is an astonishing place. Looking back on those days, it seems that the Physiological Laboratory was not the

ideal place to settle in that august university. Nevertheless, a mixture of immunology and reproduction remained my dominant themes as I rejoined Alan Parkes and Bunny Austin there. I had to do immunology to obtain a grant to support my family, but thoughts of human oocytes and embryos were never far away. One possible model of the human situation was the cow and other agricultural species, and large numbers of cow, pig, and sheep oocytes were available from ovaries given to me by the local slaughterhouse. Each species had its own timing, all of them longer than 12 hours.13 Pig oocytes were closest to humans, requiring 37 hours. In each species, maturation timings in vitro were exactly the same as those arising in vivo in response to an hCG injection. This made me suspect that a woman ovulated 36–37 hours after an injection of hCG. Human oocytes also trickled in, improving my provisional timings of maturation, and one or two of them were inseminated, but without signs of fertilization. More oocytes were urgently needed to conclude the timings of oocyte meiosis. Surgeons in Johns Hopkins Hospital, Baltimore, performed the Stein–Leventhal operation, which would allow me to collect ovarian tissue, aspirate oocytes from their follicles, and retain the remaining ovarian tissues for pathology if necessary. I had already met Victor McKusick, who worked in Johns Hopkins, at many conferences. I asked for his support for my request to work with the hospital gynecologists for six weeks. He found a source of funds, made laboratory space available, and, a wonderful invitation, introduced me to Howard and Georgeanna Jones. This significant moment was equal to my meeting with Molly Rose. The Joneses proved to be superb and unstinting in their support. Sufficient wedges and other ovarian fragments were available to complete my maturation program in human oocytes. Within three weeks, every stage of meiosis was classified and timed.14 We also undertook preliminary studies on inseminating human oocytes that had matured in vitro, trying to achieve sperm capacitation by using different media or adding fragments of ampulla to the cultures, and even attempting fertilization in rhesus monkey oviducts. Two nuclei were found in some inseminated eggs, resembling pronuclei, but sperm tails were not identified so no claims could be made.15 During those six weeks, however, oocyte maturation was fully timed at 37 hours, permitting me now to predict with certainty that women would ovulate at 37 hours after an hCG injection. A simple means of access to the human ovary was now essential in order to identify human ovarian follicles in vivo and to aspirate them 36 hours after hCG, just before follicular rupture. Who could provide this? And how about sperm capacitation? Only in hamsters had fertilization in vitro been achieved, using in vivo matured oocytes and epididymal spermatozoa.16 I met Victor Lewis, my third clinical colleague, and we noticed what seemed to be anaphase II in some inseminated eggs. Again, no sperm tails were seen within the eggs.

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An attempt to achieve human capacitation, in Chapel Hill, North Carolina, United States, working with Robert McGaughey and his colleagues, also failed.17 A small intrauterine chamber lined with porous membrane was filled with washed human spermatozoa, sealed, and inserted overnight into the uterus of human volunteers at mid-cycle. Molecules entering it could react with the spermatozoa. No matured human eggs were fertilized. Later evidence indicated that the chamber contained inflammatory proteins, perhaps explaining the failure.

Decisive steps to clinical human in vitro fertilization Back in the United Kingdom, my intention to conceive human children in vitro had grown even stronger. So many medical advantages could flow from it. A small number of human embryos had been flushed from human oviducts or uteri after sexual intercourse, providing slender information on these earliest stages of human embryology. It was time to attain human fertilization in vitro, in order to move close to working with infertile patients. Ethical issues and moral decisions would emerge, one after the other, in full public view. Matters such as cloning and sexing embryos, the risk of abnormalities in the children, the clinical use of embryo stem cells, the ethics of oocyte donation and surrogate pregnancy, and the right to initiate human embryonic life in vitro would never be very far away. These issues were all acceptable, since I was confident that studies of human conception were essential for future medicine, and correct ethically, medically, and scientifically. The increasing knowledge of genetics and embryology could assist many patients if I could achieve human fertilization and grow embryos for replacement into their mothers. Few human oocytes were available in the United Kingdom. Despite this scarcity, one or two of those matured and fertilized in vitro possessed two nuclei after insemination. But there were no obvious sperm tails. I devised a cow model for human fertilization, using in vitro matured oocytes and insemination in vitro with selected samples of highly active washed bull spermatozoa extracted from neat semen. It was a pleasure to see some fertilized bovine eggs, with sperm tails and characteristic pronuclei, especially using spermatozoa from one particular bull. Here was a model for human IVF, and a prelude to a series of events which implied that matters in my research were suddenly changing. A colleague had stressed that formalin fixatives were needed to detect sperm tails in eggs. Barry Bavister joined our team to study for his PhD and designed a medium of high pH, which gave excellent fertilization rates in hamsters. We decided to collaborate by using it for trials on human fertilization in vitro. Finally, while browsing in the library of the Physiological Laboratory, I read a paper in The Lancet which instantly caught my attention. Written by Dr P. C. Steptoe of the Oldham and District General Hospital,18

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it described laparoscopy, with its narrow telescope and instruments and the minute abdominal incisions. He could visualize the ampulla and place small amounts of medium there, in an operation lasting 30 minutes or less and maybe even without using anesthesia. This is exactly what I wanted, because access to the ampulla was equivalent to gaining access to ovarian follicles. Despite advice to the contrary from several medical colleagues, I telephoned him about collaboration and stressed the uncertainty in achieving fertilization in vitro. He responded most positively, just as Molly, Howard and Georgeanna, and Victor had done. We decided to get together. Last but by no means least, Molly Rose sent a small piece of ovary to Cambridge. Its dozen or more oocytes were matured in vitro for 37 hours, when Barry and I added washed spermatozoa suspended in his medium. We examined them a few hours later. To our delight, spermatozoa were pushing through the zona pellucida, into several of the eggs. Maternal and paternal pronuclei were forming beautifully. We saw polar bodies and sperm tails within the eggs. That evening in 1969, we watched in delight virtually all the stages of human fertilization in vitro (Fig 1). One fertilized egg had fragments, as Chang had forecast from his work on oocyte maturation and fertilization in vitro of rabbit eggs. This evidence strengthened the need to abandon oocyte maturation in vitro and replace it by stimulating maturation by means of exogenous hormones. Our 1969 paper in Nature surprised a world unaccustomed to the idea of human fertilization in vitro.19 Incredibly fruitful days followed in our Cambridge laboratory. Richard Gardner, another PhD candidate, and I excised small pieces of trophectoderm from rabbit blastocysts and sexed them by staining the sex chromatin body. Those classified as female were transferred into adult females and were all correctly sexed at term. This work transferred my theoretical ideas of a few years earlier into the practice of preimplantation diagnosis of inherited disease, in this case for sexlinked diseases.20 Alan Henderson, a cytogeneticist, and I analyzed chiasmata during diakinesis in mouse and human eggs, and explained the high frequencies of Down’s syndrome in offspring of older mothers as a consequence of meiotic errors arising in oocytes formed last in the fetal ovary, which were then ovulated last at later maternal ages.21 Dave Sharpe, a lawyer from Washington, joined forces to write an article in Nature22 on the ethics of in vitro fertilization, the first ever paper in the field. I followed this up with a detailed analysis of ethics and law in IVF covering scientific possibilities, oocyte donation, surrogacy by embryo transfer, and other matters.22 So the first ethical papers were written by scientists and lawyers and not by philosophers, ethicists, or politicians.

The Oldham years Patrick and I began our collaboration six months later in the Oldham and District General Hospital, almost

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Fig 1 A composite picture of the stages of fertilization of the human egg. Upper left: an egg with a first polar body and spermatozoa attached to the outer zona pellucida. Upper central: spermatozoa are migrating through the zona pellucida. Upper right: a spermatazoon with a tail beating outside the zona pellucida is attaching to the oocyte vitelline membrane. Lower left: a spermatozoon in the ooplasm, with enlarging head and distinct mid-piece and tail. Lower central: further development of the sperm head in the ooplasm. Lower right: a pronucleate egg with two pronuclei and polar bodies. Notice that the pronuclei are apparently aligned with the polar bodies, although more dimensions must be scored to ensure that polarity has been established in all axes.

200 miles north of Cambridge. He had worked closely with two pioneers, Palmer in Paris23 and Fragenheim in Germany.24 He improved the pneumoperitoneum to gain working space in the abdominal cavity, and used carbon fibers to pass cold light into the abdomen from an external source.25 By now, Patrick was waiting in the wings, ready to begin clinical IVF in distant Oldham. We had a long talk about ethics and found our stances to be very similar. Work started in the Oldham and District General Hospital and moved later to Kershaw’s Hospital, set up by my assistants, especially Jean Purdy. We knew the routine. It was based on my Edinburgh experiences with mice. Piero Donini from Serono Laboratories in Rome had purified urinary human menopausal gonadotropins (hMG) as a source of FSH, and the product was used clinically to stimulate follicle growth in anovulatory women by Bruno Lunenfeld.26 It removed the need for PMS, so avoiding the use of nonhuman hormones. We used low-dosage levels in patients, i.e. 2–3 vials (a total of 150–225 IU) given on days 3 and 5, and 5000–7000 IU of hCG on day 10. Initially, the timing of oocyte maturation in vitro was confirmed, by performing laparoscopic collections of oocytes from ovarian follicles at 28 hours after hCG to check that they were in metaphase I.27 We then moved to 36 hours to aspirate

mature metaphase II oocytes for fertilization. Those beautiful oocytes were surrounded by masses of viscous cumulus cells and were maturing exactly as predicted. We witnessed follicular rupture at 37 hours through the laparoscope. Follicles could be classified from their appearance as ovulatory or nonovulatory, this diagnosis being confirmed later by assaying several steroids in the aspirated follicular fluids (Fig 2). It was a pleasure and a new duty to meet the patients searching for help to alleviate their infertility. We did our best, driving from Cambridge to Oldham and arriving at noon to prepare the small laboratory there. Patrick had stimulated the patients with hMG and hCG, and he and his team led by Muriel Harris arrived to prepare for surgery. Patrick’s laparoscopy was superb. Ovarian stimulation, even though mild, produced five or six mature follicles per patient, and ripe oocytes came in a steady stream into my culture medium for insemination and overnight incubation. The next morning, the formation of two pronuclei and sperm tails indicated fertilization had occurred, even in simple media, now with a near-neutral pH. Complex culture media, Ham’s F10 and others, each with added serum or serum albumin, sustained early and later cleavages,28 and, even more fascinating, the gradual appearance of morulae and then light,

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110.9

Within-group variation

99.3

87.6

29.6

18.0

6.3

1 Ovulatory

Group

2 Nonovulatory

18.798 16.832

Within-group variation

14.866 12.900 10.935 8.969 7.003 5.038 3.072 1.106

Follicle no. Group

12

10 11 25 3 4 1

8 17 5 82 22 12 3 24 7 20 12 14 16 9 2

3

4

Fig 2 Eight steroids were assayed in fluids extracted from human follicles aspirated 36–37 hours after human chorionic gonadotropin (hCG). The follicles had been classified as ovulating or nonovulating by laparoscopic examination in vivo. Data were analyzed by cluster analysis, which groups follicles with similar features. The upper illustration shows data collected during the natural menstrual cycle. Note that two sharply separated groups of follicles were identified, each with very low levels of within-group variance. Attempting to combine the two groups resulted in a massive increase of within-group variation, indicating that two sharply different groups had been identified. These different groups accorded exactly with the two groups identified by means of steroid assays. The lower figure shows the same analysis during stimulated cycles on fluids collected at 36–37 hours after hCG. With this form of stimulation, follicle growth displays considerable variation within groups. Attempts to combine all the groups result in a moderately large increase in variation. This evidence suggests that follicles vary considerably in their state of development in simulated cycles using human menopausal gonadotropin (hMG) and hCG.

translucent blastocysts (Fig 3).29 Here was my reward – growing embryos was now routine, and examinations of many of them convinced me that the time had come to replace them into the mothers’ uteri. I had become highly familiar with the teratologic principles of embryonic development, and knew many teratologists.

The only worry I had was the chance of chromosomal monosomy or trisomy, on the basis of our mouse studies, but these conditions could be detected later in gestation by amniocentesis. Our human studies had surpassed work on all animals, a point rubbed in even more when we grew blastocysts to day 9 after they

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had hatched from their zona pellucida (Fig 4).30 This beautifully expanded blastocyst had a large embryonic disc which was shouting that it was a potential source of embryonic stem cells. When human blastocysts became available, we tried to sex them using the sex chromatin body as in rabbits. Unfortunately, they failed to express either sex chromatin or the male Y body so we were unable to sex them as female or male embryos. Human preimplantation genetic diagnosis would have to wait a little longer. During these years there were very few plaudits for us, as many people spoke against IVF. Criticism was mostly aimed at me, as usual when scientists bring new challenges to society. Criticism came not only from the Pope and archbishops, but also from scientists who should have known better, including James Watson (who testified to a US Senate Committee that many abnormal babies would be born), and Max Perutz, who supported him. These scientist critics knew virtually nothing about my field, so who advised them to make such ridiculous charges? Cloning football teams or intelligentsia was always raised by ethicists, which clearly dominated their thoughts rather than the intense hopes of our infertile patients. Yet one theologian, Gordon Dunstan, who became a close friend, knew all about IVF from us, and wrote an excellent book on its ethics. He was far ahead of almost every scientist in my field of study. Our patients also gave us their staunch support, and so did the Oldham Ethical Committee, Bunny Austin back home in Cambridge, and Elliott Philip, a colleague of Patrick’s. Growing embryos became routine, so we decided to transfer one each to several patients. Here again we were in untested waters. Transferring embryos via the cervical canal, the obvious route to the uterus, was virtually a new and untested method. We would have to do our best. From now on, we worked with patients who had seriously distorted tubes or none whatsoever. This step was essential, since no one would have believed we had established a test-tube baby in a woman with near normal tubes. This had to be a condition of our initial work. Curiously, it led many people to make the big mistake of believing that we started IVF to bypass occluded oviducts. Yet we already knew that embryos could be obtained for men with oligozoospermia or antibodies to their gametes, and for women in various stages of endometriosis. One endocrinological problem did worry me. Stimulation with hMG and hCG shortened the succeeding luteal phase, to a very short time for embryos to implant before the onset of menstruation. Levels of urinary pregnanediol also declined soon after oocyte collection. This condition was not a result of the aspiration of granulosa and cumulus cells, and luteal support would be needed, preferably progesterone. Csapo et al stressed how this hormone was produced by the ovaries for the first 8–10 weeks before the placenta

took over this function.31 Injections of progesterone in oil given over that long period of time seemed unacceptable since it would be extremely uncomfortable for patients. While mulling over this problem, my attention turned to those earlier endocrinologists who believed that exogenous hormones would distort the reproductive cycle, although I doubt they even knew anything about a deficient luteal phase. This is how we unknowingly made our biggest mistake in early IVF days. Our choice of Primulot depot, a progestogen, meant it should be given every 5 days to sustain pregnancies, since it was supposed to save threatened abortions. So, we began embryo transfers to patients in stimulated cycles, giving this luteal phase support. Even though our work was slowed by having to wait to see if pregnancies arose in one group of patients before stimulating the next, enough patients had accumulated after 2–3 years. None of our patients was pregnant, and disaster loomed. Our critics were even more vociferous as the years passed, and mutual support between Patrick and me had to pull us through. Twenty or more different factors could have caused our failure, e.g. cervical embryo transfers, abnormal embryos, toxic culture dishes or catheters, inadequate luteal support, incompatibility between patients’ cycles and that imposed by hMG and hCG, inherent weakness in human implantation, and many others. We had to glean every scrap of information from our failures. I knew Ken Bagshawe in London, who was working with improved assay methods for gonadotropic hormones. He offered to measure blood samples taken from our patients over the implantation period using his new hCG-β assay. He telephoned: three or more of our patients previously undiagnosed had actually produced short-lived rises of hCG-β over this period. Everything changed with this information. We had established pregnancies after all, but they had aborted very early. We called them biochemical pregnancies, a term that still sticks today. It had taken us almost three years to identify the cause of our failure, and the finger of suspicion pointed straight at Primulot. I knew it was luteolytic, but it was apparently also an abortifacient, and our ethical decision to use it had caused much heartache, immense loss of work and time, and despair for some of our patients. The social pressures had been immense, with critics claiming our embryos were dud and our whole program was a waste of time; but we had come through it and now knew exactly what to do next. We accordingly reduced levels of Primulot depot, and utilized hCG and progesterone as luteal aids. Suspicions were also emerging that human embryos were very poor at implanting. We had replaced single embryos into most of our patients, rarely two. Increasingly we began to wonder if more should be replaced, as when we replaced two in a program involving transfers of oocytes and spermatozoa into

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Fig 3 Successive stages of human preimplantation development in vitro in a composite illustration made in Oldham in 1971. Upper left: 4-cell stage showing the crossed blastomeres typical of most mammals. Upper middle: 8-cell stage showing the even outline of blastomeres and a small piece of cumulus adherent to the zona pellucida. Upper right: a 16–32-cell stage, showing the onset of compaction of the outer blastomeres. Often, blastocelic fluid can be seen accumulating between individual cells to give a “stripey” appearance to the embryo. Lower left and middle: two living blastocysts showing a distinct inner cell mass, single-celled trophectoderm, blastocelic cavity, and thinning zona pellucida. Lower right: a fixed preparation of a human blastocyst at 5 days, showing more than 100 even–sized nuclei and many mitoses.

Fig 4 A hatched human blastocyst after 9 days in culture. Notice the distinct embryonic disc and the possible bilaminar structure of the membrane. The blastocyst has expanded considerably, as shown by comparing its diameter with that of the shed zona pellucida. The zona contains dying and necrotic cells and its diameter provides an estimate of the original oocyte end embryo diameters.

the ampulla so that fertilization could occur in vivo. This procedure was later called GIFT (gamete intrafallopian transfer) by Ricardo Asch. We now suspected that single embryo transfers could produce a 15–20% chance of establishing pregnancy, just as our first clinical pregnancy arose after the transfer of a single blastocyst in a patient stimulated with hMG and hCG.32 Then came fantastic news – a human embryo fertilized and grown in vitro had produced a pregnancy. Everything seemed fine, even with ultrasound images. My culture protocols were satisfactory after all. Patrick rang: he feared the pregnancy was ectopic and he had to remove it sometime after 10 gestational weeks. Every new approach we tested seemed to be ending in disaster, yet we would not stop, since the work itself seemed highly ethical, and conceiving a child for our patients was perhaps the most wonderful thing anyone could do for them. In any case, ectopic pregnancies are now known to be a regular feature with assisted conception. I sensed that we were entering the final phase of our Oldham work, seven years after it began. We had to speed up, partly because Patrick was close to retiring

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Textbook of Assisted Reproductive Technologies

Mrs. MP ODGH 12/1/73

hMG (amps)

8000 IU hCG Laparoscopy

LMP ampules

1 preovulatory oocyte + 1.6 x 106 sperm into ampulla

3 3 3 3

RTM

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hCG (IU) 150015001500 1500

100

10

50

5

0

Urinary pregnanediol (mg/day)

Urinary estrogens (µg/day)

150

0 0

4

8

12

16

20

24

28

32

36

Days of cycle

Fig 5 The first attempts at gamete intrafallopian transfer (GIFT) were called oocyte recovery with tubal insemination (ORTI). In this treatment cycle, using human menopausal gonadotropin (hMG) and human chorionic gonadotropin (hCG), including additional injections of hCG for luteal support, a single preovulatory oocyte and 1.6 million sperm were transferred into the ampulla. ODGH, Oldham and District General Hospital; LMP, last menstrual period; RTM indicates stages of the menstrual cycle.

from the National Health Service. Four stimulation protocols were tested in an attempt to avoid problems with the luteal phase: hMG and hCG; clomiphene, hMG, and hCG to gain a better luteal phase; bromocryptine, hMG, and hCG because some patients had high prolactin concentrations; and hCG alone at mid-cycle. We also tested what came to be known as gamete intrafallopian transfer (GIFT), calling it ORTI (oocyte recovery with tubal insemination, by transferring one or two eggs and spermatozoa to the ampulla) (Fig 5). Natural-cycle IVF was introduced, based on collections of urine samples at regular intervals eight times daily, to measure exactly the onset of the LH surge, using a modified HiGonavis assay (Fig 6). Cryopreservation was also introduced, by freezing oocytes and embryos that looked to be in good condition when thawed. A recipient was given a donor egg fertilized by her husband’s spermatozoa, but pregnancy did not occur. Lesley and John Brown came as the second entrants for natural-cycle IVF. Lesley had no oviducts. Her egg was aspirated in a few moments and inseminated simply and efficiently. The embryo grew beautifully and was transferred an hour or so after it became 8-cell. Their positive pregnancy test a few days after transfer was another milestone – surely nothing could now prevent their embryo developing to full term in a normal reproductive cycle, but those nine months lasted a very long time. Three more pregnancies were established using natural-cycle IVF as we abandoned the other approaches. A triploid embryo died in utero – more

bad luck. A third pregnancy was lost through premature labor on a mountain walking holiday, two weeks after the mother’s amniocentesis.32,33 It was a lovely, well-developed boy. Louise Brown’s birth, and then Alistair’s, proved to a waiting world that science and medicine had entered human conception. Our critics declared that the births were a fake, and advised against attending our presentation on the whole of the Oldham work at the Royal College of Obstetricians and Gynaecologists.

IVF worldwide The Oldham period was over. Good facilities were now needed, with space for a large IVF clinic. Bourn Hall was an old Jacobean house in lovely grounds near Cambridge (Fig 7). Facilities on offer for IVF in Cambridge were far too small, so we purchased it mostly with venture capital. It was essential to conceive 100 or 1000 IVF babies to ensure that the method was safe and effective clinically. The immense delays in establishing Bourn Hall delayed our work by two years after Louise’s birth. Finally, on minimal finance, Bourn Hall opened in September 1980 on a shoestring, supported by our own cash and loans. The delay gave the rest of the world a chance to join in IVF. Alex Lopata delivered an IVF baby in Australia, and one or two others were born elsewhere. Natural-cycle IVF was chosen initially at Bourn Hall since it had proved successful in Oldham, and we became experts in it. Pregnancies flowed, at 15% per cycle. An Australian team of Alan Trounson and Carl Wood announced the establishment of several IVF pregnancies after stimulation by clomiphene and hCG and replacing two or three embryos,34 so they had moved ahead of us during the delayed opening of Bourn Hall. Our own effort now expanded prodigiously. Thousands of patients queued for IVF. Simon Fishel, Jacques Cohen, and Carol Fehilly joined the embryology team among younger trainees, and new clinicians joined Patrick and John Webster. Patients and pregnancies increased rapidly, and the world was left standing far behind. Howard and Georgeanna Jones began in Norfolk using gonadotropins for ovarian stimulation. Jean Cohen began in Paris, Wilfred Feichtinger and Peter Kemeter in Vienna, Klaus Diedrich and Hans van der Venn in Bonn, Lars Hamberger and Matts Wikland in Sweden, and Andre van Steirteghem and Paul Devroey in Brussels. IVF was now truly international. The opening of Bourn Hall had not deterred our critics. They put up a fierce rearguard action against IVF, alongside LIFE, SPUC (Society for the Unborn Child), individual gynecologists, and others. Objections raised against IVF included low rates of pregnancy (no one mentioned the similar low rates of pregnancy with natural conception), the possibilities of oocyte and embryo donation, surrogate mothers, unmarried parents, one-sex parents, embryo

Prelims Gardner:Prelims Gardner

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Introduction LH lapy surge

LH lapy surge

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LH lapy surge

Total estrogens (µg/24 h)

110 60

40

20

LH by HiGovanis (IU/h)

Pregnanediol (mg/24 h)

0 4 2 0

6 4 2 1 2 ml.2

Sperm concentration A variety of counting chambers are available for determining sperm concentration. Those more commonly

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used include the hemocytometer, the Makler counting chamber, and the MicroCell. Regardless of the type of chamber used, an aliquot from a homogeneous, mixed semen sample is placed onto a room temperature chamber. The chamber is covered with a glass coverslip, which allows the sperm to distribute evenly in a very thin layer. Sperm within a grid are counted, and a calculation is made according to the formula for the type of chamber used. Accuracy is improved by including a greater number of rows or squares in the count. Sperm counts should be performed immediately after loading semen onto the chamber. Waiting until the heat from the microscope light increases the speed of the sperm may inaccurately enhance the count. As indicated earlier, a particular patient’s sperm count may vary significantly from one ejaculate to another. This observation holds true for both fertile and infertile males, further complicating the definition of a normal range for sperm concentration. Demographic studies employing historic controls were used to define a sperm concentration of