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IVF and related assisted reproductive technologies (ART) offer great hope to infertile couples the world over. Because these techniques are so expensive, however, they are out of the reach of the vast majority of couples - and especially of those in the developing world. This is because IVF programmes are too technology-intensive at present - and anything which is complicated is bound to be expensive.
A high-tech approach is especially counterproductive in the developing world, where doctors usually blindly duplicate what foreign IVF programmes do. They imitate the Western ideal that is so tempting with its sophisticated equipment - ‘never mind the cost’. If this approach were successful, then there would be little to criticize, but it can never be practical because the infrastructure to support such sophisticated services is simply not available in the developing world. Thus, for example, it is easy to buy an imported CO2 incubator or a reverse-osmosis water-preparation system - but with just no maintenance and after-sales services to keep them functioning properly the result is that these systems often become white elephants.
IVF has developed in two different directions today. One is the high-tech approach, which includes such glamorous techniques such as micro injection, pre-implantation genetic diagnosis, and embryo co-cultures. These’ second generation IVF procedures’ are very expensive and labor- intensive, however; they are applicable to few patients; and while worthwhile in advanced IVF laboratories in the West, are not relevant in the developing world, where the basic goal of an IVF clinic service to infertile patients.
The other direction in which IVF is evolving is towards simplification. While it is true that these ‘ simplified IVF techniques’ do not as yet offer as good a pregnancy rate as conventional IVF, they are much more relevant in the developing world. What have these simplifications been?
A major expense of the IVF cycle is the cost of the gonadotropin injections used to induce super ovulation. Super ovulation using GnRH (gonadotropin - releasing hormone) analogs and hMG (human menopausal gonadotropin) has now become the norm for most clinics, since stimulated cycles produce more eggs and therefore more embryos and a higher pregnancy rate. Not only, however, does super ovulation carry the risk of ovarian hyper stimulation carry the risk of ovarian hyper stimulation (a condition in which the ovaries become very enlarged because of the multiple follicles, which can be potentially life- threatening), but also the risk of multiple pregnancies and the related problem of what to do with the unwanted eggs and embryos. A number of clinics are therefore now returning to the ‘natural’ unstimulated cycle for IVF - which is much less expensive!
The major problem with this protocol was the need for frequent blood or urine tests for LH (luteinising hormone) to determine egg maturity; and the need to be ready to do egg pickups at all hours of the day or night. However, newer protocols using the natural cycle allow ovulation to be induced with hCG (human chorionic gonadotropin), which in turn allows one to minimize LH monitoring, and also to time egg pickup to be during the day. IVF is now turning full circle - remember, the ovum of the first test - tube baby was in fact recovered in a ‘natural’ cycle.
© Dr. Aniruddha Malpani and Dr. Anjali Malpani www.drmalpani.com
Credits: How to Have a Baby: Overcoming Infertility
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