INDICATIONS FOR ARTS

• Male factor infertility
• Female factor infertility: tubal, uterine and hormonal causes.
• Endometriosis
• Genetic or chromosomal abnormalities in previous pregnancies
• Need for third-party reproduction/donor eggs or gestational surrogate
• Unexplained infertility
• Gender selection
• self-imposed single parenthood.

TYPES OF ART

• In vitro fertilisation (IVF)
• Intracytoplasmic sperm injection (ICSI)
• Gamete Intra-fallopian Transfer (GIFT)
• Zygote Intra-fallopian Transfer (ZIFT)
• Tubal Embryo Transfer (TET)
• Cryopreservation of eggs, sperms and ovaries
• Gamete and embryo cryopreservation
• Gamete and embryo donation and gestational surrogacy

Note that intrauterine insemination (IUI) is not a form of ART

IN-VITRO FERTILISATION (IVF)

In-vitro fertilisation (IVF) is a procedure that involves the surgical removal of the mature oocyte from the ovary and its fertilisation by a sperm in the Laboratory. This has revolutionised the treatment of infertility, offering hope to millions of people globally. Since the first successful birth in 1978, in Vitro Fertilisation has advanced significantly, becoming a cornerstone in assisted reproductive technology (ART). This technique has been instrumental to overcoming various fertility challenges, such as tubal blockage, male infertility, and unexplained infertility.

Numerous factors, including the quality of the eggs and sperm, embryo development, maternal age, and uterine conditions, influence the success of in-vitro fertilisation. The advances in cryopreservation, genetic screening, and embryo culture media have further enhanced IVF outcomes, allowing for better customisation of treatment protocols and minimising risks. Despite its remarkable success rates, IVF remains a complex and expensive procedure, with ethical, social, and psychological implications that continue to be subjects of debate to date.

Steps of IVF

The procedure for IVF includes patient selection and adequate counselling, controlled ovarian hyperstimulation and follicular tracking, oocyte retrieval, oocyte fertilisation, embryo culture, embryo transfer, luteal phase support, follow-up, and monitoring of pregnancy outcomes. The preliminary preparations for IVF are as crucial as the IVF procedure itself.

• Controlled Ovarian Hyperstimulation

Controlled Ovarian hyperstimulation is a technique used in assisted reproduction involving the use of fertility medications to stimulate the ovaries to produce multiple eggs by developing several mature follicles instead of one each potentially containing an egg in a menstrual cycle. These multiple follicles can be retrieved by oocyte retrieval for use in IVF.  This ovarian hyperstimulation can be achieved through the long protocol, short protocol, or ultra-short protocol.

• Oocyte Retrieval

When follicles reach optimal size (typically 18–20 mm), an injection of human chorionic gonadotropin (hCG) or a GnRH agonist is administered to trigger final oocyte maturation. Oocyte retrieval is then performed under ultrasound guidance approximately 34–36 hours after the initial procedure.

• Sperm Collection and Preparation

Sperm is collected through masturbation or testicular extraction. Sperm preparation is necessary before IVF to avoid the consequences of intrauterine injection of semen plasma proteins and prostaglandins. It involves the efficient removal of seminal plasma and the elimination of dead sperm, leukocytes, immature germ cells, epithelial cells, and microbial contamination. The ideal sperm preparation technique leads to the recovery of highly functional spermatozoa and enhances sperm quality and function without inducing damage. The available methods for sperm preparation include the swim-up technique, density gradient centrifugation and glass wool filtration.

• Oocyte Fertilisation

The retrieved oocytes are activated when the spermatozoa successfully penetrate the oocyte. The activation is a complex series of events that culminates in a cortical reaction, with the release of substances from cortical granules, and the enzyme-induced zona reaction leading to the hardening of the zona pellucida and the inactivation of ligands for sperm receptors, thereby preventing polyspermy. The resumption of meiosis and the formation of the male and female pronuclei, accompanied by the extrusion of the second polar body, are other significant events that occur following sperm penetration of the oocyte. Fertilisation is confirmed after 16–18 hours by observing the presence of two pronuclei. Fertilisation can be achieved in IVF by conventional insemination or by intracytoplasmic sperm injection(ICSI).

• Embryo Culture

Fertilised embryos are cultured in specialised media under controlled laboratory conditions. Embryo development is monitored over 3–5 days, and embryos are graded based on morphology and developmental progress.

• Embryo Transfer

Embryo transfer is typically performed about three to five days after oocyte fertilisation, when the embryos are usually in the 4- to 8-cell stage of embryonic development. Following advances in extended culture, transfer can also be made at the blastocyst stage on the 5th or 6th day after oocyte fertilisation. The embryo is deposited into the uterine cavity using a specialised catheter, which is re-examined under the dissecting microscope to ensure complete expulsion of the embryo.

• Luteal Phase Support

Luteal phase support may be provided in the form of a progesterone pessary or oral progestogen, which can be used for ten to twelve weeks, depending on the outcome of pregnancy.

• Pregnancy Test and Follow-Up

A serum beta-hCG test is typically conducted approximately 10–14 days after embryo transfer. If positive, a follow-up ultrasound is performed to confirm intrauterine pregnancy and viability in about 6 weeks when the heat can be seen. If negative, the luteal support is gradually withdrawn.

Complications of IVF

• Complications associated with the drugs used for controlled ovarian hyperstimulation: Ovarian Hyperstimulation Syndrome (OHSS), Thromboembolism, Adnexal Torsion
• Complications associated with oocyte retrieval: Haemorrhage, Pelvic Infection, Accidental injury to bowel, bladder and other contiguous viscera
• Complications associated with pregnancy resulting from IVF: Multiple Pregnancy, Ectopic Pregnancy, Heterotopic Pregnancy, Miscarriage
• Complications associated with pregnancy resulting in an abnormal baby: Imprinting error
• Psychological and emotional problems associated with IVF

GAMETE INTRAFALLOPIAN TRANSFER (GIFT)

Gamete intrafallopian transfer (GIFT) is a form of ART where the oocytes and sperm are collected and introduced directly into the fallopian tubes for fertilisation after the initial process of Controlled Ovarian Hyperstimulation, Oocyte Retrieval and Sperm Collection and Preparation. The process mimics natural fertilisation, allowing fertilisation to occur within the fallopian tubes. GIFT has a lower success rate compared to in vitro fertilisation (IVF).

ZYGOTE INTRAFALLOPIAN TRANSFER (ZIFT)

ZIFT is a type of ART transfer of an in-vitro fertilised ovum into the fallopian tube. It has a better success rate compared to GIFT.

TUBAL EMBRYO TRANSFER (TET)

This involves transferring a formed embryo into the fallopian tubes.

EMBRYO AND GAMETE CRYOPRESERVATION

Sperm, eggs or embryos can be frozen and stored for possible use in the future. This is known as cryopreservation. Elective egg freezing allows young women to freeze their oocytes in an attempt to avoid age-related infertility and to be able to have children at a time that is right for them, later in their lives. Egg freezing can also be as a result of a medical condition that may curtail fertility, for instance, a cancer diagnosis that may involve fertility-limiting treatment. Egg-freezing success rates are optimal at young ages.

GAMETE AND EMBRYO DONATION

Gamete and embryo donation have offered some couples who have lost hope of fertility the opportunity to conceive. Typically, individuals with poor-quality or absent gametes, regardless of sex, are offered this treatment. In embryo donation, the developing embryos created through IVF are donated to couples who might be having challenges with conception.

SURROGACY

Surrogacy was coined from the Latin word “surrogatus,” meaning “to substitute.” Surrogacy is gaining more popularity in the ART world. It is an arrangement where a surrogate mother carries and gives birth to a baby for an intended parent(s) who are unable to do so themselves due to medical issues that prevent pregnancy. Single parenthood, same-sex couple, congenitally absent uterus, and iatrogenic hysterectomy are some of the reasons for surrogacy globally.  There are two types of surrogacy, viz:

• Gestational Surrogacy: The surrogate carries the pregnancy, but the intended parents' gametes are used, making the surrogate not genetically related to the child. 

• Traditional Surrogacy: The surrogate carries the pregnancy and is also the egg donor, making her genetically related to the child. 

In some sub-Saharan African countries, ART, including gamete and embryo donation as well as surrogacy, is still not widely accepted due to socio-cultural, ethical and religious beliefs.

ART AND RELIGIOUS BELIEF

Historically, sub-Saharan Africa had a deeply rooted traditional religion before the advent of Christianity and Islam; however, the ancestral African religion is rapidly fading away, such that its believers are now predominantly Muslims and Christians. Religion plays a significant role in people’s attitudes towards assisted reproduction, and various faiths have reacted to this treatment in different ways, ranging from total acceptance to total rejection of all techniques of assisted reproduction, with many shades in between

Religious beliefs regarding assisted reproductive technology (ART) vary across different spiritual cultures. Sunni Islam allows ART in the context of marriage and medical justification without any third-party involvement, such as gamete donation and surrogacy. Shias are more lenient as they accept gamete donation, donor insemination, and surrogacy.

Some of the Christian churches are opposed to ART, but some are more fiercely opposed than others. Roman Catholics disapprove of all forms of assisted reproduction. However, Intrauterine Insemination (IUI) could be accepted when semen is collected via sexual intercourse, but artificial insemination with donor sperm and surrogacy are controversial and may be frowned upon. Eastern Orthodox churches allow IUI with a husband’s semen but do not encourage IVF and other forms of ART involving gamete and embryo donation as well as surrogacy.

The growing utilisation of ART will transform the way a substantial proportion of couples procreate in the near future. Given the rapid scientific and technological evolution of ART, it is imperative that both the public and regulatory bodies be engaged in establishing a framework for the ethical evaluation of these emerging technologies. ART has opened great opportunities for achieving conception and procreation of the Human species, which we are almost making a statement that “anybody can be pregnant”.