Fifth pregnancy, first baby.
After four pregnancies resulted in losses — and doing things as natural as possible and leaving it up to the birds, bees, and fate — my husband and I decided to explore in vitro fertilization (IVF).
Drugs to direct my follicles to produce more eggs, an egg retrieval procedure, genetic testing of our embryos, a quick procedure to remove a residual uterine septum from my uterus, drugs to thicken my endometrial lining to prepare my body to receive an embryo, an embryo transfer, steroids to suppress my immune system so my body would accept the pregnancy, blood thinner shots to promote blood flow to the baby, and 10 weeks of progesterone in oil shots later and we're days away from welcoming our first baby into our lives.
In short, there's more than one way to define "miracle baby."
Global estimates say 48 million couples and 186 million individuals struggle with infertility. On average, 2 million infants born in the United States each year are conceived through assisted reproductive technology and the demand for treatments like IVF have doubled in the last decade.
Now the need for treatments outweighs clinician availability. "We have about 1250 practicing fertility physicians in the US to serve the whole country, which is highly inadequate," said Eduardo Hariton, MD, a reproductive endocrinology physician in San Francisco and managing director of the US Fertility Innovation Fund. "We have people that want to get care waiting 1 to 3 months to be seen."
Hariton explains that US IVF clinics are performing around 250,000 to 300,000 IVF cycles per year and need to be doing a million-plus to meet demand. This, plus the cost of fertility treatments — an average IVF cycle runs $23,500 and the majority of patients need multiple cycles to conceive — keep the barrier to entry high.
Enter technology: New advances are on the way to help the assisted fertility process to run smoother and be less costly. "The field is really coming into an age of great progress and innovation," added Zev Williams, MD, PhD, chief of the Division of Reproductive Endocrinology and Infertility at Columbia University Fertility Center, New York City.
I'm personally grateful that such technology exists. Here is a look at some recent game changers in reproductive tech and what the future may hold.
AI Will Help, of Course
Fertility treatments involve endless analysis, diagnosis, and recommendations — dozens if not hundreds of decisions from each physician for each patient. Human action and reaction can affect this process, Hariton explained.
For example, if he hyper stimulated a woman during the follicle growing stage of her egg retrieval and ended up with eggs too large to retrieve, Hariton said he may subconsciously be more inclined to be extra cautious with his patients the week after, and vice versa.
This is where AI can help. "Rather than me making decisions from a couple of thousands of cycles of experience, I get to leverage hundreds of thousands of cycles from different providers over different people," said Hariton. "I get to use all the data from that patient today — her age, her weight, what happened last cycle, how she's doing — and make a very objective decision about the optimal time to give that woman or that couple the best outcome possible."
AI can also assist with tasks like embryo grading. "Once our embryos are made in the lab, we usually have an embryologist looking at those embryos, grading them on a three-variable scale, and then picking the nicest one for transfer," said Hariton. Machine learning computer vision software can help doctors select the best embryo.
Many of these AI products are in trials in the United States and some AI-based technology is already being used in fertility labs, especially in other countries. "ALife recently launched a suite of products to help with their decisions during stimulation that can help with the quality KPIs [key performance indicators] in the lab," said Hariton. "There's also a company that does AI-based predictions of success to give patients a better estimate called Univfy." More AI products are still in development or awaiting FDA clearance.
Robots Lend a Hand
Like artificial intelligence, robots can be a big help in the IVF lab. Columbia University Fertility Center recently became the first to use an articulated (ART) robot to handle precise and highly repetitive work.
"IVF, from the initial point, involves creating these special plates where embryos can grow, and you do that by making little droplets," said Williams. "It's very time-consuming to create tons of these little droplets for the embryos to grow." Thus, the lab created a robot to help squirt drops of the media substance required to sustain embryos in a way that is 10 times more precise than that of a trained embryologist.
"It's a win-win because you allow the robots to do things better than a human can and this allows the humans to do things that a robot just can't do," explained Williams. He and his team began using this technology in the beginning of November 2022.
Williams sees ART robots being used in many more parts of the fertility treatment journey along the way, like preparing eggs after they are retrieved and performing Intracytoplasmic Sperm Injection (ICSI), with the robot injecting the sperm into the egg.
Launching with the plate making, said Williams, is a low stakes entry point for robotic technology in the lab. "It allows us to introduce robotics to automate and optimize each step along the way, but to do so in the safest possible way."
Williams estimates that robots will have their hands on actual eggs and sperm in 5 years.
Updates in Genetic Testing
Currently, if a couple wants to have their embryos genetically tested, also known as preimplantation genetic testing, each embryo must be frozen, then a biopsy of that embryo is performed and sent to the lab.
"It takes time to get the results," said Williams. "The whole time you're waiting, you don't know if you're going to have any embryos that are transferable or if next month you're going to have to do another IVF cycle."
Columbia researchers recently developed a new in-house test that can determine if a fetus or embryo has the right number of chromosomes. This STORK (Short-read Transpore Rapid Karyotyping) can be performed without freezing embryos and sending them out, which Williams said can save couples money and time, as they won't necessarily need to do a separate embryo transfer cycle and can transfer an embryo in the same cycle. "You can test in the morning and transfer in the afternoon," said Williams.
The test is currently awaiting approval and will first be used to test miscarriage samples to see if embryos were genetically normal or not, which he said should cost around $200 vs the $2,000 to $4,000 it can cost to have fetal tissue sent to the lab — and insurance doesn't cover the procedure until after a second or third miscarriage.
This, said Williams, should be in the field in less than a year, and he estimates that the test will be used for fresh embryos in about a year and a half.
Sperm Collection Made Simpler
Typically, a man delivers a sperm sample in a room at an IVF clinic or by collecting a sample at home and rushing it to the clinic before it degrades, which Williams said can happen in as little as 15 minutes.
In 2020, Williams and his team began using a custom at-home sperm collection box that houses sperm in a recyclable foam container that holds a sample cup, which is filled with a special sperm-supporting media, at an angle that prevents evaporation and maintains temperature and pH. This allows patients to collect samples in the comfort of their homes and increases the clock to 3 hours.
"It's great for the patients because it's much more comfortable," said Williams, who notes that having to "perform" on-site can be stressful for men. Studies the team has conducted have shown sperm collected in this manner have a better success rate than those collected in the lab, and 90% of Columbia's Fertility Center patients are now providing sperm samples this way.
At-Home Monitoring: More and Better
Wearable reproductive health devices are also helping more women get pregnant. "I am very excited about biometric data harnessed in wearables to predict periods, ovulation, and fertility," said Amander Clark, PhD, director of the UCLA Center for Reproductive Science, Health and Education, Los Angeles, California.
The Tempdrop Fertility and Ovulation Tracker, for instance, is a wearable sensor with an accompanying charting app that helps a woman identify her most fertile days to conceive. The Bellabeat Ivy is a women's health smart bracelet with a strong focus on tracking a woman's cycle and fertility, pregnancy, and postnatal symptoms. And Mirvie, which is currently in development, is a blood test that will be able to predict pregnancy complications earlier.
Physicians are also looking to move as much of the lab experience as they can into a patient's home, which streamlines processes while offering privacy and comfort. For example, Hariton, who runs a strategic venture capital fund for physicians, said his team is currently working with a company that does remote ultrasounds.
And Mira, an at-home hormone monitor, uses patented AI algorithms to accurately measure the levels of major reproductive health hormones (E3G, LH, PdG, FSH) in urine, said Meir Olcha, MD, chief medical officer at Sama Fertility. The product recently completed a clinical trial, which showed it was a viable alternative to blood serum for patients undergoing IVF.
Stem Cells Could Make Eggs Ageless
Research shows that a woman's egg quality decreases gradually but significantly starting at age 32 and more rapidly after 37. Sperm quality may also decrease with age. A possible workaround: Scientists are actively researching how to create eggs and sperm from stem cells.
"I think getting eggs from stem cells will happen in the future," said Hariton, who notes that this type of technology would be a game changer in his clinic. "It will make some of the hardest diagnoses that I have — which is daily basis, 'I'm so sorry, you're in premature menopause' or 'I don't think we're going to be successful getting you pregnant with your own eggs; here are some other options like donor eggs' — much better," he added. And stem cells are currently being used to research causes of infertility.
Clinics like UCLA have already been making strides. "We are using stem cells to identify new genes required for reproduction and to define the role of these genes in human fertility and infertility," said Clark, a member of the Eli and Edythe Broad Center of Regenerative Medicine and Stem Cell Research at UCLA, who recently led a study in this arena. "In vitro gametogenesis (IVG), another stem cell technology, is currently used in the research lab to understand causes of infertility."
These stem cell-based embryo models, she said, can help researchers understand the first few days of embryo development after an embryo implants and be used to provide critical information on causes of early pregnancy loss or birth defects.
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Medscape Medical News © 2023
Cite this: Nicole Pajer. The Fertile Future of Fertility Technology - Medscape - Jul 27, 2023.