The Heart and Soul of ART……is in the Laboratory The Inside Story Prof Prakash Trivedi, Priti P Trivedi
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1The Heart and Soul of ART……is in the Laboratory The Inside Story2
3The Heart and Soul of ART……is in the Laboratory The Inside Story
Editors Prof Prakash Trivedi Chief Gynaecological Endoscopist, Urogynaecologist and Laser Surgeon National Institute of Laser and Endoscopic Surgery (NILES), Mumbai Jaslok Hospital and Research Centre, Mumbai, India Scientific Director: Aakar IVF-ICSI Centre, Mumbai, India Hon. Asst. Prof. Pd. DY Patil Medical College and VC Gandhi-Rajawadi Municipal Hospital Priti P Trivedi Chief Embryologist Aakar IVF-ICSI Centre, Mumbai, India Fellowship in Sydney IVF Centre, Sydney Fellowship in National University Hospital, Singapore
4Published by
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Jaypee Brothers Medical Publishers (P) Ltd
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The Heart and Soul of ART……is in the Laboratory The Inside Story
© 2004, Prakash Trivedi, Priti P Trivedi
All rights reserved. No part of this publication should 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 written permission of the editors and/or the publisher.
First Edition : 2004
9788180613241
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd., A-14, Sector 60, Noida
5Foreword
Eighth decade of the 20th century has for ever made its impression in the study of human reproduction with the birth of ‘Louise Brown’ — The first human Test Tube Baby. It was a significant achievement considering the facilities, funds and instruments available in those days for such projects. Even in England, instead of encouragement, a chorus of criticism accompanied every advance in establishing In Vitro Fertilization as mode of treatment for infertility.
Assisted Reproductive Technology (ART) is an excellent example of harmony between clinical science and basic science. Due to limitations in obtaining human gametes for research purpose, extensive study of reproductive system in animal models helped to a great extent in establishing current procedures of ART in human. To achieve a respectable consistent pregnancy rate, it is absolutely essential for both these faculties to put their efforts together. The procedure which was originally aimed for treating diseased fallopian tubes is now covering a wide range of indications like endometriosis, male factor, PCOS and unexplained infertility. Considering the breathtaking pace of advances in this field, it is mandatory for us to keep update in all fronts.
Extracorporeal fertilization of human gametes has fascinated many infertility specialists. It is astonishing to realize that prior to tedious efforts of Dr Edwards, only a handful of scientists had ever seen a living human egg. Today, though handling of gametes is more common and many centres offer most advanced procedures like micromanipulation, it is essential to establish a well equipped and standardized laboratory before these ART procedures are offered as mode of treatment to the patients. To make this highly specialized and skillful treatment modality available to maximum couples dreaming of their own offspring, it is necessary to create interest among the infertility specialists by sharing our knowledge and experience with them. I appreciate efforts of Dr Prakash Trivedi and Mrs Priti P Trivedi to compile such a book that provides the much needed compendium which emphasizes relatively back seated aspect of ART- The laboratory. The eminent contributors from India and abroad have made it easy to understand the basic principles for the beginners, at the same time, the finer points of different techniques including laboratory maintenance, semen preparation, sperm retrieval and gamete manipulation will help those already working in the field. I am sure this book will be useful to infertility specialists contemplating to start an ART centre.
Sadhana K Desai
Professor and Head
Department of Obstetrics and Gynaecology
Bombay Hospital and Research Centre
Past President, FOGSI
6Foreword
Since 1978, IVF has become a well established treatment of infertility. Over the years, a steady stream of discoveries and technological progress has led to an expansion of the indications treatable by IVF, such as severe male factor infertility by intracytoplasmic sperm injection (ICSI), egg donation and IVF in premature ovarian failure, surrogacy in women with absent or diseased uterus and in some genetic disorders. IVF together with these different discoveries and technologies collectively termed as “Assisted Reproductive Techniques (ART)” have indeed revolutionized the science of infertility.
But the major problems of ART which still adversely affect the clinicians, scientists and the patients are the cost, the complicated treatment procedure, multiple pregnancies. Ovarian hyperstimulation syndrome and above all, the limited success rate. Concerned scientists and technologists are determined to minimize some of these current problems in near future. Few advances already initiated are use of GnRH antagonists, in vitro maturation of immatured oocytes, improvement of culture condition by setting up of an well equipped embryology laboratory, single embryo transfer, embryo screening, preimplantation genetic diagnosis and many others.
These developments require a close collaboration of scientists and clinicians. As there is no end point in research and scientific developments, which may lead to an adverse social or legal consequences, a regulatory supervision as applicable in different countries is essential.
This book has brought together all these diverse aspects written by experts in this discipline who describe in a clear and concise manner “how, why, when and therefore” of ART. The book will be of use to research fellows who want to get an insight into the technical developments achieved so far; by clinical and scientific team who want to start or upgrade their clinical acumen and embryology laboratory and also to those who are already in the field and want an update review of the newest techniques and advances. I strongly feel that this book will benefit all who read it.
The principal work of genius is not perfection but originality the opening of new frontier. The world makes way for people who know where they are going and also taking others.
BN Chakravarty
Director, IRM
Institute of Reproductive Medicine (IRM)
Salt Lake, Kolkata, India
7Preface
The vastness of human mind, great depth of scientific knowledge of Clinicians, Biologists, Embryologists, Andrologists, Laboratory technologists, pharmaceutical company executives active interest and ability of the amount of hard work which the medical fraternity can put, is unbelievable, yet still we are in no position to totally master to achieve enviable success in the field of Infertility and Assisted Reproductive Technology.
History is full of giants who have made their mark in the world, yet greatest of the workers, joys, pleasure and grief are more often silent and behind the curtains.
On one side with a deep sense of appreciation towards the silent scientists working hard behind the scene in Infertility — Andrology — Embryology or research lab and on the other side with a great sense of respect as a tribute to the Infertility or ART Consultants directly dealing with the Infertile patients sharing their grief, pain, joy, counseling, scientifically explaining the new avenues/options in the field of advanced infertility treatment, working relentlessly to find simplicity out of complex problems, make harmony from the discord and in the middle of all difficulties they find an opportunity to give the most dreamt solution as the greatest gift to an Infertile couple, a child.
We have brilliant write-ups from the Embryologists, Clinicians, Andrologists and Researchers view points in this field of ART. It is covering the theoretical and practical aspects of understanding and handling the Gametes development and fertilization. It is also covering the recent advances of Cryopreservation, Assisted Hatching, Preimplantation Genetic Diagnosis and Stem Cells.
In the chapters contributed by the Embryologists and Infertility Lab experts they have tried to make Embryology and Andrology — simplified. We thank all our International and National contributors who have been so kind to share their expertise and accepted to contribute for this book who are pioneers and masters in their field which we dream to achieve.
Trying to cover various intricacies of this vast subject and simplifying this for the busy clinicians and sharing the knowledge with fellow scientists in this unpredictable yet greatly rewarding field of advanced infertility management, editors have selected the contributors who are the hidden gems or pearls in this vast ocean of knowledge.
We thank Dr Uddhavraj Dudhedia, Mrs Jasmine Kunder, Dr Trishala Meghal, Mr CM Chhabra who have helped us in computer designing and proofreading. It was Dr Trivedi and Mr Chhabra who were the motivators for releasing such a book and we are sure that anybody in the field of Infertility and ART whether wants to set-up an IUI Lab or IVF Lab will be benefited by the contents of this book.
Learning, educating, teaching, rectifying is an art which few have mastered remaining as the consistent honest students with the giants in the field with the sole interest to benefit the pregnancy rates and outcome in every interested reader or infertile couple. An expert or a relatively new comer will find the book useful to systematically upgrade their level of knowledge, skill and success.8
No book in Advanced Infertility and Assisted Reproductive technologies can be complete. Editors and contributors have made efforts to utilize their vast knowledge over the years in simplified form to make interesting reading, stimulate you to further advance and share their knowledge with others.
Prakash Trivedi
Priti P Trivedi
13Contributors