Journey of Gamete from Vivo to VitroChapter 1

In Indian mythology in Mahabharata, it was also shown that birth of hundred Kauravas by Guru Dronacharya either by hundred surrogates or 100 clones or 100 artificial uterus to grow them and give birth in just 1 minute. According to history, mother of Kauravas-Gandhari aborted and these abortus material was cut into 100 pieces and implanted in either surrogate or 100 artificial uterus because in whole epic story she had given birth only to Dusshala—a female child.

In 1786, Hunter performed the first artificial insemination in humans and in 1866 Sims had done first AID (artificial insemination donor).

As early in 1833—van Beneden: The cytologist had first demonstrated that gametes had only two chromosomes in the Ascari—so two chromosomes of male nucleus would join with the two chromosomes of female to make new zygote making a mile stone discovery in the hereditary principle.

In 1890 at the University of Cambridge, England Walter Heape a professor and physician had reported the first case of embryo transplant in rabbit—a way before one had thinking of human IVF.2

In 1932, Aldous Huxley 's Brave New world: A science fiction novel he described the realistic story of IVF.

In 1934, Pincus and Enzmann form Harvard University Published a paper saying that there is possibility of development of human eggs outside body, i.e. in vitro.

Second half of 20th century gave very good start of animal and human in vitro fertilization.

In 1954, Thibault did first fertilization in vitro in rabbits and then Change also get first rabbit embryo after ovum was derived and fertilized in vitro in 1959.

Dr Edward in 1965 showed that human oocyte removed from biopsied ovary will require 37 hours to complete their maturation in vitro.

First congress on infertility was held in New york in 1959 and before 5 years, i.e. 1954 first human pregnancy derived from frozen sperm.

Gregory Pincus: Robert Edward a name famous for contraceptive pills was a teacher and father of IVF, his work was a great deal of maturation of mammalian oocyte in vitro. He was the first to show how oocyte was aspirated from their follicle and begins to mature in vitro and expelled a first polar body. Pincus et al also have great contribution in studies of human oocyte as they have done study from extraction of oocyte from excised ovaries.

In late 60 between 1958 and 1960, Gemzell and Lunenfeld gives first pregnancy by using hPG (human pituitary gonadotropin) and hMG (human menopausal gonadotropin).

In 1961, Klein and Palmer had described the first aspiration of human oocyte during laparoscopy.

Professor Edward had completed his PhD in 1958 on developmental genetics in mice is the first person to work on animal models to get IVF in human pregnancy.

In 1969 working with PhD student Barry Baviser Edward was able to fertilize human egg without obvious need for sperm capacitation.

Edward at work in London with clinician to get human oocyte, he knew that human oocyte would take much longer time for maturation compared to mouse model.3

Patrick Steptoe and Edward join together in 1968, Steptoe had wide experience in laparoscopy and Edward in embryology a long lasting partnership in reproductive medicine and what we are doing today is the vision of a true prophet.

A story of travelling daily 180 miles to get human oocyte after laparoscopic pick up and first embryo transferred in 1971 with different usage of ovarian stimulation like hMG, clomiphene, and with luteal support even though there were failure in all 32 embryo transfer and get first ectopic pregnancy in 1975.

First successful IVF baby we know Louise Brown born on 25 July 1978 by natural cycle ovum pick up by laparoscope a milestone achievement in history of human IVF and immediately after first IVF baby borne Edward and Steptoe had extended their clinical work in Bourn Hall Clinic in UK and since then we have never looked back … .

The first IVF cycle was a result of natural cycle and laparoscopic oocyte pick up was done after determining natural LH peak and it made a new thought for development of culture media.

In June 1978, Howard, Georenna Jones and Edward all had been asked by Andrews to set up a division of reproductive medicine in at the Eastern Virginia Medical School in Norfolk, USA, and they began IVF in 1980 and done forty-one laparoscopic oocyte collection and achieved embryo cleavage in only thirteen patients and absolutely no pregnancy following transfer… .

So in 1981 Geogeanna had used hMG and stimulate cycle and get more number of oocyte and had first American IVF baby born in December 1981.

In France two groups, one with Clamart hospital as Frydman as a clinician and test art as biologist and developed as assay of LH peak and making time more suitable for oocyte pick up and second at nonuniversity hospital Mandelbaum the biologist Plachot and Jean Cohen had develop transfer of oocyte in thermos for about 30 minutes taxi drive at laboratory. At same time Pez and Joe Cohen were developing ultrasound monitoring of oocyte at Serves.

At National Institute for Agricultural Research (INRA) in France veterinary researcher had develop B2 culture media for embryo growth and was of great help for human embryo and known as French medium.4

In France since the first IVF baby born in February 1982 in Clamart then there is chain of IVF Barons in Sweden, Finland, Netherland, and Germany.

In 1981, Bourn Hall a meeting organized by Edwards and others from different places like Basel, Gothenburg, Manchester, Melbourne, Norfolk, Paris, and Vienne and concluded with following remarks:

Until 1982 there was only 11 reported IVF birth in world and now everywhere people were in search of learning and training in this new field and making service to mankind and giving them chance of parenthood.

Journey of Gannets from 1982 to 1992 is just like fast and furious and getting new invention year after year like these.

ICSI has done revolutionary changes made in male infertility in all three parameter like motility, morphology and concentration.5

Throughout the decade IVF and ICSI born baby rates have gone up to 2000 in 1986 and reach to 18000 in year 1991.

There is also more number of twin pregnancies because of ovulation induction and more embryo transfer.

Transvaginal route of pick up is now establishing way of practice and laparoscopic pick is outdated procedure, due to better laboratory quality control and media.

First time ethics in IVF was thought of under chairman ship of Warnock in UK in 1982 and he reported a list of recommendations, which include a statutory licensing authority, a good legislation and regulation regarding ART.

All discussion and concern about IVF in society was well narrated by Sir Edward and Brody in 1995 in Textbook of ART in chapter “The History and Ethics of Assisted Conception”.

Till today all countries in the world do not have the same rules and regulation of assisted conception and because of that medical tourism in IVF is famous worldwide to get benefit for the human race.

After 35 years of first birth of Louise Brown in world till date we do not have same legislation worldwide for ART and this is the reality. Year by year we have got good number of successful pregnancy outcome by ART ranging from 22% to 31% in 2000 but because of no regulation on embryo transfer we have so many multiple pregnancy, early pregnancy loss and ectopic pregnancy.

Recently we are more worried regarding increased risk of malformation or development abnormality in baby born after IVF and ICSI because of risk all are associated with ovarian hyper-stimulation, laboratory procedure and infertility itself.

From 1991 after the introduction of ICSI ART has got so many miles stone like:

In 21st century we have a better understanding of genetics and chromosome abnormality that can be transferred to offspring like single gene defect, some inherited disease via ART.

Dolly: The sheep born in 1996 in Scotland by cloning raised the issue of reproductive or therapeutic cloning has been exposed. So we may have the treatment of disease like Parkinson, diabetes and more via therapeutic cloning.

Now gynecologist can take part and become scientist, researcher, or become genetic specialist.

Invention were done in all fields of IVF like, stimulation protocol, culture media, aspiration technique, handling of oocyte, how to improve fertilization, different technique of freezing and cryopreservation and vitrification, future in manipulation of oocyte and embryo.

Now we will see how many changes are there in stimulation protocol in the journey of gametes… .

First phase of IVF started with or without stimulation and first IVF birth Louise Brown was a outcome of natural cycle IVF and now a days also circle come to the same and we are in process of low stimulation or no stimulation and gets eggs as minimal to get few good day 2–3 embryo or one good blastocyst for transfer.

Second decade of IVF is full of different protocol for ovarian stimulation and hyperstimulation by using different protocol like long, short, flare up, step up, step down…

As time passed by everybody agreed on one statement that in terms of pregnancy outcome long protocol is more effective and gives best result.

Gonen, Jacobson and Casper pioneer in the use of oral contraceptive pill for follicle and cycle synchronization in IVF.

Casper has shown that during the development of various stimulation protocols the steroid production during luteal phase was not optimal and use of hCG in low dose for support of luteal phase in ART cycle.

Frydman was the first to publish use of GnRH antagonist in stimulation protocol and prevent premature LH surge and progesterone.7

Itskovitz-Eldor had used recombinant FSH and GnRH antagonist and got first pregnancy.

Now-a-days all three gonadotropins are available in recombinant technology like FSH, LH, hCG and Agrawal et al has reported first IVF baby by using them all.

Last 30 years were the years of new invention in stimulation protocol and edprairie et al had also used LHRH agonist for ovulation induction by producing endogenous LH.

Recently new technology for IVM (in vitro maturation) for patient PCO and after retrieval oocyte priming with hCG will increase maturation rate and produce high pregnancy rate up to 40%.

Culture media has change its path so many time for HTF (human tubal fluid) to day 1, day 2 up to day 5 and now single culture medium… as time passes we are much more knowledgeable about what embryo wants and what level, better understanding of the need of zygote and embryo optimum culture media is available in market.

First French medium was available and in 1985 Quinn and Warnes had developed HTF that will give the same in vivo experience to embryo in vitro.

Gardner is pioneer in using sequential media and now-a-days blastocyst transfer is reality and we are in path of SET (single embryo transfer).

In 2000 there was development of completely protein-free embryo culture medium for both egg and sperm and used for both in IVF and ICSI and got very good results since then almost all medium remained same except few changes.

Aspiration of oocyte had started its journey laparoscopically with first birth of in 1978 by Patrick and Steptoe against laparotomy in past for infertility patients and made a day care center for minimal invasive surgery.

Ultrasound have done tremendous advancement for oocyte aspiration started by Lenz and Lauritsen by using transabdominal transvesicle oocyte aspiration using needle.

Transvaginal or transvesical aspiration of oocyte by using vaginal sector scanner by Wikland with Hamburger and Nilsson in 8Gothenburg, Sweden have made todays easy and fast oocyte pick via transvaginal probe with needle in very less time and patient can go home same day within hours after pick up.

Embryo transfer with use of transabdominal USG was described by Strikler et al and his technique get support by work of Feichtinger and Kemeter and its till today the way of smooth and easy transfer with MIP (maximum implantation potential) point.

There is definite improvement in fertilization technique in journey of gamete form convention IVF to GIFT SUZI, and ICSI.

We definitely believe that all invention had occur to get good pregnancy rate to infertility patients it may be a good idea to do GIFT (gamete intrafallopian tube transfer) or it may be an accident occur in lab in Brussels by Palermo et al when they are doing SUZI (subzonal insemination of sperm) and sperm went into cytoplasm and next day oocyte fertilized and give an ICSI (intracytoplasmic sperm injection) a reality of today for severe male factor infertility.

For better outcome after recurrent failure in IVF and with advance maternal age it is suggested to do the cytoplasmic transfer technique based on hypothesis that a vital molecule like ATP or cell cycle related kinase or an organelle such as mitochondria is defiant at early stage of development and it is very crucial stage.

Choen et al was first to report a transfer of anucleate cytoplasm in patient whose oocyte had poor quality cytoplasm with donation of ooplasm from fresh young fertile donor.

As we know more in stimulation and much more in aspiration and culture technique we are getting more number of embryo for transfer and with time we understand that too much is crowding and gets nothing some time or multiple pregnancy so an idea of getting it stored by freezing was adopted for animal husbandry and with minor modification well used in human.

In 1990 Gordyts et al had reported first human cleavage stage embryo vitrification turned in delivery.

Kuleshova et al in 1999 had reported birth after vitrification of human oocyte cryopreserved and given birth.

Porcu et al reported first birth of both testicular sperm and oocyte cryo-preserved also in 1999.9

In 2006 Bedaiwy et al was first to do successful cryopreservation of human ovary with its vascular pedicle.

In 2008 Porcu et al had given birth to twins after getting oocyte from cryopreservation of both ovaries in cancer patient.

It was the Monash IVF team who had achieved birth in women without ovaries by using donor eggs giving luteal support up to 10 weeks in 1983 and same year there are publication which shows that birth is possible by using in vitro maturation of morphologically immature oocyte.

Till today role of assisted hatching is debatable, Cohen et al in 1985 reported in lancet about birth after replacement of hatching blastocyst cryopreserved at the expanded blastocyst stage.

PGD have given a good tool by getting polar body biopsy and single cell biopsy by using laser and FISH technique to know the abnormality in embryo and we are able to transfer normal embryo in chromosomally abnormal parents to get healthy and nondiseased child.

With advancement in journey of embryo from vivo to vitro since 1978 to 2014 we still are in search of good quality ovarian stimulation by newer drugs with lesser side effect, good culture medium, more friendly use of latest USG 3D, 4D and color Doppler to get more oocyte with less trauma to ovary, best culture media for growth in healthy incubator environment and quality embryo to be transfer in womb to get its implantation into reality a live healthy baby in hand of an infertile patient.