Playing God or merely 'assisting' nature?

By Meg Williams

"We are not playing God. We are merely assisting nature," said Professor Ariff Bongso, the benign giant in the field of biotechnology, about the man-made marvel of the test-tube baby.

This new generation of human beings scattered across the globe would not be here if not for the discovery and application of artificial insemination. Though the first IVF (invitro fertilization) baby, Louise Brown, was born in 1978 in Britain, this medically-assisted conception technology came to Sri Lanka only recently. Till then Sri Lankans were obliged to travel to Singapore or India to get the benefits of this wonder treatment.

Now, however, a state-of-the-art IVF laboratory with the latest Singapore pioneered techniques is in operation at the Vindana Reproductive Health Centre in Colombo 5. Set up one year ago, with the assistance of Professor Bongso — a Singaporean who is presently Research Professor and Scientific Director of the famous Medically Assisted Conception Program at the National University Hospital in his home country - Vindana celebrated the births of its first batches of IVF and ICSI babies a few weeks ago.

With 18 out of 54 patients becoming pregnant, the clinic has had a 34% success rate in its first year. These results are equal to those of any of the best centres in the world such as those in Cambridge and Singapore.

The Vindana clinic is chaired by Professor Harsha Seneviratne and provides reproductive health care for a wide variety of obstetric and gynaecological problems. The IVF team is led by Clinical Coordinator Dr Rohana Haththotuwa and Mrs Wijeratne, both of whom have been trained at the National University Hospital, Singapore under the guidance of Professor Bongso.

No shortcuts have been taken in setting up the Vindana laboratory, with high professional standards and stringent quality control features and cleanliness. "The sperm simply will not fertilize the egg in an unhygienic environment. If one mosquito is sighted in the laboratory, the complex must be shut down," stressed Prof. Bongso at a press conference on Tuesday.

With a basic cost of Rs. 350,000 for one treatment, the founding of Vindana and another clinic in Colombo means that IVF and other treatment for infertility are now affordable to couples, who were previously denied this opportunity due to the added expense of going abroad.

The objective of biotechnologists such as Prof. Bongso and the Vindana team is to counteract infertility in its totality. A remarkable reversal has also occurred in the thinking on infertility over the past half-century. According to Prof. Bongso, in the 1940s it was estimated that 60% of infertility problems were with women and only 40% with men. In recent years 60% of the problems are found to be with men and only 40% with women.

The growing problem of male infertility has also been looked into. In 1988, the Singaporean team developed the ICSI technique of micro-manipulation, whereby just one sperm from the male can be precisely injected into the female egg. This has been a huge step forward for all biotechnologists working in "healthy competition" with each other.

IVF technology procedures, including testicular sperm aspiration with intracytoplasmic sperm injection (TESA-ICSI) are now practised at the Vindana clinic. With TESA, a minute probe is inserted into the testicle and a small segment of tissue extracted. The sperm contained there is then injected into the egg. The combined procedure not only overcomes the obstacle of a hopelessly low sperm count (with ICSI) but also impotency and the inability to ejaculate (with TESA).

The first step in the process of medically assisted conception is for the clinic to diagnose the couple as suitable for parenthood. Controversy was caused last week in Australia when a law was passed making IVF available to lesbian couples. In contrast to an expedient number of mainly western countries wherein artificial insemination is being given to women in de facto relationships, the Vindana clinic's moral principles run in concordance with the traditional Sri Lankan code of ethics. Thus only heterosexual, married couples are diagnosed as acceptable by Dr Hathtotuwa.

Whether one agrees with Prof. Bongso's insistence that: "We are not playing God" or not, there's no shutting out the whole new world of opportunity that has been opened out by this technology. The poignant and open-ended question here is whether or not we can trust ourselves and our children to channel this discovery in a purely humane direction. Only God will have the answer to that.

IVF procedure

Day 1-14 The process has to start on the twenty first day of the female patient's menstrual cycle. For two weeks she receives daily injections of a hormone named Burselin, which suppresses the release from her brain of her own female hormones (oestrogen). On the fourteenth day a blood test is taken to ensure that her oestrogen levels have been effectively down-regulated.

Day 15-21 For the next six days a new series of daily injections are given containing a hormone called rFSH (Follicular Stimulating Hormone). The follicular is a visible grip-like structure that holds the microscopic egg. Thus this hormone stimulates the ovaries to produce the eggs. On the twenty-first day of the process the ovaries are scanned.

Day 21-30 The rFSH injections continue but at an increased or decreased dosage depending on how well the woman is responding to the hormone.

Day 31 (p.m.) The patient must attend the clinic in the evening for her final "night injection". This is because the HCG hormone (Human Corionic Gonadricomine) which she is given, works over a 36-hour period to soften the follicular walls which makes the extraction of the egg from its grip a great deal easier. Dr Bongso states that side-effects from the above dosages of hormones are negligible.

Day 33 (a.m.) The husband and wife go to the clinic together. First the woman is sedated and undergoes a 45-minute, painless "flushing" operation. The insides of her pelvis area are visible to the doctor and the embryologist on an ultrasound machine. A probe (a fine vacuum tube with a minute needle attached to its end) is carefully inserted through the vagina and up into the womb by the doctor who is constantly being guided towards the folliculars by the display on the monitor screen. Once successfully targeted the eggs are delicately sucked out into the tube and examined under a microscope. If the operation proves successful then a private room is allocated to the husband in which he must make himself ejaculate. All debris and dead cells are then cleaned out of the semen and the best sperm is allocated.

It is only at this point that the doctor can determine whether the assisted conception will occur through invitro bio-fertilization (the original method) or through micro manipulation (ICSI), the technique discovered by Dr.Bongso whereby it is now possible to inject a single sperm into an egg. The latter is only carried out if the husband's sperm count is very low as with IBF 100,000 sperm must be applied to one egg for a high chance of a zygote being created. A zygote is recognised by its two nuclei.

Day 33 (p.m.) Now the zygote is placed in an incubator that exactly replicates the womb. (Among other things, international cooperative/competitive expertise has lead to the production of the highest quality embryo replicas. The Sri Lankan clinics avoid disasters caused by the frequency of power cuts by connecting the incubators to uninterrupted power systems with the extra back up of a powerful generator.)

Day 35 If the two-cell embryo has happily developed it should consist of eight cells by its third day. In most centres this is the day when the embryo is placed back in the patient's womb. Exceptions to this rule occur when the woman is over 35 years old due to the unquestionable link between a female's age and her fertility. Because each woman is blessed with a fixed number of eggs from birth, the later one decides to have a child the older one's eggs are and the less chance of survival the zygote will have in its first few precious days. Again, it was a Singapore pioneered technique, known as blastocyst culture assisted hatching, that has subsequently be0en developed, which means it is now possible to leave the transfer of the embryo back into an older patient's womb until the fifth day of its development (Day 37 of treatment) by which time the embryo is more resilient. This is excellent news considering that more and more career-minded modern women are postponing motherhood until middle-age. If the third or fifth day transfer moment has been reached with the zygote in good condition then the success rate increases to 45%.

Next comes the crucial point of transfer when three embryos are inserted with the probe, back into the woman's uterus. "A sound working relationship between the embryologist and the doctor is equally essential to possessing an exceptionally steady pair of hands, absolute concentration and a strong set of eyes." Prof. Bongso said, "There is no other biotechnology that needs as much precision as artificial insemination."

Three embryo's instead of one are inserted because this triples the chance that life will form. With three embryos there is a chance of one in five that the parents will have twins but they will not be genetically identical.

The female patient must now lie still for six hours. Whether this actually makes it more likely that the embryo will stay alive has not been confirmed. Superstitious or not, all clinics request that the patient does this. However, what has been proven is the serious effects that stress has on the prognosis of the embryo so at the end of the day the patient is given strict instructions to go home and relax.

Day 53 Eighteen days after the transfer procedure has been carried out the couple return to the centre to have a pregnancy test. If the wife has become pregnant then she experiences the remaining seven months of pregnancy just as any other mother would. Many couples that are determined to have a child have to go through the above process as many as ten times before becoming pregnant. A minority never succeed or run out of the money necessary to try again and again. Yet positively speaking, the pregnancy rate is cumulative with each attempted cycle and the first step for many patients is to save up enough money for three or four cycles.

Because of the social stigma attached to infertility, as well as the means used to combat it, the names of patients and newly-born babies at the Vindana clinic have been withheld.

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