The area of assisted reproduction has seen development of a great number of technologies. Some have come and gone, while others have established their importance and have been further developed over the years. And, while it is clear that great steps have been made in the effectiveness of assisted reproductive technology (ART), there are still some key improvements to be made. These include:
- Reducing incidence of OHSS
- Reducing psychological pressure
- Reducing financial pressure
- Increasing access to treatment
When considering how to make these improvements, we must consider the value of the procedures being offered in clinics today. Are there some that may be being overused? And are some not being used enough? At COGI 2018, we listened as a panel of expert speakers discussed these key questions.
In vitro maturation (IVM) involves the procedure of retrieving early follicles, followed by their maturation in the laboratory. The process was initially developed by Pincus and Enzmann in 1935, with Cha et al the first to successfully deliver a human live birth in 1991. However, in recent years the procedure has been relatively side-lined in clinics.
Dr. Johan Smitz discussed why this may be. He explained there were two key reasons why IVM remains under-utilized:
- Follicle heterogeneity - injecting hCG on the small 6-12 mm follicles can cause asynchronous maturation of the oocyte
- Inappropriate signalling - IVM can result in spontaneous re-initiation of meiosis
In addition, further issues are associated with IVM. There is a steep learning curve for those undertaking the procedure and a current lack of clear standard operating procedures means that there is a risk that success would not be easily standardised between centres. Also, Dr. Smitz explained that there are certain prejudices related to IVM, with many women believing that the treatment is more painful than IVF. However, this may not necessarily be the truth.
Despite these issues, IVM has a number of significant advantages. When compared with IVF, IVM requires less consultations, monitoring and injections. Dr. Smitz also explained the treatment can be more cost effective and more comfortable.
IVM is also the only ART with zero risk of OHSS. This means that the procedure could be especially suitable for women suffering from Polycystic Ovary Syndrome (PCOS).
How can we improve IVM?
Dr. Smitz outlined five key steps to improve the IVM procedure.
Abandon the hCG injection to avoid the issues associated with asynchronous maturation
- Apply a positive in-vitro maturation stimulus to help to avoid the issues related with inappropriate signalling
- Give FSH or HO-hMG Priming at 2-3 days
- Use defining culture media
- Use a pre-maturation culture
Is Capacitation – IVM a step to the future?
Adopting capacitation culture (CAPA) conditions was shown to improve success of IVM. Dr. Smitz shared data from five pilot studies demonstrating that CAPA-IVM can result in high implantation rates and increased number of embryos per oocyte-pickup. The results of these studies remain unpublished at this time however we cannot wait to read the full reports! Further study, improvement and adoption of this procedure can clearly benefit the field and we are excited to see what comes next.