IVF Finally Recognized With Nobel Prize

It took 2 years to hire the right people, get IRB (institutional review board) approval, and treat their first patient – and even longer to achieve their first birth, Dr. DeCherney recalled.

In the meantime, the first birth outside England of a child conceived through IVF was reported in 1980 in Australia. In 1981, the first IVF baby in the United States, Elizabeth Carr, was born in Norfolk, Va., after the in vitro technique was performed at the Eastern Virginia Medical School there, now home of the Jones Institute for Reproductive Medicine. During 1982 and 1983, IVF births were reported at Yale University, New Haven, Conn., other U.S. institutions, and in other countries. By the end of 1983, 150 IVF babies had been born.

The early 1980s were full of continual improvements in clinical IVF – the improvement of embryo culture conditions and transfer techniques, for example, as well as the cryopreservation of surplus embryos, oocyte and embryo donation, and the development of ovarian stimulation regimens using various compounds during the follicular, mid-cycle, and luteal phase.

“There were constantly changes in the lab,” Dr. DeCherney said in an interview. “And switching from laparoscopy to [transvaginal] ultrasound [which also occurred in the early 1980s] was a very big change.”

Dr. G. David Adamson, who did his first IVF procedures in the mid-1980s at Stanford (Calif.) University before starting his own fertility practice in Palo Alto and San Jose, Calif., recalled how “a program with a 10% live birth rate was doing very well at that point.”

Then, “in the early 1990s, there was another rapid increase in the quality of the labs, and ICSI [intracytoplasmic sperm injections] was developed – this made a huge difference in pregnancy rates. … and there was a rapid increase in the number of programs,” said Dr. Adamson, who became interested in IVF in 1976, when, as a resident, he read Dr. Edwards’ and Dr. Steptoe’s report on the first ectopic IVF pregnancy, published as a letter in the British Medical Journal.

In 1986, when Dr. Adamson began doing IVF procedures in Stanford’s new program, the number of IVF babies born worldwide was 2,000. Almost a decade and a half later, by the year 2000, that number had soared to 1 million.

The problem was, with the focus on raising pregnancy rates and the simultaneous improvements in technique, the rate of multiple pregnancies as a result of IVF soared. In 1997 and 1998, the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technologies (SART), respectively, published their first guidelines recommending maximal number of embryos for transfer, according to the women’s age, embryo quality, and the opportunity for cryopreservation. The guidelines were amended in 1999 to include a new category called “most favorable” for which the transfer of no more than two embryos is recommended.

In 2004, fertility researchers announced success in significantly reducing the number of triplet and higher-order multiple births without hurting pregnancy rates (N. Engl. J. Med. 2004;350:1639-45), and just last year, the ASRM released even tighter guidelines, specifying that even in exceptions of patients with a “less favorable” prognosis, only one more embryo than called for in the guidelines should be transferred.

A Future of Challenges

Despite efforts to rein in multiple pregnancies and encourage more single-embryo transfers, multiple-embryo transfer is still the most common practice in the United States, and twin pregnancies – including what experts say is a substantial number of risky pregnancies – continue to increase. Fertility specialists still feel the tug between the need to control the multiple birth rate on one hand, and the principle of patient autonomy and free enterprise on the other, said Dr. Bradley J. Van Voorhis, who directs the IVF program at the University of Iowa Hospitals and Clinics in Iowa City. Too often, he said, patient autonomy still wins over.

“In many cases, the reason for implanting multiple embryos is that ‘that’s what the patient wanted,’ ” he said. “I’m not sure that’s a good answer anymore.”

Efforts to further reduce multiples and improve pregnancy rates with single-embryo transfers might be boosted in the future by further improvements in culturing and embryo transfer techniques, leaders say, but it is embryo selection – finding the healthy, most viable embryos, those most likely to implant – that they are pinning their hopes on.