New techniques in IVF offer… :

Fresh hope for childless couples

By Carol Aloysius

Time was when desperate couples who were unable to have their own child were forced to adopt a child. Some even resorted to illegal methods such as kidnapping newly born babies from hospitals, or buying them from poor mothers. This is because many of them are unaware they have access to an alternative, safe method. Medical technology has given them new hope by opting for In-Vitro Fertilisation (IVF), which has up to date successful results, not just in Sri Lanka, but globally as well.

Infertility physician and Clinical Embryologist Dr HELARUWAN PASAN KUMARA talks to the Sunday Observer on some of the recent advances in this speciality.

Excerpts…

Q. In-vitro fertilisation (IVF) has become a major technique for couples who have failed to have a child by other methods. Explain what IVF means.

A. IVF means fertilisation of a woman's ovum (eggs) and man’s sperm which takes place outside the body in a specialised lab environment.

Q. Since infertility is the root cause for using this technique, what are the reasons that make couples infertile in the first place? Genetic problems? Birth defects? Accidents? Age of mother and father? Lack of sperms or limited number of sperms?

A. Infertility is caused by three ways: Women's reproductive problems, men's sexual problems and idiopathic causes. The main problem for women is not being able to produce good quality eggs to conceive due to various reasons such as ovulatory failure, age, genetic issues, radiation etc. Other than that, fallopian tubal problems, diseases such as endometriosis and other endocrine problems can also affect women's fertility.

Q. What about men?

A. In the case of men, their sperm count can be low due to genetic issues, infections, sperm travelling tubal obstruction, hormonal imbalances etc. The number, speed and morphology of the sperm is important for fertilisation. When the clear cause is not detected for their infertility they fall into the Idiopathic category.

Q. Prior to IVF, do they have other methods to become fertile?

A. Timed intercourse in natural cycle, Intra Uterine Insemination (IUI), are methods they should try to address the root cause before they enter into an IVF program.

Q. Are those methods less drastic than IVF? Less harmful to the mother and unborn child?

A. Yes. IVF is the most invasive method of all. But it is also the most successful method. Even other methods like IUI can lead to some side effects. But current methods of new ovulation induction leads to less harmful IVF cycles.

Q. Describe the IVF procedure. Is it done manually or with machines?
A. Most of the procedure is done manually. But for freezing of embryos some centres use machines.

Also latest techniques such as embryoscope are now being used for ease of the procedure.

Q. Does a couple have to be hospitalised for this procedure? If so for how long?
A. There is no need to be hospitalised over night. Only during an egg retrieval procedure, it will be necessary for admission to hospital for two to three hours. 

Hospitalisation is not required even during embryo transfer.

Q. What is an IVF cycle?
A. Firstly using hormones multiple follicles produced from the woman's ovary.

Then the eggs are retrieved from follicles transvaginally with minimal invasive methods. 

Next, the man’s sperms are collected and from them, the best sperms are selected. Thereafter, the sperms and eggs are mixed together in special culture media under special environmental conditions or else undergo ICSI procedure. The growth of embryo is checked everyday till day three or five in special culture media. Best embryos are selected and transferred in to the mother’s womb on day two, three or five with special hormonal support for the embryos.

Q. What happens to the extra embryos?

A. Extra embryos are frozen for future use. They are stored in -296 c.

Q. What advice do you give to parents during an IVF cycle?

A. They should not smoke or drink alcohol during and before procedure.

Doctor should be informed of all medication both partners are using before and during the procedure. We also advise them to spend a less stressful lifestyle for more successful results.

Q. What safety measures are there in the lab?

A. All labs are well planned specialised areas. There are special techniques for quality control and quality assurance of the labs. There are special guidelines for embryologist to control lab.

Most of the equipment in the labs are to produce environment similar to the mother’s womb. They should be zero percent infection free. All embryos grow inside special incubators, so embryo handling is done with special care.

Q. How do you ensure the quality of the eggs? How do you decide how many eggs to transfer, once the procedure is over?

A. Quality of eggs depends on the woman's age, stimulation protocol and manipulation during egg retrieval, and all steps are taken to control and produce the best quality eggs.

Transferred number of embryos depends on quality of embryos, patients request and available number of embryos. Usually one or two embryos are transferred depending on age of embryo.

Q. How long can the eggs be stored? Can sperms be stored from a dead person?

A. Eggs and embryos can be frozen and kept for about 10 years or more in specialised conditions. Even a dead person’s eggs can be frozen for future use. But this has to be done very quickly. Sperms also can be frozen for future use.

Q. When is the first pregnancy test after the eggs are inserted?

A. A blood test is done 14 days after the embryo transfer.

Q. What happens if she fails to get pregnant? Can she try again? For how long?

A. If she has frozen embryos she can transfer them back. Or she can try again and undergo fresh IVF cycles as many times she wishes till she produce good quality eggs.

Q. Is IVF legally allowed for any infertile couple?

A. In Sri Lanka any couple can enter the IVF program. All our procedures are also done on a confidential basis.

Q. What are the medical ethics involved?

A. Informed written consent is major area. Donor embryos, and surrogate and sex selection issues are also major areas involving medical ethics. All donors and surrogate mothers are screened for STDs specially HIV/AIDS and have to pass the quarantine period before entering the program.

Q. When was IVF first introduced 1) globally 2) in Sri Lanka?
A. Globally - end of 1970. In Sri Lanka - end of 1990.

Q. What does the procedure cost?

A. Cost is usually around Rupees five lakhs. But this cost can be reduced to half if they go under an egg sharing program. In future we plan to reduce the cost more.

Q. Any recent breakthroughs in the techniques used?

A. ICSI (Intracyto Plasmic Sperm injection) is a recent technique, which enables almost all infertile males to produce babies. Also new freezing techniques like Vitrification increase the success of IVF. PGD (Pre Implantation Genetic Diagnosis) ensures more healthy babies being produced with the best genetic material.

Q. Are they available in Sri Lanka?
A. Yes, we have all new techniques except PGD. Hopefully this will be available in the near future.

Q. Your advice to couples without children?

A. Couples who have failed with other methods, over a period of time since marriage, should enter the IVF program quickly for more successful results, as age is an important factor. 

Those with financial problems can discuss an egg sharing procedure which is less costly.

Polypill increases adherence to post MI treatment

A new polypill increases adherence to treatment following a myocardial infarction (MI), according to results from the FOCUS Study presented for the first time at ESC Congress 2014 by principal investigator Dr Valentin Fuster, director of Mount Sinai Heart in New York, US (1). The novel treatment regime has the potential to prevent more patients having a second heart attack.

Dr Fuster said: “Despite continuous advances in all areas of cardiovascular (CV) medicine, cardiovascular disease (CVD) has steadily increased in prevalence to become the number one cause of death worldwide. It is estimated that half of the overall reduction in CVD mortality observed over the past 20 years in western countries could be attributed to appropriate use of CV medications for secondary prevention. But lack of adherence to treatment impedes adequate secondary prevention and contributes to the CVD pandemic.”

He continued: “The most important factors responsible for a lack of adherence to treatment are the complexity of treatment and the daily number of prescribed pills.

The idea of using a polypill for CVD prevention has gained increasing momentum because it could increase adherence and therefore contain the progression of CVD. A polypill could simplify healthcare delivery, improve cost-effectiveness, support the comprehensive prescription of evidence-based cardioprotective drugs, and reach underdeveloped regions of the world.”

The Fixed-dose Combination Drug for Secondary Cardiovascular Prevention (FOCUS (2)) study was established to investigate adherence to secondary prevention medication and test a new polypill.

The study was conducted in two subsequent phases. FOCUS 1 included post MI patients in a multi-country comprehensive analysis of socio-economic, comorbidity, and other factors

that determine adherence to CV medications. FOCUS 2 was a randomised controlled clinical trial testing the effect of a fixed-dose combination (FDC), the CNIC-FS (3)-FERRER polypill, containing acetylsalicylic acid (ASA) 100 mg, simvastatin 40 mg and ramipril 2.5, 5 or 10 mg, on adherence and control of CV risk factors in post MI patients.

FOCUS 1 included 2 118 patients with a history of MI from five different countries (Spain, Italy, Argentina, Brazil and Paraguay).

The degree of adherence to prescribed medications was calculated using the Morisky Green Adherence Questionnaire, a self-reported method with four questions on adherence behaviour.

The researchers found an average baseline adherence level of 45.5 percent.

The researchers also conducted a descriptive analysis of variables that impede adequate adherence.

They found that patients below 50 years of age, those taking more than 10 pills, following a complex regimen (i.e. those taking medications other than orally), current smokers and those with sedentary lifestyles were significantly more non-adherent.

Dr Fuster said: “Importantly, there was a significant trend towards more non-adherence with a higher score of depression

(as measured by the PHQ-9 questionnaire). Of the socio demographic variables, illiteracy level, lower social support and lower percentage of insurance cover showed significantly lower levels of adherence as well as those patients being treated by general practitioners (as opposed to cardiologists) and being treated in a private centre (as opposed to a public health centre).”

In a stepwise forward regression model, FOCUS 1 found that the risk of being non-adherent was independently associated with younger age (under 50 years old), scoring high on the depression scale, and following a complex (administrations other than oral) treatment.

On the other hand, the odds of being adherent increased with higher percentage of health insurance coverage, and with optimal levels of social support.

In FOCUS 2, a total of 695 patients were enrolled from four countries and followed for a period of nine months. Patients were randomised to receive either the polypill or the three drugs separately.

Adherence was measured with two methods: self-reported adherence using the Morisky Green Adherence Questionnaire as well as a direct method, the pill count.

The results after nine months of follow up are shown in figure 1.

Dr Fuster said: “Patients were more likely to take their medication to prevent a heart attack when it was given as a polypill, rather than as three separate pills. We found this using two methods. With the self-reported questionnaire, 68 percent of patients in the polypill group took their drugs compared to just 59 percent of patients in the group assigned to three drugs.

With the pill count, we found that 92 percent of patients in the polypill group were adherent compared to only 84 percent in the group assigned to separate drugs.”

- MNT

Abdominal fat increases risk of high blood pressure

People with fat around their abdominal area are at greater risk of developing hypertension when compared to those with similar body mass index but fat concentrations elsewhere on the body, according to a study published in the Journal of the American College of Cardiology.

Obesity is a known risk factor for hypertension, or high blood pressure, and it is widely reported that the location of fat on a person's body can lead to increased risk of other health issues such as heart disease and cancer. However, the relationship between hypertension and overall obesity versus site-specific fat accumulation is unclear.

For this study, 903 patients enrolled in the Dallas Heart Study were followed for an average of seven years to track development of hypertension. Hypertension was classified as a systolic blood pressure of greater or equal to 140, diastolic blood pressure of greater or equal to 90, or initiation of blood pressure medications. Patients also received imaging of visceral fat, or fat located deep in the abdominal cavity between the organs; subcutaneous fat, or visible fat located all over the body; and lower-body fat.“Generally speaking, visceral fat stores correlate with the ‘apple shape’ as opposed to the ‘pear shape,’ so having centrally located fat when you look in the mirror tends to correlate with higher levels of fat inside the abdomen,” said senior author Aslan T. Turer, a cardiologist in Dallas.

- MNT

A Pictorial Journey of Surgery

An unusual exhibition, probably the first of its kind will open to the public on September 12 - 14, when a long experienced surgeon, Dr Gamini Goonetilleke shares his portfolio of photographs spanning 33 years, of surgeries he has performed.

Titled A Pictorial Journey of Surgery Through the Lens, he says his main objective in holding the exhibition, is to educate the public and inform them of the various surgical techniques now available to them for different diseases, and to detect early symptoms of diseases such as breast and bowel cancer. On view will be different types of hernia and surgery complications, surgery and need for early medical advice on goitre, latest techniques on removal of gall bladder stones as well as the terrible consequences of road accidents and drinking alcohol and why they should be avoided at all costs.

Also on view will be some rare conditions such as Rapunzel syndrome (eating hair) which too has been successfully treated by him.

The exhibition is open to all while entrance for school children is free, if accompanied by school authorities.

It will be held at the Auditorium of the College of Surgeons, No 6, Independence Avenue, Colombo 7 from 9 am to 8 pm on September 12 to 14.