The world of fertility medicine is a constantly changing and improving field, due largely to innovative pioneers with the commitment to push forward the boundaries of our knowledge. Without their passion, drive and determination the founders of IVF treatment would never have succeeded in creating the treatments that we take for granted today.
At Trinidad & Tobago IVF & Fertility Centre our Research Department takes an active role in conducting clinical trials to understand the unique issues faced by T&T couples with fertility difficulties and to look at new ideas and treatments that might benefit all patients worldwide.
Our current research studies include:
- Male fertility in Trinidad and Tobago. A detailed research study analyzing sperm morphology in Trinidad and Tobago
- An analysis of AMH as a predictor of fertility potential in Caribbean women. Prospective assessment of AMH levels and fertility potential in egg donor recruits.
- National study of the incidence and causes of female fertility problems in Trinidad and Tobago
- A study of the effects of lubricants on sperm function
- Experience with the introduction in Trinidad & Tobago of AMH (Anti-Müllerian Hormone) for assessment of oocytes numbers. C Minto-Bain, N Jess, S Sookram, SS Ramsewak. 2010
Trinidad & Tobago IVF and Fertility Centre, 1B Rookery Nook, Maraval, Trinidad.
ORAL PRESENTATION Trinidad & Tobago Medical Association Annual Research Conference.
The probability of achieving a pregnancy is directly related to oocyte reserve, i.e. number of oocytes remaining within the ovary. Oocyte reserve decreases with age, and other factors – iatrogenic, environmental, genetic & immunological. Age alone is an inaccurate marker of fertility potential. Current assessments of oocyte reserve (basal FSH, Inhibin B, ovarian volume & antral follicle count) provide limited information, hence the search for more accurate markers.
AMH (or Müllerian inhibiting substance) is produced by male fetuses causing regression of the female reproductive tract. Adult females produce AMH from ovarian granulosa cells of pre-antral and antral follicles. Studies have suggested AMH as the most effective marker of oocyte reserve and recent studies have shown good correlation with IVF outcomes. We introduced AMH into clinical practice in February 2010, and present here the first three months results.
An observational study of two groups of infertility patients. Group 1 are women with suspected reduced ovarian reserve or unexplained infertility. Group 2 are women under 34 years applying to our egg share donor programme, with expected good oocyte reserve (normal basal FSH levels). AMH levels were assessed on fresh serum samples with ELISA AMH assay (DSL kit, Beckman Coulter, USA). Oocyte reserve was rated according to the Beckman-Coulter range (undetectable fertility, low fertility, satisfactory fertility, optimal fertility, very high AMH (likely PCOS or granulosa cell tumour)).
42 AMH results from 39 patients were evaluated. Of the 28 patients in group 1 (unexplained aetiology or predicted low ovarian reserve), all had AMH levels in the undetectable (17.8%) or low fertility (82.2%) range. A trend was seen towards lower AMH levels in older women, women with endometriosis and women who had undergone previous ovarian surgery. Of the 11 patients in group 2 (expected good oocytes reserve), 8 (72.7%) had satisfactory or optimal fertility, however 3 (27.3%) had low fertility and were therefore rejected as potential egg donors. All three had AMH levels repeated and confirmed. Two of these three patients had undergone prior ovarian surgery.
Our results agree with other studies showing AMH as a potentially earlier and more accurate marker of reduced oocyte reserve, particularly in young women. AMH is a cheap and easy investigation to identify couples that should be referred earlier for more aggressive fertility treatments. It is an additional test for couples with unexplained infertility, revealing an egg factor in many cases. It should also reduce the number of egg donor IVF cycles that are cancelled due to low oocyte yield. Further studies are required to correlate AMH levels with fertility potential in large populations and further define population normal ranges.
- Male Infertility in Trinidad and Tobago.
ORAL PRESENTATION Trinidad & Tobago Medical Association Annual Research Conference 2011.
Cristina FL Hickman, Sonja S Sookram, Catherine Minto, Samuel Ramsewak.
To determine the incidence of normospermia, azoospermia, severe oligospermia, teratospermia and asthenospermia in patients attending a fertility clinic in Trinidad and Tobago.
- To compare the semen parameter profiles from patients attending a fertility clinic in Trinidad and Tobago with other countries as published in the literature.
- To determine whether geographical location of residence, age and abstinence are factors affecting semen analysis parameters.
Retrospective analysis of 663 semen samples analyzed according to WHO guidelines . Data collected from a local fertility clinic from 2007 to 2011. The geographical location of residence of the patient was categorized as North(n=258), Central (n=184) and South (n=175) of Trinidad, Tobago(n=19) and International (n=18). Data are presented as mean±standard deviation. Geographical location of residence, age (37±7 years,range 22 to 66) and abstinence (5±3 days,range 0.4 to 31 days) were assessed as factors affecting semen analysis parameters (total sperm count, sperm concentration, semen volume, total sperm motility, total sperm progressive motility and morphology) using analysis of variance and regression and considered significant if p<0.05. Data from this study were compared to data from subfertile populations found in the international literature (literature search in PubMed using the terms ‘semen parameters’ and ‘subfertile population’) using two sample t-test or chi-square test as appropriate.
Out of 663 samples, 51% of semen samples were normospermic (compared to 58% elsewhere), 9% were azoospermic (compared to 4.9% elsewhere), 34% were oligospermic (of which 12% were severely oligospermic), 3% were teratospermic and 22% were asthenospemic. Total sperm count (Trinidad vs elsewhere, 90±107 vs 283±245 milion sperm) and sperm concentration (31±31 vs 94±71 million sperm per mL) were significantly lower than reported elsewhere. Volume (2.9±1.6 mL), total motility (50±27%), progressive motility (37±22%) and morphology (13±4) were comparable to reported elsewhere. Geographical location of residence did not significantly affect any of the sperm parameters. Total sperm count (p=0.02) and total progressive motility (p=0.049) decreased with increasing age. Volume (p<0.001), total motility (p<0.001) and total progressive motility (p<0.001) decreased with increased abstinence.
This study suggests that semen parameters in men attending a local fertility clinic in Trinidad are suboptimal compared to men attending fertility clinics abroad. Semen parameters are not affected by geographical location of residence. This calls for further studies to identify reasons for reduced semen parameters (and possibly fertility) in Trinidad and Tobago.
- A comparison of headﬁrst and tailﬁrst microinjection of sperm at intracytoplasmic sperm injection. Bryan J. Woodward, M.Med.Sci., Keith H. S. Campbell, Ph.D. and Samuel S. Ramsewak, M.D.
School of Biosciences, University of Nottingham, Sutton Bonington, Leicestershire, United Kingdom; and
Department of Obstetrics and Gynaecology, University of the West Indies, Saint Augustine, Trinidad and Tobago
Objective: To investigate whether the direction of sperm loading and exit from the injection pipette during intracytoplasmic sperm injection (ICSI) had any bearing on ability to cause fertilization or affect subsequent embryonic development.
Design: Prospective randomized trial.
Setting: Hospital-based IVF center.
Patient(s): Twenty-ﬁve couples participating in an intracytoplasmic sperm injection (ICSI) program.
Intervention(s): Sperm microinjection was randomly divided into either headﬁrst injection or tailﬁrst injection.
Main Outcome Measure(s): Fertilization, embryo quality, and implantation rates.
Result(s): There were no signiﬁcant differences in the fertilization rates or the proportion of good-quality embryos, according to the direction of sperm injection. Of the embryos selected for transfer, 41.3% originated from headﬁrst sperm injection, and 58.7%, from tailﬁrst sperm injection. After transfer of either two or three embryos into 24 patients, 11 embryos implanted, with an equal probability that these embryos originated from either headﬁrst or tailﬁrst sperm injection. However, one dizygotic twin pregnancy was traced to the transfer of two embryos; one resulted from headﬁrst sperm injection, and one from tailﬁrst sperm injection.
Conclusion(s): The direction of sperm microinjection at ICSI appears to have no effect on fertilization or subsequent development. The preliminary ﬁndings of this study have some interesting practical implications for the procedure of ICSI.
- Intracytoplasmic Sperm Injection (ICSI) – experience in a Caribbean IVF Unit. Presented at the Association of urologists, 2006, Trinidad.
C L Minto-Bain and S Ramsewak.
1 Medical Associates Hospital Reproductive Medicine Unit, St Joseph, Trinidad.
1,2 Unit of Obstetrics and Gynaecology, The University of the West Indies, St. Augustine,Trinidad
Although the first IVF baby was born in 1978, it was not until 1992 that reproductive technology could help couples with severe male-factor infertility to also achieve pregnancies. The technique now in common clinical usage worldwide for these couples is intracytoplasmic sperm injection (ICSI). This is where a single immobilized spermatozoon is injected directly into the ooplasm and can also utilize epididymal and testicular sperm so allowing some azoospermic men to achieve pregnancies. Because of these manipulations, it is potentially destructive to both sets of germ cells, which could be therefore reflected in poorer success rates than with standard IVF.
We have been using ICSI for the past eight years in our IVF service and we have analysed our last 85 IVF cycles to compare the two techniques. Clinical features within the groups were similar, and 41.3% of cycles were IVF and 58.7% were ICSI. The latter group included 3 subjects with normal semen parameters planned for IVF where no IVF fertilization occurred and rescue ICSI was performed.
Pregnancy rates per cycle started (including women who did not get to egg collection) were 30.6% in the IVF group and 28.6% in the ICSI group (NS). However the pregnancy rates per embryo transfer were higher in the ICSI group (56%) as compared to IVF (44%). Pregnancy rates are known to be largely dependant on the female partner’s age, and our figures reflect this, with pregnancy rates of 50% in women under 30 years, 40% in those aged 30-34 years and 21% in those aged 35-39 years. In women aged 40-46 years, we noted a surprisingly high pregnancy rate of 43%, but the number in this group was small (n=7). Miscarriage rates in older age groups were higher than in their younger counterparts.
Our results reflect the general data in the published medical literature suggesting that ICSI techniques have age-related pregnancy rates as good as or exceeding those of traditional IVF.