Historical perspective
Louise Brown, the first person to be born after conception in vitro was delivered by elective caesarean section at Oldham General Hospital in Lancashire, United Kingdom, on 25 July 1978.
Her mother was infertile because of tubal blockage, and in vitro fertilization (IVF) was developed as a means of bypassing the blocked tube by taking the oocyte from the ovary and replacing the embryo in the uterine cavity. Her pregnancy resulted from collaboration between a pioneering laparoscopic surgeon, Mr Patrick Steptoe, and a Cambridge embryologist and scientist, Professor Robert Edwards. Edwards was awarded the Nobel Prize for Medicine in 2010 for this work (1).Louise was conceived after over 200 failed attempts at IVF by this group, and after a pregnancy that ended as ectopic conceived after IVF in Melbourne. The principles used in IVF have not changed over the years since her birth although the processes have been refined and improved in numerous ways. The first IVF births followed a laparoscopy performed after the natural luteinizing hormone (LH) surge had been identified using frequent blood sampling. A needle passed transabdominally was guided under laparoscopic control to penetrate the single preovular follicle. Follicular fluid was aspirated and examined microscopically to try to isolate the oocyte. This was placed into culture medium and then incubated with a sample of the partner's sperm. If the egg fertilized, then the resulting embryo would be transferred into the uterine cavity using a transcervical catheter passed under direct vision.
The procedures involved were complex and highly inefficient. Things frequently went wrong at every stage, and the evolution of IVF has revolved around refining and improving the various steps of the IVF pathway. The major developments in assisted reproductive technology (ART) that have improved pregnancy rates, patient acceptability, and safety are outlined in Table 52.1.
Since the early days of IVF in the 1980s, the group of IVF-related treatments known as ARTs have resulted in the birth of over 7 million children. Several countries now see more than 3% of all births following ART and ART is globally accessible with major growth of centres in China, India, and South East Asia along with Europe and the United States. ART has become increasingly complex, with many centres now performing intracytoplasmic sperm injection (ICSI) in more than 50% of cycles and increasing numbers of cycles with embryo biopsy for preimplantation genetic diagnosis (PGD) or preimplantation genetic (aneuploidy) screening (PGS) (2). Many clinicians also use a variety of adjuvant treatments to try and improve oocyte number or quality although the effectiveness of most of these treatments remains unproven.