Professor Pal, throughout the last decades there have been many advances across all aspects of fertility treatments. Can now anyone who wants to have a baby, get a baby?
Fertility technologies are developing at a rapid pace. And probably the most important breakthrough is IVF.
Today, successful pregnancies can be achieved with the use of IVF in couples where there are very few sperm in the ejaculate. Successful pregnancies have been achieved in men with no live sperm by using testicular sperm.
Also, thanks to IVF, a woman doesn’t need normal open tubes to get pregnant.
We can also surgically correct the uterus.
IVF with use of donor eggs has allowed us to help women who are older, who don’t have ovaries or who have undergone premature ovarian failure to have a biological child; the child has the partner’s genetics but it is the recipient’s uterus and her body that nurtures this baby until birth and is therefore theirs in all biological senses. Egg donation and IVF options have allowed us this option.
Gestation surrogacy has allowed those women who don’t have a uterus to be a biological parent. Similarly, with the participation of an egg donor and a gestational surrogate (the same woman can donate her eggs as well as be a gestational surrogate), two male partners can now farther a child.
In the near future, we’ll be able to routinely help women who were born without a uterus or lost their uterus to a disease process, conceive after uterine transplant. Theoretically, I think we are there, but safety of this technology still needs to be established in the long term.
Colloquially, fertility is about the “seed” and the “soil”. The egg and the sperm are the seeds whereas the lining of the uterus is the soil. With IVF, we can achieve embryo development outside the woman’s body. And now we are trying hard to focus on strategies that will help us to get the best of the seeds.
What are the options for same-sex couples?
We’ve made so much progress in recent years!
Let’s start with same-sex females who need a sperm donor. That donor could be someone known to the woman/couple (known donor) or may be an anonymous donor.
Once the sperm source is selected, one of the female partners can go through a simple and cost-effective strategy of donor sperm insemination. This is the simplest and the cheapest approach. A more participatory, but complicated approach is that one woman undergoes IVF, serving as an egg donor; her eggs are then mixed with the donor sperm to create embryo/s, which are then transferred to the uterus of the female partner. This allows an opportunity for both female partners to contribute to the pregnancy: one contributes genetically, the other – physiologically.
Same-gender females who have no success with their egg/s also have the option of adopting an embryo and get an opportunity of physiological parenting.
The same-sex male partners have the sperm but need an egg donor and a gestational surrogate to carry the embryo as we are not there in transplanting a uterus to a male yet!
They may choose to get an egg from one person and then have another female to carry that embryo, or the same woman may provide her eggs as well as choose to carry the baby for the male couple.
They may also choose to have both partners sperm being used to inseminate the eggs. And this gives each of the two male partners an opportunity to contribute to the pregnancy genetically.
They also have the option of adoption. They can adopt an embryo but, in this case, they won’t contribute to the pregnancy.
What are the limitations?
We have achieved major advances in the field of genetics. Yes, we are now able to identify genetically normal and abnormal embryos through using preimplantation genetic testing techniques. We have come to appreciate that genetically tested embryos are sometimes in a gray zone (neither completely normal nor completely abnormal) and embryos in this zone are called mosaics.
What we know is that mosaicism is not as bad as abnormal and is not as good as completely normal. Mosaic embryos have resulted in normal live born children.
However, we still have not been able to reassure the public that a mosaic embryo will grow into a child without health problems because we don’t have data on the long-term health of these babies. These are the limitations right now.
Despite the many advances in the field of infertility, we have still not been able to cure the aging egg. We are just beginning to learn what impact aging in men may have on the health and wellbeing of a child. In recent years, we have learnt that certain health conditions in children, such as autism, may be linked to aging of fathers.
So, while we currently focus on egg freezing to minimize risk of aging related infertility in women, maybe timely sperm freezing for the sake of health of progeny is also something we should be thinking about.
Indeed, there have been tremendous advancements in infertility management over the last few decades. [About the ones we haven't mentioned, you can read here.] But we are still so far away from assuring that every person who so desires, can get pregnant with a biological child.
If you want to learn more about the preconception planning, read the first part of the interview with professor Pal.