FROM TEST-TUBE TO KINDERGARTEN

The problem of sterility today remains urgent for millions of married couples all over the world. Despite the variety of sterility treatment methods and recovery of disturbed reproductive functions, artificial fertilization for many is the only way to the desired pregnancy and maternity. Successful operations of IVF (in vitro fertilization) and ICSI (intracytoplasmic sperm injection) have been carried out in Armenia for 3 years already in the SRI of Mother and Child's Health Protection, due to which over hundred babies were born. As the Director General of the SRI of Mother and Child's Health Protection, professor Georgy Okoyev, noted in an interview to the, the specialists of the Marseille Institute of Human Reproduction, who have been actively cooperating with the Armenian doctors within several years, contributed greatly to the formation and development of artificial fertilization methods in Armenia.

- Mr. Okoyev, which methods of artificial fertilization would you mark out as the most efficient?

- Before talking of efficiency of one or another method, I will note that the artificial fertilization is a rather capacious concept. Artificial insemination by a donor sperm is the simplest method of auxiliary reproductive technologies. Thousands of such operations were carried out since 1985, when a sperm bank was created in our center for the whole region (Armenia, Azerbaijan, Georgia and Krasnodar territory). However, a very delicate psychological moment exists here, namely, a child from the donor arouses the husband's suspicion and unwillingness to take this step. Certainly, it is a quite natural response since everyone wants to have his (her) own child. It is not random that the number of artificial insemination by a donor sperm has considerably reduced in the Republic with implementation of the extracorporal fertilization method. Moreover, in cases when carrying of pregnancy is contraindicated or impossible (no uterus, inoperable injuries of uterus/endometrium, etc.), some of our patients agree for an ersatz maternity. Three such cases are already fixed in Armenia by this time - the patient's immediate relatives have become ersatz mothers.

- By which criteria are the ersatz mothers, as well as the donors of sperm and ovum selected?

There is a great difference between an ersatz mother and a donor. An ersatz mother must be absolutely healthy and we carry out a strict examination for infections, transferred by genital tracts and check that pregnancy is not contraindicated to her. Unlike her, the donor is a carrier of a gene, chromosome and hereditary information. Therefore, we also carry out a medical-genetic investigation to make certain that the donor is a not a carrier of any severe hereditary disease. Nearly 15 young and healthy men-donors of sperm are registered in the center for today. We change our donors from time to time so as not to increase the risk of birth of a great number of kindred children. As for the ovum donors, they are intimate patients, as a rule (but not of her husband, so that to avoid a kindred marriage). Unlike sperm, ovum does not stand the freezing process, therefore, we use it just after stimulation of the woman-donor's ovaries and obtainment of oocytes by method of paracentesis.

- As far as I know, you achieved the first positive results of using IVF in February, 2004, when a citizen of Georgia, who had been suffering sterility for 12 years before that, gave birth to triplet babies. For how many patients more the treatment has become efficient for the last three years?

About 300 women have addressed our center for this period, not only from Armenia but from other countries of the world as well, namely, from Belgium, Iran, Holland and the USA. Unfortunately, most of them address us very late, the main contingent of our clients re women above 30. This circumstance is especially oppressive since the IVF and ICSI efficiency considerably decreases with age. Thus, if the efficiency of such operations at the age of 30 makes up 40%, after 35 it makes up only 20%. As you see, the effectiveness of artificial fertilization directly depends on woman's age. The more is the age the less is the percent of pregnancy. Unfortunately, the science could not yet give an unambiguous answer to the question, which processes exactly in the woman's organism hamper a 100% pregnancy appearance and why no implantation of fetal ovum to uterus happens after successful fertilization by IVF and ICSI methods.

- What is the reason of the women's address to your Center in a more mature age?

First of all, one of the indications for IVF conduction is a disturbance of uterine tubes function. Usually, in case of such pathologies, the young woman is prescribed a laporoscopy. However, if 6 months later the treatment is of no desirable effect, the patient is again prescribed drugs and her uterine tubes "open" again… As a result, having spent a lot of time and money for inefficient treatment, the woman addresses us, sometimes 8-12 year later, but "treated" by hormones, ovulation stimulators and often with resected ovaries. All these factors, as well as the patient's mature age, considerably reduce the efficiency of our interference.

- How exactly the operation for artificial fertilization is conducted?

We stimulate the patient's ovulation (super ovulation) under influence of definite medicines as a result of which the woman's organism starts to produce a great number of ovums. After fertilization in a test-tube, 2-5 days later, we transfer the embryo to the cavity of uterus. The ICSI operation is conducted similarly with only difference that here the spermatozoon is injected directly into the ovum. If indications for IVF are an unexplainable sterility (sterility of unclear genesis), from which 10% of married couples suffer, as well as a commissural process in the abdominal cavity, the indications for ICSI are an expressed sperm quality loss or a severe autoimmune men's sterility. To note, we also carry out a freezing of embryos, obtained during an artificial fertilization, which afterwards can be transplanted to the cavity of uterus after an unsuccessful attempt of IVF or if the patient wishes to give birth to one baby more. In many countries of the world, the embryo is considered a biological creature with human rights, therefore, we thoroughly discuss the issue of further freezing of embryos together with a married couple. Embryos of about 15 women are now stored in our Bank.

- If a pre-implantation genetic diagnosis is carried out in your Center?

I hope very much that such a diagnosis will be carried out in our Center since it helps to prevent a child's birth with hereditary or genetic diseases. Despite the fact that this is, unfortunately, an expensive pleasure (it costs $2-3 thsd on average), however, the PGD is a kind of a necessity for 35-38-year-old married couples since a risk of development of trisomy, Down's syndrome, Klinefelter's syndrome and other severe and incurable diseases at the child vastly increases during a late pregnancy. Moreover, the PGD allows to reveal "embryos-carriers" of diseases with late manifestation and genetic predisposition to severe diseases (oncology, Alzheimer's disease, etc.). Pre-implantation diagnosis at the age of 36-37 is substantiated in these cases, as a woman gives birth to a healthy child due to the "screening" of genetically abnormal embryos.

- In your opinion, how much actual is the problem of sterility in Armenia?

I must note with regret that sterility in the Republic grows younger, the reason of which are, first of all, hereditary diseases, transferred by genital tract. About 30% of Armenian families today suffer sterility. I think, definite steps are to be undertaken at a governmental level to increase the birth rate in the country. As of today, the operations for artificial fertilization are inaccessible for a considerable part of the Republic's population. Even despite the fact that the citizens of Armenia pay only for the necessary medicines and reagents in our Center, the IVF and ICSI cost 900,000 drams at best. However, I hope that definite programs will start to be implemented in Armenia, due to which the Republic's women-dwellers of moderate means, who suffer sterility, will also be able to feel the happiness of maternity.

Karina Manukyan, ArmInfo, 18 October 2006