CONSULTANCY
Your experience in the ART world ranges from lab directing to quality management, including lecturing at university, embryologist training, consultancy… What would you say it is the most important thing in assisted reproduction to date?
“I think that its contribution to people, science and biotechnology is important. It enabled advances in medicine through helping significant number of couples globally. Scientifically, it has expanded our understanding of mechanisms in reproductive biology. In the meantime, it accomplished substantial progress in the field of biotechnology to an extent that forces our limits due to certain ethical concerns. I consider ART as one of the most important achievements of the last decades.”
How do you think people see fertility treatments? From your own experience, how has this view changed over time in the general population? Since you have worked in different countries, is there a main difference in how different cultures conceive this issue, or would you say there is a common thought for all patients?
“I remember the headlines in the newspapers when Louise Brown was born. It was then considered as a miracle and most people approached to IVF technology cautiously and with scepticism. Understandably, it has not been accepted in all regions of the world immediately due to various cultural and/or religious perspectives and backgrounds. However, IVF turned out to be a well-recognised treatment in a relatively short period of time in almost all around the world. I think that the amount of accumulated data and probably word of mouth from those who underwent treatment enabled people to appreciate the technology. From an industry perspective, IVF is still a growing market. Its market value is predicted to double within the next ten years. South East Asia is expected to be the driving force in the expansion of the market during this period as the region is heavily investing into healthcare. Sadly, but truly, although the correlation has not been clearly shown, the demand for ART appears to grow concomitant to the deteriorating environmental conditions. It is likely that this has an impact on gamete quality, particularly on the male gamete but probably also on the female gamete (data is not available due to the lack of parameters that assess egg quality!). Another reason for the observed increase in the need for the infertility treatment is postponement of motherhood for socioeconomical reasons.”
You have been the head of departments and director of specific fertility units in different centres and clinics. What is the one thing in the fertility world that is always in the mind of the embryologists, regardless of their position?
“As a clinical embryologist I may be biased in my opinion but I believe that this profession is special in the way that it creates humans through dealing with gametes and embryos, which are valuable, but also vulnerable and sometimes very few. So, I think that the stress and the joy this profession brings to embryologists are unique. In my view, clinical embryologists need to have certain common personal characteristics or has to learn these in time in order to be successful. I believe that discipline is of utmost importance. Although this principle applies to any profession, because of the critical work they perform, clinical embryologists must be extra conscious to adapt a healthy and disciplined life style and to look after themselves. They must sleep properly the night before they come to work. An embryologist coming to work with an energy drink is unacceptable, to my opinion. They are working with a living material that has a potential of being a human, hence it must be treated accordingly. Another required personal trait for a clinical embryologist is honesty. Any mistakes or incidents experienced by embryologists, regardless of how minor they can be, must be reported otherwise the consequences can be unbearable. It is a statistical fact that every manipulation has a risk to go wrong after it is repeated for a certain number of times and if an embryologist performs that manipulation that many times, then it is likely that one incident is likely to happen. It is therefore essential to recognise that one incident to be able to rectify it. I think lab directors/supervisors, as a role model to clinical embryologists in most situations, have to encourage honesty. When I worked as a lab director, I tried to work this out by talking about my own experiences.”
You have been in charge of the setting-up of many clinics worldwide. What is the most important thing for an IVF unit to be successful in their treatments and how can that group guarantee good clinical outcomes?
“Success in any IVF unit depends on many factors, which are correlated to each other. I think the top of my list will be having a dedicated team, which is not merely the embryologists and/or the physicians but everyone who is involved in preparation and handling of the gametes and embryos as well as those involved in the maintenance of the environment in which these materials are treated. As an example, the personnel, who describes the patient how to administer the hormones during ovulation induction is partly responsible for the quality of the egg that the physician will retrieve and the embryologist will inseminate. Similarly, the cleaning personnel of the unit are partly responsible for being cautious not to introduce any toxic substances and to maintain the clean environment for the growth of the embryos. Every member of the staff contributes to the overall success of the unit and therefore awareness and optimal performance is a prerequisite. Appropriate training, documentation, tracking/monitoring and quantification of the QC parameters for assessment are key elements for maintaining optimal performance of the unit. It is then possible to claim that the outcome is within the acceptable range.”
In the past you have contributed to the growth and expansion of centres, clinics and hospitals, changing dynamics from hundreds of cycles a year to several thousands. How these improvements change the inner dynamics of the groups and what do they need to consider to take charge of such responsibilities?
“I think this is a very important question as the scale of many IVF clinics are expanding due to increased demand in the infertility treatment and also due to on-going mergers. In my experience, accelerated growth phase in an IVF centre can be challenging and requires successful business solutions. It may cause unhappiness among the staff and may receive resistance to adopt. I think that at its core the human factor is the major determinant to decide whether the transition will succeed. Many years ago I remember that in an ESHRE meeting I have listened the presentation of the director of a globally recognised IVF Group from Spain. He talked about his experiences on how he and his group managed this accelerated growth period. He said that the most important challenge was allocating responsibility to the right people. My personal experience agrees with this observation. An accurate business model has to be implemented through the right people in order to achieve such a transition smoothly and successfully.”
To round up this interview, any piece of advice to people struggling to conceive who may be considering seeking for professional help?
“I like to quote the first line of a book about the psychology of infertility that I have read many years ago: “infertility is the most challenging problem that a couple encounters.” Because it is so challenging it needs to be shared by the couple. They need to support each other during this process otherwise it can be a huge burden on one’s shoulders. Achieving a successful outcome may take some time. Positive expectations in a short period of time may result in disappointment, so better be patient and keep in mind that after few treatment cycles, the chances will increase as the cumulative pregnancy rate will be higher. ART is an advancing technology, which means that the professionals in the field are better equipped to help the infertile couple as compared to the past.”
RESEARCH
What is your current main interest in research/your current main responsibility? As the founder of OvoScore Ltd., which is devoted to improving the outcomes of fertility treatments, could you tell us about the general policy and how you aim to contribute to a better development of ART?
“As the name of my business emphasises, my main current research interest is predicting egg quality, particularly its developmental competency. The quality of the oocyte is the most important determinant of the success of IVF treatment. It provides half of the genetic material of the embryo, almost all cytoplasmic constituents and it also has the capacity (varying among individual gametes) to repair the damage that the embryo inherits from the sperm. With the current IVF technology because we lack the parameters to predict egg quality we inseminate all retrieved mature oocytes with random developmental competencies and try to select the viable embryos through a subjective parameter; morphology. Apparently, this approach is not feasible since the oocyte to baby rate is around 6-7%. This means vast majority of valuable biological material is wasted mainly due to lack of understanding the mechanisms that attain developmental competency to eggs. If we were to identify tools to predict the developmental competency of the oocyte then it would be possible to acquire strategies to minimise the wastage and to increase the efficiency in ART. Such knowledge would also contribute to in vitro maturation studies, storage of gametes and embryos, artificial gamete technology as well as to other industries (e.g. agriculture).
“As a research topic, I am also interested in integration of artificial intelligence into ART and dynamic monitoring of early embryo development. This is because I think that in the age of technology, ART will have to minimise the risk of human factor in the procedures as well as decreasing the impact of subjective parameters mainly in embryo selection. I predict that automation will gain popularity and we will observe increasing applications of artificial intelligence besides its combinations with image processing and outcome predictions in the fore-coming years. From these perspectives I value the time-lapse imaging technology. We also observe other examples aiming to minimise the human factor, such as attempts to automatize vitrification, semen analysis/processing and the gaining popularity of RFIDs.”
Improvement in the quality of eggs could lead to a better usage of oocytes from patients, but this would also imply better mechanisms to predict embryo development. Can we expect some progress on these matters in the short-term future?
“There are many scientists who are studying in this field and trying to resolve this problem by approaching from various perspectives. I think that we are getting to a point where our focus is gradually diverting from understanding the mechanisms by which embryos attain viability towards exploring more on gamete biology. This is necessary because gametes make up the embryos. An embryo is an end product of on-going interaction of qualities/characteristics of two gametes. The more we know about the latter the better we understand about the embryo viability. However, to my personal experience, I must admit that industry still finds embryo selection as a commercially more attractive area.”
Is there anything people can do to actually improve egg quality?
“Unfortunately, according to our current knowledge, there is not much people can do to improve egg quality other than maintaining a healthy life style. Egg quality is dependent on a combination of its inherited and acquired characteristics. A healthy life style can only contribute to the latter and may have an impact on improving the characteristics that have already been inherited. The potential benefits of dietary and medical supplements are therefore limited. This is why predictive tools/parameters that can identify/select good oocytes are essential for increasing the efficiency of IVF treatments.”
Society in industrialised countries has been leaning towards a delay in motherhood. Consequences of this are huge not only in terms of social dynamics or micro-economical drifts in the general population, but obviously in fertility, since aging significantly affects oocyte quality. How does this affect the present and future of ART? Are we to expect differences in how we think in fertility treatments?
“Dealing with aged oocytes will inevitably bring a more challenging atmosphere in the IVF clinics to achieve success. I think that this may enable the IVF professionals and scientists to gradually divert their focus more on egg quality, which I believe will bring advancements in our understanding to the mechanisms that make a good egg. And I think that it will be the next great achievement of reproductive biology and ART.”
© 2015 Roberto de la Fuente interview