Accessible Infertility Care: From Dream to Reality

Abstract

The consequences of involuntary childlessness in developing countries (DCs) create more wide-ranging societal problems compared to Western societies, particularly for women. Because many families in developing countries completely depend on children for economic survival, childlessness has to be regarded as a social and public health issue and not only as an individual medical problem. These negative psychosocial and economical consequences for childless couples are often severe and underestimated by the local and international society. In The Walking Egg Project, we strive to raise awareness surrounding childlessness in resource-poor countries and to make infertility care in all its aspects, including assisted reproductive technologies, available and accessible for a much larger part of the world population. We hope to achieve this goal through innovation and research, advocacy and networking, training and capacity building and service delivery. Right from the start, the Walking Project has approached the problem of infertility in a multidisciplinary and global manner. It gathers medical, social, ethical, epidemiological, juridical and economical scientists and experts along with artists and philosophers to discuss and work together towards its goal. We realize that universal access to infertility care can only be achieved when good quality but affordable infertility care is linked to effective family planning and safe motherhood programmes. Only a global project with respect to sociocultural, ethical, economical and political differences can be successful.

Addendum 1: The TWE-Lab Simplified IVF Procedure Method

The TWE-lab system is based on a simple chemical reaction in a closed environment which removes the need for an expensive IVF laboratory with CO₂ incubators, medical gas supply and air purification systems. CO₂ is necessary to equilibrate the pH of the IVF culture medium to a value between 7.25 and 7.40, optimal for embryo development. Continuous culture at 37 °C is necessary for viability of the embryo and can be achieved by an incubator, heated box or warm water bath. The simplified IVF method uses 2 chemicals, citric acid and sodium bicarbonate, to produce the CO₂ necessary to adjust the pH. The TWE-lab system was designed in collaboration with Jonathan Van Blerkom and is now a standardized procedure to perform an IVF treatment, for which all materials are available in a compact ready-to-use kit. The simplified IVF method uses 2 glass tubes in which the first tube serves as the generator of CO₂ by a chemical reaction between citric acid and sodium bicarbonate to produce the CO₂ for equilibration of the culture medium in the second tube (Fig. 20.4). A connection between the tubes is established by needles and tubing to transport the produced gas from the generator tube to the tube with culture medium. The connection can easily be removed after the 24-h equilibration of the culture medium has completed. The tubes with culture medium can be used immediately, or they can be stored in a cold (2–8 °C) environment. To keep warm, the tubes are placed in a heated block (alternatively water bath or simple incubator without the need for a gas supply) at 37 °C. After oocytes have been harvested from the follicles, they are inserted individually in the equilibrated tubes using a 1-ml syringe and needle, without opening the tube or disturbing the air environment inside the tube. The TWE-lab system provides a closed environment to ensure stable culture conditions and protect the gametes and embryos from possible adverse external effects. Between 1000 and 10,000 sperm cells are injected in a similar way to the tubes to inseminate the oocytes. After 24 h, fertilization is assessed by keeping the tubes at a slant and looking through the glass walls at the oocytes to see the 2 pronuclei that are a sign of sperm protrusion. Fertilization and embryo development are assessed through the glass walls of the tube. This simplified method removes the need for expensive air control systems and gives a very stable and safe environment for embryos to develop. The search for the materials needed in the kit has been extensive, and all items have important specifications that ensure good operation of the low-cost IVF method. Changing as little as the tube or the needle can result in a complete loss of function of the TWE-lab system.

Fig. 20.4

TWE-lab method: a equilibration of the culture medium in tube 2 by the CO₂ produced in tube 1, b production of CO₂ in the generator tube, c phenol red shift from dark pink (pH > 8.00) to salmon pink (pH around 7.30), d embryo evaluation through the glass walls of the closed tubes, e an embryo visualized in the TWE-lab tube

Outcomes from the low-cost culture method were compared with those from a conventional IVF culture system in a study conducted at the IVF unit in Genk Belgium and were shown to be identical [45]. As we performed the study in routine IVF cycles, surplus embryos were frozen and these from the TWE-lab system that were thawed and replaced have also led to the birth of healthy children [54]. These studies prove the TWE-lab system to be an alternative low-cost system for a routine IVF procedure. Next step is to implement the TWE-lab IVF system in a centre that is limited in resources. Our goal is to open the first low-cost TWE-lab centres in two African countries in 2015.