The oldest form of assisted reproduction is artificial insemination, in which a syringe or a pipette is used to bring the sperm into close proximity with the mouth of the womb. In 1780 the Italian scientist Spallanzini was the first to do this successfully, with a bitch. In 1799

John Hunter was the first to carry out the procedure with a woman. The sperm involved was that of a man with a deformation of the urethra, and Hunter injected it into the vagina of the man’s wife. The technique did not catch on: there was quite simply no one to be found who wanted to take on this ‘blasphemous’ process. It was i866 before the American gynaecologist J. Marion Sims, later a celebrated figure, took up artificial insemination again, putting sperm directly into the womb. From that time on the treatment was used very sparingly, mostly with married couples where the husband had become infertile because of bilateral gonorrhaeal inflammation of the epididymis.

In his book Fertility in Marriage and Ways of Influencing It, Th. H. van de Velde gives an account of how the pioneering American researcher Robert Latou Dickinson (1861-1950) conveyed the sperm directly to the Fallopian tube via the womb. H. Sellheim constructed an apparatus, the Tubenbesamer, with which the sperm could be blown into the Fallopian tubes; G. Fraenkel went even further: his advice was that if for any reason the abdomen had to be opened up, the ejaculate or punctuate from the epididymis should be brought into the immedi­ate vicinity of the ovaries. . . Yet another gynaecologist suggested the idea of injecting sperm directly into the abdominal cavity from the back of the vagina, reasoning that by no means all sperm cells would immediately perish and that a few might even reach one of the ovaries.

Today artificial insemination is practised mainly by farmers. Appro­ximately 90 per cent of cows and between 10 and 30 per cent of pigs are artificially inseminated. From the point of view of the breeder arti­ficial insemination has many advantages over natural servicing, including the non-transmission of sexually transferable diseases.

Up to the mid-1970s artificial insemination was the only method of assisted reproduction available to help those suffering from involun­tary childlessness. However, in the 1970s researchers and doctors developed a totally new kind of assisted fertilization: in-vitro fertiliza­tion (ivf). Two countries played a pioneering role – Australia and Great Britain – and four men are regarded as the founding fathers: the Britons Patrick Steptoe and Robert Edwards and the Australians Alan Troun- son and Carl Wood.

Ultimately it was the British pair who took the crown: in 1978 Steptoe and Edwards were able to present the first ‘test-tube baby’ to the world. The miracle baby’s name was Louise Brown. Incidentally, her sister Natalie, four years younger, was to be the first woman conceived by ivf herself to become a mother, only this time in the natural way. icsi is a complementary technique developed by Dr Gianpiero Palermo at the Free University of Brussels. In icsi a single living sperm cell is introduced into the ovum with a micropipette. The
first experiments were carried out on mice, and in 1991 the first preg­nancy was induced in a woman using icsi. By 2005 more than 400,000 had been born through icsi worldwide.

As of 2007 in Western Europe it is estimated that one in forty chil­dren were born with the help of the test tube – over one million babies worldwide – and if one includes other fertility-enhancing treatments, the proportion rises to one in twenty: these figures are hard to dismiss. Women not eligible for test-tube fertilization are those who are obese, those over the age of forty and those with ‘bad’ ovaries. The last condition can be tested by determining the level of fsh in the blood. Assisted fertilization methods include iui, icsi, pesa, tese, tesa. The table below gives an overview.

Подпись: What exactly is it? The injecting of sperm cells into the uterus Fertilization in the test tube Treatment

iui Intrauterine insemination

Defying Darwin Подпись: Intracytoplasmatic sperm injection Percutaneous epididymal sperm aspiration Testicular sperm extraction Подпись: Injecting a sperm cell into an ovum Aspiration via the skin of sperm cells from the epididymis Obtaining sperm cells from testicular tissue

ivf In-vitro fertilization

One of the biggest problems in assisted reproduction techniques is the occurrence of multiple pregnancies. The risk of course increases in proportion to the number of embryos replaced. With multiple births delivery carries higher risks and there are frequent premature births, meaning that the babies not only spend a long period in hospital but also run the risk of, for example, retarded development. Doctors usually aim to replace as few embryos as possible.

Intracytoplasmatic sperm injection (icsi) is nothing more than a complement to in-vitro fertilization (ivf). In icsi a single living sperm cell is introduced into the ovum with a micropipette. Through the microscope the analyst selects a suitably mobile sperm cell, gives it a tap on the tail so that it is stunned for a second, then picks it up with a pipette and injects it into the ovum. As a potential parent you natu­rally hope that a Rolls Royce sperm cell is picked up, but the fact remains that you are defying Charles Darwin. . . In icsi at least, processes that play a part in natural fertilization are bypassed. In con-

Defying Darwin

trast to ivf, icsi requires only one mobile sperm cell per ovum. In cases of azoospermia through obstruction, pesa is the most common tech­nique: with obstruction the number of properly mobile sperm cells is highest in the head of the epididymis, with a production problem the chance of finding mobile sperm cells is greatest in the tail.

In pesa a needle is inserted into the epididymis under local anaes­thetic and withdrawn as suction continues. The needle is connected to a syringe via a tube, which is then injected with growing medium so that the content can be assessed by an analyst for the number of mobile sperm cells. This procedure can be repeated several times in a session. Usually one starts on the side of the larger testicle, and if the count is low one can try the other side.

In a tese treatment sperm cells are taken from the testicle itself, and subsequently sperm cells are extracted in a laboratory from the section of testicular tissue removed. This has the advantage that a section of testicular tissue can immediately be obtained for the Johnsen score.

The treatment of fertility problems is generally felt to be very onerous. There are many stressful events, including (for women) daily hormone injections, blood samples, and diagnostic procedures such as exploratory operations, and masturbating to order and ‘epididymal sperm aspiration’ in men. Intercourse tends to become reproduction – led, potentially placing the desire for sex under pressure. In addition there is the situation of being constantly tossed back and forth between hope and fear. It becomes particularly burdensome when one wants to keep treatments secret from family, friends and colleagues. Taking time off work without letting colleagues in on the secret necessarily involves some fibbing.