Reproductive BioMedicine Online (2011) 23, 245– 262

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ARTICLE Robert Edwards: the path to IVF

Martin H Johnson

The Anatomy School, Department of Physiology, Development and Neuroscience and The Centre for Trophoblast Research, Downing Street, Cambridge CB2 1HW, UK E-mail address: [email protected]

Martin H Johnson is an Editor of Reproductive BioMedicine Online and Professor of Reproductive Sciences in the Anatomy School at the University of Cambridge UK. He was Chair of the British Society for Developmental Biology (1984–1989); the first CIBA Foundation Public Debate Annual Lecturer on ‘Human Embryo Research’, Swansea (1990); a member of the Human Fertilisation and Embryology Authority (1993–1999); treasurer and founding scientific member of the Cambridge Socio-legal group (2000–2011); and specialist scientific advisor to the Joint Lords and Commons Committee scrutinizing the Draft Human Embryos and Tissue Bill (2007). In 2004 he was elected a scientific Fellow of the Royal Society of Obstetricians and Gynaecologists. He is author of Essential Reproduction (seventh edition, Blackwell Science due 2012), co-editor of Sexuality Repositioned (2004), Death Rites and Rights (2007) and Birth Rites and Rights (2011), and has authored over 250 papers on reproductive science, history, ethics, law and medical education.

Abstract The early influences on Robert Edwards’ approach to the scientific research that led to human IVF are described. His inter- est as a graduate student in the genetics of early mammalian development stimulated him later to investigate whether the origins of human genetic diseases such as Down, Klinefelter and Turner syndromes might be explained by events during egg maturation. This clinical problem provided the most powerful stimulus to achieve both oocyte maturation and fertilization in vitro in humans. Indeed, preimplantation genetic diagnosis was his main goal until he met Patrick Steptoe in 1968. A re-evaluation of his meeting with Step- toe suggests that initially Steptoe’s laparoscopic skill was of interest for its potential to solve the sperm capacitation problem. Step- toe’s impact on Edwards was twofold. First, Steptoe’s long-held interest in infertility raised this application of IVF higher in Edwards’ priorities. Second, Steptoe offered a long-term partnership, in which oocyte collection without in-vitro maturation was a possibility. The professional criticism generated by their work together encouraged Edwards to pursue a deliberate programme of public edu- cation about the issues raised and to challenge and develop professional bioethical thought and discourse about reproduction. RBMOnline ª 2011, Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved. KEYWORDS: Edwards, genetics, history, infertility, IVF

Introduction to IVF that differs in a number of places from the conven- tionally accepted version and adds further detail. Robert G Edwards was awarded the 2010 Nobel Prize for Physiology or Medicine ‘for the development of in vitro fer- Materials and methods tilization’ (Nobel, 2010). There is a variety of accounts of the events leading up to this discovery and its acceptance, Primary sources used were: the publications by Edwards and most of them by participants (see Johnson et al., 2010), Steptoe during the 1950s, 1960s and 1970s; archives of the but historical scholarship is rarer. This account uses verifi- Royal Society of Medicine, Cambridge University, the Phys- able sources to produce a historical narrative of the path iology Library at Cambridge and the personal papers of RG

1472-6483/$ - see front matter ª 2011, Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.rbmo.2011.04.010 246 MH Johnson

Edwards (courtesy of Ruth Edwards); unpublished tran- These early experiences were formative. Edwards scripts of interviews with RG Edwards, K Elder and RL Gard- became a life-long egalitarian, for 5 years a labour party ner; personal recollections from the late 1970s by Edwards councillor (Ashwood-Smith, 2002), willing to listen to and and Steptoe as recalled in interviews with Danny Abse for talk with all and sundry, regardless of class, education, sta- the autobiographical account ‘A Matter of Life’ and on film tus and background. Second, he developed an enduring curi- with Peter Williams; members of RG Edwards’ family and his osity about agricultural and natural history and especially colleagues and former students and staff members for clari- the reproductive patterns among the Dales’ sheep, pigs ficatory evidence about personal recollections by Edwards, and cattle. Finally, he claimed great pride in being a ‘York- for additional verifiable information and with whom to test shire man’, traditionally having attributes of affability and some new interpretations. generosity of spirit combined with no-nonsense blunt-speak- ing. Indeed, following his only meeting with Gregory Pincus (1903–1967; Ingle, 1971) at a conference in Venice in May Results 1966, at which Edwards, the young pretender, clashed with the ‘father of the pill’ over the timing of egg maturation in Childhood background humans; he paid Pincus the biggest compliment he could imagine, saying ‘He would have made a fine Yorkshireman!’ Robert Geoffrey Edwards was born on 27 September 1925 in (Edwards and Steptoe, 1980, p. 43). the small Yorkshire mill town of Batley, the year of the Bat- The intervention of World War II was to provide an ley deluge and ‘great flood’. He arrived into a working-class unwelcomed interruption to Edwards’ education: when he family, and Edwards, who was known by his middle name of left school in 1943, he was conscripted for war service into Geoff until he was 18, was the second of three brothers, the British Army for almost 4 years (Figure 1). To his sur- with an older brother, Sammy and a younger, Harry. These prise, as someone from a working-class family, he was iden- brothers he describes as competitive, ‘all determined to tified as potential officer material and sent on an win or, if not to win, to go down fighting’ (Edwards and officer-training course, before being commissioned in 1946. Steptoe, 1980, p. 25). Sammy was named after his father, However, his army experiences were broadly negative, the Samuel, who was frequently away from home working on alien lifestyle of the officers’ mess not being to his taste the railways, maintaining the track in the Blea Moor tunnel and reinforcing his socialist ideals. The one positive feature on the Carlisle to Settle line. It was an unhealthy place to of his war service was the chance to travel overseas, partic- work, some 2600 m long and filled with coal-fired smoke ularly appreciated was his time in the middle-east. The that exacerbated Samuel’s bronchitis, a consequence of years in the army were broken by 9 months compassionate being gassed in World War I. The one perk of working on leave back in the Yorkshire Dales, to which he was released the railways was the free rail pass for the family’s annual holiday, which was regularly taken in far-away Sout- hend-on-Sea, located near the mouth of the Thames and considered then to be a top-spot resort by working-class families. Edwards’ mother, Margaret, was a machinist in a local mill. She came originally from Manchester, to where the family relocated when Edwards was about five, having been offered the relative security of a council house at 25 High- gate Crescent in the suburb of Gorton. It was in Manchester that Edwards was to receive his education. In those days, bright working-class children could take a scholarship exam at age 10 or 11 in competition for the few coveted places at a grammar school: the potential pathway out of poverty and even to University. All three brothers passed the exam, but Sammy decided against grammar school, preferring to leave education as soon as he could to earn. His mother was reportedly furious at this wasted opportunity, and so when her two younger sons passed, there was no question that they would continue in education and it was with that that Geoff/Bob progressed in 1937 to Manchester Central Boy’s High School (in the building that now houses Shena Simon College in Whitworth Street), which also claims James Chadwick FRS (1891–1974) as an earlier pupil. Chadwick, like Edwards, was a Cambridge professor and the 1935 Nobel Laureate in Physics for discovering the neutron (Massey and Feather, 1974). The Edwards’ summers were spent in the Yorkshire Dales, to where their mother took her sons to be closer to their father’s place of work. There, Edwards laboured on the farms and developed an enduring affection Figure 1 Edwards on National War Service 1940s (courtesy for the Dales. Ruth Edwards). Robert Edwards: the path to IVF 247 to help and run a farm when his farmer friend there fell ill. However, his low spirits did not last long. He learnt that So engaged did he become in farming life that, after dis- John Slee had been accepted on a postgraduate Diploma charge from the army in 1948, he returned home to Gorton, course in Animal Genetics at Edinburgh University under from where he applied to read agricultural sciences at the Conrad Waddington FRS (1905–1975; Robertson, 1977), University College of North Wales at Bangor. who had moved there in 1947 from Christ’s College in Cam- Having gained a place and a Government grant to fund it, bridge, home also to both Marshall and Parkes. Edwards the 6 or so months that intervened were occupied in a Gov- applied, and, despite his pass degree and to his amazement, ernment desk job in Salford, Greater Manchester, helping to he was accepted. That summer, he worked in Yorkshire and organize the newly formed National Health Service. This Wiltshire harvesting hay, as well as portering bananas and office-work experience reinforced the anticipatory attrac- heaving sacks of flour in Manchester docks and taking a tions of agricultural science. So his disappointment in the menial job with a newspaper, all to earn enough to pay course offered at Bangor was acute. By that time, he was his way in Edinburgh (Edwards and Steptoe, 1980, p. 18). a relatively experienced 23-year-old, described by his impressionable 18-year-old public-school educated and Family life self-described ‘unlikely’ friend, John Slee (Slee, 2002; Figure 2), as being ‘both ambitious and flexible, and unusu- In Edinburgh, Edwards not only started to map out his scien- ally confident in his own judgement’. In Edwards’ confident tific career, but importantly also met Ruth Fowler judgement, the course on offer was not ‘scientific’, and he (Figure 3), who was to become his life-long scientific was bored through 2 tedious years of agricultural descrip- collaborator and whom he was to marry in 1954, their five tions, after which he reported that his teachers were ‘glad daughters following between 1959 and 1964: Caroline, to see the back of him’ in Zoology for a year, a course much Sarah, Jenny and twins Anna and Meg. When they met, more to his style and led by the more intellectually chal- according to Edwards, in a statistics class, Ruth was study- lenging Rogers Brambell FRS (1901–1970; Oakley, 1973). ing for a genetics degree. Edwards claims that he was ini- However, that year was not enough to salvage his honours tially somewhat overwhelmed, even ‘intimidated’ by degree, and in 1951, aged 26 he gained a simple pass. Unbe- Ruth’s august family background. Her father, Sir Ralph known to him at the time, he was not alone in this undistin- Fowler FRS (1889–1944; Milne, 1945) and her maternal guished academic embarrassment, as neither ‘Tibby’ grandfather, Lord Ernest Rutherford FRS (1871–1937; Eve Marshall FRS (1878–1949; Parkes, 1950), the founder of and Chadwick, 1938), were not only both ‘titled’, but both the Reproductive Sciences, nor Sir Alan Parkes FRS also had the most impressive academic credentials imagin- (1900–1990; Polge, 2006), the first Professor of Reproduc- able: a world away from a working-class Northern family. tive Sciences at Cambridge, who was later to recruit Ralph Fowler was Plummer Professor of Mathematical Phys- Edwards there, distinguished themselves as undergraduates. ics in Cambridge from 1932 to 1944. He was evidently an In 1951, however, Edwards ‘was disconsolate. It was a disas- exceptionally talented mathematical physicist, a fine ter. My grants were spent and I was in debt. Unlike some of sportsman and ‘an inspirational teacher and leader of men’ the students I had no rich parents ... I could not write home, (Milne, 1945). Back in Cambridge in 1919 after World War I, ‘‘Dear Dad, please send me £100 as I did badly in the he was stimulated to work with Rutherford, who had exams’’’ (Edwards and Steptoe, 1980, p. 7). recently arrived there to take the chair of Experimental Physics. Rutherford was the first Nobel laureate in Ruth’s family, having been awarded the 1908 Nobel prize for Chem- istry ‘for his investigations into the disintegration of the ele- ments, and the chemistry of radioactive substances’ (Eve and Chadwick, 1938).

Figure 3 Ruth Fowler in laboratory, Edinburgh 1950s (cour- Figure 2 John Slee, 1960s (courtesy Ruth Edwards). tesy Ruth Edwards). 248 MH Johnson

Ralph Fowler not only worked under Rutherford, but in the course of doing so met his only daughter, Eileen, whom he married in 1921. They had four children, of whom Ruth was the last, born in December 1930. Tragically her mother died shortly afterwards and Ruth was to know only Mrs. Phyllida Cook as her ‘mother’, both families moving into Cromwell House in Trumpington, Cambridge and being brought up together (Milne, 1945). Her father, although himself unwell, was to undertake gruelling high security war work at the Ordnance Board and later at the Admiralty during World War II. His health deteriorated and he died at the relatively young age of 55 when Ruth was 13.

Edwards, the research scientist

The intellectual spirit of scientific enquiry that Edwards Figure 4 Julio Sirlin with Edwards, 1950s (courtesy Julio experienced in Edinburgh fitted his aptitudes well, for Sirlin). Waddington rewarded his Diploma year with a 3-year PhD place (1952–55), followed by 2 years of post-doctoral 1980, p. 27–28). Together they labelled spermatozoa research, and funded it to the princely sum of £240.00 per radioactively in vivo in order to study the kinetics of sper- year (Edwards and Steptoe, 1980, p. 20). His chosen field matogenesis and then to follow the radioactive products of research was the developmental biology of the mouse. post-fertilization, thereby to demonstrate the fate of the Edwards saw that to understand development involved male contributions to early development. They also exposed engaging in an interdisciplinary mix, not just of embryology males and/or their spermatozoa to various agents, such as and reproduction, the conventional view at the time, but chemical mutagens and UV- or X-ray irradiation, and exam- also of genetics. Given the scientific and social emphasis ined the effects on sperm-fertilizing capacity, and where it on genetics over the last 40 or so years, it is important to was shown to be present, how the treatment impacted on understand how advanced this view was in the 1950s, when development. In some cases, sperm activation of the egg genetic knowledge was still rudimentary and largely alien to was evident, but in the absence of any functional sperm the established developmental and reproductive biologists chromatin, and so gynogenetic embryos were formed. These of the day, as Edwards himself was later to recall (Edwards, experiments resulted in 14 papers, including four in Nature, 2005). For example, it was in the 1950s that DNA was estab- between 1954 and 1959 (see Gardner and Johnson, 2011, for lished as the molecular carrier of genetic information a full bibliographic record for Edwards). (Watson and Crick, 1953a,b; Franklin and Gosling, 1953; Eggs and embryos were not as abundant as spermatozoa, Wilkins et al., 1953), that it was first demonstrated that and overcoming this problem led Edwards to two discoveries each cell of the body carried a full set of DNA/genes (Gur- that proved to be of particular significance for his later IVF don, 1962a,b; Gurdon et al., 1958) and that genes were work. First, working with his wife Ruth, they devised ways of selectively expressed as mRNA to generate different cell increasing the numbers of synchronized eggs recoverable phenotypes (Weinberg, 2001). Moreover, it was only by from adult female mice through a series of papers, the first the late 1950s that cytogenetic studies led to the accepted published in 1957 (Fowler and Edwards, 1957), on the con- human karyotype as 46 chromosomes (Ford and Hamerton, trol of ovulation induced by use of exogenous hormones. 1956; Tjio and Levan, 1956), that agreement was reached In doing so, they overturned the conventional wisdom that on the Denver system of classification of human chromo- superovulation of adults was not possible. Second, working somes (Denver Conference, 1960) and that the chromosomal with an American post-doc, Alan Gates (Figure 5; Edwards aneuploidies underlying developmental anomalies such as and Gates, 1959), Edwards described the remarkable timed Down, Turner and Klinefelter Syndromes were described sequence of egg chromosomal maturation events that led up (Ford et al., 1959a,b; Jacobs and Strong, 1959; Lejeune to ovulation after injection of the ovulatory hormone, et al., 1959). human chorionic gonadotrophin. The dates of these discoveries make Edwards’ research His 6 years in Edinburgh, between 1951 and 1957, give an between 1952 and 1957 all the more remarkable. Working early taste of his prodigious energy, resulting in 38 papers under his supervisor Alan Beatty, he generated haploid, trip- (Gardner and Johnson, 2011). Indeed so productive was this loid and aneuploid mouse embryos and studied their period that the last of the Edinburgh-based papers did not potential for development. In order to undertake what appear in print until 1963. These papers firmly placed the were, in effect, early attempts at ‘genetic engineering’ in young Edwards at the forefront of studies on the genetic mammals, he needed to be able to manipulate the chromo- manipulation of development and started to attract somal composition of eggs, spermatozoa and embryos. In attention. mice, spermatozoa were abundant, and were studied in It was also in Edinburgh that Edwards’ interest in ethics experiments mostly undertaken with a visiting Argentinian was first sparked by the interdisciplinary debates among sci- post-doc, Julio Sirlin (Figure 4), whom Edwards describes entists and theologians that Waddington organized, and, as as being ‘... the first man with whom I collaborated who a result, he went on what he describes as a ‘church crawl’, was prepared to work at my pace’ (Edwards and Steptoe, trying the 10 or so variants of Christianity on offer in 1950s Robert Edwards: the path to IVF 249

Figure 5 Edwards as ‘a very recent PhD student’ (centre) and Alan Gates (extreme left) at a meeting in Trinity College, Cambridge in the late 1950s (courtesy Ruth Edwards).

Edinburgh. He did not emerge from his consumer testing maternal immune attack inside the mother’s uterus (Meda- ‘God-intoxicated’ (Edwards and Steptoe, 1980, p. 23–24), war, 1953). This confluence of reproduction and immunol- but convinced that man held his own future in his own ogy excited Edwards’ restless curiosity and hence the hands. Edwards’ humanist ethical sympathies and antipathy choice of Tyler. Significantly, the subject also offered fund- to the ‘revealed truths’ of religion were to be developed ing possibilities via the Ford and Rockefeller Foundations further in all his later encounters (Gardner and Johnson, and the Population Council, which were increasingly 2011). concerned about world population growth and the need for better methods to control fertility (Clarke, 1998, pp. 207–230; Connelly, 2008; Marks, 2001, p. 31, pp. 195–236). An American diversion Immuno-contraception then seemed to offer tantalizingly specific possibilities, alas not much closer to being realized These 1950s’ studies in science and ethics were to form the today (Naz et al., 2005). platform on which Edwards’ later IVF work was to be based, So when Edwards returned to the UK from CalTech in but before that his interests and life took a diversion to the 1958 at Alan Parkes’ invitation to join him at the Medical California Institute of Technology for the year 1957–1958. Research Council (MRC) National Institute for Medical He describes his year at Caltech as being ‘a bit of a holiday’, Research (NIMR) at Mill Hill in north London, it was to work but it was a holiday, which with hindsight had both distract- on the science of immuno-contraception (Ashwood-Smith, ing and significant consequences. He went there to work 2002). This period in the USA initiated a series of 23 papers with Albert Tyler (1906–1968; Horowitz et al., 1969), an on the immunology of reproduction between 1960 and 1976 influential elder statesman of American reproductive sci- (Gardner and Johnson, 2011). It also prompted Edwards’ ence, working on spermatozoon–egg interactions. Caltech first involvement in founding an international society in was then a hot bed of developmental biology, and Tyler 1967 in Varna Bulgaria, (Figure 6) when the International had clustered around him an exciting group of young scien- Coordinating Committee for the Immunology of Reproduc- tists, which included that year a visit by the English doyen of tion was created (Rukavina, 2008). Immuno-reproduction fertilization, Lord Victor Rothschild FRS (1910–1990; Reeve, was, in retrospect, to prove a distracting diversion from 1994). Rothschild was later to clash scientifically with what was to become Edwards’ main work, albeit one that Edwards over his IVF work (Rothschild, 1969), a clash in continued to enthuse and stimulate his imagination for which the younger man triumphed again (Edwards et al., many years. Indeed, it was his research into immuno-repro- 1969b), just as he had with Pincus. Tyler was exploring duction that led serendipitously to his first meeting with the molecular specificity of egg–spermatozoon interactions Patrick Steptoe (see later). The period at Mill Hill, between and had turned for a model to immunology. Immunology was 1958 and 1962, seems to have been a period of increasing then at an exciting phase in its development, with the intellectual conflict for him. Whilst enthusiastic about the engaging Sir Peter Medawar FRS (1915–1987, Nobel Laure- science underlying immuno-contraception, his old interests ate in Physiology or Medicine, 1960; Mitchison, 1990), influ- in eggs, fertilization and, in particular, the genetics of entially for Bob, extending his ideas on immunological development were gradually reasserting themselves. His tolerance to the paradox of the ‘fetus as an allograft’: a day job was therefore increasingly supplemented by evening semi-paternal graft nonetheless somehow protected from and weekend flirtations with egg maturation. 250 MH Johnson

Figure 6 Edwards at one of the Varna meetings on Immuno-Reproduction; Schulman is speaking and to Edwards left is Bratanov, and seated two to his right is Shanta Rao (courtesy Barbara Rankin).

The crucial egg-maturation studies as was IVF and thereby studies on the genetics of early human development. Edwards’ excitement at seeing eggs The stimulus that re-awakened Edwards’ interest in eggs spontaneously maturing was temporarily blunted by his was provided by the then recent consensus about the num- library discovery that Pincus in the 1930s (Pincus and Enz- ber of human chromosomes and, more particularly the mann, 1935; Pincus and Saunders, 1939) and MC Chang descriptions in 1959 of the pathologies in man that resulted (1908–1991; Greep, 2010; Chang, 1955) earlier in the 1950s from chromosomal anomalies. Thus, his 1962 Nature paper had been there before him, using both rabbit and, Pincus begins: ‘Many of the chromosomal anomalies in man and claimed, human eggs. animals arise through non-disjunction or lagging chromo- In order to pursue his cytogenetic studies on maturation, somes during meiosis in the oocyte. Investigation of the ori- he needed a reliable supply of human ovarian tissue from gin and primary incidence of such anomalies would be which to retrieve and mature eggs. This requirement posed greatly facilitated if meiotic stages etc., were easily avail- difficulties for a scientist with no medical qualification, able’ (Edwards, 1962). given the elitist attitudes and lack of scientific awareness The idea that these aneuploidies in humans might result then prevalent amongst most of the UK gynaecological pro- from errors in the complex chromosomal dance that he and fession (Johnson et al., 2010; MRC, 1969; RCOG, 1967). His Gates had observed in maturing mouse eggs drove his first breakthrough came with Molly Rose, who was a gynae- thinking. The possible clinical relevance of his work on cologist at the Edgeware General Hospital, northwest Lon- egg maturation and aneuploidy in the mouse was becoming don, near Mill Hill. Edwards was introduced to her through significant. John Humphrey FRS (1915–1997; Askonas, 1990), who was So Edwards resumed his experimenting with mice, trying the medically qualified Head of Immunology at Mill Hill. to mimic in vitro the in-vivo maturation of eggs, one ratio- Humphrey, notwithstanding his more privileged social back- nale being that this route would open the possibility of sim- ground, was a kindred spirit for Edwards, sharing his passion ilar studies in humans, in which not even induced ovulation for science, its social application and utility, as well as his had then been described (Gemzell, 1962). He tried releasing left-wing politics; indeed he had been a Marxist until 1940 the immature eggs from their ovarian follicles into culture and was for many years denied entry to the USA as a result. medium containing the ovulatory hormone human chorionic Edwards asked Humphrey if he knew anyone who might be gonadotrophin, to explore whether he could simulate their helpful, and he not only suggested Rose, but also offered in-vivo development. Amazingly he found it worked first to arrange an introduction. Rose was to provide biopsied time, the eggs seemed to mature at the same rate as they ovarian samples intermittently for the next 10 years. had in vivo. However, they did so whether or not the hor- Between 1960 and 1962, Edwards used human ovarian mone had been added. The eggs evidently were maturing biopsies provided by Rose to try to repeat and extend Pin- spontaneously when released from their follicles. The same cus’ observations from the 1930s. Given the sporadic supply happened in rats and hamsters. If this also were to happen of human material, he also tried dog, monkey and baboon in humans, then the study of the chromosomal dance during ovarian eggs, but in all cases with limited success compared human egg maturation was a realistic practical possibility, with smaller rodents. In the 1962 Nature paper (Edwards, Robert Edwards: the path to IVF 251

1962), he cautiously interprets the few maturing human for different types of cells were not available then, nor (3/67), monkey (10/56) and baboon (13/90) eggs that he were appropriate techniques with which to critically test had observed as most likely arising from in-vivo stimulation the developmental potential of the cultured cells. and thus partially matured at the time of their recovery from the biopsy. He suggests that Pincus’ observations on The move to Cambridge human eggs are also likely to be artefactual, the source of his Venice spat with Pincus some 4 years later (vide supra). Edwards arrived in Cambridge from Glasgow in 1963 as a This 1962 paper ends with the report of an ingenious exper- Ford Foundation Research Fellow. He had previously visited imental approach to try and persuade the reluctant human Cambridge at least once, as ‘a recently graduated PhD’ in eggs to mature. Thus, the ovarian arteries of patients the late 1950s for a conference on Reproduction held in undergoing ovarian removal were cannulated and perfused Trinity College (Figure 5), where he recalls meeting some with hormones post-removal, perhaps unsurprisingly in ret- of the big names in the subject, including John Hammond, rospect, without success. Alan Parkes, MC Chang, Thaddeus Mann, Rene Moricard, However, by this time, his quest for human eggs, and his Bunny Austin and Charles Thibault (Edwards, 2005). dreams of IVF and studying the genetics and development of Although Edwards was to remain in Cambridge for the rest early human embryos, had reached the ears of the then of his career, in 1963 his reactions to the place were mixed. Director of the Institute, Sir Charles Harington FRS He describes how he immediately reacted against the then (1897–1972; Himsworth and Pitt-Rivers, 1972), who banned extant ‘misogynist public-school traditions; the exclusivity’, any work on human IVF at NIMR (Edwards and Steptoe, 1980, ‘the privileges given to the already privileged’. But he set p. 48). Alan Parkes was no longer able to defend Edwards, against that the ‘sheer beauty of the place’, the concern having left in 1961 to take up his chair in Cambridge and, with the truth and high seriousness’, the ambience of scien- although he had asked Edwards to join him there, funding tific excellence ... I was surrounded by so many talented was not available until 1963. So by the time Edwards left young men and women’ (Edwards and Steptoe, 1980, p. 51). Mill Hill in 1962 for a year in Glasgow, he had encountered He, Ruth and his five daughters settled into a house in Gough a taste of the opposition to come. Way, off the Barton Road. Edwards worked in a cluster of seven smallish rooms at the top of the Physiological Laboratory backing onto Down- Glasgow and stem cells ing Place (Figure 7). These were known collectively as the ‘Marshall laboratory’ and were to be shared eventually with Edwards had accepted an invitation from John Paul to spend two other groups. One group was led initially by Sir Alan Par- a year in the Biochemistry Department at Glasgow Univer- kes, the first Mary Marshall and Arthur Walton Professor of sity. Paul was then the acknowledged master of tissue cul- Reproductive Physiology at the University (Polge, 2006), ture in the UK and had got wind of some experiments that who had arrived in 1961. His group included scientists with Edwards had been doing on the side at NIMR attempting to mainly zoological or comparative interests, such as his wife generate stem cells from rabbit embryo cultures (Edwards, Ruth Deansley, Bunny Austin and Dick Laws FRS, who with 2005). The objective of this strategy was to use these stem Parkes was often away ‘in the field’ collecting material, cells to study early developmental mechanisms, either especially in Uganda at the Nuffield Unit of Tropical Animal in vitro,orin vivo after their incorporation into embryos. Ecology (Polge, 2006). Much of this material was examined Paul had proposed that they work together, with fellow histologically under the skilled eye of Frank Lemon, senior Glasgow biochemist Robin Cole, to see what progress might technician. Research students included Martin Richards, CJ be made. This must have been an attractive invitation, not Dominic, Margaret Mitchell and Barbara Weir (Parkes, 1985, simply because the challenge was scientifically interesting, pp. 77–83). Parkes was also much involved at this time in but also because Edwards could learn more about culture writing and committee work, especially with the World media for his eggs and hopefully later embryos, then an uncertain prospect, successful mouse embryo culture only recently having been described (McLaren and Biggers, 1958). However, by this time, the Edwards family was grow- ing, so Ruth remained in north London with their young daughters, while her husband commuted to Glasgow for the working week. The collaboration was to result in two papers (Cole et al., 1965, 1966) remarkable for their prescience. They describe the production of embryonic stem cells from both rabbit blastocysts and the inner cell masses dissected from them. The cells were capable of proliferating through over 100 generations and of differentiating into various cell types. These experiments were initiated some 20 years before Evans and Kaufman (1981) described the derivation of embryonic stem cells from mice. That this work has largely been ignored by those in the stem cell field is prob- ably mainly attributable to its being too far ahead of its Figure 7 Edwards in his office backing onto Downing Place in time (Edwards, 2001). Thus, reliable molecular markers the Marshall laboratory (1970s) (courtesy Barbara Rankin). 252 MH Johnson

Health Organization which was then becoming concerned about world population growth and ways to curb it (Polge, 2006). Parkes was also acting as unpaid company secretary to the then fledgling Journal of Reproduction and Fertility (called Reproduction since 2001; Parkes, 1985, pp. 332–334; Cook, 1994; Clarke, 2007). In 1967, Parkes retired. Edwards applied for his chair on 6 January 1966 (Edwards, 1966), but was unsuccessful, the chair passing to Thaddeus Mann FRS (1908–1993; Polge, 1993), who worked on the biochemistry of semen. Mann decided not to relocate to the Physiology Laboratory from his Cambridge base at the Agricultural Research Council Unit of Reproductive Physiology and Biochemistry at Hun- tingdon Road, where he was Director. Neither was the lead- ership of the Marshall laboratory to pass to Edwards, as the Figure 9 Barbara Rankin holding a cartoon of Edwards, University appointed as its head his more senior colleague Steptoe and Purdy holding Lousie Brown, drawn by Alan and friend Colin ‘Bunny’ Austin (1914–2004; Short, 2004), Handyside, who also took the photograph. With Austin (left), who had been in Cambridge intermittently since 1962 (Fig- Edwards and Purdy (right), after the return of the latter two ures 8 and 9). Austin was elected the first Charles Darwin from Oldham and the birth of Louise Brown in 1978 (courtesy Professor of Animal Embryology (1967–1981) and began Barbara Rankin). attracting several upcoming reproductive biologists to the Marshall Laboratory, including John Marston, David Whit- tingham and Matthew Kaufmann. In addition, a new group was formed in 1967, with the arrival from the Strangeways laboratory of Denis New (1929–2010), as University lecturer in Histology (Arechaga, 1997). New built a group comprising initially research assistant Pat Coppola (to be followed later by Stephanie Ellington) and PhD students Chris Steele and David Cockroft, later joined by post-doc Frank Webb, and visiting scientists such as Joe Daniels Jr, on leave from the University of Colorado. It was against this varied scientfic background that Edwards, who was already 38 when he arrived in Cambridge, began for the first time to assemble his own group. Initially, his technical assistance was provided by Clare Jackson and then Valerie Hunn, after whom he recruited Jean Purdy (Figure 10) in 1968, one of her attractions being her nursing qualification, a sign of the increasing importance that his forays into use of clinical material was assuming. Purdy was to stay with him until her early death aged 39 in 1985

Figure 10 Jean Purdy (1946–1985) (courtesy Barbara Rankin).

(Edwards and Steptoe, 1985). Also joining him as part-time secretary in 1969, Barbara Rankin (b. 1933; Figure 9), was to remain with him until 1987. He also began recruiting his first graduate students. Initially, he helped co-supervise (with Alan Parkes) Anne Vickers (1967), who sexed fixed whole-mouse blastocysts by karyotyping. This work led directly to his collaboration on preimplantation genetic diagnosis (PGD) (see later) with Richard Gardner, one half of his first pair of graduate students, the other being this author. The two students started PhD training with Edwards in 1966 (Gardner, 2011; Gardner and Johnson, 1991, 2011). Figure 8 Edwards with ‘Bunny’ Austin (1960s) (courtesy Ruth Gardner studied early mouse embryology from 1966 to 1971, Edwards). and until 1973 as a post-doctoral worker, before moving to Robert Edwards: the path to IVF 253

Table 1 Key points in the programme of research laid out in the Discussion to Edwards’ 1965 Lancet paper.

a 1 Studies on non-disjunction of meiotic chromosomes as a cause of aneuploidy in humans 2 Studies on the effect of maternal age on non-disjunction in relation to the origins of trisomy 21a 3 Use of human eggs in IVF to study fertilization 4 Study of culture methods for human eggs fertilized in vitro 5 Use of priming hormones to increase the number of eggs per woman available for study/use 6 Study of early IVF embryos for evidence of (ab)normality – especially aneuploidies arising prior to or at fertilizationa 7 Control of some of the genetic diseases in mana 8 Control of sex-linked disorders by sex detection at blastocyst stage and transfer of only female embryosa 9 Intra-cervical transfer of IVF embryos into the uterus 10 Use of IVF embryos to circumvent blocked tubesb 11 Avoidance of a multiple pregnancy (as observed after hormonal priming and in vivo insemination) by transfer of a single IVF embryo aFive aims relating specifically to genetic disease. bOne aim relating specifically to infertility relief.

Zoology in Oxford. This author worked on immuno-repro- duction from 1966 to 1969, returning as a post-doc between 1971 and 1974 after 2 years in the USA before moving to the Anatomy Department in Cambridge. From 1969 onwards, Edwards’ group increased in size substantially as more accommodation was made available to the Marshall laboratory. David Griffin (now retired from the World Health Organization) was to join as Head Techni- cian between 1970 and 1975, with junior technicians includ- ing Sheila Barton, Sally Fawcitt, Sylvia Jackson, Vinitha Dharawardena and Brenda Dickstein, in addition to Jean Purdy. Early graduate students recruited included Roger Gosden (1970–1974), Carol Readhead (1972–1976) and Rob Gore-Langton (1973–1978), all working on follicle growth, Craig Howe (1971–1974) working on immuno-repro- Figure 11 Edwards talks about his ‘production line’ hypoth- duction and Azim Surani (1975–1979) working on implanta- esis (late 1960s) (courtesy Ruth Edwards). tion. A ‘third generation’ of graduate students also arrived, for example, Janet Rossant (from 1972) studied with Gard- by Pincus. These cytogenetic studies were reported in two ner and Alan Handyside (from 1974) studied with Johnson. seminal papers in 1965 (Edwards, 1965a,b), both of which Post-doctoral workers also arrived, including Ginny Papa- are primarily concerned with understanding the kinetics of ioannou (1971–1974), Hester Pratt (1972–1974) and Frank the meiotic chromosomal events during egg maturation. In Webb (1976–1977). Ruth Fowler-Edwards also resumed its discussion, the Lancet paper displays a breathtaking clar- working in the laboratory, developing hormonal assays and ity of vision as Edwards sets out a programme of research studying the endocrine aspects of follicle development that predicted the events of the next 20 years and beyond and early pregnancy. Thus, slowly until 1969, and more rap- (Table 1). Significantly, if not surprisingly given his research idly thereafter, Edwards built a lively group, its members interests, the early study and detection of genetic disease is working in diverse areas of reproductive science that afforded a heavy focus compared with the slight emphasis reflected his own broad interests and knowledge. Moreover, on infertility alleviation. Edwards encouraged a spirit of open communication and This genetic focus continues in his research papers over egalitarianism, which extended across all three groups, with the next 4 years. Thus, within 3 years, working with gradu- sharing of resources, space, equipment, knowledge and ate student Gardner, he provided proof of principle for PGD, ideas, as well as social activities. in a paper on rabbit embryo sexing published in 1968 Through the 1960s, Edwards was funded by the Ford (Gardner and Edwards, 1968), a paper that was to anticipate Foundation via grants first to Parkes and then to Austin to the development of PGD clinically by some 22 years continue work on basic reproductive mechanisms, with an (Theodosiou and Johnson, 2011). Likewise, working with eye to developing new methods of fertility control. So he Cambridge geneticist Alan Henderson, Edwards was to continued to pursue both the immunology of reproduction develop his ‘production line theory’ of egg production to and egg maturation, for the latter collecting pig, cow, explain the origins of maternal aneuploidy in older women. sheep, the odd monkey and some human eggs. He showed Thus, the earliest eggs to enter meiosis in the fetal ovary that eggs of all these species would indeed mature were shown to have more chiasmata and to be ovulated ear- in vitro, but that the eggs of larger animals simply needed lier in adult life than the those entering meiosis later in longer than those of smaller ones, human eggs taking up fetal life (Figure 11; Edwards, 1970; Henderson and to 36 h rather than the 12 h or less erroneously reported Edwards, 1968). 254 MH Johnson

The problem of fertilization of the human egg

Notwithstanding his broad range of scientific interests, Edwards’ ambitions to achieve IVF in humans remained undiminished. In 1966, this was no trivial task, having been accomplished convincingly only in rabbit and hamster (Chang, 1959; Yanagimachi and Chang, 1963). In trying to achieve this aim, he was engaging in two struggles: the first being simply but critically the continuing practical difficulty in obtaining a regular supply of human ovarian tissue. Local Cambridge sources proved unreliable and Rose was now 2–3 h drive away in London, so during the summer of 1965, Edwards turned to the USA for help and approached Victor McKusick, a leading American cytogeneticist at The Johns Hopkins University. There he initiated his longstanding con- Figure 12 Patrick Steptoe (1913–1988) (courtesy Andrew tact with Howard and Georgeanna Jones in Obstetrics and Steptoe). Gynecology (Jones, 2002). The supply of American eggs they generated during his 6-week stay allowed him to confirm the deaf ears of the conservative gynaecological hierarchy, and maturation timings that were published in 1965. indeed incited considerable opposition and some outright However, it was the second scientific struggle that was hostility (Philipp, 1988; Edwards, 1996). Edwards’ claims then occupying most of his attention, namely that in order that he was scanning the medical and scientific journals in to fertilize these in-vitro matured eggs, he had to ‘capaci- the library and came across a paper by Steptoe describing tate’ the spermatozoa, a final maturation process which his experiences with laparoscopy (Edwards and Steptoe, spermatozoa undergo physiologically in the uterus and that 1980, p. 59; Edwards, 1989, 1996). Edwards goes on to is essential for the acquisition of fertilizing competence. describe how he rang Steptoe to discuss a possible Failing to achieve this convincingly at Johns Hopkins, he collaboration, but was ‘warned off’ Steptoe by London made a second transatlantic summer journey in 1966 to visit gynaecological colleagues (Edwards, 1978). This warning, Luther Talbot and his colleagues at Chapel Hill. He tried a and the daunting prospect of a collaboration in far-away variety of ways (Edwards et al., 1966) to overcome the Oldham, deterred him from following through. Edwards problem of ‘sperm capacitation’, one of the most ingenious reports finally actually meeting Steptoe later at a meeting of which was to construct a 2.5-cm-long chamber from a at the Royal Society of Medicine, at which, ironically, nylon tube, plugged at each end, and with holes drilled in Edwards was talking about his work on immuno-reproduc- the walls which were encased in panels made of Millipore tion, not his attempts at IVF. membrane (Edwards et al., 1968). The chamber, which The Steptoe paper that Edwards found that day in the had a short thread attached to it, fitted snugly inside an library was cited in his tributes to the then deceased Step- intrauterine device’s inserter tube and so could be placed toe (Edwards, 1989, 1996) as being a Lancet paper entitled into the volunteer woman’s uterus intra-cervically at ‘Laparoscopy and ovulation’ (Steptoe, 1968). However, mid-cycle, where it sat for up to 11 h before being recov- these later recollections do not withstand scrutiny. Thus, ered by gently pulling on the thread, exactly as was being the Lancet paper cited was published in October 1968, but done routinely for insertion and removal of intrauterine their first meeting was in fact earlier that year, on Wednes- devices. By placing spermatozoa within the chamber, the day 28 February 1968 at a joint meeting of the Section of membrane of which permitted equilibration of its contents Endocrinology of the Royal Society of Medicine with the with uterine fluid, he hoped to expose them to a capacitat- Society for the Study of Fertility held at 1 Wimpole Street ing environment. However, this ingenious approach, like the (Table 2; Hunting, 2002, pp. 252–253). Moreover, accord- many others, failed, in this case most probably because the ing to Steptoe (1969), they had already commenced collab- chamber itself induced an inflammatory response or a local orating prior to October 1968; indeed their first paper bleed. For all the ingenuity of his various experimental together was submitted for publication later that year in approaches to achieve capacitation, and despite the occa- December 1968 (see next section). Clearly, the paper read sional evidence of early stages of fertilization using such by Edwards must have been another, earlier than October spermatozoa, no reliable evidence for the completion of 1968, one that proceeded February 1968 by several months. the process was forthcoming. Then in 1968 both struggles Indeed, in an earlier account, Edwards describes the library began to resolve. ‘Eureka’ moment as occurring in ‘one autumn day in 1967’ (Edwards and Steptoe, 1980, p. 59). So which was the paper The meeting with Patrick Steptoe by Steptoe that Edwards saw and what about it attracted his attention? Looking at Steptoe’s possible publications in Patrick Steptoe (1913–1988; Figure 12) had been Consul- journals, there is none listed for 1967, but there are two tant Obstetrician at Oldham General Hospital since 1951 1967 conference reports and Steptoe’s book on gynaecolog- (Edwards, 1996), where for several years he had been pio- ical laparoscopy (Steptoe, 1967a–c). Of the few journal neering the development and use of the laparoscope in papers, only two concern laparoscopy, one from January gynaecological surgery (Edwards, 1996; Steptoe, 1967a). 1966 in the British Medical Journal (BMJ), and one from Much to his frustration, his progress had fallen on the largely August 1965 in the Journal of Obstetrics and Gynaecology Robert Edwards: the path to IVF 255

Table 2 Edited record from the RSM Endocrinology Section: General Minutes, 1946–1975 (ref: RSM/J/19/4/1) p.365 (with permission).

A joint meeting of the SECTION OF ENDOCRINOLOGY of the Royal Society of Medicine with the SOCIETY FOR THE STUDY OF FERTILITY was held at 1 Wimpole Street, W.1., Wednesday, 28 February 1968, at 10.00 am. The meeting was attended by approximately 127 Fellows, members and guests and the programme was as follows: ‘FERTILITY AND INFERTILITY’ 10.00: Chairman’s opening remarks 10.10: Sperm capacitation. C.R. Austin, Department of Embryology, Cambridge 10.35: Immunological aspects of infertility. R.G. Edwards, Department of Physiology, Cambridge 11.00: Coffee 11.30: The rating of semen quality by chemical methods. Dr. T. Mann, Department of Physiology of Reproduction, Cambridge 11.55: Endocrine studies in women with secondary amenorrhoea. Prof. Ivor H. Mills and R.J. Wilson, Department of Investigative Medicine, Cambridge 12.20: Some investigation in male hypogonadism. Prof. F.T.G. Prunty, Department of Chemical Pathology, St Thomas’s Hospital Medical School, London 12.45: Lunch 2.15: A gonadotrophin stimulation test for ovarian responsiveness. G.I.M. Sawyer, University College Hospital Medical School, London 2.40: Factors affecting the response to clomiphene therapy. D. Ferriman, A.W. Purdie and M. Corns, North Middlesex Hospital, London 3.05: Comparison of clomiphene and F.S.H. for treatment of anovulation. A.D. Tsapoulis and A.C. Crooke, Department of Clinical Endocrinology, Birmingham 3.30: TEA 4.00: Time cause of urinary oestrogen exoetion after various schemes of Pergonal therapy. J.K. Butler, G.D. Searle and Co., High Wycombe, Bucks 4.25: Recent developments in the control of fertility. Sir Alan S. Parkes, Cambridge 4.50: General discussion [signed] C.L. Cope 26/6/1968 [pasted in] 26th June 1968

Table 3 Steptoe’s papers from 1967 and earlier.

Publication Title Type of publication Location in Cambridge; date of arrival

Steptoe Laparoscopy in Gynaecology Book University library; March 1967 (1967a) Steptoe A new method of tubal sterilisation Conference proceedings Physiology library; Arrival date (1967b) (Stockholm) unknown, published in November 1967 Steptoe Laparoscopic studies of ovulation, its Conference proceedings University library; May 1968 (1967c) suppression and induction, and of (Sydney) ovarian dysfunction Steptoe The fifth freedom BMJ letter (22 January), Physiology library; January 1966 (1966) 234 Steptoe Gynaecological endoscopy – laparoscopy Paper in J Obstet University library; August 1965 (1965) and culdoscopy Gynaecol Br Commonw (moved to Clinical School library 72, 535–543 after 1973)

of the British Commonwealth (JOGBrC). Which of these five confirm that tubes were indeed blocked. The JOGBrC paper publications (Table 3) did Edwards read? (Steptoe, 1965) is titled ‘Gynaecological endoscopy – lapa- The 1966 BMJ publication (Steptoe, 1966) is a letter roscopy and culdoscopy’, and reviews the history of endos- headed ‘The fifth freedom’. It responds to a paper by Sir Dug- copy and Steptoe’s experiences with it. It is in essence a ald Baird on the ‘problem of excessive fertility in women’. very abbreviated version of his book (Steptoe, 1967a), which Steptoe concurs that there is a problem, but disagrees with was to be published in the following year. The two reports of the proposed contraceptive solution, advising laparosopic the conference proceedings (Steptoe, 1967b,c) are slightly sterilization for women as safer and more effective. He also more detailed accounts than the BMJ letter and are much discusses how laparoscopy can be used post-operatively to abbreviated versions of the JOGBrC paper. 256 MH Johnson

Of these five publications, the Sydney conference pro- on page 70, he writes ‘An extended post-coital test can be ceedings (Steptoe, 1967c) can probably be dismissed as they done by aspirating fluid from the tubal ostium ...’. More- only arrived in a Cambridge library in May 1968. The pro- over, Steptoe’s book arrived in the University library in ceedings from Stockholm (Steptoe, 1967b) are now no March 1967. However, against this conclusion sits Steptoe’s longer available in Cambridge, but evidence of their pres- recollection that Edwards had rung him just before his book ence in the Physiology library in 1967 has been uncovered was published, that is before March 1967 (Edwards and Step- in an old catalogue record, and so they would have been toe, 1980, pp. 75–76). This memory conflicts with both his newly available to Edwards from November 1967 at the ear- and Edwards’ memories elsewhere of the phone conversa- liest. The BMJ letter (Steptoe, 1966) seems unlikely. tion being in the autumn of 1967, so the matter remains Although Edwards was involved in contraceptive studies one for conjecture, but the book seems the most likely over this period through his work on immuno-reproduction source. It is possible that Edwards’ attention was drawn to and was a member of the Royal Society Population Study the book by a review of it in the BMJ on 11 November 1967 Group at the time (Polge, 2006, p. 280), and so may well (Morrison, 1967). have read this correspondence, it seems unlikely that the BMJ letter would have caught his eye to such dramatic effect and so long after its publication in January 1966, The fertilization of the human egg resolved being readily available each week in the Physiology Library. The JOGBrC paper from 1965 was located in the University Despite the initiation of the collaboration with Steptoe, the library, which was physically more remote from Physiology actual solution to the capacitation problem lay nearer to and not so immediately available to Edwards. However, it home than Oldham: in the laboratories shared with Austin. was in exactly the sort of clinical journal that he might then In the early 1950s, Austin, and independently MC Chang, have been trawling retrospectively in his attempts to solve had discovered the requirement for sperm capacitation (Aus- the problem of sperm capacitation. Thus, whereas in the tin, 1951; Chang, 1951). After his appointment to the Cam- more recent accounts of these events, Edwards (1989, 1996) bridge chair, Austin’s first graduate student (1967–1972) records his motivation for contacting Steptoe as being the was Barry Bavister, who set to work to try and resolve the fac- potential value of the laparoscopic approach for egg collec- tors influencing the capacitation of hamster spermatozoa tion, in 1967 eggs were not foremost on his mind. Indeed in in vitro. In 1968, Bavister discovered a key role for pH, show- two earlier accounts, one written (Edwards and Steptoe, ing how higher rates of fertilization could be obtained by sim- 1980, p. 59) and one spoken (Edwards, 1978; Supplementary ply increasing the alkalinity of the medium (Bavister, 1969). video), Edwards claims he saw laparoscopy as a way of Edwards seized on this observation and co-opted Bavister to recovering capacitated spermatozoa from the oviduct by his project. That proved to do the trick, and in December flushing with a small volume of medium: ‘a practical way 1968 Edwards, together with Bavister and Steptoe, submitted ... of letting spermatozoa be in contact with the secretions the paper to Nature, in which IVF in humans is described con- of the female tract’ (Edwards and Steptoe, 1980, p. 59). He vincingly for the first time (Edwards et al., 1969a). says he actually rang Steptoe to ask whether this really was The 1969 Nature paper makes modest claims. Only 18 of possible and was reassured by him that this was the case. 56 eggs assigned to the experimental group showed evi- However, the only publication by Steptoe that explicitly lays dence of ‘fertilization in progress’, only two of which are out this possibility is his book (Steptoe, 1967a). Thus, on described as having the two pronuclei to be expected if fer- page 27 he reports ‘By means of laparoscopy, Sjovall (1964) tilization was occurring normally (Table 4). However, like has carried out extended post-coital tests and has recovered Edwards’ other papers, this one is a model of clarity, spermatozoa from the fimbriated end of the tubes ...’; and describing well-controlled experiments, cautiously inter- preted. Despite the relatively small numbers, this paper Table 4 Summary of data from Edwards et al. (1969a). convinced where previous claims had failed (Hayashi, 1963; Petrov, 1958; Petrucci, 1961; Rock and Menkin, 1944; Shet- Egg characteristic Experimental Control tles, 1955, pp. 505–510; Yang, 1963), precisely because the group group skilled hands and creative intellect that lay behind it are so evident from its text. Assigned 56 17 The provenance of the eggs described in the 1969 paper Surviving 54/56 17/17 is not immediately clear from the paper itself. All were Matured to metaphase II 34/54 7/17 obtained by in-vitro maturation after ovarian biopsy. In Some evidence of sperm 18/34 – addition to Steptoe’s co-authorship, four other gynaecolo- penetration gists are thanked in the Acknowledgements section of the Spermatozoon within the 6/18 – paper: Molly Rose, Norman Morris (1920–2008; Professor zona pellucida of Obstetrics and Gynaecology at Charing Cross Hospital, Spermatozoon inside zona 5/18 – London from 1958 to 1985; Anon, 2008), Janet Bottomley pellucida (c.7 h post- (1915–1995; Consultant Obstetrician and Gynaecologist at insemination) Addenbrooke’s Hospital, Cambridge from 1958 to 1976) Evidence of pronuclei 7/18 0/7 and Sanford Markham (b. 1934; Chief of the Section of (c.11 h post- Obstetrics and Gynaecology at the US Air Force Hospital, insemination) South Ruislip, to the north west of London from 1967 to No. with two pronuclei 2/18 – 1972). Markham, now Professor of Obstetrics and Gynecol- ogy at Florida International University, Miami, writes: Robert Edwards: the path to IVF 257

‘‘I believe that I met Bob by introduction from Dr. Roger ‘‘Cyril Adderley, not Abberley, was the Group Pathologist Short at a Royal College of Medicine conference in Lon- in Oldham. Geoff Garrett ... was also a pathologist there don ... probably in early 1968 [possibly the Royal Society ... there was no L. Davies there but a John Davies, a hae- of Medicine’s 28 February meeting at which Steptoe and matologist, and a Vincent John Davies, a histologist ... Edwards first met?]. Bob mentioned that he was in need and my money would go on V. J. as I think a histologist of ovarian tissue from reproductive aged women ... I rather than a haematologist would have been of more offered to obtain tissue if we could work out a scheme help to him ...?’’ to transport the tissue ... to Cambridge ... He provided The first two of these have elsewhere been described as the media and container and a driver that came to our helpful in setting up the embryology laboratory in Oldham, hospital ... I remember three samples, however, there largely through the provision or loan of equipment required may have been others. In each case the whole wedge locally for egg maturation and fertilization, so their involve- ... or ... ovary was sent (after sampling for pathology). ment in direct provision of eggs seems unlikely. In all cases the patients provided their consent for utili- The Nature paper also supports Oldham as the source of zation of their tissue for research. They were not told the remaining eggs: ‘Some eggs were transported from Old- what the research work involved. These samples were ham to Cambridge’ (Edwards et al., 1969a), and in his retro- most likely sent in mid to late 1968 and possibly in early spective 1980 account of the events, Edwards says that at 1969 ... These ... were planned surgeries which were Oldham they began to repeat the experiment: accomplished at specific times in their menstrual cycle. Unfortunately, I do not know if the tissues supplied were ‘‘Twelve women whose ovaries had to be removed [pre- indeed the tissues used in data for his 1969 paper pub- sumably laparoscopically] for serious medical conditions lished in Nature.’’ provided us with the necessary eggs over the next few months. We fertilized many more eggs and were able It is possible that they were used, but unsuccessfully, not to make detailed examinations of the successive stages contributing to the 18 eggs showing fertilization. Thus, of fertilization (Edwards and Steptoe, 1980, pp. according to Edwards (Edwards and Steptoe, 1980, pp. 82–83).’’ 81–82), Jean Purdy drove to Edgeware General Hospital to collect: So it seems reasonable to conclude that those eggs described in the paper as ‘undergoing fertilization’ were ‘‘the last piece of ovarian tissue that I was to obtain from provided in roughly equal numbers by Rose and Steptoe. the Edgware General Hospital. It yielded me 12 human However, with Steptoe on board, Rose no longer fea- eggs. Those eggs were soon ripening in mixtures of cul- tured as a supplier of eggs (Edwards and Steptoe, 1980,p. ture medium I had used over many years to which some 81). Whilst the initial attraction of laparoscopy for Edwards of Barry [Bavister]’s fluid had been added. Thirty-six had been the recovery of capacitated spermatozoa from the hours later we judged that they were ready for oviduct, once working with Steptoe he rapidly saw the wider fertilization.’’ possibilities for recovery of in-vivo matured eggs from the Nine of these were inseminated, leaving three as controls. ovary (Steptoe, 1968). Indeed, the 1969 paper includes Ten hours later, when Edwards and Bavister returned to the following statement: the laboratory late at night: ‘‘Problems of embryonic development are likely to ‘‘A spermatozoon was just passing into the first egg ... An accompany the use of human oocytes matured and fertil- hour later we looked at the second egg. Yes, there it ized in vitro. When oocytes of the rabbit and other spe- was, the earliest stages of fertilization. A spermatozoon cies were matured in vitro and fertilized in vivo, the had entered the egg without any doubt – we had done it pronuclear stages appeared normal but many of the ... We examined other eggs and found more and more resulting embryos had sub-nuclei in their blastomeres, evidence. Some ova were in the early stages of fertiliza- and almost all of them died during the early cleavage tion with the sperm tails following the sperm heads into stages ... When maturation of rabbit oocytes was started the depths of the egg; others were even more advanced in vivo by injecting gonadotrophins into the mother, and with two nuclei – one from the sperm and one from the completed in the oviduct or in vitro, full term rabbit egg – as each gamete donated its genetic component to fetuses were obtained (Edwards et al., 1969a, pp. the embryo.’’ 634–635).’’ This (unverified) account suggests that Rose provided the The paper goes onto discuss how use of hormonal priming first group of eggs to be fertilized in ‘Bavister’s medium’. to stimulate intra-follicular egg maturation might be Moreover, since only 18 of the eggs in the paper showed evi- achieved and reports: ‘Preliminary work using laparoscopy dence of fertilization (Table 4), nine of those seem to have has shown that oocytes can be recovered from ovaries by come from Rose, including presumptively the two described puncturing ripening follicles in vivo ...’. as having two pronuclei. Rose was invited to be a co-author, Through these preliminary collaborative studies, Edwards but declined for reasons unknown. The source of the and Steptoe were already building a research partnership. remaining nine eggs is unknown, but may have come from Although both were very different personalities, and brought Oldham General Hospital. The Acknowledgements thank very different skills to the project, they shared energy, com- ‘for their help’ Drs. C Abberley, G Garrett and L Davies, mitment and vision. Each was also marginalized by his profes- all of Oldham General. John Webster, a later gynaecological sional peers, a marginalization that also perhaps helped to colleague of Steptoe, having consulted his colleague John cement their partnership (Johnson et al., 2010). Battie, writes of these: 258 MH Johnson

With the paper’s publication, announced to the media on Obstetricians and Gynaecologists and the MRC during the St Valentine’s day (Anon, 1969), all hell was let loose. The 1960s examining the areas of gynaecological ignorance that impossible tangle of TV cables and pushy reporters trying needed academic attention, infertility simply did not fea- to force their way up the stairs to the fourth floor laborato- ture (MRC, 1969; RCOG, 1967). Overpopulation and family ries proved a major disruption to the Physiological labora- planning were seen as dominant concerns and the infertile tory in general and to the members of the Marshall were ignored as, at best, a tiny and irrelevant minority laboratory in particular. It was something that was to recur and at worst as a positive contribution to population con- episodically over the next 10 years. trol. This was a values system that Edwards did not accept (Edwards and Sharpe, 1971, p.87), and the many encourag- ing letters he received from infertile couples spurred him on The battles begin and provided a major stimulus to his continued work later, despite so much professional and press antagonism. For But 1969 seemed to be a good year for Edwards. Not only did his professional colleagues, however, the fact that infertil- IVF succeed at long last, and his partnership with Steptoe ity was not seen as a significant clinical issue meant that any seemed set to flourish, but also so impressed were the Ford research designed to alleviate it was viewed not as experi- Foundation with his work that in late 1968 they had estab- mental treatment, but as using humans in experiments. lished, at Austin’s prompting (Holmes, 1968), an endow- Given the sensitivity to the relatively recent Nazi ‘medical ment fund with the University of Cambridge to cover the experiments’, the formal acceptance of the Helsinki Decla- salary cost of a Ford Foundation Readership (a half-way step ration (1964; Hazelgrove, 2002) and the public reaction and to a professorship; Hankinson, 1968). Elated by his promo- disquiet surrounding the recent publication of Human tion and their achievement, Edwards and Steptoe pressed Guinea-pigs (Pappworth, 1967), this distinction was critical. on, the latter’s laparoscopic skills coming to the fore, first The MRC, in rejecting the grant application, took the in 1970 with the collection of in-vivo matured eggs from fol- position that what was being proposed was human experi- licles after mild hormonal stimulation (Steptoe and mentation, and so were very cautious, emphasizing risks Edwards, 1970), and then achieving regular fertilization of rather than benefits, of which they saw few if any (Johnson these eggs and their early development through cleavage et al., 2010). to the blastocyst stage (Edwards et al., 1970; Steptoe Edwards and Steptoe were also attacked for their willing- et al., 1971). So well was the work going that in late 1970 ness to talk with the media. It is difficult nowadays, when and early 1971 they confidently applied to the UK Medical the public communication of science is embedded institu- Research Council for funding. tionally, to understand how damaging to them this was. However, any illusions that Edwards may have had that The massive press interest of the late 1960s was unabated their achievements would prove a turning point in his for- in the ensuing years, and so Edwards was faced with a tunes were soon shattered. The hostility of much of the choice: either he could keep his head down and allow press media coverage to his work in 1969 heralded the dominant fantasies and speculations to go unanswered and unchal- pattern of scientific and medical responses for the next lenged, or he could engage, educate and debate. For him 10–15 years and resulted just 2 months later in the MRC this was no choice, regardless of the consequences profes- rejecting the grant application (Johnson et al., 2010). The sionally (Gardner and Johnson, 2011). His egalitarian spirit practical consequences of this rejection were profound – demanded that he trust common people’s common sense. both psychologically and physically – not least that for His radical political views demanded that he fought the cor- the next 7 years, Edwards and Purdy shuttled on the ner of the infertile: the underdog with no voice. The York- 12-h-round trip between Cambridge and Oldham, Greater shireman in him relished engagement in the debate and Manchester, paradoxically just north of his schoolboy haunts argument. In Edwards and Sharpe (1971), he sets out his rea- of Gorton, where Steptoe and he set up a small laboratory sons for public engagement and acknowledges the risk to his and clinic in Dr. Kershaw’s cottage hospital, all the while own interests: leaving Ruth and his five daughters in Cambridge. The professional attacks on Edwards and his work took a ‘‘Scientists may have to make disclosures of their work number of forms (Johnson et al., 2010), and one must try to and its consequences that run against their immediate make a mental time trip back to the 1960s and 1970s to interests; they may have to stir up public opinion, even understand their basis. Despite the nature of the political lobby for laws before legislatures.’’ and religious battles to come, his scientific and medical col- And risk it was. One of the scientific referees on their leagues did not focus on the special status of the human MRC grant application started his referee’s report declaring embryo as an ethical issue. Ethical issues were raised pro- the media exposure distasteful: fessionally, but took quite a different form. It is perhaps dif- ficult now to comprehend the complete absence of ‘‘Dr. Edwards feels the need to publicise his work on infertility from the consciousness of most gynaecologists radio and television, and in the press, so that he can in the UK at the time, of whom Steptoe was a remarkable change public attitudes. I do not feel that an ill-informed exception (Edwards, 1996, p. 436; Edwards and Steptoe, general public is capable of evaluating the work and 1980, pp. 11–15). Indeed, even Edwards’ strong commit- seeing it in its proper perspective. This publicity has ment to treating infertility came to the fore only after he antagonised a large number of Dr. Edwards’ scientific had teamed up with Steptoe, his previous priority being colleagues, of whom I am one (Johnson et al., 2010).’’ the study and prevention of genetic and chromosomal disor- Edwards’ pioneering role in the public communication of ders. In the several reports from the Royal College of science proved to be disadvantageous to his work. Robert Edwards: the path to IVF 259

The Edwards and Sharpe (1971) paper is a tour de force in ing up to the 1969 Nature paper describing IVF and the final its survey of the scientific benefits and risks of the science validation of the claims made in that paper with the birth of of IVF, in the legal and ethical issues raised by IVF, and in Louise Brown in 1978. It is evident even from the earliest the pros and cons of the various regulatory responses to stages of his late entry into research that Edwards is a them. It sets out the issues succinctly and anticipates social man of extraordinary energy and drive, qualities sustained responses that were some 13–19 years into the future. throughout his long career, witnessing his prodigious output Edwards built on his strong commitment to social justice of papers between 1954 and 2008 (Gardner and Johnson, based on a social ethic in subsequent years, as he engaged 2011). Indeed, several of the referees on the unsuccessful at every opportunity with ethicists, lawyers and theolo- MRC grant application specifically criticized his ‘over- gians, arguing, playing ‘devil’s advocate’ (literally, in the enthusiasm’, doubting that he could achieve the programme eyes of some), and engaging in what would now be called he sets out therein as ‘too ambitious’ (Johnson et al., 2010). practical ethics as he hammered out his position and felt Tenacity of purpose comes through clearly in Edwards’ able to fully justify his instincts intellectually. work, a trait he is inclined to attribute to his Yorkshire However, the establishment was, with few exceptions, origins, but which may also be fuelled by his working-class unwilling to engage seriously in ethical debates (Edwards, determination to show himself as good as the next (wo)man. 1974; Jones and Bodmer, 1974) in advance of the final vali- The influence of Waddington’s Edinburgh Institute, of dation of IVF that was to come in 1978 with the birth of Lou- Waddington himself, and of his superviser, Alan Beatty, on ise Brown (Figure 13; Edwards and Steptoe, 1978). Only Edwards’ interests and values is also clear from the domi- then did the UK social, scientific and medical hierarchies, nant role that developmental genetics played in his such as the MRC, the British Medical Association, the Royal thinking, especially until the time he met Steptoe. Indeed, Society and Government move gradually from their almost from examination of Edwards’ papers and interests, his pas- visceral reactions against IVF and its possibilities to serious sionate conversion to the cause of the infertile seems engagement with the issues (Johnson and Theodosiou, directly attributable to Steptoe’s influence. Admittedly, 2011). Then, to their credit, both the MRC and the Thatcher Edwards’ forays into immuno-reproduction did involve con- Government of the time came on board, but it was not until sideration of immunological causes of infertility, but these 1989, 24 years after Bob’s 1965 visionary paper in the Lan- were more usually of interest to him as models for develop- cet, that the UK Parliament finally gave its stamp of ing new contraceptive agents. Indeed, Edwards was as cap- approval to his vision, and then only after a fierce battle tured as most reproductive biologists of the time by the lasting some 11 years (Johnson and Theodosiou, 2011; Mul- 1960s’ consensus on the need for better methods of world kay, 1997). population control. This position was understandable given the reality of those concerns, as is demonstrated now in Discussion the problem of global warming that is attributable at least in part to a failure to control population growth. It is a mea- sure of his imagination and empathy that he could grasp so This paper describes some of the early years of Edwards’ life rapidly Steptoe’s understanding of the plight of the infertile and work, in order to provide a context for the events lead- and so flexibly incorporate this understanding into his plans. That empathy clearly reflects his under-privileged origins, his espousal of the cause of the junior, the disadvantaged, the ill-informed and the underdog being a thread running through his career. Edwards can be very critical, but I have found no one who can remember him ever being nasty or vindictive. Even when he disagrees with some one passion- ately, he never loses his respect for them as people. That Steptoe tapped into this sentiment is clear. The way in which Edwards met Steptoe has been absorbed into folklore, but an examination of the evidence seems to warrant some revision to commonly held later reminiscences. It remains uncertain exactly which publica- tion(s) by Steptoe it was that Edwards read in 1967, but seems likely that he did read Steptoe’s book. Thus, it was spermatozoa, not eggs, that were exercising Edwards in 1967, and it was the problem of sperm capacitation, not egg retrieval, to which Steptoe and his laparoscope seemed to offer a solution. The book is the only place that this issue is specifically addressed. Their actual meeting at the Royal Society of Medicine is also re-evaluated: Edwards was an invited speaker lecturing about his work on immuno- reproduction, so, paradoxically, what has been seen as a side track to his main work, was, albeit serendipitously, the reason for their actual meeting. Figure 13 Louise Brown holding the 1000th Bourn Hall baby The early collaboration between them involved the 1987 (courtesy Bourn Hall Clinic). recovery of ovarian biopsies, just like those Rose and others 260 MH Johnson

7, 9 and 10, Andrew Steptoe for permission to reproduce Figure 12, Bourn Hall Clinic for permission to reproduce Figures 13 and 14, and Peter Williams for permission to in- clude the movie clip in Supplementary material. The re- search was supported by a grant from the Wellcome Trust (088708), which otherwise had no involvement in the re- search or its publication.

References

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