What has happened? where are we?

Howard W.Jones Jr

The Jones Institute for Reproductive Medicine, Eastern Virginia Medical

School, Norfolk, VA23507, USA Downloaded from https://academic.oup.com/humrep/article/11/Supplement_5/7/669059 by guest on 01 October 2021

Introduction

It is my very special privilege to open this colloquium. This gathering is the result of a chance encounter at the International Federation of Gynecology and Obstetrics (FIGO) meeting of Jean Cohen, Lars Hamberger, Howard Jones and Georgeanna Jones in Montreal in September 1994. In the Brownian movement which takes place between sessions, our respective paths happened to converge. The conversation lamented the huge size of the meeting with its attendant disadvantages and, particularly, the lack of opportunity for intimate challenge and discussion. This led to further lament about the size and disadvantages of our own international in-vitro fertilization (IVF) meetings and raised the question of whether there was still a role for small intimate colloquia. The vote of the four Brownian particles was unanimously 'aye', and here we are. The preference for the venue was easy. The four particles remembered the Hall meeting of 1981 when the camaraderie, the mutual respect, the absence of competition and the desire to solve a common problem was the order of the day, i.e. then it was simply to make the IVF system work and to understand why. It is astonishing to recall that, at that time, it was possible to count on the fingers of one hand the number of programmes throughout the world that had a continuing pregnancy, or the birth of a normal child from in vitro. The 1981 meeting was convened by Bob Edwards, Patrick Steptoe, and Jean Purdy. It took less than a minute in Montreal to agree that a meeting should be held and where it should be held, and less than a minute to think and hope that Ares­ Serono would be willing to make Bourn Hall available to sponsor the Cambridge and Bourn aspect of the meeting. Within another minute or so, Jean Cohen suggested that we talk to Isabelle Stilger, whom he had seen in Montreal. Isabelle agreed to discuss the matter with the appropriate people in the company and we are now able to express our appreciation to them and to , and to Bob and the staff here at Bourn for their role in this meeting. We can also thank Ares-Serono for the weighty and beautiful volumes on Italy which I interpret as a hint to hold subsequent meetings, if any, in Italy.

Human Reproduction Volume 11 Supplement 1 1996 © European Society for Human Reproduction and Embryology 7 H.W.Jones Downloaded from https://academic.oup.com/humrep/article/11/Supplement_5/7/669059 by guest on 01 October 2021

Figure 1. The cover of the programme of the Bourn Hall meeting of 1981 (see Appendix I).

The invitation list was a matter of considerable delicacy. The goal was to have a working group of world leaders where it would be possible to layout and to debate the potential of the future with those qualities of camaraderie, mutual respect, absence of competition, a desire to be mutually helpful and the challenge of benefiting by common opportunities. Hence, the invitees are the available descendants of the surviving programmes of 1981 supplemented by the principal innovators of the last decade. It needs to be observed that we are involved, not only in a scientific colloquium, but in an evaluation of the place in contemporary affairs of a meeting of this kind. I hope we will discuss this and perhaps, by the time we break up on Saturday evening, there will be a consensus one way or the other about the appropriateness of such small meetings and the usefulness of any publication if such meetings are held. If they are to take place in the future, it is obvious that young leadership must be involved. The old guard must be replaced by the new. An examination of the 1981 programme (see Appendix I) recalls that we were mainly grappling with the basic problem of understanding the inefficiency of the in-vitro process (Figure 1). It may be useful to spend a moment or two re-examining the 1981 programme session by session. However, let me insert a disclaimer. What you will hear are the recollections of one person. They may well be inaccurate and my impressions may need to be corrected and supplemented; but knowing this group, I am sure both will happen. Furthermore, the slides that I will use, with one exception, are from my collection of antiques from the era of 1981, and are, therefore, biased by our own data, but hopefully, they will serve the purpose of a take-off point for further discussion.

8 Where are we now?

Of course, there is some danger in returning to 1981. The important thing in life is to look ahead, not backward, but there seems to be a thread of substance and attitude expressed in 1981 which indeed might be of benefit in 1995. We will see. Let us now turn to Session I of 1981. The conventional wisdom in 1980 was that we should use the natural cycle (Table I). There were certain tenets which Downloaded from https://academic.oup.com/humrep/article/11/Supplement_5/7/669059 by guest on 01 October 2021 were expressed, namely to use the natural cycle, that the in-vitro maturation of the oocyte was impossible from a useful point of view, although Bob Edwards himself had clearly shown that in the human, meiotic maturation was resumed by liberating the oocyte from the ovary. It was thought that a minimal interval from harvesting to insemination was desirable and that the transfer should occur at the 8- to 16-cell stage. As it turned out, what was state-of-the-art in 1980 quickly became passe. At the end of 1980, which was the year we started working in Norfolk, USA, we knew that there had been two live births from the natural cycle in , UK. We knew that there was one on-going pregnancy in Melbourne, Australia, which had been established in 1979; the child was eventually born in June 1980. These were the data at the beginning of 1980. In the same year, pregnancies were initiated at Bourn Hall. It was interesting that in Melbourne, although two pregnancies resulted from the 1979 experience with the same in 1980, no further pregnancies occurred. Nevertheless, we began with the natural cycle in March 1980. The beginning of the programme in Norfolk was actively opposed (Figure 2). Indeed, this experience was duplicated elsewhere, although we seemed to have had it in spades. There was a forum for this opposition because we required an official document, a so-called 'Certificate of Need', to inaugurate any new programme and it was the granting of this 'Certificate of Need' which offered an opportunity to the right-to-lifers and others. Suffice it to say that after about 5 or 6 months and numerous hearings, the laboratory was approved, but after that, we had a court battle to face in the form of an injunction, which was finally resolved. I introduce this sociologicial note because we need to come back to that later, as not only was in-vitro fertilization (IVF) introduced by Bob Edwards, but he also introduced ethical problems which society had never faced before. From a scientific point of view, we spent ou~ time early on working out what every programme had to work out, i.e. exactly when to do the to retrieve that precious single egg in the cycle using the tools available to that programme. We happened to have a 4 hour oestradiol assay and a 6 hour

Table I. Conventional wisdom (January 1980)

Use natural cycle

In-vitro maturation of oocyte impossible Minimal interval from harvesting to insemination Transfer at 8-16-cell stage

9 H.W.Jones Downloaded from https://academic.oup.com/humrep/article/11/Supplement_5/7/669059 by guest on 01 October 2021

Figure 2. A page from the Norfolk newspaper The Ledger Star, reporting the public hearings necessary to obtain a 'Certificate of Need' to begin the in-vitro project.

luteinizing hormone (LH) assay on blood serum which was worked out for us by George Wright, our Professor of Immunology at Eastern Virginia Medical School. Therefore, we studied cases with this technique and Figure 3 which was shown here at Bourn Hall in 1981 demonstrated the effort to track the ovulatory time in relation to the LH rise,

10 Where are we now? Downloaded from https://academic.oup.com/humrep/article/11/Supplement_5/7/669059 by guest on 01 October 2021

Figure 3. An example of the study designed to ascertain the relationship between the spontaneous luteinizing hormone (LH) surge and .

Figure 4 shows the summation of these studies and it was from these data that, at least in the system we were using, it seemed that we needed to carry out the laparoscopy within about 28 h of the initiation of the LH rise. Nevertheless, in spite of doing the best we could in 1980, from 41 laparoscopies we obtained an egg in a little over half of these cases, transferred 13 cleaving pre-embryos, but no pregnancies resulted. A glance at the 1981 programme shows that in Melbourne they were using clomiphene, but over the Christmas holidays in 1980-81, Georgeanna Jones prevailed in her view that we should go to human menopausal gonadotrophin (HMG, Pergonal; Serono) although Bob had tried this quite extensively, unsuccess­ fully, prior to going back to the natural cycle. Figure 5 shows that we had a mole within our group. We think she was a nurse on the delivery floor who was a right-to-lifer where we worked and the newspapers often had a report of what we were doing and published it before all the members of the team were aware. This made it exceedingly important that we toed the line of our stated ethical position in everything we did. In any case, as you can see from Table II, Alex Lopata summarized the world data on stimulated cycles as of December 1980. In Oldham, there had been 77 transfers with three pregnancies, none of which went to term. In Melbourne, there were 48 attempts with clomiphene, resulting in three pregnancies, but none went to term. Bob Edwards' view in the discussions we had with him at that time was that HMG was not working because it caused a short luteal phase, and indeed this is the case, as you can see in Figure 6. There was a cut -off of the corpus luteum in stimulated patients at about day 10 and this was identified as the problem which caused Bob Edwards to abandon the effort.

11 H.W.Jones

LH SURGE TO ASPIRATION j

(9) Preovulatory oocyte (mucification): 12

't Corpus Luteurn: 3

~ Corpus Luteum & "reovula~ory oo~y!e, I

Oocyte retrieval failure,! 5

...c;;x Downloaded from https://academic.oup.com/humrep/article/11/Supplement_5/7/669059 by guest on 01 October 2021 ~i o lmmuu;e oocyte: 1

Figure 4. A summary of the cases studied to ascertain the relationship between the luteinizing hormone (LH) surge and ovulation. On the basis of such studies, it was concluded that aspiration needed to be accomplished -28 h after the determination of the beginning of the LH rise.

Figure 5. The newspapers knew of the decision to shift from the natural cycle to the stimulated cycle before some members of the in-vitro fertilization (IVF) team had been informed.

Figure 7 shows that the cut-off at 10 days was related to the intensity of the stimulation and that if it were gentle, the luteal phase would not be cut off. Only later was this phenomenon understood more fully. In 1981 when we were at Bourn Hall, we showed Figure 8 which documented the first pregnancy in our programme. You will notice that the patient had a total of only eight ampules of HMG. She would have had a short luteal phase, even with that gentle stimulation, as you can see by the drop in progesterone at LH + 10 days. Notice, however, that as the exogenous human chorionic gonadotrophin (HCG) disappeared, it was replaced by endogenous HCG which rescued the corpus luteum as shown by the rising progesterone values. Indeed, this was demonstrated in many cases, so that it seemed that the short luteal phase could be overcome if pregnancy took place.

12 Where are we now?

110

e 100

'"c 90 QJG w • PE II:~ 80 AJB ...w AJG [l 70 .8M CIa Downloaded from https://academic.oup.com/humrep/article/11/Supplement_5/7/669059 by guest on 01 October 2021 g: 60

10 e 9 g> 8 w 7 ~ 6 ffi 5 tii 4 ~ 3 ~ 2 • : Mense. ~ O~-T~~~~~~~~~~~~~-+~~·~~- 2024 8 1624 R 2 4 6 8 10 12 14 HeG. HOUR LUTEAL CYCLE DAY

Figure 6. A plot of the luteal phase progesterone in several patients who had received ovarian stimulation. Note the high levels of the progesterone and the cut-off of the luteal phase at about day 10.

Table II. Stimulated cycles. World data (December 1980)

Oldham (1978) Melbourne (1980)

Stimulations NA NA Aspirations NA NA Transfers 77 48 Pregnancies 3 3 Deliveries 0 0

NA = not available. Source of data Lopata (1980) Nature, 642 (25 Dec).

Early on, it was quite evident. that patients did not all respond the same way to HMG stimulation, as seen in Table III, which I suspect was made to show at Bourn Hall in September 1981, because this is a 1981 slide phase II of the Norfolk programme which was going on while we were here. However, it does not contain the total number of cases in phase II of our programme, so that it must have been made for the Bourn Hall meeting. At any rate, it points out that there are basically three different types of responders (normal responders, low responders, and high responders) and demonstrates that this is not due to the amount of HMG that is given, but in fact, the high responders took less than the low. It is fantastic to realize that this was new information in 1981. It was also perfectly clear, that in spite of the fact that oestradiol values in intermediate responders and high responders were well above the oestradiol values of the

13 H.W.Jones M.e.

50 45 ,E 40 OJ c 35 w z 30 0

a: Downloaded from https://academic.oup.com/humrep/article/11/Supplement_5/7/669059 by guest on 01 October 2021 w 25 / ...... o,~. "·'O..•... ~. TlMULATED f- (fJ 20 w ? 0 15 "a: 0- 10 0 5 li/o ...... ··0 ...... o ~.-r-~-,-,-.-.-T~-r-r~~--- o 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Retrieval +.. 10 day .. 14 day ...... : ...... ~ LUTEAL CYCLE DAY

Figure 7. The difference in the luteal phase length in the same patient with gentle stimulation, and with what is called hyperstimulation, but which was still rather modest by modem standards. This clearly shows that with increased stimulation, the luteal phase is truncated.

Figure 8. The plot of oestradiol, progesterone and human chorionic gonadotrophin (HCG), together with a stimulation in the first successful pregnancy. The interrupted line is of the progesterone, which even with a mild stimulation, is headed for a cut-off about 10 days until rescued by the rising endogenous HCG shown in the solid line. The solid line HCG prior to day 16 is the result of the HCG injection.

normal cycle which triggered an LH response, that the LH surge did not occur in the stimulated patients (Figure 9). This was a new phenomenon in 1981 and, in fact, the paper describing this was turned down by a prestigious journal as being ridiculous. It was finally accepted by and Sterility. In any case,

14 Where are we now?

900

700

500

280 300 Downloaded from https://academic.oup.com/humrep/article/11/Supplement_5/7/669059 by guest on 01 October 2021

200 1 e :s- 120 i lrt---I :s 60 1-_----: 120 40 60 ---+--f+- ,--t-l-~,AHi

Houro - ...a-40-32-34-16 -e 0 81634 48 Doy'--9 -8 -1 -6 -5 -4 -3 -2 t HCG

Figure 9_ The oestradiol (E:!) response of the three categories of patients: low, intennediate and high responders, together with the luteinizing hormone (LH). Note that there is no spontaneous LH surge in spite of the fact that, for the intennediate and high responders, the oestradiol values had been well over the trigger point to cause an LH surge. The LH shown on the plot is the result of the cross-reaction with the exogenous human chorionic gonadotrophin.

Table III. Serum oestradiol response and human menopausal gonadotrophin (HMO) dosage in 24 cycles

Oestradiol response No. cycles HMO (SD)

Low 3 14.0 ± 2.8 Normal 17 12.0 ± 2.7 High 4 11.75 ± 3.7 at the end of 1981, seven pregnancies had occurred in the Norfolk programme, all of which carried to term. One of the interesting things about the early stimulated patients was that miscarriage was extremely rare, so that one cannot help but wonder whether the gentle stimulation then in vogue was able to recruit the really good eggs and that the subsequent more high-powered stimulation recruited eggs of lesser qUality. In summary, in the first 1981 session, we were dealing with the endocrine details of the normal cycle with technology then available (I think Bourn was using only urinary assays) figuring out when the laparoscopy should be done. Australia was testing the waters with clomiphene and Norfolk with HMG. Session II, which was presided over by Jean Cohen, was called 'The Ovary'. Wilfred Feichtinger described the preovulatory follicle and the oocyte. I do not think we were at the level of sophistication of determining the meiotic state of the oocyte at aspiration, i.e. whether it was an metaphase II or a prophase I

15 H.W.Jones

Table IV. Follicular fluid volumes associated with single transfer and pregnancy (mature oocytes only) (n = 26)

Follicular fluid volume (ml) No. Percentage

0.1-1.0 4/26 15 1.1-2.0 9/26 35 65% } Downloaded from https://academic.oup.com/humrep/article/11/Supplement_5/7/669059 by guest on 01 October 2021 2.1-3.0 4/26 15 3.1--4.0 2126 8 4.1-5.0 2126 8 5.1--6.0 2/26 8 6.1-7.0 0/26 0 7.1-8.0 3/26 12 >8.0 0/26 0

oocyte. Rather, I think we were happy to have any kind of oocyte. I can remember that one of the questions was, 'How did the oocyte detach from the inside of the follicle? When did it detach? What was its state of maturation at that particular point?' In truth, I am not sure we really know the answer to those questions at this time. We were dealing entirely with the laparoscopic approach to harvesting the egg. We were interested in such simple matters as the relation of the size of the follicle in the natural cycle to the type of egg in the follicle. There were sometimes two follicles to aspirate and it seemed important to record the fact that when one aspirated these secondary follicles in the natural cycle, the possibility of getting a preovulatory oocyte was nil, but immature oocytes were possible. This was the era of the importance of the volume of follicular fluid in relation to maturation, and although Table IV is from 1984, the emphasis on follicular fluid volume remains there. This was also the era of analyses on follicular fluid and correlations with the maturational state of the oocyte and the potential of the oocyte to create pregnancy. Bob and Ruth Fowler certainly did a great deal of analysis of the follicular fluid early on making these various correlations. Figure 10 is simply a reminder to us from that era and happens to show that, in the stimulated cycle, inhibin as tested by bioassay at that time by Channing was greatly increased in the stimulated cycles. We thought this could be responsible for the suppression of the spontaneous LH surge in stimulated cycles. It later proved that luteinizing surge-inhibiting factor (LSIF) was an inhibin-like substance which was identified by Doug Danforth at Norfolk after working about 10 years. One of the main points of discussion was not only the technique of laparoscopic retrieval, but concerned the gas used for the abdominal inflation. Bob Edwards and Patrick Steptoe were very keen that the pH be disturbed as little as possible, and therefore, thought that it was unwise to use carbon dioxide in the peritoneal cavity, which was the standard gas at the time. They always used nitrogen and flushed this out at the end with carbon dioxide. The nitrogen scared some of us,

16 Where are we now?

HUMAN PREOVULATORY FOLLICULAR FLUID

3200 o CONTIlOL NON-TIlEATED 3000 ( n=15)

2800 1.4 IJIl PERGONAL TREATED 2600 ltd (n-IO) 13 ~ 2400 • P< 0.01 12 VS CONTIlOL I 220 ~ 2200 • 1.1 Downloaded from https://academic.oup.com/humrep/article/11/Supplement_5/7/669059 by guest on 01 October 2021 :; 200 " 2000 ::l. C) 10 ~ Q 180 ~ 1800 0.9 9 ~ o ...J " 160 II) 1600 O.B ~ II) Q 82 !:: 140 i5 1400 0.7: 7 ;:; N ~ 120 ffi 1200 0.6 6 C;; i 100 t; 1000 0.5 5 W ...J In 80 BOO 0.4 4 U ~ 60 600 0.3 3 j I 40 400 0.2 2 e ~ 200 ..J INHIBIN PROG EST VOL INHIBIN PROG EST ll.4/E VOL

Figure 10. Some early studies on follicular fluid. Note that the 'inhibin' is far higher in the stimulated cycles than in the normal follicular fluid. The bioassay in use probably was cross-reacting with what subsequently was identified as luteinizing surge-inhibiting factor (SLIF).

as we thought that there was a potential for a nitrogen embolus which could be fatal. I am unaware that this ever happened, but as we were so in the public eye, we were afraid to take a chance on this. For this reason, we used carbon dioxide from the first, but tried to compensate for this by adopting a tube containing buffered Dulbecco's solution to catch the follicular fluid so that there would be some stabilizing of the pH for the couple of minutes before we got the fluid into the laboratory. In summary then, this second session was devoted to the mechanics of getting the egg and searching for something in the follicular fluid which would be diagnostically more precise than the microscope. Interestingly, I do not think that elusive substances or combination of substances has ever been found. Session III on fertilization and Session IV on the preimplantation embryo are being merged for purposes of recall as the subject matter overlapped. There was considerable discussion about sterile techniques and media preparation, and Jean Purdy told us about that. She told us about Bell jars and oil. Methods of sperm preparation were talked about by Lola Mettler and Vera Baukloh. Everybody had their own ideas about the proper method of fertilization, but it seemed important to determine whether 20% oxygen in the incubator would be fatal. We used a rather large volume of medium with 20% oxygen, and in the end were satisfied that we did not need to use the more troublesome 95% nitrogen atmosphere which seemed to be the conventional wisdom at the time. In our first series in 1981, which we designated phase I, we did not know what the fertilization rate was, because we were not looking at the oocytes the next morning. We simply waited to see whether we had cleavage after 48 h and so

17 H.W.Jones

Table V. Results of treatment cycles; phase I (1981)

No. Percentage A Percentage B Percentage C Percentage D

A Laparoscopies 31 B Fertilizable eggs 26 84 C Fertilized eggs ND ND ND Downloaded from https://academic.oup.com/humrep/article/11/Supplement_5/7/669059 by guest on 01 October 2021 D Transfers 12 39 46 ND E Pregnancies 2 6 8 ND 17

ND = not determined.

Table VI. Results of treatment cycles; Norfolk - Phase II. Fertilization in 13 successful ovulation induction cycles with human menopausal gonadotrophin! human chorionic gonadotrophin. Figures in parentheses are percentages

13 cyclesa 1900cytes

Fertilization rate 12 (92.3) 18 (94.7) Cleavage rate 11 (84.6) 15 (78.9) Transfer rateb 11 (84.6) 15 (78.9) Pregnancy rate 2 (15.6) 2 (10.5)

aDark granulosa cells (two cycles) bSix twin transfers; five single transfers. the only we thing we knew was that we had cleavage rates of 48% per cycle, as you can see in Table V, and if we did it on a per egg basis, it was 36%. The transfer rate was fairly good for those that cleaved. Every patient who had a cleavage had a transfer and of the 12 transfers done in the early part of 1981, there were two pregnancies. Interestingly, of the 12 transfers done, there were only two that had two oocytes, 10 being single transfers. It happened that I did a single transfer on a patient immediately before leaving for Europe in May 1981 and on that trip, which was to Paris to a meeting that was attended by Jean Cohen, we stopped by Bourn Hall and spent a day with Bob Edwards and Patrick Steptoe. They were kind enough to invite us to come whenever we had a chance. At the end of that day, I went back to the hotel and called Jairo Garcia in Norfolk and told him that I was puzzled by the fact that we did not have a pregnancy because I really did not see anything at Bourn Hall that indicated that we were doing anything awful. Whereupon he said, 'Well, if you remember that patient that you transferred just before you left, she's missed her period and I think she has a pregnancy', so we learned of our first pregnancy while we were in Bourn Hall. Phase II was going on while we were here in September of 1981, and Table VI was made for the 1981 meeting. We had started to look at the eggs the next morning and we had a 92% fertilization rate. That figure has stayed that way to the present time if we are dealing with metaphase II eggs on harvest. The cleavage rate is the same as the two-pronuclear (2PN) rate and actually the

18 Where are we now? pregnancy rate was not too bad considering we were transferring single eggs, so that this is essentially an implantation rate. So these were the data which we presented at the 1981 meeting. There are others in this room who surely remember some of the details of Sessions III and IV, but in summary, I believe we were talking about the nuts and bolts of fertilization: culture medium, importance of oxygen tension and such matters as we now regard as commonplace, but which we will re-examine Downloaded from https://academic.oup.com/humrep/article/11/Supplement_5/7/669059 by guest on 01 October 2021 at least in part in this 1995 meeting. Session V had to do with replanting embryos. Ian Johnston described the endometrium and the myometrium in the early luteal phase. Georgeanna Jones talked about luteal phase defects and their unimportance in the stimulated cycle and then every group talked about its favourite method of transfer. We, ourselves, used the knee-chest position thinking that we would like to have every help we could get, and that gravity would even be important in the tiny embryo. We designed our own closed-end catheter which was in use continuously for many years. We sometimes use an open-ended catheter now, but the old closed-end catheter works fine and it has been very seldom that we have had a failed transfer using this technique. One of the things that was of great concern then and really has not been completely resolved is the subject of the session that Alex Lopata will moderate in 1995, and that is the endometrium and the peri-ovulatory events and its change at the time of transfer and implantation. We are dealing with the situation where, by transferring on day 16, if we count day 14 as day 1, we are putting the pre-embryo in the endometrium probably 24 or 48 h before it normally gets there at a stage which is quite different from the stage in which it normally arrives. There have been a number of studies on the endometrium trying to figure out the optimum situation there. Early on, it seemed clear from studies that we had done on endometrial biopsies that very often the endometrium was advanced to day 17 or more on day 16 when we transferred. We thought that was helpful and I believe those data were correct. Remember, however, that this was with very gentle HMG stimulation. With the larger stimulation now, I believe that the matter needs to be further reconsidered. Some time was spent discussing the rate of cleavage in vitro and Bob Edwards and Patrick Steptoe later provided us with information showing that after 48 h we were at the 16-cell stage or thereabouts. But the Carnegie description of naturally implanting embryos suggested that by 4 days, we ought to be in the blastocyst stage, so that even today we are confronted with the fact that our culture technique and the whole in-vitro process gives us a pre-embryo that is a little slower in its development than occurs in normal situations. We will hear more about that, I am sure, in one of the current sessions. In summary, in 1981 in Session V, we were worrying about the transfer of a pre-embryo at a stage earlier than it normally is when it hits the uterus at a time different from when it normally hits the uterus, trying to determine whether we could alter this in any way, and whether this had any influence on the inefficiency of the in-vitro process. This problem still is unresolved completely, although there has been a tremendous amount of work in this area, including an examination

19 H.W.Jones of endometrial proteins, the pinopodes of Alex Psychoyos, and we all look forward a great deal to the session that Alex Lopata is going to chair to further resolve these questions. Finally, there was Session VI which was sort of an odds and ends session. There was concern naturally about the normality of the children produced by IVF and Bob discussed this particular point. I think, as time has gone along, there have been enough data collected to indicate that we need have no worries Downloaded from https://academic.oup.com/humrep/article/11/Supplement_5/7/669059 by guest on 01 October 2021 about malformations as a result of the in-vitro process. Alex Trounson discussed new approaches to the treatment of idiopathic infertility. I do not really recall exactly what he said, but I suspect that, at that time, we were beginning to explore the notion that IVF might be useful for something other than tubal disease. You must recall that in 1980-81, at least as far as we were concerned, we were dealing with IVF as a bypass to the Fallopian tube. Brian Leiberman talked about amniocentesis in these pregnancies and the appropriateness of that, and it is a continuing subject as far as many patients are concerned. Finally, there was some discussion of the ethics of what we were about and I seemed to have drawn the assignment, largely I suppose, because of the ethical confrontations we had in an overt manner early in our experience. I will have something further to say below about the ethics of what we are about. To summarize 1981 then, we were at a very primitive time. We left Bourn Hall in 1981 with a feeling of camaraderie and comfort that everyone had the same problems and that we were working together on the solutions. Interestingly, many of the problems that are before us in 1995 are not entirely different. Then we were talking about the normal cycle and early stimulation, now we are talking about LH antagonists and recombinant gonadotrophins. Then we were talking about how to aspirate by laparoscopy; now we talk about ultrasound­ guided vaginal aspiration. Then we were talking about the identification of oocyte quality by considering the follicular fluid. This problem of identification of oocyte quality still eludes us, as the microscope is limited in its ability. Then we talked about fertilization, sperm preparation, culture medium, early cleavage; now we talk about co-culture and hatching. Then we talked about implantation; now we talk about implantation. Then we talked about the concern about abnormalities. We seem to be reassured on that point, although studies of babies from cryopreservation and intracytoplasmic sperm injection (IeSI) remain to be completed. Then we were talking only about indications other than tubal disease. Even now, indication is somewhat of an open-ended question when we consider age, for instance the use of donor oocytes and other matters. Then we were talking about ethics; now we will talk about ethics. However, there are some entirely new subjects: preimplantation genetic diagnosis is one and this offers the opportunity for redesigning the human genome in the future. We are also talking about cryopreservation which was not on the 1981 programme. Nevertheless, there are still undiscussed basic fundamental issues. We know nothing about the acquisition of gonadotrophin sensitivity. It would be very helpful if we understood' this. We know very little about the factors influencing

20 Where are we now? oocyte maturation or the factors influencing oocyte ageing. We have leap-frogged male infertility in a sense, in that we have come up with a very satisfactory solution to the problem, but we understand little about the cause of defects of spermatogenesis. Indeed, we understand very little about deficiencies of oogenesis, its identification, when it occurs, and what are the factors associated with it. You have the 1995 programme before you. When Jean Cohen and I drew up Downloaded from https://academic.oup.com/humrep/article/11/Supplement_5/7/669059 by guest on 01 October 2021 this programme over lunch in Versailles last October, these seemed to be the dynamic issues for discussion. Note that they all involve technological questions. There are, of course, other technical questions of importance which could not be included. However, there are other issues of a more encompassing nature involving technology, to be sure, but also involving ethics and public policy which are of burning importance to us all and will certainly be actively discussed in the foreseeable future, but which could not be included in the programme. A prime example of this type of problem has multiple variables, i.e. the number of pre-embryos to transfer, the extent of the pool from which the transferred preembryos are selected, the time of selection from the pool, the fate of deselected preembryos, the role of cryopreservation, the role (if any) of selective reduction in the event of multiple pregnancies, and the issues of ethics and public policy in solving this multi variant calculus. If politics and gossip fail to fill the cocktail hours and lunches and dinner, perhaps the solution to this calculus would be useful table conversation. A second example is the general question of the role of the biological and clinical scientist in the on-going discussions about the ethics and public policy of what we are about. I happen to be persuaded that we must play a role which I regard as essential. As a minimum, this role is to provide the biological background without which discussions of morality, ethics and public policy can often get off the track. A useful precept is that bioethical validity depends on biological understanding. We must provide the biological understanding and there are numerous opportunities to do so. Our role could be expanded to expressing an opinion about matters which are normally thought to be in the province of the professional ethicist or moral theologian. However, to do this we must all school ourselves in their vocabulary and become knowledgeable in the source of their authority so that we will have validity in their eyes. The moral theologians and the ethicists do not have exclusive use of a hotline to heaven and I believe our moral interpretation of the biological facts can help members of society at large understand why they think about things as they do. This requires considerable homework on the part of the clinical and biological scientist. It is a role, however, we cannot shirk. In closing, let us remember with humility, great appreciation and respect the role that Patrick Steptoe and Jean Purdy played in the 1981 meeting, which was the mother meeting to other small gatherings in Murnau, Corsica, again here at Bourn, and other locations before this type of meeting was swallowed up by the flood of interest in assisted reproductive technology. Over the next 2 days, we

21 H.W.Jones should know whether the time has again come to have very small meetings of this kind as a step toward improving the human condition. Downloaded from https://academic.oup.com/humrep/article/11/Supplement_5/7/669059 by guest on 01 October 2021 Appendix I

Contents of Programme of 1981 Meeting

Welcome to Bourn Hall R.G.Edwards

Session 1. Monitoring Endocrine Rhythms

Endocrinology of the menstrual cycle with reference to fertilization in vitro J.Cohen Discussion Control of the menstrual cycle with clomiphene and hCG J .Leeton & A. Trounson Discussion Patient selection and monitoring cycles Each group Recommendations

Session 2. The Ovary

Chairman, J.Cohen

The preovulatory follicle and oocyte W.Peichtinger Discussion Laparoscopy of the normal and disordered P.C.Steptoe & J.Webster Discussion Methods of follicular aspiration Each group Recommendations

22 Where are we now?

Session 3. Fertilization

Chairman, A. Trounson Concepts of fertilization in vivo and in vitro S.Fishel & R.G.Edwards Discussion Sterile techniques and media preparation J.M.Purdy Downloaded from https://academic.oup.com/humrep/article/11/Supplement_5/7/669059 by guest on 01 October 2021 Discussion Immunological and other problems with spermatozoa L.Mettler & YBaukloh Discussion Methods of fertilization in vitro Each group Recommendations

Session 4. The preimplantation embryo

Chairman, R.G.Edwards Factors which influence embryo development A.Trounson Discussion Cleavage of human embryos in vitro A. Lopata Discussion Methods of embryo culture Each group Films of cleaving human embryos L.Hamberger Recommendations

Session 5. Replanting embryos

Chairman, H.Jones The endometrium and myoendometrium in the early luteal phase !.Johnston Discussion Luteal phase defects G.Jones Discussion Animal studies on embryo transfer after storage J.Testart Discussion Methods for replanting embryos Each group Foetal growth after implantation Each group Recommendations

23 H.W.Jones

Session 6. Essential topics

Chairman, P.C.Steptoe Causes of human malfonnations at conception: register of pregnancies and births R.G.Edwards

Discussion Downloaded from https://academic.oup.com/humrep/article/11/Supplement_5/7/669059 by guest on 01 October 2021 New approaches to the treatment of idiopathic infertility ATrounson Discussion Amniocentesis in precious pregnancies B.ALiebennan & P.Dyer Discussion Ethics of in-vitro fertilization H.Jones Discussion Farewell P. C. Steptoe

24