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The ground-breaking donor egg programme initiated by the Vindana Reproductive Health Centre has given hope to many childless couples here, reports Kumudini Hettiarachchi
‘Let’s make a baby’
The couple is desperate. Relatives and friends keep asking embarrassing questions, the barbs being knowing looks and hints about being vanda or infertile. Both the husband and the wife have undergone a battery of tests and the results are heart-rending.

Sometimes the wife may not have even one egg (ovum) or the husband may not have active sperm. Hopes are shattered and in the past they may have been compelled to seek help abroad or resort to adoption.

Now, however, there is hope for such couples. For somewhere in Sri Lanka are babies, including twins, born through a donor egg programme initiated by the Vindana Reproductive Health Centre in Colombo.

In-vitro fertilization (IVF) or helping couples with fertility problems to have a “test-tube baby” has been the forte of Vindana since its inception in 1998, but what many may not know is that now it offers a range of services in this field.

In recognition of Vindana’s contribution, the IVF team consisting exclusively of Sri Lankan specialists was presented the National Science Award for 2005 for “excellence in multi-disciplinary team efforts in research and development in the area of Assisted Reproduction Technology” by the Ministry of Science and Technology. The IVF team comprises Prof. Harsha Seneviratne, Dr. Athula Kaluarachchi and Dr. Sarath Wijemanne, all of whom are clinicians; Sumedha Wijeratne, Embryologist; Dr. Champa Nelson, IVF Coordinator; Dr. Manori Seneviratne, Consultant Anaesthetist and Dr. Kamini Alahakoon, IVF Counsellor.

Since July 1, 2002, when the first IVF baby was born under a pregnancy and birth managed by a totally Sri Lankan team, Vindana has many firsts to its credit.

“We started Vindana because of the desperate need of infertile couples in Sri Lanka. At that time advanced facilities were limited only to Intra Uterine Insemination of processed sperm from the husband,” says Dr. Champa Nelson, Vindana’s IVF Coordinator. “Most people were seeking help abroad. Initially, we launched the IVF programme with expertise from abroad but a full local team then took on the responsibility in 2001 and the first baby by the team consisting of all local experts was born on July 1, 2002. The little girl is now a healthy three-year-old.”

The Assisted Reproductive Technique (ART) has three levels, says Dr. Nelson.

Basic management or Level 1 –
Both the husband and the wife are checked for the basic requirements of reproduction to ascertain whether he is producing good quality semen samples and she is ovulating satisfactorily. The reproductive tubes of both should also be patent for the sperm and eggs to travel easily while her womb should be normal to maintain a pregnancy.
If a problem is detected at this stage, then the couple moves onto supportive techniques or Level 2.
Supportive techniques or Level 2-
The wife is given medications to stimulate maturation of the eggs while good quality sperms of the husband are separated from the seminal fluid through seminal processing. The separated sperms are then deposited in the uterus (womb) of the wife at the correct time using a fine tube. This delicate procedure is called Intra Uterine Insemination (IUI).
“The couple moves to Level 3 or high-tech assistance only if the wife’s fallopian tubes are blocked, the husband’s semen quality is very poor or when other measures have failed to result in a pregnancy. This step-wise progress to more advanced treatment methods is the recommended practice,” says Dr. Nelson, adding that at this level Vindana offers many services.
High-tech assistance or Level 3 –
The services include IVF, ICSI, embryo freezing, egg donation, egg sharing, surrogacy and sperm donation.

In-vitro Fertilization (IVF): Using medication, a large number of eggs are grown in the wife and then taken out of her body and allowed to fertilize with the sperms of her husband in a petri dish (a small flat dish and not a test tube). Once the eggs and the sperms fuse (fertilize), the resulting embryos, the tiniest stage of a baby, are placed in the uterus.

Intra Cytoplasmic Sperm Injection (ICSI): This differs from routine IVF at fertilization as one sperm is selected and injected into the egg. This technique is used when it is found that the number of sperms in the semen is very low, when sperm is retrieved from the male reproductive tract, or if fertilization has failed in a previous cycle.

The subsequent development is the same as natural fertilization in both these fertilization procedures.Referring to the Testicular Sperm Aspiration (TESA) technique, she says sometimes men produce sperm in the testes but fail to ejaculate them. This could occur due to blockages in the male tubes through which they normally pass the sperms to the exterior.

“Then, under a painless technique, the sperm may be obtained directly from the testes or the male tubes and used to fertilize the egg using ICSI procedure,” explains Dr. Nelson. Embryo freezing: When a large number of embryos are produced in one cycle, the surplus ones are stored under special conditions, to be deposited in the wife’s womb at a later date.

Egg donation: When the wife is not producing eggs or the eggs produced are of very poor quality, eggs may be obtained from a consenting, healthy and fertile female. Then fertilization is carried out on these eggs with the sperm from the husband and the resulting embryos are deposited in the womb of the wife. Although the wife’s eggs are not used, she nurtures the pregnancy.
Egg sharing: If the wife of a couple who require IVF treatment is able to produce a large number of eggs in a cycle, she (donor) could share her eggs with another couple where the woman is unable to produce eggs (recipient). The number of eggs are then fertilized by the sperms from the respective husbands of the donor and the recipient and the embryos are placed in the wombs of the respective donor and the recipient.

In an egg-sharing programme, the cost of the whole IVF treatment cycle of the couple consenting to donate the eggs will be borne by the recipient couple.

“This is a tremendous help to couples with young (under 35 years) female partners who require this treatment for the management of their infertility problem if they are facing economic constraints. All precautions are taken to ensure that these donors are protected from exploitation,” says Dr. Nelson.

Surrogacy: If the wife does not have a healthy womb to carry a pregnancy, embryos grown from the eggs she produces in her ovaries and fertilized with sperms from her husband are deposited in the womb of another woman who has consented to carry the pregnancy for the infertile couple.

Sperm donation: If the husband is unable to produce a semen sample with adequate good quality sperm, a sample of sperm from the sperm bank donated by another male, could be deposited in the wife’s womb, allowing a pregnancy to occur.

“Confidentiality regarding the identity of the sperm donor is maintained at all times,” says Dr. Nelson. In all these instances, the bonding between the parents and the baby would be stronger than in an adoption, she stresses.
Donation of eggs and sperm is wonderful. In blood donation it is from one living being to another. In this instance it is creation of life, she says.

Leaving aside medicine and the latest technology, the most poignant moment for the Vindana team is when they see the sheer joy of an infertile couple as they hold their newborn baby, adds Dr. Nelson.

In the hands of the embryologist
State-of-the-art equipment apart, how does the sperm-egg fusion occur in this miracle of creating new life in ART? This process requires the gentle but very firm handling of gametes (egg and sperm) and embryos by the embryologist. At Vindana, this is the task of Sumedha Wijeratne. With many years of experience and commitment she takes all precautions to produce and select the best quality embryos to be placed in the wombs of women seeking children.

Starting basic work in the field when she was a lecturer at the Colombo Medical Faculty she says the faculty provided the foundation for these advanced techniques to be developed. She hopes that one day this technology could be offered through the state health service, as the Colombo Medical Faculty is ideally suited to provide these facilities if financial assistance is available.

Now a Senior Lecturer at the Medical Faculty, Mrs. Wijeratne says all the experience she gained from handling hamster eggs etc., during her own post-graduate studies has helped her tremendously. “When bringing sperm and eggs together in a petri dish, your hands can’t shake,” she smiles adding that when handling very sensitive equipment a firm hand is needed.

Being in charge of a laboratory of this kind is no easy task. Whether there are patient procedures or not, the sterility of the laboratory has to be maintained and all equipment needs to be calibrated continuously, according to Mrs. Wijeratne who feels that the quality of the laboratory and the skills of the embryologist are the key factors leading to producing good quality embryos with a potential for a pregnancy.

And she should know for the success rate at Vindana for 2005 has been 40%, says Dr. Nelson.

Detailing her work, Mrs. Wijeratne says, “The culture media have to be processed prior to use. The clinicians handle the egg aspiration from the woman under ultra sound guidance and then hand over the tube containing aspirated fluid to the laboratory. This fluid is then placed in a petri dish and examined for eggs, under a microscope. The eggs are then washed to clear them of blood and follicular fluid. It is crucial to place the eggs, as soon as possible in the incubator under specific conditions and allow them to undergo in-vitro maturation for a few hours.”

Meanwhile, the sperm sample is prepared with the best quality sperms being separated and made to required concentrations and placed in the incubator. “We try to maintain and mimic an environment similar to the human body for both the eggs and the sperm,” she says. The eggs are monitored for maturity and suitability for insemination. Once the eggs are matured they are taken out of the incubator and each egg is introduced to a sperm droplet under paraffin oil. This is time consuming,” she explains.

The insemination time is about 18-19 hours, after which the eggs are denuded (cleaned) and checked again. Each egg should have two pro-nuclei now, the sperm’s and the egg’s. “You must spot two pro-nuclei before further culture is undertaken as it is the indicator that fertilization has occurred,” stresses Mrs. Wijeratne.

The embryos are then graded and the patients are shown their embryos with a detailed explanation. A selected number of the best quality embryos are then deposited in the womb. The chosen embryos are loaded into a fine catheter, handed over to the clinician to be placed in the womb under ultra sound guidance. The remaining good quality embryos are frozen and stored for future use by the couple.

Seated in one place for long hours, sometimes as much as eight hours, in a dark room, looking through a microscope Mrs. Wijeratne considers her work a kind of meditation involving the coordination of eyes, hands and mind.

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