Navigating the Science of FertilityJan 01, 2016 ● By Carolyn Cameron
Today, the barrage of treatment options for those facing infertility are boundless. Currently, with at least 38 ways to “make a baby,” the possible configurations and therapies are mind-numbing. Infertile couples are confronted with an alphabet soup of options including artificial insemination by husband (AIH), artificial insemination by donor (AID), gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), in vitro fertilization (IVF), surrogacy and many others. With so many couples desiring children and with so many options available to them, making decisions about reproductive technologies can be extremely difficult and, at times, ethically challenging. And, with this new technology comes an onslaught of questions and potential opportunities for abuse.
Dr. Marius Meintjes, one of the founding members and the current director of the Frisco Institute for Reproductive Medicine (FIRM), is a Bible-believing Christian who sees struggling and hurting couples in his facility every single day. “Understanding the devastation of infertility in a couple’s life is immeasurable, and it is my goal to help individuals make better decisions about when to start and how to go about the process of facilitating life. What most people do not realize is that infertility is a disease. Heart disease is a rampant disease here in America. Infertility is just as much a disease that negatively affects the reproductive system like heart disease negatively affects the circulatory system,” he notes. “As such, my mission is to help those who are suffering. In science, we know a great deal about human life, and we have advanced tools at our disposal to help those in need, but many mysteries of life remain. I am blessed to have a wealth of knowledge and information about assisted reproduction, and here, we utilize common sense and strict ethical guidelines to treat this disease with the most compassion and nurturing response possible.”
According to the American Society for Reproductive Medicine, infertility is medically defined as “the inability to conceive or carry a pregnancy to term after 12 months of trying to conceive, and if a woman is over the age of 35, the time of trying to conceive is reduced to 6 months.” Infertility is a medical condition, found equally in both men and women, and the harsh truth is that infertility affects one of out every six couples in the U.S., as stated by the American Pregnancy Association. Infertility holds no socioeconomic discrimination and cuts across all racial, ethnic and religious lines. It strikes diverse groups and knows no bounds.
Chances are great that most know a friend, relative, neighbor or individual who is coping or dealing with the medical and emotional aspects of infertility in his or her life. In the U.S., and around the world, rates of infertility are on the rise. Women are waiting longer to have children, due to a variety of reasons, including their own career aspirations, which contributes to the infertility increase. Since 1980, the birth rate in women greater than the age of 35 has increased by nearly 60 percent in the U.S., whereas the birth rate for women ages 20 to 34 years has increased by only 10 percent.
Infertility is not just a “woman problem.” As much as they would not like to admit it, problems in males are just as likely to be the cause of fertility difficulties as those in women. Experts in recent years have raised the alarm bells over what some are calling a “sperm crisis,” because it is believed that men’s sperm counts have been decreasing for a decade or more. One recent study in Northern Europe found that as many as one in five young men have sperm counts low enough to affect fertility, according to Richard Sharpe, a male reproductive health specialist at the University of Edinburgh. External factors, such as weight, environmental elements and lifestyle choices can impact sperm count in adulthood.
“The causes of infertility are diverse and sundry, and despite what some may think, male factors account for 50 percent of fertility problems. Frankly, you probably know someone experiencing infertility, even if you don’t personally know someone in the throws of it currently,” explains Dr. Meintjes. “A woman’s fertility decreases dramatically at age 34, given the age of her eggs inside the womb for nine months, so I encourage couples to seek help earlier in the process rather than later. We have a lot of individuals who are in second marriages or have become caught up in their careers and come to us very late in their reproductive lives. There are three things required to make a baby: a sperm, an egg and a uterus, and if a patient needs help with one of those items, we can help. However, if the patient needs more than one factor, we believe we are crossing the line to becoming a baby factory and do not treat them. In every case, we have to consider numerous aspects, including the health and well-being of the child.”
Opened in 2008, FIRM was established by Dr. Meintjes because of his passion and desire to help couples with infertility issues while maintaining clear ethical guidelines and standards. After beginning his career in serving as the scientific director for the Assisted Reproductive Technology Services (ARTS) program from 1998 to 2008, Dr. Meintjes left the system and desired to open a facility that was dedicated to offering state-of-the-art, cutting-edge treatment options for his patients, while adhering to clear guidelines and defined ethics according to the sanctity of life. He holds a doctorate degree in reproductive physiology and embryo biotechnology and is renowned as one of the top three embryologists in the world. He is often featured as a national and international speaker on in vitro laboratory excellence and design as well as various aspects of the optimization of assisted reproduction success rates.
“I wanted a place where we could offer the best of science while ensuring we are doing what is right in a responsible manner. We provide a plan for individualized treatment, making sure our patient care is second-to-none. Everything we do is for the benefit of our patients, whether it’s our expert physicians, cutting-edge labs or our clinical staff, every person in our office is driven to help our patients succeed from the moment they walk through our doors,” notes Dr. Meintjes. “Our goal is to be comprehensive in nature while minimizing invasiveness, if at all possible. Not everyone needs in-depth treatment, but ultimately, our goal is to be successful in treating the disease of infertility.”
Treatments for both males and females to identify the infertility problem can include lifestyle changes, vitamins and supplements, surgery, medication or assisted reproduction. Initial fertility tests for women might include testing for appropriate hormone levels, in addition to evaluating menstrual and gynecological problems or treat causes of abnormal bleeding. Initial fertility testing for men includes semen analysis as well as genetic and hormone tests to determine causes of potential causes and inhibitors to fertilization. “Honestly, you wouldn’t believe it, but sometimes the inability to conceive might be as simple as couples being off on their timing. Often, it might be a small tweak in the hormones or blood work tests to identify a thyroid problem, for example. If not one of those areas, we begin to look at the anatomy of the patients to identify and resolve any possible blockages or other issues.” Dr. Meintjes continues, “Humans are the most infertile species on the planet. The natural fertility rate for men and women is 20 percent, whereas in animals, it ranges between 90 and 98 percent. From my previous experience as a wildlife veterinarian in South Africa, I have seen how animals reproduce, and it’s quite efficient. However, for humans, 80 percent of the time, when the sperm and egg come together, the genetic embryo is abnormal, so only 20 percent of embryos will develop and be potentially viable.”
When a couple does not respond to medication or surgical interventions, many often turn to ART, which is technology used to achieve pregnancy. These procedures might include fertility medication, artificial insemination, IVF and surrogacy. One of the most popular and successful treatments currently used to achieve pregnancy is IVF, a laboratory procedure that retrieves a woman’s eggs, fertilizes them with a man’s sperm and places the resulting embryo into a woman’s uterus to achieve pregnancy.
Almost since its inception, IVF has been celebrated by some and has been a subject of moral and ethical controversy for others. With the birth of the world’s first test tube baby, Louise Brown, in July of 1978, the field of reproductive medicine was revolutionized and gave infertile women hope that they could become mothers. In the case of Ms. Brown’s mother, she had blocked fallopian tubes, which is still one of the most frequent causes of infertility in women. Today, it is estimated that more than five million couples around the world have conceived babies using IVF. However, the procedure has been surrounded by controversy, as the procedure can result in multiple embryos, and often times, many couples are faced with weighty decisions about what to do with extra embryos. Christians typically believe life begins at conception or the moment a human egg and sperm unite, creating a unique, genetic individual. Because the IVF process typically involves screening embryos, proceeding with only chromosomally “normal” ones and going forward with cryopreservation, or freezing of remaining embryos for future pregnancies, IVF can create a quandary and a source of controversy in almost every step.
“The controversial and fundamental question for most is ‘when does life actually begin?’ Many believe life begins at conception, but in my in-depth studies of both science and the Bible, I believe there is a different answer,” notes Dr. Meintjes. “In the book of Leviticus within the Bible, a case can be made that life begins not at the time of fertilization, but when blood first appears in the embryo, and interestingly, an embryo begins having a rudimentary blood circulatory system on about day seven of its development. Additionally, when we watch an embryo develop and naturally-occurring twins occur, they split on day three or four, and it just doesn’t make sense that the soul is split in half. So, we are taught that conception begins on day one, but practically, from a scientific point of view, either the soul must enter the embryo after day five or the soul is split in half, which doesn’t make sense. These are difficult issues, but based on what I know and understand scientifically, life actually begins after day six of the embryo’s existence,” explains Dr. Meintjes.
The process of IVF at FIRM begins in their state-of-the-art laboratory, which is at the heart of all the successful outcomes for successful IVF treatment cycles. Specifically dealing with male infertility issues, patients undergoing treatment at FIRM have access to the high-complexity, accredited andrology lab, which performs semen analysis, detailed counts, morphology (or the shape of the semen) assessments and other specialized tests.
For their patients’ convenience, FIRM provides all of their fertility services under one roof, including surgery to correct or address fertility problems. Within the IVF procedure, once eggs are extracted, they are exposed to the sperm in the lab, and the resulting embryos are safeguarded and incubated for up to six days. Waiting for this time period allows full distinction between baby and placenta, which verifies that the embryo is sustainable, viable and truly alive.
Embryos kept in FIRM’s IVF laboratory are contained in computerized, low-oxygen incubators to keep embryos at exactly the right temperature and humidity, precisely controlling the acidity level of the culture media. Specially installed air-pollution filtration systems (called “air scrubbers”) have been installed for the IVF laboratories. These operating rooms cost several hundred thousand dollars, to ensure that the embryos are exposed only to the purest air possible. These systems not only remove microscopic particles, but they also remove the much smaller chemical compounds through non-specific absorption and specific chemical elimination reactions. All of these preparations ensure the cleanest air possible to protect embryos and provide the possible live-birth outcomes when performing IVF. Without the purest air, IVF laboratories may frequently experience unexplained drops in the pregnancy rates.
Research performed in the laboratory has shown that when embryos are cultured under these low oxygen conditions, more girl embryos survive, resulting in higher pregnancy rates and more babies born overall. Dr. Meintjes adds, “We take extra precautions to ensure the oxygen rates are very low and super clean, otherwise it will reduce our success rates for girl embryos and thus our overall pregnancy success rates in general.”
Another one of the IVF lab’s newest, cutting-edge technologies is the time-lapse assisted embryo culture. Embryo incubation and assessment is a vital step in IVF. Normally, embryos are removed from the incubators once per day to obtain a snapshot of embryo development. FIRM is currently the only IVF lab in Texas, and one of only a few in the country, to offer time-lapse-assisted embryo selection using computer-controlled microscopes. Embryos are cultured in the Embryoscope®, a special incubator in which a computer takes a low light-intensity picture every five minutes or less for the five to six days of embryo culture.
Instead of receiving a snapshot of embryo development once every second day, a continuous video of embryo development can be observed by specialists without removing them from the incubator. Furthermore, patients can be provided with a dynamic video of their embryo’s development, from fertilization all the way to the time of embryo transfer, rather than just having a one-time, static picture. The benefit of this technology allows one the opportunity to evaluate or “catch” several morphological events that are not seen with conventional scoring methods, and it can significantly reduce the miscarriage rate.
Once developed, an embryo may be transferred to the live womb, but more often than not, embryos are preserved using cryopreservation, which involves the freezing and storage of mature eggs, sperm or embryos for later use. Ninety percent of patients choose to freeze their embryos and then come back the next month in a replacement cycle. This allows better preparation for the uterus for a smooth implantation, raising the pregnancy rates almost 20 percent.
“We do have couples that desire to not freeze their embryos, and in this instance, we counsel them to not fertilize all of their eggs. We respect life and will do whatever we can in this process,” Dr. Meintjes adds. “However, it is not an option for us to fertilize the embryos for a couple and then discard those healthy embryos just because they do not want to freeze. It’s not a practice that is allowed to occur here.”
There are two major techniques for cryopreservation: the slow programmable freezing (SPF) method and vitrification. Prior to 2000, embryos were frozen by the SPF method in ethylene glycol freeze media and transferred directly to recipients immediately after water thawing, without a laboratory thawing process. The survival rate of this embryo transfer after thawing, even in expert hands, was only about 50 percent, at most.
Vitrification is the newer technique, and it uses ultra-rapid cooling, together with a much higher concentration of cryoprotectants. Vitrification has been used for cryopreservation of eggs and embryos and does not cause damage to those entities. The cryoprotectants act like antifreeze, lowering the freezing temperature, and they also increase the viscosity. Instead of crystallizing, the syrupy solution turns into an amorphous ice, and it vitrifies. FIRM has been using vitrification for a number of years to cryopreserve both embryos and eggs. As a result, vitrification allows no trauma to the embryo and provides high survival rates for both embryos and eggs, providing a better than 95 percent freeze-thaw survival rate, and a pregnancy generating potential that is comparable to fresh embryos. Frozen embryos can be stored for extended periods of time, even years, and then used when needed for a follow up embryo transfer. Typically, the patient freezes between one to three embryos, but in the cases where there are a large number of embryos, an embryo adoption program is also available. “We encourage our patients to use their embryos quickly, and if within a year’s time or so, an embryo is thawed and used, we do not charge any storage fee. However, if some time elapses, a $1,000 fee is applied each year for the patient, which is much higher than the standard storage fee around town,” he notes. “Honestly, this isn’t about the money. Instead, it’s about encouraging the responsible use of these embryos and not abandoning them in any way, shape or form. This seems to get the job done for us.”
FIRM has some of the best live birth rates in the world using vitrification. Freezing occurs on day five, when one can truly identify a baby and placenta within the embryo, but before day seven, when a blood system begins developing within the embryo. An accurate grading system is further used on the embryos for likely viability, given many years of experience and practice.
Dr. Meintjes continues, “In my scientific opinion, we respect life as much as possible, and for those embryos that are not clearly developing into a baby and a placenta, we give them plenty of time. I don’t have a problem discarding them because they do not have the promise of life. Of course, the real problem is that we aren’t 100 percent accurate, but we are very, very close. In this case, I have to make an informed decision. Out of 470 programs, this is the only one with a Christian director. So, do I perform the best job I can, to the best of my ability, not knowingly discarding anything that is a baby? Or do I withdraw and let someone else come in and take over, who doesn’t have the values I do, who would allow questionable practices within the field? I’ve chosen the first option. Even though I’m not perfect, I believe it is a very important job. In addition, this position provides me with opportunities to speak with high standing officials, such as the Health Minister of China, on value-based and Christian topics. If I’m at an event and I’m sitting next to an influential person, I might be able to speak about the deterioration of mankind, and hopefully, I’m able to penetrate the international scientific world with knowledge and wisdom that otherwise I wouldn’t have the opportunity to do,” he notes.
A separate but interesting adjunct to Dr. Meintjes’ work are his studies in adult stem cells, which use the same facilities as FIRM. Implementing an alternative non-narcotic, non-surgical approach to musculoskeletal injuries, his company, Texas Cell Institute, uses cell therapy techniques to enhance the body’s own natural abilities to heal injuries, whether it’s located on the hip, knee, neck, elbow or any other area commonly hurt on the human body. Also called “regenerative medicine,” the treatment uses a range of traditional treatments, while adding biologics, such as platelet-rich plasma (PRP) and stem cell therapy, to effectively heal and regenerate damaged tissue. This technology is believed to be able to bridge the gap between conservative and invasive care and provide cutting-edge treatments for healing.
“Even though this industry is in its infancy, there is huge promise in the healing ability of stem cells. Really, it’s quite remarkable,” says Dr. Meintjes. “I believe oxygen levels have a great deal to do with the healing of the human body, and we’ve already seen amazing findings with oxygen levels and our embryos. Going back to the time of pre-Noah and the Flood, there was no rain at that time. Humans lived on vegetation because everything was so nutritious and organic. Interestingly, the Bible speaks about a canopy being over the earth, creating a hyper-oxygen environment. And, we see that the life span during this time was greatly increased, and through my calculations, the oxygen levels in the atmosphere were 80 to 85 percent. Today, we live in a period where the oxygen levels are at 18 percent in the atmosphere, and this is indicative, as it clearly impacts our health and well-being. We do know there is great promise of stem cell research for adults, and I believe it is worthwhile to study to bring quick healing and even rejuvenation to those living in this day and age. This is one of those areas that I definitely want to continue to research and discover new solutions for the human race as a whole.”
Regardless of Dr. Meintjes’ focus, his goal is always to help people. He concludes, “I believe it is my mission to work and treat the disease of infertility or help others through stem cell research. While I believe it is a tremendous responsibility, I’m always interested in learning how to help other people.”