India’s first scientifically documented IVF baby Harsha Chawda is 33 years old now and is the mother of two —a boy and a girl, who were also born in the same hands that gave birth to their mother three decades ago. While Harsha’s birth was a medical wonder in India then, the magic hand that made it happen, Dr Indira Hinduja, is still active in her tireless journey of creating such breakthroughs in the field of assisted reproductive techniques. Dr Hinduja is the country’s most celebrated gynaecologist and the mother of India’s IVF, who again made history with India’s first GIFT (Gamete intrafallopian transfer) baby in 1988 and the country’s first baby through Oocyte Donation technique in 1991. Now, Dr Hinduja is part of another ambitious research project. It aims to create eggs and sperm from human skin cells — a much bigger dream that the world of biomedical research is currently chasing in the field of assisted reproduction. In this edition’s Straight Talk with CH Unnikrishnan, Dr Hinduja says our country has got the brains that can create even greater wonders with a little more support and hard work. Edited excerpts:
You pioneered IVF in India in the eighties. It has become a big industry now and many players are there to provide treatment. Although many childless couples have benefited from it, do you think it is being over-exploited by the industry with a commercial motive, and the passion for further research is lost among the providers?
The ART segment has grown big in India today and there are also research initiatives happening side-by-side, though it is not in proportion to the big ‘business’. But, as it is in any other industry, there are black sheep in this field as well and patients have been exploited with no proper treatments, overcharging and other unethical practices. However, with the new set of guidelines laid out by ICMR, I believe most organised players follow them.
But, when I look at my own experience at the time, it was sheer passion to pursue research that led to such breakthroughs in a developing country like India where we didn’t have proper infrastructure, money or motivation. I got interested in it when I was doing my MD. That was the time when the world’s first test-tube baby was born and there were media reports all around. I used to read such reports with much curiosity and followed every development taking place in this area across the world. I remember IVF was then perceived as a miracle and the doctors who were involved in it were considered like Gods. So, I used to always think, is it possible?
How was the beginning?
I tried to read all available literature related to earlier research, especially how they did it in animals like rats, mice etc.. At that time, India had no infrastructure and opportunities for one to pursue research in this field. So, I thought I will go to the UK once I finish my MD, to pursue this. It was at that time that I happened to notice that there is an ICMR Institute of Research in Reproduction near the bus stand close to KEM Hospital in Mumbai, where I was doing my MD. Though it excited me, I had no guts to approach it as it was a government organisation and there the regulations are different. One day I went and met Dr Peter at the institute who was doing reproduction in animals, in hamster etc., as part of his Ph.D. I asked him if I can know exactly how he is doing it and why it’s not done in humans. He was excited when I offered that, since we do sterilisation in women at KEM and sometimes we find ovulation and collect the egg, we could give it to him to be used in his research. That was the beginning. It was in early 80s, and we designed a long spiral needle to collect eggs, though many of my attempts to collect the human egg failed. Finally, I managed one and we tried to see the difference between the hamster egg and human egg and if they required the same medium to grow etc. Since that was a breakthrough, we wanted to present it in a Boston conference. I had no money to go to Boston and one of my friends bought a ticket for me. While we presented the paper, there was overwhelming response as we were there from a developing country. But unfortunately, I couldn’t pursue the same project with Dr Peter as he left Mumbai when I was back from the US. But later, I had to register for Ph D under Dr Anant Kumar from ICMR to continue the project and literally struggled between my working hours in KEM for MD and the additional time at ICMR institute for Ph.D.
Those days were tough but exciting. I would collect the ovulation fluid from hospital and come running to the lab to keep it in the incubator and again come in the afternoon to screen the egg. This is how I started, with a grant from ICMR and also with active support from KEM. I actually went through a lot of struggle. And, when I got the first pregnancy in vitro, I just couldn’t believe it and I came running to Kusum (my friend) and to my hospital to say that I got it positive. The pregnancy test [result] was announced and flashed in the media. At the same time, I got a firing from my team at ICMR for giving it to the media, though it all happened accidentally after a media person picked up the news at a KEM meeting. Shortly after that, I got the second result, and another day, three conceptions together. Without any infrastructure, I used to distil and autoclave the water and prepare the media, though all these are readily available today.
IVF has revolutionized the field of reproductive technology, providing hope, faith and a chance at parenthood to childless couples suffering from a variety of causes including male factor, who struggle with various medical and social aspects of infertility. Could you elaborate the process that you followed in this revolution?
Infertility is a multifactorial disease in which couples are unable to achieve a pregnancy even after being sexually active and not using any contraception. In vitro fertility in India was inspired by the success of Dr Patrick Steptoe and Dr Robert Edwards — the scientific team that created the world’s first ‘test tube baby’ — Louise Brown — in 1978. We, under the aegis of the Institute of Research in Reproduction of the Indian Council of Medical Research (ICMR) and Kings Edward Memorial Hospital (KEM) in Mumbai, started testing the therapeutic and surgical procedures initially on laboratory animals. Success in animals was followed by extensive work for an attempt to achieve the same in humans. From August to December 1985, a number of cycles were taken up for IVF-ET. Each cycle of failure taught us what could be further improved in our methods and techniques. The patient, Maniben, was then 23 years old and married, and whose fallopian tubes had been damaged due to a tuberculous infection and subsequent surgery. Consolidating the lessons that we learnt from previous patients, we used the following procedure.
Ovaries of women contain millions of eggs since birth, and a number of eggs start growing in each menstrual [cycle], one egg matures in a single cycle and releases eggs (oocytes) for the purpose of fertilisation. For in-vitro fertilisation, we needed that the ovaries should release more than one egg. Hence, the ovaries were stimulated by giving Oral medication namely, (clomiphene citrate 100mg) from day 3 to day 7 of the menstrual cycle. The oral medication was supported by administering an injection of human menopausal gonadotropin, which was also given intramuscular daily from day 5 to day 10 of the cycle in a dose of 75 IU per day. The number and size of the growing follicles was monitored by doing transabdominal sonography. The growth of these follicles suggested that multiple eggs were maturing in the ovary. We correlated this with levels of blood oestradiol, a hormone released by growing follicles.
An increase in the level of this hormone means that ovaries are responding to treatment and the eggs are growing. In this manner, we were able to see at least four growing follicles in each of the ovaries of the patient.
When the follicles were adequately grown, an injection of Human Chorionic gonadotropin (hCG) 10,000 IU was administered to the patient on day 13 to mature the egg within the follicle. This was in order to make the egg ready for fertilization. Thirty-four hours after hCG, the eggs were retrieved. Using an abdominal approach, the ovaries were seen, and a needle was inserted in each follicle to remove the fluid collected in the follicles. This fluid was screened under microscope for the presence of oocytes / eggs. In this way, we found 5 mature eggs and 3 immature eggs.
Simultaneously, the semen of the husband was taken, washed and centrifuged. This helped us to isolate the best and most rapidly motile sperm from the sample for fertilisation. The eggs that were retrieved were combined in a laboratory dish with her husband’s sperm. The eggs were seen after 24 hrs for penetration of sperm in it and it was checked after 48 hours and 72 hours for further growth, i.e., 2-4 cells and 6-8 cells. Shortly, (on November 30, 1985), we transferred the embryos into the patient Maniben’s uterus. On December 18, we did BhCG testing, which indicated a positive pregnancy test and subsequently confirmed the pregnancy by redoing the BhCG test on 26 December 1985. Ultrasound was done on January 6, 1986 which showed a healthy growing pregnancy.
Have you ever wondered why none attempted this before you in India even as the world’s first test tube baby was born in 1978?
I think there were many reasons, including the lack of infrastructure and a focused effort from the larger institutions, as well as the controversies surrounding artificial reproduction in humans. We all remember the strong opposition and the uproar against artificial reproductive techniques and IVF in 1978 from key religious bodies like the Vatican Church and some Muslim organizations.
What about the other ART breakthroughs that came your way after IVF?
The later projects, such as the first case of GIFT in 1988 and the first case of egg donation in 1990, enabled the use of somebody else’s egg in women whose ovaries can’t produce eggs for natural fertilisation. In the case of GIFT, the egg and the sperm are inserted in the fallopian tube of the mother before fertilisation. Whereas, under the egg donation, a woman’s ovaries are stimulated to produce multiple mature eggs, which are then harvested and donated, usually for the purpose of assisted or third-party reproduction. These eggs may also be frozen for later use or for in vitro fertilisation.
There are apprehensions, even among gynaecologists, about defective or multiple pregnancy in IVF and future health issues in ART children. Any comments?
Such fears are baseless. In IVF, there are rare possibilities of pregnancy happening in the tube, which you cannot prevent, because the embryo that is inserted into the uterus may migrate into the fallopian tube. This happens in the natural process as well, and it has nothing to do with IVF in particular. In order to ensure the success rate in ART, we put in multiple eggs, where chances of multiple pregnancy are more. But mostly, the patients do accept it or rather they wanted it. The concerns about future health issues in both ART as well as natural pregnancy are mostly addressed by the latest NGS technologies and parental and neonatal screening and tests.
What is next in focus?
While stem cell treatment to rejuvenate ovaries to produce eggs is one of the latest focus areas in the field of biomedical research, another revolutionary concept that is currently being worked on in the world, including India, is to create eggs and sperm from human somatic cells like the skin, fertilise it and preserve it. It has been proved in animal studies. We have created in our lab stem cell from the skin, but we haven’t differentiated it into egg and sperm. We will start that work once we get the required permissions. There are additional processes required to extract stem cells from the skin and then stimulate it in such a way that they differentiate into egg and sperm, which has been proved. We have already got a grant from BARC to create a stem cell from women’s skin.
Stem cells are the first cells to come from the embryo. Before the embryo becomes a baby, you can create organs using the stem cells in it. Now, from the skin, you can create tissues similar to the embryo, and from this, stem cells can be sourced to create any organ such as the heart or the liver, and now, eggs and sperm. This can overcome the ethical issues surrounding embryonic stem cells. We have already created stem cells from skin biopsy. This revolutionary technique offers help to couples eager to have a child that is genetically theirs, but who lack the eggs or sperm to make it. This project is inspired by the path-breaking finding of a Japanese research team led by biologists Shinya Yamanaka and Kazutoshi Takahashi. It could also result in any one of the couple providing both the sperm and the egg, creating a ‘unibaby’.