According to a report published by the WHO in early 2023, 17.7% of the global population is affected by infertility, which translates to about one in six people. In Morocco, this trend is also noticeable. The Ministry of Health estimates that between 850,000 and 900,000 people are affected, which is just over 17% of Moroccan couples. It is important to remember that infertility refers to the difficulty in conceiving a child. The causes can be female (ovulatory issues, endometriosis, fibroids, tubal occlusion, etc.), male (generally due to sperm abnormalities), or a combination.  Meanwhile, the field of ART is constantly evolving.

The latest technologies now utilize artificial intelligence and nanorobots. Some clinics also employ enhanced DNA sequencing to detect genetic and chromosomal disorders in embryos before implantation. But how far should we go? Does this ultra-precise selection raise ethical concerns? Whether these practices are already in place or still in the research phase, we will review the various advances that all share the common goal of offering hope to those dreaming of starting a family.

Current ART techniques

It is estimated that a couple faces infertility after 6 months to a year of unsuccessful attempts. The first step is to understand the root of the problem. This involves a comprehensive evaluation by a gynecologist and a specialized fertility laboratory. Following this assessment, a diagnosis can be made, allowing for various solutions to be proposed. “This may involve surgical indications, such as a patient with polyps or certain uterine fibroids, or a man with a varicocele (a dilation of the veins in the testicles). In these cases, surgery may be performed first, hoping to restore spontaneous fertility. For other couples, we immediately turn to ART,” explains Réda Benmansour. There are currently three different ART techniques. Artificial insemination or intrauterine insemination is the simplest. It involves stimulating the woman’s ovulation with injections to synchronize ovulation with the insemination of sperm directly into the patient’s uterus.

The second technique is the most commonly used worldwide: in vitro fertilization (IVF). This includes two scenarios: classic IVF and ICSI (intracytoplasmic sperm injection). “The choice between the two techniques primarily depends on the sperm count of the partner. In all cases, we start with ovarian stimulation using hormones that the woman will inject daily during the first part of her cycle to collect as many oocytes as possible. These will be retrieved in the operating room under general anesthesia, 36 hours after ovulation. On the same day, the husband will provide his sperm for fertilization,” details the medical biologist.

If the sperm is of good quality and has enough spermatozoa, it will simply be placed in contact with the oocytes in a dish to allow fertilization to occur naturally. Conversely, if there are not enough spermatozoa, biologists will favor ICSI. “This technique involves piercing each oocyte and injecting a spermatozoon inside,” describes Réda Benmansour.

Finally, the third ART technique involves embryo donation, which is prohibited in Morocco, as are donations of oocytes and sperm.

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In search of the best spermatozoa

As you might understand, the quality of spermatozoa is crucial for the success of ART. To select the best, different techniques are available. In the case of IVF, sperm is “prepared” to boost it and recover a fraction of hyperactivated spermatozoa, ready to fertilize. “Naturally, when sperm is ejaculated, it is not fertile. It is when it passes through the cervix, where cervical mucus is present, that it becomes activated. However, when we do IVF, we bypass this step. We put the spermatozoa through a little stress test and then boost them to recruit the most fertile ones,” explains the doctor.

Today, new devices for sperm selection are being developed, such as the Fertile Chip or ZyMöt. “Fertile Chip is a microfluidic technology that replicates the natural conditions of the human body. These are small, single-use devices in which a drop of sperm is placed, and it must migrate through a viscous gel against the current. This gel mimics the action of cervical mucus and allows us to recover the most competent spermatozoa. ZyMöt operates in the same way. Both devices have the advantage of not using centrifugal force, which can damage spermatozoa. However, studies are somewhat contradictory, and the results are not always conclusive. It is promising, but there are still areas for improvement,” details the biologist.

These technologies would primarily aim to select spermatozoa with the least DNA damage. Finally, in the context of artificial insemination, a team of German researchers has developed Spermbots. These nanorobots, shaped like a helix, can wrap around the tail of a spermatozoon to help it reach the ovum.

What about Artificial Intelligence?

Artificial intelligence is also making its way into ART. For the specialist, it is particularly useful in selecting the right embryo to transfer after IVF. This includes technologies like Time-Lapse, which allows for continuous monitoring of embryos using cameras placed in the incubator. In contrast, traditional techniques involve removing embryos every day at fixed times for manual examination. “All the data collected by the Time-Lapse technology will ultimately help predict which embryos are most likely to lead to pregnancy based on morphological criteria. This applies to each couple,” adds Dr. Benmansour.

Generally speaking, AI algorithms will help clinicians make more informed decisions after analyzing a large amount of data on each patient. Although this technology is not yet available in Morocco, Réda Benmansour reassures us. “Today, protocols are becoming increasingly personalized and adapted to each patient based on her ovarian reserve, health assessment, medical history, etc. The gynecologist, in collaboration with the medical biologist, ensures close monitoring. During the stimulation period, several checks are performed using ultrasounds and blood tests to adjust the hormonal treatment if necessary.”

How far should sperm selection go?

While techniques continue to yield better results, this ultra-precise selection of spermatozoa and embryos raises ethical questions. How far can we go? “When we talk about selecting the best embryo, it is not about selecting the one that will be the most beautiful or the most intelligent, but the one that has the highest chance of leading to a pregnancy. The goal is for it to work. An embryo with the fewest morphological anomalies does not mean that the child will have fewer genetic anomalies. It simply means that this embryo has the capacity to implant in the uterus and result in a pregnancy. This is not eugenics, which is strictly prohibited,” responds Réda Benmansour.

However, some countries, such as the United States, Belgium, and Spain, allow for more extensive selection. They rely on techniques like pre-implantation genetic diagnosis (PGD). This is usually used when one of the parents suffers from a serious or incurable condition that may be hereditary. In France, for instance, it is possible to look for gene mutations within the cells of embryos to exclude those with mutations and retain only normal embryos.

Recent DNA sequencing techniques now allow for the detection of a broader range of genetic and chromosomal disorders before implantation. According to ART professionals, this examination could save time and improve pregnancy rates in women over 38, who have a higher rate of embryos with chromosomal abnormalities and thus a higher risk of miscarriages.

However, the limits of these techniques are vague. In the United States, for example, it is possible to choose the sex of a child, the color of their hair, or their eyes simply by analyzing the DNA of embryos before implantation, which raises significant eugenics concerns.

What does the future hold?             ART

Finally, increasingly innovative research and studies are underway. Among them is the emergence of artificial wombs, which would allow embryos to develop outside the patient’s uterus, potentially reducing the risks associated with traditional IVF. Another avenue is in vitro gametogenesis, which aims to create eggs and sperm from skin or even blood cells from a patient, potentially eliminating the need for donors.

ART appears to have a bright future ahead, although it remains accessible mainly only to the most privileged. . In Morocco, each attempt costs between 30,000 and 50,000 dirhams. Nevertheless, Réda Benmansour assures us that results have clearly improved in recent years. The evolution of technologies used, the enhancement of stimulation protocols, and the conditions for culturing embryos significantly increase the chances of pregnancy.

Picture (c) : the skinny confidential