In 2008, two doctors approached Dr. Jonathan Van Blerkom, a professor at the University of Colorado and longtime embryologist, with an audacious proposal: bring in vitro fertilization, the groundbreaking but expensive infertility procedure which fertilizes eggs outside the womb, to the developing world, where access to the procedure is practically nonexistent. The doctors, Dr. Sheryl Van Der Poel from the World Health Organization and Dr. Willem Ombelet, from the Belgian nonprofit The Walking Egg, wanted to set up expensive Western-style IVF labs using hand-me-down equipment. Van Blerkom was less than enthusiastic.
"I said this is doomed to failure," he recalls. A power surge — not uncommon in a country with limited infrastructure — could fry finicky but essential equipment in an instant. There would be no easy way to supply the purified medical-grade gasses required to incubate embryos, among many other problems. But Van Blerkom was intrigued. "I said there’s gotta be a simpler way."
Six years later Van Blerkom’s simpler way exists, and there are 16 Belgian babies to prove it. In a miniature IVF lab about the size of a shoebox, Van Blerkom’s system creates the same conditions necessary for fertilization as a multimillion-dollar lab, at a fraction of the cost.
Traditional IVF is expensive. A cycle averages $12,400 according to the American Society for Reproductive Medicine. This is because IVF in the US uses sophisticated, well-staffed labs, where eggs are fertilized in high-tech incubators flooded with expensive gases. Van Blerkom created a way to get the right mixture of gasses for fertilization in a tiny tube by mixing sodium bicarbonate and citric acid; a mixture not so different from Alka-Seltzer. The tube where the atmosphere is created is then linked by a tiny hose to another tube, which contains the medium where the egg and the sperm eventually mingle. Taking out the need for gasses and incubators, Van Blerkom’s procedure makes IVF much more affordable. When combined with cheaper and milder hormones, Van Blerkom’s procedure could lead to cheap IVF for patients not just in the developing world, but in places like the United States as well.
"I said there’s gotta be a simpler way."
Inspiration for the new method struck months after the 2008 meeting, at one in the morning on a Colorado highway, en route to a house Van Blerkom has high up in the Rockies. Van Blerkom was thinking about a toy from his childhood purchased with boxtops from Kellogg’s Cornflakes, a tiny plastic diver with two chambers. One chamber was filled with vinegar and the other with baking soda. Together the chambers would make CO2, causing the diver to dip and resurface, releasing bubbles along the way. CO2 is also an essential gas for IVF. The diver reminded Van Blerkom of his time as a grad student in the ’70s, driving rabbit and pig embryos between labs in Arizona and Colorado for experiments. To keep the embryos alive, he’d put them in a mix of sodium bicarbonate, water, and citric acid. If the pH got too high to keep the embryos safe, he’d inject some CO2. It was simple. It was cheap. Van Blerkom realized this old ad-hoc system to keep animal embryos alive in transport could be the basis for a whole new kind of IVF lab.
"The chemistry is trivial, it’s how you make bread," says Van Blerkom. For two years he worked out his system on mice embryos. In a vacutainer, a vial normally used to collect blood, he mixed sodium bicarbonate and citric acid, then with a rubber hose, linked that tube to another that has the medium where the fertilization will take place. The tubes can maintain the right atmospheric mood for about a week. During that time an egg is put into the tube with the medium along with 4,000 or 5,000 sperm.
"The next day without opening that tube you can see if there is fertilization and then you can follow the embryo development," says Ombelet. The procedure is made cheaper with the use of milder hormone stimulants for women than are typically used today, and works in 70 percent of infertility cases according to Ombelet. The other 30 percent of cases, which are mainly due to low sperm counts and require injecting sperm directly, through a procedure called intra-cytoplasmic sperm injection, or ICSI (although Van Blerkom is optimistic the procedure will work with men who have sperm counts lower than the normal threshold).
Six years later, the simpler way exists, and there are 16 Belgian babies to prove it.
The method proved itself for humans last year in Belgium. With the support of the Walking Egg, more pilot projects are on the way in the UK, South Africa, and elsewhere. If the procedure continues to work, it could provide hope to millions of infertile couples worldwide. But success won’t come without challenge. In the developing world, disseminating simplified IVF requires creating an infrastructure for delivering IVF where none exists, something the Walking Egg is preparing to do. In the developed world, and especially America, it will require undercutting the lucrative IVF industry.
The need for greater access to infertility treatment is acute. Up to 15 percent of couples worldwide are affected by infertility, according to the WHO. Of these millions of couples, only a fraction can access care. "Nowadays we can treat less that 2 percent of the population we need to," says Ombelet.
"It’s real human suffering when a couple cannot have children," says Dr. Dmitri Dozortsev, president of the American College of Embryology, "and people who live in countries with no infrastructure, they suffer just as much."
There’s a case that women who can’t conceive in the developing world suffer the most. According to the WHO, "In many cultures, childless women suffer discrimination, stigma and ostracism." Wives who can’t bear children might be thrown out, given to another man, or watch as their husband brings in a replacement. The burden of infertility falls "disproportionately" on women in the developing world, according to the WHO.
While the consequences of infertility might be less dire in America, the state of care is nonetheless depressing. The average cost for a round of IVF is $12,400, and most insurance plans don’t cover it. More rounds of treatment can result in expenses north of $30,000, none of which guarantee success.
"It’s real human suffering when a couple cannot have children."
After two years of testing in mice, Van Blerkom spent a year convincing the Belgian medical ethics authority that it was worth trying in humans. "It’s so simple that some people don’t believe it," he says. So far, it works, "it’s at least as good as regular IVF," says Van Blerkom. In Belgium, the pilot trial indicated that the new system can be as successful as traditional IVF. Van Blerkom says 16 babies have been born from the simplified procedure so far. In the next six months further trials will be underway in the UK, South Africa, Belgium, and Cyprus. Potential future projects in Ghana and elsewhere will be a part of a larger program that will provide training to local medical technicians, and follow up with patients to see how the treatment is affecting their lives.
Ironically, simplified IVF might be more of a challenge to implement in the US than subsaharan Africa.
"An embryologist who works in the US," says Dozortsev, "I don’t think [is] going to open a lab based on this device." While he calls Van Blerkom’s invention "ingenious" and "beautiful," he doesn’t see how an American embryologist could open up a profitable lab for just 70 percent of infertility cases.
"He’s right, it would not work at all," says Van Blerkom. "Why would I want to substitute a laboratory that has worked for a long time… for something like this?"
Instead, Van Blerkom pictures simplified IVF operating with a wholly new model. The system could be set up directly within hospitals, instead of dedicated multimillion-dollar IVF labs, with the same training and equipment provided in the Walking Egg’s programs abroad. If it cost around $1,000 to do a round of IVF in the hospital, Van Blerkom imagines insurance companies might actually be willing to start covering it.
"It’s going to be a difficult sell," says Van Blerkom, "but eventually somebody is going to say I want to start up a new IVF program, and I don’t want to invest a million dollars."