Introduction

Infertility is recognized by the World Health Organization (WHO)^1), as a disease affecting approximately 15% of couples of reproductive age worldwide² and at least 1 million people in Peru³. In vitro fertilization (IVF), a highly complex assisted reproduction technique (ART) widely used worldwide, is presented as the solution to this disease, helping women or couples to have a child^.(4.

The first IVF birth in Peru occurred more than thirty years ago⁵. The first IVF birth reported in a province of the country dates back to 2006 ⁶, and although it was a starting point, the development of fertility centers in the provinces has been quite slow. However, since 2014, Peru has experienced a dizzying increase in the number of fertility centers in the provinces, and currently there are highly complex assisted reproduction laboratories on the coast (Chiclayo, Piura, Trujillo) and the highlands (Cuzco, Cajamarca, Arequipa, Huancayo). However, many couples from the Peruvian Amazon region who seek to start their assisted reproduction treatment are forced to leave their city of residence, despite the enormous difficulties that this represents in form of additional costs of transportation, accommodation, job abandonment among others. Hence, this procedure becomes even more expensive. In our country, it has a high price and is not covered by any type of health insurance.

For various reasons, the Amazon Region has always been the most forgotten region of Peru⁷ and with the least accessibility to ART, so there are no reports of the use of low or high complexity ART in this region. Since 2017, the specialized in vitro fertilization clinic (CLINEFIV in Spanish) began its assisted reproduction program in the district of Tarapoto, San Martin province, San Martin department, with the aim to attend this sector of the population.

This report describes the first IVF birth in the Peruvian Amazon Region, being a clinical case performed with own oocytes, extended culture to blastocyst stage and deferred embryo transfer. All medical and laboratory procedures were performed entirely in the same region.

Case report

A 34-year-old woman from Picota city (62 km from Tarapoto) was referred to our center with diagnosis of bilateral tubal obstruction confirmed by hysterosalpingography and antimüllerian hormone (AMH) levels 2.2 ng/mL. Her hormonal profile on the second day of her period was within normal limits (FSH: 4.1 mIU / mL; LH: 4.6 mIU / mL; TSH: 2.6 mIU / mL; estradiol: 98 pg / mL; prolactin: 6, 2 ng / mL). Her 25-year-old husband had normal espermatogram (volume: 2.8 mL; concentration: 68 x106 million / mL; progressive motility: 52.9%) and normal sperm DNA fragmentation (9.5%). On the third day of her period, a clinical examination and transvaginal ultrasound were performed, determining 13 antral follicles, absence of residual follicle and 5 mm linear endometrium. Controlled ovarian stimulation was immediately started with 300 IU of hMG-hp and letrozole (5 mg/day) for five days. On the sixth day of stimulation, cetrorelix 0.25 mg daily was started for 3 consecutive days with three 14-mm follicles. On the ninth day of stimulation, both ovaries presented 10 follicles between 16 mm and 20 mm. 5000 IU of hCG were administered and the aspiration was performed 35 hours later.

Six mature oocytes were aspirated. The husband's seminal sample was obtained by masturbation and spermatozoa were selected by the density gradient technique. Embryos were cultured and developed in LifeGlobal culture media in a Trigas incubator (6.3% CO2 and 5.0% O2). The insemination technique consisted in conventional IVF utilizing the co-incubation of sperm and oocytes in the Global Total for Fertilization medium. After 19 hours, fertilization was evaluated, obtaining 5 embryos (fertilizationrate: 83.3%). These were cultured in Global Total for culture until 110 hours post-insemination, when we finally obtained two expanded blastocysts (blastulation rate: 40%) of excellent quality (Figure 1A) which were vitrified according to the Kuwayama technique⁸.

Figure 1 A) Photograph of blastocysts at day 5 of embryonic development. b) photograph of blastocysts after thawing, before transfer. 

On day 21, an intramuscular injection of leuprolide acetate was administered, initiating menstruation eight days after its application. From that date, endometrial preparation was started with estradiol valerate (Progynova, Bayer) 6 mg daily until 12 weeks of pregnancy. On day 15 of the cycle and 7.3 mm trilaminar endometrium, 800 mg of micronized progesterone (Utrogestan, Ferring) was started vaginally until 12 weeks of pregnancy. On day 20 of the cycle, two devitrified embryos were transferred (Figure 1B).

12 days after the embryo transfer, the quantitative beta-hCG was 466.3 IU / mL, confirming pregnancy. Two weeks later, a gestational sac was observed with cardiac activity present. Prenatal control evolved within normal limits. On December 18, 2017, a 3 920 grams male baby was born by cesarean section at 38 gestational weeks without complications. The birth symbolized the first IVF birth in the Amazon Region of Peru, where all assisted reproduction medical and laboratory procedures were carried out entirely on-site. The child is currently two years and nine months old and is in good health.

Discussion

Access to IVF varies globally⁹, being extremely low in resource-poor settings due to the lack of health coverage¹⁰. Latin America has always had less access to ART compared to developed countries¹¹. In 2017, Latin America reached 221 cycles started per million inhabitants, considering the 12 countries with reliable data reporting to the Latin American Register of Reproduction (RLA). In addition, 205 cycles per million inhabitants¹² were performed in Peru. These figures are well below the threshold of 1 500 annual cycles per million inhabitants needed to meet the needs of any population, as proposed by the European Society of Human Reproduction and Embryology (ESRHE) Capri Group¹³.

Considering the little access of patients to ART in our country and the real tendency to postpone motherhood¹⁴, we face a health problem.

Unfortunately, the displacement of patients from the Amazon Region to other cities where fertility centers do exist, further increases the gap between patients from this region who can and cannot afford and perform a fertility procedure.

This birth is an important event in the history of gynecology and fertilization in Peru and particularly for the Amazon Region, because all the medical and laboratory reproduction procedures were fully performed locally for the first time. The birth of a healthy baby is the goal of all ART procedures and, as medical professionals, we are proud to know that decentralization and access to ART in Peru is increasing.

In conclusion, this report shows that it is possible to achieve IVF births in the Amazon Region of Peru by performing all the procedures in situ, without displacement of the patients and making this medical treatment more inclusive. With this birth, assisted reproduction in this region is no longer a dream but a reality. We are pleased to report that to date we have achieved more than 20 healthy births by ART in the department of San Martin and although the road is long and full of obstacles, we will remain firm in our mission to make assisted reproduction in Peru a more decentralized and fairer health service.