Controlled ovarian hyperstimulation for the new reproductive technologies

The aim of controlled ovarian hyperstimulation (COH) is to induce multiple morphologically and functionally adequate follicles with the aim of harvesting multiple fertilizable oocytes. We compared several treatment regimens with different FSH/LH ratios: group I was the basic 2 human menopausal gonadotropins (2hMG) protocol in which 2 ampules of hMG were administered starting on day 3 of the cycle; group II was the basic 2hMG in which 2 ampules of "pure" follicle stimulating hormone (p-FSH) were added on day 3 and 4; group III was the 2 FSH protocol in which 2 ampules of p-FSH were administered beginning on day 3; finally, group IV was the 4FSH: 4 ampules of p-FSH on day 3 and 4 followed by 2 ampules of p-FSH daily. The reference regimen was the 2hMG. Except for the higher rate of immature oocytes in 2FSH and 2hMG protocols, the number of preovulatory oocytes and fertilization rate were similar in all protocols. No differences occurred in the pregnancy outcome. The low dose Lupron (LDL) stimulation was an experimental protocol applied to two groups of women who had previously failed COH. Eight women who had a premature luteinization and 8 women who showed a low response agreed to participate in the protocol. Ten micrograms of the GnRH agonist leuprolide acetate (Lupron) were injected subcutaneously every 6 hours starting on cycle day 2 and menotropin stimulation was begun on day 3-5, according to individual patient response. The LDL protocol was successful in determining a favourable estradiol pattern and fertilizable oocytes.     

Women's reproductive health: monotheistic religious perspectives.

It is important to those who practice reproduction techniques to learn about the different religious attitudes related to reproductive health problems. Religion exerts an influence on civil authorities in the field of reproduction such as prevention or procreation and in issues such as abortion and infertility therapy. The Jewish attitude towards reproduction can be learned from the fact that the first commandment of God to Adam was be fruitful and multiply. Judaism allows the practice of all techniques of assisted reproduction when the oocyte and sperm originate from the wife and husband, respectively. All Rabbinical rulings permit the use of contraception for medical indications. Economic difficulties and inconveniences of raising children are not indications for birth control practice. According to Judaism abortion on demand is forbidden but it may be performed if the mother's life is in danger. The attitude toward reproductive practice is different among the different divisions of Christianity. The practice of assisted reproduction is not accepted by the Vatican, however, it may be practiced by Protestant, Anglican and other Denomination's. According to the Roman Catholic doctrine the primary purpose of marriage is procreation. The contraceptive act destroys the potential of producing new life by sexual intercourse and violates the purpose of marriage and, therefore, is a sin against nature. The Christian tradition views the embryo as a human being since conception and, therefore, abortion is strictly forbidden. According to Islam, the procedure of IVF and ET is acceptable, however, it can be preformed only if it involves the husband and the wife. It allows contraception practice only under some circumstances and only in some special cases abortion can be preformed. Religion, being concerned with affairs that are regarded as extraordinary and as having unique importance in life, is an intrinsic aspect of the culture of all societies, religious groups, however, still exert influence on the civil authorities in issues of reproduction such as contraception, procreation, abortion, and infertility therapy. They have been active in pressing their bioethical positions on the public arena in pluralistic societies. Developments in science and technology in reproduction raise new religious questions that do not always have clear answers. The role of theology in bioethics is foremost to clarify for the different religious communities the perceived attitudes toward these developments. Therefore, it is important to those who practice reproduction techniques to learn about the different religious attitudes related to reproductive health problems.     

A satellite system for assisted reproductive technologies: an evaluation

The University of North Carolina at Chapel Hill (UNC) Satellite System for Assisted Reproductive Technologies (ART) was initiated in 1984, and now serves most of North Carolina and parts of two adjoining states. The system was established to enhance the care of infertile couples at the community level, to assure a sufficiently large volume of patients at UNC Hospitals to support appropriate quality control measures, and to allow couples undergoing ART to have most of their care in their own community. This paper reports an assessment of the outcome of this program. Neither pregnancy rates, nor any other measurable result of the program differed between patients managed in the satellites and those cared for at UNC Hospitals.     

Assisted reproductive technologies for male factor infertility

Experience in the diagnosis and treatment of infertility has led to an increased understanding of the prominent role male factors play in many couples' inability to conceive. While many forms of male factor infertility are amenable to treatment, for some patients there is no corrective therapy available. For this reason, a great deal of attention has been focused on developing technologies for semen processing and sperm utilization in cases of decreased semen quality. One area of research is the development of more sophisticated methods of assessing sperm function, as well as methods of sperm preparation. Progress is also being made in the application of technologies such as intrauterine insemination and in vitro fertilization in the treatment of male factor infertility. Such developments have improved prospects for fertility among patients suffering from decreased semen quality, as well as those suffering from such disorders as ejaculatory failure and congenital vasal agenesis. Current research also offers promise for future applications such as gamete micromanipulation. This technology holds potential for improving fertility even among patients suffering from profound male factor disorders. The following is a summary of recent publications pertaining to the application of these assisted reproductive technologies in the management of male factor infertility.     

Analgesia and anesthesia for assisted reproductive technologies

Background

Oocyte retrieval for in vitro fertilization (IVF) is one of the most common minor surgical procedures.

Objectives

To give an update on anesthesia practices used currently in the United States and Europe in assisted reproductive technology, and discuss the safety or the potential risks for oocyte and embryo quality.

Search strategy

Electronic search of MEDLINE for literature published between 1972 and 2008.

Selection criteria

Relevant studies on the types of anesthesia used for oocyte retrieval and the impact on oocyte and embryo quality.

Data collection and analysis

Relevant studies were reviewed by the authors and the ones of significant scientific merit, based on methodology, were included.

Main results

Types of anesthesia that may be used for transvaginal follicular aspiration and oocyte retrieval include: general anesthesia, neuraxial anesthesia, conscious sedation, injection of local anesthetic agents into the cervix or the vaginal wall, or any combination of the above. Conscious sedation is most commonly used in IVF because it is relatively safe and does not require the presence of an anesthesiologist when opioids or benzodiazepines are used. Propofol is the preferred anesthetic agent, but should be used by specially trained personnel.

Conclusion

Conscious sedation is the most popular method of anesthesia used in IVF. Presently, a combination of propofol, fentanyl, and midazolam is used frequently. It is easy to administer in cooperative and motivated patients and is safe in healthy individuals; it has a relatively low risk for adverse effects on oocyte and embryo quality and pregnancy rates.     

Assisted reproductive technologies on the Web

The rapid advance of the World Wide Web presents significant challenges for ensuring quality of health care information presented to a global audience. Using American Medical Association guidelines, Huang and co-authors have issued a report card for Society for Assisted Reproductive Technology-affiliated websites, indicating much room for improvement.     

The thin endometrium in assisted reproductive technology: An ongoing challenge

Thin endometrium is identified to adversely affect reproductive success rates after assisted reproductive technology (ART). Several treatment modalities have been presented to patients with thin endometrium, to improve endometrial thickness and the subsequent endometrial receptivity. These approaches comprising hormonal management by estradiol, tamoxifen, human chorionic gonadotropin (hCG) and gonadotropin-releasing hormone (GnRH) agonist, vasoactive agents such as aspirin, vitamin E, pentoxifylline, nitroglycerin and sildenafil, intra-uterine infusion of growth factor such as Granulocyte Colony Stimulating Factor (G-CSF) and the latest application of platelet-rich plasma, electrical stimulation, regenerative medicine and presentation of endometrial receptivity array. In spite of the large variety of treatment, most of the choices achieve only minor modification in the endometrium thickness and have not been validated so far. Treatment of thin endometrium remains a challenge and future enormous investigations are required to further clarification and ideal management of patients with thin endometrium.     

Male infertility: the impact of assisted reproductive technologies.

Spermatozoal abnormalities are present in up to 40% of infertile couples. Multiple etiologies may be responsible for these disorders, including pretesticular, testicular, and ductal causes. An adequate andrologic consultation, including history, physical examination, and repeated semen analysis, should be performed routinely in these cases. Evaluation of the basic sperm parameters, including sperm concentration, motion parameters (as evaluated by computer-assisted semen analysis), and sperm morphology (as judged by strict criteria), constitute the first obligatory step for a critical evaluation of male factor patients. Patients in whom fertilization disorders are suspected should be evaluated through bioassays of sperm-oocyte interaction, including the heterologous sperm penetration assay and hemizona assay, a bioassay of sperm-zona binding capacity highly predictive of in vitro fertilization outcome. Male disorders can be subjected to specific therapies (surgical or medical), or to empiric therapeutic modalities. Assisted reproductive technologies have enhanced our understanding of the physiopathology of spermatozoal disorders and also have ostensibly improved pregnancy rates in male factor patients.     

Assisted reproductive technologies in India: the views of practitioners

Background. This article documents the context of Assisted Reproductive Technology/ies (ART) services and providers' perceptions regarding services offered in India. The objective is to facilitate understanding of critical issues and relevant concerns.

Methods. A postal survey conducted with a sample of 470 gynaecologists and in-depth interviews with 39 gynaecologists in four cities.

Results. ART clinics have proliferated in cities and towns; they are commercialised and the quality of treatment is variable. Most providers perceived that patients lack knowledge about infertility and ART, costs are high, investigations unnecessarily repeated and success rates low. ART providers do not have clear selection criteria, some lack rigorous specialised training and infrastructure and most are deficient in record-keeping and counselling and lack transparency. Monitoring and regulation by appropriate authorities are also lacking.

Conclusion. Both providers and regulatory authorities need to look critically at exploitation of patients and commercialisation, excessive costs, lack of information, informed consent, and transparency, counselling, unethical practices, variations in quality of treatment and ensuring proper monitoring and regulation.     

Multipurpose prevention technologies for reproductive and sexual health

Global statistics on unplanned pregnancies, abortions and STIs show that unprotected sex is still widely practised. More needs to be done to provide women and men with a wider choice of convenient protective options. To address this need, international efforts are focusing on developing multipurpose prevention technologies (MPTs) that address two or more indications simultaneously. These technologies would have significant advantages over single-indication products. They include inter alia novel barrier devices, drugs administered either as oral tablets or vaginal/rectal gels, drugs used in combination with medical devices, and genetically engineered organisms which secrete antimicrobial substances. As an example of progress in the MPT field, this paper describes an on-demand contraceptive/antimicrobial vaginal gel, Amphora (previously known as Acidform), now in an advanced stage of development. Clinical trials are currently being planned to find out whether this product’s promising antimicrobial profile translates into protective and preventive choices.     

Preeclampsia in multiple gestation: the role of assisted reproductive technologies

OBJECTIVE: To estimate the relationship of assisted reproductive technologies and ovulation-inducing drugs with preeclampsia in multiple gestations. METHODS: This historical cohort study was conducted on 528 multiple gestations from a Colorado health maintenance organization. Using univariate and logistic regression analysis, we determined if women who conceived a multiple gestation as a result of assisted conception were at a greater risk of preeclampsia than those who conceived spontaneously. RESULTS: Between January 1994 and November 2000, there were 330 unassisted and 198 assisted multiple gestations. Sixty-nine multiple gestations followed assisted reproductive technologies (in vitro fertilization and gamete intrafallopian transfer). Human menopausal gonadotropins and clomiphene citrate were associated with 38 and 91 of the multiple gestations, respectively. Compared with unassisted multiple gestations, the relative risk of mild or severe preeclampsia among mothers who received assisted reproductive technologies was 2.7 (95% confidence interval [CI] 1.7, 4.7) and 4.8 (CI 1.9, 11.6), respectively. Adjusted for maternal age and parity, women who received assisted reproductive technologies were two times more likely to develop preeclampsia (odds ratio 2.1, CI 1.1, 4.1) compared with those who conceived spontaneously. The adjusted odds ratios of nulliparity and maternal age for preeclampsia were 2.1 (CI 1.3, 3.4) and 1.1 (CI 1, 1.1), respectively. Although the incidence of preeclampsia was greater in mothers who received clomiphene citrate and human menopausal gonadotropins, this association did not reach statistical significance at the P <.05 level. CONCLUSION: Women who conceive multiple gestations through assisted reproductive technologies have a 2.1-fold higher risk of preeclampsia than those who conceive spontaneously.     

Reproductive surgery vs assisted reproductive technologies: selecting the correct alternative

Many innovations have been made in advanced reproductive technologies (ART) over the past several years. These procedures now yield pregnancy rates of over 20% per cycle, rates that compare favorably to many types of reproductive surgery. Therefore, ART now represents a viable alternative for many patients suffering from infertility. As these pregnancy rates continue to rise, gynecologists will have to choose between ART and reproductive surgery for a larger number of patients. This article reviews the commonly performed reproductive surgical procedures and compares expected postoperative pregnancy rates to those of ART in order to help the gynecologist make this decision.