The Chemokine Connection: Hormonal and Embryonic Regulation at the Human Maternal-Embryonic Interface—A Review

Chemokines are small polypeptides that attract specific leukocyte subsets by binding to cell-surface receptors. In reproductive biology, they have been implicated in ovulation, menstruation, and embryo implantation, and pathological processes such as preterm delivery, HIV infection, and endometriosis.It is known that successful implantation requires a functionally normal embryo at the blastocyst stage and a receptive endometrium that is adequately communicated through the implantation process. This crosstalk is highly regulated, with numerous molecules taking part. Accumulated evidence suggests that chemokines produced and received by the endometrial epithelium and the human blastocyst are implicated in this molecular network. Here, we present updated information on the presence and hormonal and embryonic regulation of chemokines and their receptors during human implantation.     

Human papilloma virus infection and miscarriage: is there an association?

Human papilloma virus (HPV) infection is the most common viral infection of the reproductive tract. HPV infection is more prevalent in pregnant than in age-matched non-pregnant women and its prevalence increases as pregnancy progresses. A number of reports evaluated the role of HPV infection in miscarriages. In the present review, we summarize the existing evidence regarding the association between HPV infection and miscarriage. It is still unclear whether HPV infection is associated with increased risk for miscarriage. Studies in the field yielded conflicting findings and their conclusions are limited by a small sample size and/or methodological limitations. On the other hand, preclinical data support a role of HPV infection in placental dysfunction. Given the high prevalence of HPV infection and the possibility that vaccination against HPV might protect against miscarriage, more studies are needed to elucidate whether this common infection is associated with increased risk for miscarriage.     

Human Fetal Membranes: A Source of Stem Cells for Tissue Regeneration and Repair?

The ability of stem cells to differentiate into multiple cell lineages has ushered in exciting possibilities for stem cell based therapies that would be used to regenerate and repair damaged tissues and organs. Stem cells isolated from the embryo, fetus, adult and also the umbilical cord and placenta are being widely tested. Recent studies show that human fetal membranes also harbour cells with stem cell like properties. The amnion and chorion contain stromal cells that display characteristics and differentiation potential similar to that of adult, bone marrow derived mesenchymal stem cells. Amniotic epithelial cells share some of the features of pluripotent embryonic stem cells and multipotent mesenchymal stem cells and differentiate into multiple cell lineages in vitro. Amniotic epithelial cells also produce numerous substances that could augment tissue regeneration and repair. This review will focus on the stem cell like properties of stromal and epithelial cells derived from human fetal membranes and their potential use in stem cell based therapies.     

Obstetrics and gynecology at the crossroads--again? Still!

It seems, if one can believe presidential addresses, as if our specialty is always at some crossroads or other. In this "opinion piece," uniquely, I don't complain about managed care. I do attempt to identify some of the issues that will be of import for obstetrics and gynecology in the near and not-so-near futures. With regard to research, we await breakthroughs, for example, in the early detection of ovarian cancer, so as to finally be able to improve outcomes. A problem, though, is our failure to focus enough effort on developing a cadre of clinician scientists, who can work out research findings with direct clinical application; this is an issue with which the specialty needs to come to grips. Regarding education, I believe we need to refocus from what type of practitioners we might want to produce to best meet the needs of our patients. The bottom line should be more flexibility in training and emphasis on clinical competence, so that excellent practitioners with competence across the breadth of our specialty are available to provide a full range of appropriate women's health care. The concept of "women's health" is controversial and evolving rapidly. Review of several available sources suggests that reproductive medicine will remain an important component of women's health but that our specialty must now evolve to include other areas, as the major health problems of women change. We need to shift from an organ-based paradigm to a more holistic view, reflecting the woman-centered focus for our specialty. This "paradigm shift" will need to entail continuation of first-rate surgical and obstetrics services but will be expanded to include a full range of services, probably offered by highly trained and competent individuals with specific areas of expertise, practicing in a multi-single-specialty group. Obstetrics and gynecology at the crossroads, indeed!     

Sexual and reproductive rights at the United Nations: frustration or fulfilment?

Over the past 20 years, advocates have gained formal recognition for some rights in sexuality and reproduction and established the application of human rights standards to sexual and reproductive health issues more generally. However, careful reflection on the state of norm development across sexuality and reproduction as a field reveals fractures and stagnation in the development of standards, and a lack of synergy among advocates and between frameworks for similar rights. This paper seeks to stimulate a more careful accounting for these realities. It examines the formal processes and rules guiding standard-setting, in light of the different intellectual and ideological genealogies of sexual and reproductive rights. We use (homo)sexual orientation and abortion as case studies of current high-profile human rights standard-setting, with specific attention to the contemporary state of human rights law-making in the United Nations today. By placing these two issues in conjunction, we seek to make visible relationships between the vicious political debates in the UN on abortion and sexual orientation, and the multiple and sometimes divergent statements of independent experts and expert bodies in the UN human rights system on these and other sexual and reproductive rights issues. We offer no answers but seek to highlight the need for more investigation and self-reflection by advocates and scholars on how these forces operate and how to work with them.     

Human implantation: the last barrier in assisted reproduction technologies?

Implantation processes are highly complex involving the actions of numerous hormones, immunoglobulins, cytokines and other factors in the endometrium. They are also essential matters for the success of assisted reproduction. The nature of early embryonic development is of equal significance. It involves ovarian follicle growth, ovulation, fertilization and preimplantation growth. These processes are affected by imbalanced chromosomal constitutions or slow developmental periods. Post-implantation death is also a significant factor in cases of placental insufficiency or recurrent abortion. Clearly, many of these matters can significantly affect birth rates. This review is concerned primarily with the oocyte, the early embryo and its chromosomal anomalies, and the nature of factors involved in implantation. These are clearly among the most important features in determining successful embryonic and fetal growth. Successive sections cover the endocrine stimulation of follicle growth in mice and humans, growth of human embryos in vitro, their apposition and attachment to the uterus, factors involved in embryo attachment to uterine epithelium and later stages of implantation, and understanding the gene control of polarities and other aspects of preimplantation embryo differentiation. New aspects of knowledge include the use of human oocyte maturation in vitro as an approach to simpler forms of IVF, and new concepts in developmental genetics.     

Should the visceral peritoneum at the bladder flap closed at cesarean sections? A post-partum sonographic and clinical assessment

Objective.?To compare cesarean section (CS) using open or closed visceral peritoneum of the bladder flap (BF) in relation to fluid collection in vesico-uterine space (VUS) by ultrasound (US) and clinical outcome.

Material and methods. A prospective cohort of repeat CS in 474 in advanced first and second stage of labor was studied. All women underwent a Misgav Ladach CS, in local combined anesthesia. These were divided into two groups by surgical management of the BF at the time of CS: Group I (n = 262), with visceral peritoneum left open and Group II (n = 212), with visceral peritoneum closed. An US check for the fluid collections in the VUS was done in the third post-operative day. The two groups were also clinically compared for: intra-operative estimated blood loss, the need for post-CS pain killers, febrile morbidity and duration of hospital stay.

Results.?Visceral peritoneum (VP) closure resulted in a significant increase blood collections in the VUS (p < 0.05). VP closure resulted in a significantly higher morbidity in all the following parameters. Rate of BFHs, post-operative fever, need for post-operative analgesia, require antibiotic administration and prolonged hospitalisation (p < 0.05).

Conclusions.?VP suturing of women requiring CS for dystocia is associated to increased rate of blood collection in the VUS, which could possibly explain the higher rate of puerperal complications in these patients. These data clearly indicate that suturing the VP of the BF in women undergoing CS for dystocia is contraindicated. This data could be probably extrapolated to all cesarean deliveries.     

HIV and germinal cells: how close an association?

Whether semen from someone who is HIV-positive can be prepared so that it is safe for insemination is a critical question particularly to couples in which the male is seropositive and the female is seronegative. It is reassuring that some investigators have reported great success in using sperm washing to dramatically reduce HIV levels in the ejaculate. Such reports suggest that if free virus and leukocytes in the seminal plasma are removed, the specimen may be safe for insemination. Whether the virus ever is associated with spermatozoa themselves is not fully understood. In situ hybridization as well as electron microscopic studies have suggested the presence of viral particles but whether these are preparation artifacts or evidence of viable viral DNA is not known. Studies of whether the virus is incorporated into developing spermatozoa or is shed in the reproductive tract will aid in the elucidation of sexual transmission of HIV.     

Does the localisation of tumour at stage I endometrial endometrioid adenocarcinoma have an impact on invasion of the tumour and individualisation of the surgical procedure?

OBJECTIVE: To detect whether the localisation of the tumour has an impact on the dissemination of the tumour and whether or not surgical procedures should be individualized according to the localisation of the tumour. MATERIAL METHOD: 106 clinically surgically stage I endometrial endometrioid carcinoma cases treated multi-institutionally at Gulhane Military Medical Academy (GATA) and Dr. Zekai Tahir Burak (ZTB) Women's Health Education and Research Hospital Gynecologic Oncology Units in the last five years were evaluated retrospectively. The tumours localised near the internal cervical os and not invading the cervical canal were accepted as lower uterine segment (LUS) localisation and the corporal location as upper uterine segment (UUS) localisation. RESULTS: Tumour localisation was more frequent in the upper segment than LUS (85.9% vs 14.1%). There was no statistically significant difference between only endometrial and only serous invasion rates. Myometrial invasion less than one-half was significantly higher in the UUS group than the LUS group (p < 0.05). Lymph vascular space involvement rate was significantly higher in the LUS group (60%, 9/15) than the UUS group (23 %, 21/91), (p < 0.01). Positive peritoneal cytology rate was 20% (3/15) in the LUS group and 6.6% (6/91) in the UUS group (p > 0.05). CONCLUSION: Patients with LUS involvement should be considered as high-risk patients. Thus more expanded surgery must be taken into consideration. In this study a limitation was the low number of patients with LUS involvement. Larger prospective studies are necessary to confirm our results.     

Has clinical practice been changed by the Human Fertilisation and Embryology Act 1990?

The birth in 1978 of the first baby to be conceived through in vitro fertilization caused both wonder and controversy. Concerns that this technology would be abused led the Government of the United Kingdom to appoint a Committee of Enquiry into human fertilization and embryology, which led to the publication in 1984 of what has become known as the Warnock Report. This made recommendations on the creation of human embryos in vitro, the storage of human eggs, sperm and embryos, and research on human embryos. This report led eventually to the passing by Parliament of the Human Fertilisation and Embryology Act 1990 and the creation of the Human Fertilisation and Embryology Authority, which since 1991 has licensed and regulated all centres and practitioners of assisted reproductive technology. The effects of these regulations are considered in this article. Clinical practice has been affected by the Act, but it has generally led to higher standards of clinical and laboratory practice, improved patient information and care, and improved ethical standards.     

Has clinical practice been changed by the Human Fertilisation and Embryology Act 1990?

The birth in 1978 of the first baby to be conceived through in vitro fertilization caused both wonder and controversy. Concerns that this technology would be abused led the Government of the United Kingdom to appoint a Committee of Enquiry into human fertilization and embryology, which led to the publication in 1984 of what has become known as the Warnock Report. This made recommendations on the creation of human embryos in vitro, the storage of human eggs, sperm and embryos, and research on human embryos. This report led eventually to the passing by Parliament of the Human Fertilisation and Embryology Act 1990 and the creation of the Human Fertilisation and Embryology Authority, which since 1991 has licensed and regulated all centres and practitioners of assisted reproductive technology. The effects of these regulations are considered in this article. Clinical practice has been affected by the Act, but it has generally led to higher standards of clinical and laboratory practice, improved patient information and care, and improved ethical standards.