Invasive fetal medicine: pros and cons]

Many methods of ovular sampling now exist. They give us access to our second patient, the foetus, for the purpose of carrying out diagnoses and prognoses and of beginning treatment. These methods carry a risk for the foetus, and it is therefore to weigh up the indications carefully. In addition, some methods (embryoscopy, foetoscopy, skin and liver biopsies, foetal blood samples) have to be performed by experienced specialists in reference centers. These methods also raise numerous ethical problems, notably in view of the multiple diagnostic possibilities and the relatively limited therapeutic possibilities.     

Recurrent implantation failure: gamete and embryo factors

Chromosomal abnormalities, sperm DNA damage, zona hardening, inadequate culture conditions, and suboptimal embryo development all play a significant role in the etiology of recurrent implantation failure. Evidence suggests that preimplantation genetic screening does not increase implantation or live birth rates. Comparative genomic hybridization array and analysis of single nucleotide polymorphisms could enable a more comprehensive screening of chromosomes. Assisted hatching may help to overcome zona hardening in selected cases. Optimal culture conditions and blastocyst transfer could contribute toward improving implantation and pregnancy rates. Novel embryo assessment and selection procedures, such as time-lapse imaging and metabolomics, may help in better evaluation of embryo quality and viability and help in selecting embryos with the highest implantation potential. The safety and efficacy of emerging treatment modalities should be evaluated in prospective randomized clinical trials before being applied in routine clinical practice.     

The amniotomy question: examining the pros and cons of rupturing membranes

The culture of birth establishes practices and embraces rituals. Currently there is a movement toward midwifery and away from hospital births as women and professions question the values of some practices and interventions common in hospital births. Amniotomy is a well-established practice that is accepted as an intervention to help women in their birth process, with the hope that it will shorten labor. There is little research regarding the psychological implication of amniotomy on the infant. This paper explores the pros and cons of amniotomy, its role as a ritual for birth attendants and the possible psychological effects on the infant.     

The use of grafts for anterior vaginal prolapse repair: pros and cons

PURPOSE OF REVIEW: To review the advantages and disadvantages of ungrafted and grafted methods of anterior vaginal prolapse repair. RECENT FINDINGS: Successful correction of anterior vaginal prolapse remains one of the most challenging aspects of pelvic reconstructive surgery. Anterior colporrhaphy is associated with an unacceptably high recurrence rate. Paravaginal repairs are technically more difficult to perform and may be associated with more complications. The low success rate has consequently led to more frequent use of grafts in anterior vaginal prolapse repair. Although retrospective case series of graft-reinforced anterior vaginal prolapse repair shows promising short-term success rates, mesh-related complications are of concern. SUMMARY: The goal of pelvic surgery should be restoration of anatomic support without deleterious effects on visceral and sexual function. Limited data are available on quality of life and sexual function following both traditional and graft-reinforced anterior vaginal prolapse surgery. Although mesh-reinforced repair is associated with lower short-term anatomic recurrence, the long-term durability and safety of mesh-reinforced repair is unknown. Further research is required to determine whether surgical technique and type of graft used impact surgical outcome and complications.     

Clinical perspectives on gamete and embryo donation

Clinical staff involved in assisted reproduction frequently encounter ethically complex clinical problems. Such difficulties often relate to the use of donor sperm, eggs or embryos. Despite a fall in the number of donor insemination (DI) cycles performed in the UK over the last few years, which is partly explained by the availability of intracytoplasmic sperm injection (ICSI), there is still a considerable demand for the treatment both in natural cycles and in IVF. The burden on clinics in providing sound recruitment and screening strategies for donors is enormous and is the subject reviewed in this report. If remuneration of donors were withdrawn, as proposed by the Human Fertilisation and Embryology Authority (HFEA), the capacity to maintain a clinical service would be in doubt. Advances in technology are now pushing to the extremes the limits of what is socially acceptable. Those involved in providing clinical services face decisions on rationing the limited funds available to treat patients, which in some instances may impinge on patient autonomy. Clinical ethics committees may have a role in assisting providers in reaching decisions regarding access to treatment. Inequity of access to treatment may relate to the inability to pay for treatment, with the consequent danger of different ethical standards applying to different sectors of the population.     

Five years of single embryo transfer with anonymous and non-anonymous oocyte donation

Single embryo transfer (SET) has been the main embryo transfer strategy in the oocyte donation programme at the authors' clinic since 2000. The primary aim of this study was to evaluate the effect of SET on the clinical outcome in an unselected group of oocyte recipients. A retrospective analysis of the outcome in 142 recipient cycles (116 from anonymous donors; 26 from known donors) was performed. The oocytes from each anonymous donor were shared between two recipients if at least 10 oocytes were obtained. The proportion of SET of all fresh transfers was 77.3%. The clinical pregnancy rate (CPR) was 43.2% and the delivery rate 31.1% per embryo transfer. The outcome was similar in recipients undergoing anonymous and non-anonymous donation. The delivery rates were similar after SET (30.4%) or double embryo transfer (DET) (33.3%), whereas the twin rate was 0% after SET and 40% after DET. The implantation rate was significantly better (P < 0.01) with good-quality embryos (54.7%) compared with non-optimal embryos (27.1%). Of 152 frozen-thawed embryo transfer cycles, 78.9% were SET. The CPR was 28.3% and the twin rate was 7.1%. In fresh oocyte donation cycles, elective SET can be recommended if the embryo quality is considered good, and always if there is a contraindication for twin pregnancy.     

Operative treatment of genital prolapse of the female: pros and cons of mesh materials

The development of different mesh materials has led to an improvement of the individual surgical correction of genital prolapse. Macroporous monofilamentous synthetic meshes seem to be the optimal material in case of recurrent prolapse or of severe insufficiency of the pelvic floor. The use of biological meshes shows a markedly better tolerance with fewer infections or erosions despite the lack of evidence-based information on their long-term efficacy and safety. The surgical correction of genital prolapse has to carefully consider all risks and benefits in order to improve quality of life. In this respect, mesh materials can be particularly advantageous in the recurrent situation.