From reproductive choice to reproductive justice

Since the 1994 Cairo Conference on Population and Development, the human rights movement has embraced the concept of reproductive rights. These are often pursued, however, by means to which objection is taken. Some conservative political and religious forces continue to resist implementation of several means of protecting and advancing reproductive rights. Individuals' rights to grant and to deny consent to medical procedures affecting their reproductive health and confidentiality have been progressively advanced. However, access to contraceptive services, while not necessarily opposed, is unjustifiably obstructed in some settings. Rights to lawful abortion have been considerably liberalized by legislative and judicial decisions, although resistance remains. Courts are increasingly requiring that lawful services be accommodated under transparent conditions of access and of legal protection. The conflict between rights of resort to lawful reproductive health services and to conscientious objection to participation is resolved by legal duties to refer patients to non-objecting providers.     

Male reproductive proteins and reproductive outcomes

Male reproductive proteins (MRPs), associated with sperm and semen, are the moieties responsible for carrying male genes into the next generation. Evolutionary biologists have focused on their capacity to control conception. Immunologists have shown that MRPs cause female genital tract inflammation as preparatory for embryo implantation and placentation. These observations argue that MRPs are critically important to reproductive success. Yet the impact of male reproductive proteins on obstetrical outcomes in women is largely unstudied. Epidemiologic and clinical observations suggest that shorter-duration exposure to MRPs prior to conception may elevate the risk for preeclampsia. A limited literature has also linked sexual behavior to bacterial vaginosis and preterm birth. We offer a clinical opinion that MRPs may have broad implications for successful reproduction, potentially involved in the composition of vaginal microflora, risks of preterm birth and preeclampsia, and success of assisted reproduction.     

Assisted reproductive technology

Several aspects of reproductive technology are discussed. In tubal infertility, the choice between surgery or in vitro fertilization and embryo transfer (IVF-ET) is addressed. In cases with bilateral distal occlusion or otherwise bad prognosis, IVF is probably more successful and less expensive. IVF in unstimulated cycles has given promising results, with pregnancy rates comparable to the results from the National IVF-ET Registry. If these results can be confirmed by more studies they will probably have a great impact on the choice of treatment in tubal infertility. The results obtained with various transfer procedures in nontubal infertility have still to prove tubal transfer to be a more effective procedure than IVF. Finally, studies on microinsemination in male infertility or unexplained infertility with previous fertilization failure in IVF show promising results with the subzonal insemination and partial zona dissection procedures.     

Redefining reproductive surgery

With the availability of and improvements in in vitro fertilization (IVF), the role of reproductive surgery has been questioned. Yet, the scope of reproductive surgery today is much larger than in the past. Hysteroscopic correction of intrauterine disease is an important endoscopic procedure in women with infertility. Evidence suggests that correction of intrauterine disease is often followed by spontaneous pregnancy and improved IVF outcome. Hysteroscopic examination should be considered after 1 failed IVF. Today, it is clear that removal of the hydrosalpinx leads to a higher IVF-related live birth rate. The procedure should be performed thoroughly without compromising the ovarian blood supply. The IVF pregnancy rate is not affected by the presence of ovarian endometriomas, and small endometriomas need not be removed; however, large and symptomatic endometriomas that interfere with oocyte retrieval should be excised. When excision of the cyst wall is difficult, fenestration and ablation should be considered. This might lead to an increased recurrence rate, but is associated with less interference of the ovarian reserve. Although the role of reproductive surgery as primary treatment for tuboperitoneal infertility is limited, it has an important role in enhancing the outcome of IVF treatment and in preservation of fertility. Surgical preservation of fertility consists of ovarian suspension, ovarian excision for cryopreservation, and ovarian tissue transplantation.     

New reproductive technologies

The ethical calculus is described. There are four entities that have a stake in all ethical decisions. These are the individual, family, community and society at large. Values assigned to these entities can be modified by experience, cultural background, religious authority and the law. In the simple case of in vitro fertilization (IVF), there seems to be general international acceptance, except for the official position of the Roman Catholic Church, the origin of which dissent is extensively discussed. There is concern about the number of pre-zygotes/pre-embryos to be transferred, the disposition of any unfertilized egg and the reporting of results. Clear ethical considerations arise as IVF is applied in more complex situations, such as unmarried couples, the use of donor gametes and donor pre-embryos, the use of cryopreservation, intracytoplasmic sperm injection (ICSI), prenatal genetic diagnosis, surrogate gestational motherhood and research on the pre-embryo. The ethical, religious and legal acceptance of these depends on the weight given to elements of the ethical calculus as described in the chapter.     

Short-changing reproductive health

Health sector reformers, particularly the economists among them, are prone to reject calls for more financial support for reproductive health as “special pleading” even when the argument is made that reproductive health is a basic human right. Reproductive health is not alone in this. Up to now, however, the idea that the right to reproductive health care should take precedence over other health rights has not been put on the table. Economists ask how much interventions cost and whether there is enough money to cover all of the interventions being proposed; if not, they ask which interventions will be funded. Basing decisions about spending for health on evidence about the burden of disease is a way of using the principles of economics to improve health systems performance. However, this methodology poses some special problems for reproductive health as pregnancy is not a disease. Further, economic principles are not the only valid criteria for decisions about health care funding. Those who are concerned about reproductive health need to remain vigilant about the impact of these changes and counter with their own evidence on how they may or may not be contributing to improved health system performance and to reproductive health and rights.     

Assisted reproductive technology has been detrimental to academic reproductive endocrinology and infertility

The author perceives that there has been a shift away from academics and toward private practice in reproductive endocrinology and infertility over the last 25 years. It has been difficult to integrate assisted reproductive technology into academic medicine in the United States.     

Phytoestrogens and reproductive biology

Phytoestrogens are naturally occurring plant substances that can either mimic or antagonize the action of endogenous estrogens. This is because of the similarity of the functional structure of phytoestrogens and endogenous estrogens. In premenopausal women, phytoestrogen intake might induce a decrease in luteinizing hormone, follicle-stimulating hormone and estradiol (E₂), which are associated with a longer follicular phase. The circulating transport protein, sex hormone-binding globulin, is increased, resulting in less cellular availability of E₂. Phytoestrogens inhibit the activities of E₂ synthetic enzymes through adenylate cyclase and tyrosine kinase cascades. This might decrease of risk of hormone dependent cancers. A phytoestrogen-rich diet might reproduce normal body composition, affecting the course of polycystic ovary syndrome (PCOS). Some herbs used in traditional Japanese medicine contain phytoestrogens that influence endogenous hormone levels to directly regulate the pituitary-ovarian system, in particular, the chemotactic effects on ovaries. (Reprod Med Biol 2005; 4 : 225 –229)     

生殖免疫学进展

生殖免疫学进展林其德生殖免疫学是随着生殖医学及免疫学进展而发展起来的一门重要的边缘学科,涉及生殖生理、妊娠生理、病理妊娠以及生殖控制等,其核心问题是母体对同种异体抗原（胚胎）为何不排斥,反而呈可接受状;过去主要从系统免疫状态对此问题加以解释,如母胎间...     

Selenium in reproductive health

Selenium is an essential trace element of importance to human biology and health. Increasing evidence suggests that this mineral plays an important role in normal growth and reproduction in animals and humans, and selenium supplementation is now recommended as part of public health policy in geographical areas with severe selenium deficiency in soil. This review addresses the biological functions of selenium followed by a detailed review of associations between selenium status and reproductive health. In many countries, selenium dietary intake falls below the recommended nutrient intakes and is inadequate to support maximal expression of the selenoenzymes. Numerous reports implicate selenium deficiency in several reproductive and obstetric complications including male and female infertility, miscarriage, preeclampsia, fetal growth restriction, preterm labor, gestational diabetes, and obstetric cholestasis. Currently, there is inadequate information from the available small intervention studies to inform public health strategies. Larger intervention trials are required to reinforce or refute a beneficial role of selenium supplementation in disorders of reproductive health.     

Glycol ethers reproductive risks

Glycol ethers (GE) are a family of solvents, the use of which has increased dramatically since the 60's, in domestic and occupational mainly water-based products, such as paintings, inks, varnishes, cleaning agents. There are two subgroups: E series and P series. EGME, among the E series, is the reference substance. This is a reprotoxic chemical causing infertility and genital apparatus atrophy on both sexes, embryofetal toxicity through maternal exposure (malformation, growth alterations and functional deficits). European Union has classified nine other GE as reprotoxic. P series, with the beta isomers exception, has no specific reprotoxicity. Epidemiological studies published from the 80's onwards, have confirmed animal data (malformation, oligoazoospermia, spontaneous abortion, hypofertility). The effects can be observed even after the end of exposure. Risk assessment studies tend to prove that this massive exposure during several decades could have had an important impact on reproductive human health. Even if this exposure has considerably decreased since the last few years, a ban of reprotoxic GE, as required by two official bodies (CSC, CSHPF), seems necessary, due to the high risk level. Classification should be completed for some GE, not classified now (EGBE). Health assessment of past exposure should be carried out. Physicians should look after a possible glycol ethers responsibility when facing this kind of reprotoxic effects.     

Zoonoses in reproductive medicine

After reviewing the importance of three zoonoses, namely toxoplasmosis, listeriosis and brucellosis, Authors focus on their experience in prophylactic treatment of the acquired toxoplasmosis in 72 gravidae with high risk pregnancy and the history of toxoplasmosis. Listeriosis and brucellosis currently seem not to bear a clinical significance as perinatal risk factors. Toxoplasmosis, however, should be taken into account a cases of unexplained pregnancy loss. The Authors' experience suggests the positive effect of the combined prophylactis antitoxoplasmic treatment in the selected cases.     

Prolactin and reproductive medicine

PURPOSE OF REVIEW: This review aims to summarize current knowledge about prolactin, and outlines recent information that affects the management of patients with hyperprolactinaemia. RECENT FINDINGS: The actions of prolactin have been clarified by studies of prolactin-receptor-deficient mice, which have a clear phenotype of reproductive failure at multiple sites. The treatment of patients with hyperprolactinaemia or prolactinoma is largely achieved using dopamine agonist drugs, which induce the shrinkage of pituitary prolactinomas as well as control of the endocrine syndrome. Recent findings indicate that successful cabergoline treatment may be able to induce long-term remission, allowing drug withdrawal in a substantial proportion of patients. SUMMARY: At present, dopamine agonist drugs remain the best treatment for hyperprolactinaemic patients, and can help most affected women achieve pregnancy. Future work is likely to help understand the basis of long-term remission in patients with pituitary prolactinomas.