Journal of Human Reproductive Science
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EDITORIAL  
Year : 2016  |  Volume : 9  |  Issue : 3  |  Page : 133-134
 

From the Editor's desk


Dr. Patil's Fertility and Endoscopy Clinic, Bangalore, Karnataka, India

Date of Submission26-Sep-2016
Date of Decision26-Sep-2016
Date of Acceptance26-Sep-2016
Date of Web Publication12-Oct-2016

Correspondence Address:
Madhuri Patil
Dr. Patil's Fertility and Endoscopy Clinic, Bangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-1208.192038

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How to cite this article:
Patil M. From the Editor's desk. J Hum Reprod Sci 2016;9:133-4

How to cite this URL:
Patil M. From the Editor's desk. J Hum Reprod Sci [serial online] 2016 [cited 2020 Apr 1];9:133-4. Available from: http://www.jhrsonline.org/text.asp?2016/9/3/133/192038


Tuberculosis is endemic in a developing country like India. Pelvic infection is always secondary to systemic infection, which could be pulmonary or osseous. Infection always spreads down intraluminally from tubes to the endometrium. The ovaries can also be affected resulting in decreased ovarian reserve. Tubal infection is present in 100% of cases of tubercular endometritis. In clinically and microscopically evident tubercular endometritis and salpingitis, fertility is badly affected. If the ovaries are affected, it results in decreased ovarian reserve. Course of the disease depends on host-organism interactions, virulence of organism and immune response of host. There are many types of species that can infect the humans and the bacteria live in latency by causing immune modulation within the body the host. Macrophages, T lymphocytes, B lymphocytes and consequent cytokines help to fight infection. Granulomatous inflammatory changes due to the host immune response system, T lymphocytes can also directly kill infected cells. In cases where TB bacilli overcome the immune system defenses there is progression from tuberculosis infection to tuberculosis disease. Healing and fibrosis balance tissue destruction and necrosis as a result of tuberculosis. In this issue we have two articles on tuberculosis, one is a review article on the diagnosis and management of sub-clinical tuberculosis in infertile women and the other ovarian function and how we can protect it in genital tuberculosis. We must know that there is no case definition for genital tuberculosis there is no single sign or symptom that is pathoganomonic of genital tuberculosis. There is also no single test that is definitive of the disease except direct visualisation of the bacterium in the tissues.

The second original article by Shikha Jain and
Abha Majumdar 
looked at the pregnancy rates following administration of of GnRH antagonist in a gonadotropin intrauterine insemination cycle (IUI). We know that a gonadotropin (given daily) IUI cycle has a higher pregnancy rate compared to oral ovulogens and IUI. Today low dose protocols are preferred over high dose protocols, which increased risk of multiple pregnancy and ovarian hyperstimulation syndrome (OHSS) as low dose protocols do not differ significantly in success, when compared to high dose ones. When using gonadotropins for ovulation induction the chance of premature luteinizing hormone (LH) surge occurs in 25 - 30% of the cycles. Though LH surge is an absolute requirement for final maturation of the oocyte, follicle rupture and luteinization, it may interfere with timing of IUI or result in cancellation and more treatment failures if monitoring is improper. LH surge can be prevented with the use of GnRH analogues. GnRH-agonists have no role in IUI programs as they increase costs and risk of multiple pregnancies and OHSS. With the use of GnRH antagonist there is an increase in ongoing pregnancy rate by 5.3% but the numbers required to treat (NNT) is 20. That is to obtain one additional pregnancy GnRH antagonist needs to be administered to twenty patients. This original paper concluded that use of GnRH antagonist did not increase the pregnancy rates but allowed flexible timing of hCG injection and insemination, thereby decreasing the need of extensive cycle monitoring and avoiding 
IUI during weekends. 
Further studies are required to determine the role of GnRH antagonists in mild COS/IUI programs.

Prevention of LH surge is important for all In-vitro fertilization (IVF) cycles, so that there is no spontaneous rupture of the follicles and oocytes can be collected at oocyte retrieval. Normally GnRH analogues either agonist for antagonist is used to suppress the LH surge. Aparna Singh et al. compared clomiphene citrate (CC) given from day one of menstrual cycle till the day of trigger plus gonadotropins with gonadotropins plus GnRH antagonist in oocyte donor cycles for prevention of premature LH surge. This study demonstrated a comparable pregnancy and live birth rate in both the groups and so concluded that controlled ovarian stimulation (COS) using CC and gonadotropin is a viable option in oocyte donor cycles. The cost and number of injections used per cycle can be reduced as neither of the analogues was used. Use of CC to prevent LH surge is based on the concept that continuous use of CC from Day 1 or 2 of the menstrual cycle blocks estrogen receptors sites at the hypothalamus and pituitary. CC e used in this fashion mimics the action of a GnRH analogue and prevents an LH surge due to rising estrogen levels, a result of follicular development.

The aim of every fertility clinic is to have an ovarian hyper stimulation syndrome (OHSS) free clinic. The randomized controlled trial (RCT) conducted by Depika Krishna et al. showed that GnRH agonist trigger instead of human chorionic gonadotropin (hCG) is the best method to prevent OHSS without compromising the results.

Multiple pregnancy is not an optimal outcome of ART and its prevention is of utmost importance. This can be done by mild stimulation in IUI, where one aims at only 2 -3 follicles and if there are more either the cycle s cancelled or converted to IVF. In ART, one can prevent multiples by restricting the number of embryos transferred to one or at the most two. Despite single or double embryo transfer there still could be multiples as monozygotic twining is still a possibility. The study published here looks at the perinatal outcome in women with multiple pregnancies following spontaneous fetal reduction (SFR) verses multi fetal pregnancy reduction (MFPR). According to this study, MFPR has better prognosis than SFR in terms of perinatal outcome though singleton pregnancies have the best outcome.

Today, fertility preservation is becoming more and more important as there has been an increase in incidence of cancer during the reproductive age and the survival and cure rates of cancer are improving. Radiotherapy and chemotherapy is gonadotoxic and if the woman is interested in fertility preservation, the women should be counseled about the different techniques available for fertility preservation along with the success rate of the procedure used. In India, the gynecologist is the first point of contact to these patients and therefore are in a unique position to guide the cancer patients on issues of fertility after cancer treatment and options for fertility preservation. Nalini Mahajan et al. conducted a survey among the gynecologist to assess their knowledge about the effect of cancer on fertility, techniques of fertility preservation and barriers that exist, which refrain the patient from undergoing fertility preservation. In this survey it was observed that there is lack of awareness among the gynecologist about fertility preservation techniques, their availability in India, its efficacy and the centers that provide such services. Identifying and selecting the female patient with cancer to whom we can offer fertility preservation depends upon a variety of factors each with significant as well as unique importance. Cost, oncologic prognosis, quality of life and time available before therapy are the main factors that prevent referral for fertility preservation. Having updates on fertility preservation and an in-house fertility preservation department in every oncological unit may be of great value.

Today the incidence of male sub-fertility is on the rise and chromosomal abnormalities and "Y" chromosome microdeletion may be one of the etiological factors. A study by Mariano Mascarenhas 
looks at its prevalence and correlates it with successful sperm retrieval for intra-cytoplasmic sperm injection (ICSI). Etiology of azoospermia affects clinical outcome and thus identifying the underlying etiology and predicting the chances of finding spermatozoa from the testis are essential for counseling patients desiring paternity. This study found a high prevalence of genetic abnormalities in men with azoospermia and severe oligoasthenospermia. The incidence of unsuccessful surgical retrieval of mature spermatozoa was very high in men with chromosomal abnormalities and "Y" microdeletion. Thus evaluation for chromosomal abnormalities and "Y" microdeletion play an important role in prognostication and counseling of these couples prior to undertaking assisted reproductive technology (ART) procedures. However, one must remember that predictions are often unreliable and a final answer can frequently only be achieved by testicular biopsy.

Sperm morphology, viability and maturation are important sperm parameters, which determine the success of either IUI or ART. There is an original article, which looked at four sperm separation techniques, viz., Swim-up, Swim-down, Sucrose and Ficoll-400 density gradient for their efficacy in separation of good quality fraction of spermatozoa. This study concluded that Ficoll-400 density gradient was the best technique in isolating good quality sperms for assisted reproductive procedures.

There are three case reports in this issue. One on preimplantation genetic diagnosis at IVF for screening of embryos free from c.1537G>A; p.G513S mutation within the COL4A1 gene for which the father was known to be heterozygous. The second on successful use of trans cranial magnetic stimulation in difficult to treat hypersexual disorder and the last one on birth after human chorionic gonadotropin-primed oocyte in vitro maturation and fertilization with testicular sperm in a normo-ovulatory patient.




 

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