Journal of Human Reproductive Science
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EDITORIAL  
Year : 2018  |  Volume : 11  |  Issue : 1  |  Page : 1-2
 

From the editor's desk


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

Date of Web Publication27-Mar-2018

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


DOI: 10.4103/jhrs.JHRS_32_18

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How to cite this article:
Patil M. From the editor's desk. J Hum Reprod Sci 2018;11:1-2

How to cite this URL:
Patil M. From the editor's desk. J Hum Reprod Sci [serial online] 2018 [cited 2018 Oct 23];11:1-2. Available from: http://www.jhrsonline.org/text.asp?2018/11/1/1/228606




Mitochondrial donation or transfer (MRT) could prevent transmission of mitochondrial disease from mother to child and so can be used by those who have severe mitochondrial disease to have optimal outcome. It would entail replacement of pathogenic mtDNA with unaffected mtDNA and could have implications for the ethical, legal, social, and policy issues. In 2013, the Human Fertilization and Embryology Authority (HFEA) in the UK completed an extensive public consultation on mitochondrial replacement therapy, and then in 2015, the UK Parliament voted to allow mitochondrial donation, which can be performed on case by case basis. In 2016, the HFEA approved the use of mitochondrial donation in specific cases; and in March 2017, the HFEA granted the first clinical mitochondrial donation in the United Kingdom. The US Food and Drug Administration in 2016 has prevented from further evaluating clinical applications of MRT as it involves genetic modifications that affect the next generation. At this stage, it is difficult to say whether MRT is a boon or curse as the long-term effects of this technique have still not been looked at. Probably, it may prove be a boon for those affected with mitochondrial disease to minimize or stop the transfer of mitochondrial diseases from mother to offspring thereby improving the quality life for their future children. We still need to wait to include the use of this technique routinely in the armamentarium of fertility experts. The review article by Saxena et al. discusses methodological details and issues related to MRT.

An original article by Basu et al. looks at the relationship between stress-associated factors and alterations in body composition among women with polycystic ovarian syndrome (PCOS). Although this study concludes that stress and stress-associated factors are positively associated with body composition alterations in PCOS individuals, we need to further look at the relationship between PCOS and stress. We need to assess whether it is obesity/body image, biochemical hyperandrogenism, or clinical hyperandrogenism with the presence of acne, hirsutism, and hair loss or diabetes and insulin resistance results in stress with anxiety and mood disorders or it is the other way round. Many publications have shown a higher incidence of anxiety, depression, and mood disorders in women with PCOS. It has also been observed that disordered eating; including eating disorders, negative body image, and psychosexual dysfunction are manifestations of anxiety and depression in women with PCOS. It has also been seen that lifestyle factors usually act as moderators but not as mediators of body composition. In PCOS women, one must target both lifestyle and stress to improve the body composition.

The article on using diagnostic hysteron-laparoscopy for evaluation of infertility in all patients without subjecting them to ultrasound is very controversial. The aim of any fertility clinic should be to choose the simplest method to diagnose the problem and use the most successful treatment to restore fertility. Several factors need to be considered when advocating hysteron-laparoscopy as a primary investigation in a subfertile couple in the era of ultrasound where 2/3D ultrasound, saline salpingography, and HYCOSY can diagnose pathologies with precision. These include age and ovarian reserve, presence of other infertility factors, risk and cost involved with the procedure and most important the efficacy and experience of the surgeon to treat pathologies if present. Probably, hysteron-laparoscopy could be a primary diagnostic procedure in women with a history of pelvic inflammatory disease, previous ectopic pregnancy, suspected endometriosis, previous surgery, and presence of intrauterine pathology.

The aim of any fertility clinic should be to minimize the occurrence of multifetal gestation, particularly high-order multiples while maintaining acceptable overall pregnancy and live birth rates following in vitro fertilization (IVF) and embryo transfer. No factors are identified which specifically predicted occurrence of pregnancy after single embryo transfer or multifetal pregnancies after transfer of multiple embryos. With occurrence of multiple pregnancy, assisted reproductive technologies (ARTs) results shift from success to complications thus preventing multiple pregnancies is of utmost importance. The number of embryos transferred should be individualized to each patient depending on the age, etiology, oocyte and embryo quality, previous failures, clinics policy on cleavage stage or blastocyst transfer, efficiency of cryopreservation program, and data analysis of each clinic. Single-embryo transferred (eSET) should be performed in all women with favorable prognosis-young age, presence of one or more high-quality embryos, presence of euploid embryos, previous live birth after an IVF cycle and availability of vitrified, high-quality, day 5, or day 6 blastocysts for transfer in frozen embryo transfer cycle. Single-blastocyst transfer as compared to double-blastocyst transfer has no significant impact on cumulative live-birth rates. Marni B. Jacobs et al. looked at clinical equivalency of single versus double-embryo transfer at the blastocyst stage and found no difference in the pregnancy rates using utilizing equivalence analyses in good prognosis patients. The live birth rate reported by them was slightly lower with eSET as compared to eDBT after looking at the confounding factors such as BMI, number of oocytes obtained, and number of oocytes fertilized. Elective SET reduced the multiple pregnancy rate, and this outweighs the slightly higher live birth rate with eDBT.

The objective of any treatment for subfertility especially ovulation induction (OI) should be to optimize response and outcomes, minimizing the risks. In non-ART cycles, the goal of any OI therapy should be mono-follicular development and the protocols used to need to be individualized. The most common oral ovulogen used is clomiphene citrate (CC), but it can have anti-estrogen effects on endometrium and cervical mucus. Anti-estrogen effect on endometrium results in endometrial thinning, estrogen receptor downregulation and depletion, suppression of pinipode formation. No pregnancies when endometrial thickness at midcycle was <7 mm. Letrozole and tamoxifen are both promising alternative to CC for ovarian stimulation in the subgroup of patients who failed to develop an adequate endometrial thickness in a previous OI cycle. An original article by Sunita Sharma et al. compares the role of tamoxifen and gonadotropins in women with endometrial thickness of <7 mm. Although their results show comparable results for both tamoxifen and gonadotropins in intrauterine insemination cycles, according to me both cannot be compared in this study as there were a lot of confounding factors, the dose of gonadotropins was too high with a high cancellation rate, and the human chorionic gonadotrophin was given at a larger follicular diameter in cases who did not reach an endometrial thickness of 7 mm. Moreover, they have reported a high incidence of luteinized unruptured follicle, which has an entity is questioned today.

Modifying conventional stimulation protocols according to patients' characteristics and ovarian reserve makes it patient-friendly and optimizes the chance of live births. In a randomized controlled trial done at Christian medical college Vellore compared conventional protocol based on follicle stimulating hormone (FSH) and age verses anti-Mullerian hormone (AMH) and found no difference in clinical pregnancy rate per initiated cycle and per embryo transferred. This could be because of using age and FSH levels to select the dose and GnRH analogs for OI. Hence, in the Indian setting, probably one could individualized protocols using age, FSH and antral follicle count rather than AMH, making it more cost-effective.

Establishment of pregnancy even with compromised ejaculated (dysfunctional and/or with high rates of DNA fragmentation) may be attributed to the corrective role of selecting a single spermatozoon for intracytoplasmic sperm injection (ICSI) and corrective ability of the oocyte. Several sperm selection techniques have been used before ICSI–physiological ICSI (PICSI) hyaluronic acid binding which selects mature sperms, intracytoplasmic morphologically selected sperm injection (IMSI), which selects sperms based on ultra-morphology, sperm head birefringence and confocal light absorption and scattering spectroscopic (CLASS) microscopy, sperm surface charge, which uses electrophoretic separation and zeta potential and magnetic-activated cell sorting and glass wool technique which selects nonapoptotic sperms. In this issue, we have an original paper which compares results of IMSI in those cases which failed to conceive in the previous ICSI cycles. This study reports a better embryo quality with more optimal clinical outcome with the use of IMSI. The evidence for the use of IMSI is controversial, and the current evidence does not support using IMSI as there is no evidence of benefit for embryo quality, clinical pregnancy rate, live birth, and miscarriage rate.

Apart from the stimulation protocol, oocyte, and embryo quality endometrial receptivity is a hurdle in an optimal IVF outcome.






 

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