Year : 2017 | Volume
: 10 | Issue : 4 | Page : 239--241
From the Editor's Desk
Dr. Patil's Fertility and Endoscopy Clinic, Bengaluru, Karnataka, India
Dr. Madhuri Patil
Dr. Patil's Fertility and Endoscopy Clinic, Bengaluru, Karnataka
|How to cite this article:|
Patil M. From the Editor's Desk.J Hum Reprod Sci 2017;10:239-241
|How to cite this URL:|
Patil M. From the Editor's Desk. J Hum Reprod Sci [serial online] 2017 [cited 2020 Jul 10 ];10:239-241
Available from: http://www.jhrsonline.org/text.asp?2017/10/4/239/223272
On behalf of the editorial board and the executive committee of Indian Society for Assisted Reproduction, I wish all the readers a very happy and prosperous 2018. Semen analysis today is the first test done in an infertile couple. Semen evaluation provides diagnostic information on the functional status of the male reproductive potential that is the function of the testis along with outflow tract which includes epididymis, vas deference, and accessory sex glands. It is also a useful tool for follow-up of treatment regimens used for male subfertility. It serves as a snapshot of male fertility and reflects male's general health in preceding 72–76 days, and one must remember that semen quality can vary among samples of the same person. In 1677, van Leeuwenhoek was for the first time able to view sperm cells. Almost 100 years later, Lazzaro Spallanzani in 1771 observed spermatic animalcules in various species, including humans, and documented the fertilizing capacity of the sperm. In 1837, Rudolf Wagner made substantial contribution by documenting his observations on spermatozoa of more than 400 species, including humans. It was a landmark paper by Macomber and Sanders in 1929 that quantitatively assessed spermatozoa. Subsequently, lot of work was done by Amelar and Williams and Rune Eliasson. Based on these studies by pioneers in Andrology, the World Health Organization (WHO) published its first manual on semen analysis in 1980, which summarized the clinical experience and research from the previous 80 years. In its subsequent updates in 1987, 1992, 1999, and 2010, the WHO manuals provided substantial improvements on how to assess and interpret the seminal parameters. The review in this issue, on history of semen analysis, will provide the links on how semen analysis was first started and the progress made in the technique and interpretation.
Genetic testing options include cystic fibrosis transmembrane conductance regulator testing for men with congenital absence of the vas, while karyotype, Y chromosome microdeletions, and other specific genetic tests may be warranted depending on the clinical context of severe oligospermia (OA) or nonobstructive azoospermia (NOA). Prevalence of microdeletions is supposed to be approximately 3% in unselected infertile men, 8% in men with NOA, and 5.5% in men with severe OA. The results of genetic testing guide management options as genetic testing for Y microdeletions may predict the outcome of sperm retrieval techniques. We have another review article, which looked at the evaluation of azoospermia factor C subregion of the Y chromosome.
We have an article from Agrawal et al., which is a randomized control Trial on ovulation induction using clomiphene citrate using stair-step regimen versus traditional regimen in Polycystic Ovary Syndrome Women. This article concluded that stair-step protocol had a significantly shorter treatment period without any detrimental effect on the ovulation and pregnancy rates. This article is in accordance with an article published by Deveci et al., in Archives of Gynecology and Obstetrics 2015. Stair-step protocol is novel, where the clomiphene citrate dose is increased in the same cycle to a maximum of 150 mg in the absence of response similar to gonadotropin cycles. This protocol is associated with similar ovulation and pregnancy rates as the conventional protocol.
The second original article looks at the impact of progesterone levels on the day of human chorionic gonadotropin (hCG) on the clinical pregnancy rate in the patients undergoing in vitro fertilization (IVF) Premature progesterone elevation (PE) in assisted reproductive technique (ART) cycles is possibly associated with lower clinical pregnancy rates. We know that PE on the day of hCG administration is associated with a decreased probability of pregnancy achievement in fresh IVF cycles, and so, it is highly recommended to closely monitor ovarian stimulation cycles by measuring serum progesterone (P4), at hCG trigger. There is a lower detrimental threshold of P4 for low responders and a higher detrimental threshold of P4 for high responders. Adverse effect of PE does not seem to be present in frozen-thawed and donor/recipient cycles. Freezing all embryos and transfer in a subsequent artificial endometrial preparation cycle is recommended in case there is PE in a fresh cycle. The incidence of PE may be reduced by avoiding the use of high doses of recombinant follicle-stimulating hormone or adding hCG driven LH bioactivity, adoption of milder ovarian stimulation regimens and use of gonadotropin-releasing hormone (GnRH) agonist trigger instead of hCG trigger if E2 levels on the day of hCG are more than 3500 pg/mL. These strategies may provide an effective clinical approach in improving implantation as beneficial effects have been seen both on endometrial receptivity and embryo quality. The article by Jawa Ashmita et al. concluded that the clinical pregnancy rates were significantly higher in the absence of PE where the cut off value was 1.5 ng/ml. As this study included poor, normal, as well as high responders and did not segregate agonist and antagonist cycles, there is a possibility of bias. They also reported higher incidence of PE in GnRH agonist cycle than antagonist cycle, which is quite unrealistic. The incidence of PE is on the contrary should be higher in the antagonist cycle as luteinizing hormone (LH) is not suppressed in the early follicular phase especially if flexible antagonist protocol is used. A study without many confounding factors would have thrown more light on effect of PE on day of hCG in IVF cycles.
LH surge induced by a single bolus of GnRHa at mid-cycle results in a shorter LH surge than in natural cycles, with LH levels returning to baseline levels after 24 h. There has been concern, therefore, that the GnRHa-induced LH surge may not adequately induce maturation and full developmental competence of the oocytes. Double trigger where GnRH-agonist and hCG are coadministered for final oocyte maturation has been published with beneficial effects on oocyte yield especially in those women with low/poor oocytes yield despite an apparently normal follicular development and E2 levels and in the presence of optimal hCG levels on the day of oocyte retrieval. Here, we have a randomized control trial, which used two doses of GnRH agonist for trigger at an interval of 12 h. This study concluded a better cycle outcome than a single dose in terms of maturity of oocytes, higher number of blastocysts, and a trend toward higher clinical pregnancy than a single dose in polycystic ovary syndrome patients undergoing IVF in antagonist cycles. There was no positive effect reported on the hormonal levels 12 h after the first trigger.
Neovascularization may be of prime importance in the growth and selection of ovulatory follicles, in addition to the subsequent development and function of the corpus luteum.
There is a physiological relationship between follicular blood velocity, oocyte recovery, and the production of a high-grade preimplantation embryo, and thus, perifollicular vascular perfusion appears to be an important factor in determining the outcome of stimulated cycles. Nikita Naredi et al. have looked at perifollicular vascularity on the day of oocyte retrieval and concluded that perifollicular perfusion and follicular oxygenation affect the oocyte maturation and thus the embryo quality. This may then influence the implantation potential of the embryo transferred with higher pregnancy rates for embryos obtained from oocytes aspirated from follicles with more than 75% of their surface being perfused.
Apart from the follicular competence with good-quality oocytes and embryos, endometrial receptivity plays an important role in the outcome of an ART cycle. The presence of endometrial fluid before embryo transfer (ET) in IVF cycles is associated with poor prognosis and may be due to cervical mucus that ascends into the endometrial cavity, fluid reflux from a hydrosalpinx, subclinical uterine infection, or abnormal endometrial development. If there is a presence of persistent fluid accumulation, freeze all embryos and postpone ET to a subsequent cycle. The study in this issue has compared the ART outcome of endometrial fluid accumulation in fresh versus frozen ET cycles. They obtained higher pregnancy rates in fresh cycles despite transient fluid collection in the endometrial cavity. A poor outcome was reported if the fluid accumulation was noticed in a frozen ET cycle.
We have a good article on the use of intravaginal insemination for nonconsummation of marriage. Unconsummated marriage in today's era is quite common due to vaginismus or erectile dysfunction and stressful lifestyle. It can have detrimental effects on the psyche of the individual partners; it can lead to low self-esteem in individuals, frustration, depression, frequent fights among partners, extramarital affair, fights within family or both the families if appropriate help is not available. This problem is a major crisis especially in India for predominantly not being able to conceive and give birth to a child. Intravaginal insemination at home by the partner proves to be a simple, short, economical, effective, and painless procedure for conception in this group of patients.
We have two papers related to genetics, one on Turner's syndrome and another on prevalence of cytogenetic abnormalities in women with recurrent pregnancy loss. The missing or altered X chromosome of Turner's syndrome causes errors during fetal development and other developmental problems after birth, for example, short stature, ovarian insufficiency, and heart defects. Physical characteristics and health complications that arise from the chromosomal error vary greatly depending on the presence or absence of mosaicism. There is no cure for Turner's syndrome, but there are some treatments for the symptoms. Growth hormone often helps girls reach heights that are close to average if diagnosed early. Hormone replacement can help start sexual development. ARTs can help some women with Turner's syndrome get pregnant. If mosaic, one could offer fertility preservation by freezing ovarian tissue or oocytes at an early age. Hence, identifying Turner's syndrome at an earlier age is very important to initiate therapy at the earliest to prevent complications.
Vishali Kalotra et al. evaluated 243 recurrent miscarriage (RM) couples and 208 with RM. Patients were screened to rule out inherited thrombophilia, antiphospholipid syndrome, incompetent cervix, uterine anomalies, factor V Leiden mutation, infections, endocrinological imbalance, cytogenetic abnormalities, and any other known causes of RM. This study reported an incidence of 3.1% for structural chromosomal aberrations and 1.9% polymorphic variations. They also reported a significantly higher incidence of RM in male carriers of balanced translocations as compared to female carriers. Chromosomal disorders contribute to the underlying basis of reproductive failure in a varying proportion of cases Etiologic identification of genetic factors represents important clinical information for genetic counseling and appropriate patient management.
There is one case report on primary amenorrhea with Swyer Syndrome with gonadal dysgenesis.