Year : 2018 | Volume
: 11 | Issue : 2 | Page : 83--85
From the editors 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 editors desk.J Hum Reprod Sci 2018;11:83-85
|How to cite this URL:|
Patil M. From the editors desk. J Hum Reprod Sci [serial online] 2018 [cited 2020 Apr 1 ];11:83-85
Available from: http://www.jhrsonline.org/text.asp?2018/11/2/83/238224
This issue has four ethics opinion developed by the working group of the International Standards of Accounting and Reporting. The topics for these are fertility treatment in couples with seropositivity for human immunodeficiency virus, upper age limit for assisted reproductive technologies, provision of fertility services for women at increased risk of complications, and maximum number of embryos to be transferred in assisted reproductive technologies cycle. Polycystic ovary syndrome (PCOS) is characterized by anovulation with clinical (hirsutism/acne) and/or biochemical evidence of androgen excess and typically presents during adolescence. Typical endocrine features are raised testosterone, luteinizing hormone, and insulin levels. It is also associated with metabolic abnormalities and increased risk of type 2 diabetes. Etiology of PCOS is uncertain but has strong evidence for a major genetic contribution and is said to be an inflammatory condition. Important links between total and regional body fat, insulin resistance, low-grade chronic inflammation, and circulating sex hormones have been observed in PCOS women. Oral contraceptive pills (OCP) are being used as first-line therapy for concurrent treatment of menstrual irregularity, acne, and hirsutism in PCOS. Consensus statement on the use of OCPs in PCOS Women in India will help health providers to choose the right type of OCP, which will alleviate the symptoms with least side effects. This consensus will provide insight to practitioners on indications, contraindications, drug interactions, noncontraceptive use, and the duration for which it can be used.
We have two review articles, one on comparison of urinary versus recombinant gonadotropins for ovarian stimulation in women undergoing assisted reproductive technology (ART) and the other on role of autologous bone marrow-derived stem cell therapy for follicular recruitment in premature ovarian insufficiency (POI). The first review looked at the response as well as oocyte and embryo quality with urinary and recombinant gonadotropin preparation. There was no difference seen in the implantation rate, clinical and ongoing pregnancy rate, live birth rate, and miscarriage rate.
Stem cells are undifferentiated cells that are present in the bone marrow, are pluripotent and can give rise to differentiated cells for any tissue or organs. New therapeutic practices for the treatment of infertility use this quality of high differentiation potential of the stem cells. Most of these therapies were tried for this endometrium or Asherman's syndrome. This review article discusses on the use of autologous stem cells in a women with POI. This group also reported the first pregnancy with ART after injecting bone marrow autologous stem cells in the ovary of perimenopausal women. Probably, these stem cells help in follicular recruitment, thus avoiding the use of donor oocyte. As and when more cases would be done, and increase in AMH would be documented in most cases, this method of treatment will be included in the armamentarium of all clinician, though experimental now.
Endometriosis is very common in infertile women. Although the etiology for endometriosis is multifactorial with genes, reduced apoptosis, increased proliferation, hormonal imbalance, impaired immune response with neoangiogenesis, and increased adhesiveness, and invasiveness being responsible. The original article by Sadia Nazir looked at the role of ubiquitous environmental contaminants like diethyl hexyl phthalate (DEHP) in the physiopathology of endometriosis. High levels of DEHP in women diagnosed with endometriosis suggest a role of phthalates in the etiology of endometriosis and permit careful use of such compounds.
The original article by Prabhu Yogamaya et al. screened for polymorphisms of transcription factor 7-like 2 (TCF7 L2) gene in PCOS using polymerase chain reaction-restriction fragment length polymorphism analysis (polymerase chain reaction-restriction fragment length polymorphism [PCR-RFLP]). PCOS is a polygenic disorder and the multiorgan dysfunction risk for metabolic disease is due to gene-environment interaction. TCF7 L2 gene is shown to be associated with insulin secretion and has susceptibilities with type 2 diabetes in PCOS. This study did not find any significant allelic variation observed among the PCOS patient and the control samples. From this PCR-RFLP analysis, it was concluded that there are no expected gene polymorphisms seen and TCF7 L2 rs7903146 gene cannot be considered as the candidate gene for the occurrence of PCOS.
Recurrent pregnancy loss (RPL) is a significant stressful and negative event in the life of a couple, and the repetitive nature may intensify the grief experienced. In almost 50% of the cases it is unexplained. In the remaning, the female causes include genetic, anatomical and endocrine abnormalities, infectious and immunological causes, thrombopholic disorders and antiphospholipid syndrome. The male causes include high sperm DNA fragmentation index, sperm chromosomal aneuploidies or structural abnormalities, and genetic and epigenetic anomalies. DNA methylation is the main epigenetic phenomenon which regulates the correct development of sperm and is regulated by methylenetetrahydrofolate reductase (MTHFR) enzyme. MTHFR gene polymorphisms are known causes of reduced MTHFR enzyme activity resulting in low availability of methionine and global DNA hypomethylation, which can result in reduced sperm counts, leading to male infertility, and RPL. One of the original studies published in this issue looked at the association of gene-specific methylation of the promoter region of MTHFR in the causation of recurrent miscarriages both independently and also in light of MTHFR C677T polymorphism, hyperhomocysteinemia, folate, and Vitamin B12 deficiency. This study concluded that methylated allele poses a significant for RPL, and this risk increased with Vitamin B12 deficiency.
The evidence today does not support the use of either gonadotropin-releasing hormone (GnRH) agonist and antagonist in an intrauterine insemination (IUI) cycle; however, we had a randomized control trial conducted comparing the use of GnRH antagonist in a fixed and flexible protocol with control in a clomiphene citrate and gonadotropin cycle I women undergoing IUI. Although the sample size was very small, it showed improvement in pregnancy rates with lower incidence of premature luteinization. Only with future studies with a larger sample size will really confirm the positive effect of GnRH antagonist on the pregnancy rates in an IUI cycle.
Implantation is the most critical step in reproduction, a complex process where blastocyst becomes intimately connected with maternal endometrium/decidua and requires a competent embryo at blastocyst stage, a receptive endometrium, and synchronized dialog between maternal and embryonic tissues. Disturbance in embryo–maternal dialog is a major reason for 60% of all pregnancies being terminated at the end of the peri-implantation period. Thus, implantation is the bottleneck for any ART procedures. In the presence of normal uterine anatomy, nonreceptive endometrium, subendometrial contractions, and increased endometrial peristalsis due to high estradiol levels may hamper implantation by affecting the dialogue between the embryo and the endometrium. Several precautions are taken to avoid the initiation of uterine contractions. The precautions include use of soft catheters, avoiding touching the uterine fundus gentle manipulation, and administration of single oral dose of 10 mg of piroxicam one to 2 h before embryo transfer. Instead of piroxicam, one can use atosiban which is a mixed oxytocin/vasopressin V1a receptor antagonist and reduces uterine contractility with added advantage of reduction in prostaglandin F2 alpha production and improved endo-myometrial perfusion. A study by Vineet Mishra et al. has shown improvement in the implantation rate, clinical and ongoing pregnancy rate in those women undergoing embryo transfer where atosiban was used in comparison with placebo.
Preventing multiple pregnancies is of utmost importance as with multiple pregnancy ART results shift from success to complications. There are no factors that have been identified till date, which will specifically predicted twin pregnancies. A proper embryo selection with a single embryo transfer and with patient education and counselling in an appropriate way will reduce the incidence of higher order pregnancies. Thus, individualized controlled ovarian stimulation protocols with either elective single embryo transfer (eSET) or freeze all could help in increasing the success of ART and decreasing stress, anxiety, and complications. There is an original article on the cumulative outcome after two elective single-embryo transfers as compared to double-embryo transfer (DET). As expected, the cumulative live birth rate was higher with lower incidence of multiple births, prematurity, and low birth weight after two eSET versus one DET both in self- or donor-oocyte cycles.
Third-party reproduction is a process that allows infertile couple to take part in the procreation of a child while getting help from an anonymous person. Although third-party reproduction has given new hope for infertile couples, it has raised several ethical, legal, moral, and social questions, which should be looked into stringently. In this issue, we have a article which looked into the acceptance of third part reproduction by the couple. This article concluded that the overall acceptance of donor eggs, sperms, or embryos in Indian infertile couples is low. The acceptance rate of females for donor eggs or donor sperms is same; however, males are more amenable to accept donor eggs than donor sperms.
With the advances made in the field of ART, we have neglected the emotional impact of infertility and its treatment and that the problem is just reduced to a biological or medical one. However, in addition to the necessary medical procedures, one should also focus on the patients' psychosocial and emotional needs by understanding the impact of childlessness on the couple, giving information on the problem and its treatment modalities and ensuring it is processed and understood by the couple and offer implications, support counseling, and therapeutic counseling to all couples. The Indian social and culture have great value on having children and considers it to be an essential part of life after marriage. This makes the life of the infertile couple very stressful along with the stress of treatment. This aspect of infertility treatment is very important and should be taken into account by the health-care providers in their approaches, treatments, counseling, and solutions. In this issue, we have two articles, one which has looked into the sociocultural aspect of infertility and other into the emotional aspect of infertility.
There are four case reports one on adult granulosa cell tumor: A sinister differential for clomiphene-resistant infertility, second on ART in a patient with history of venous thromboembolism, third on pregnancy with ART in a case of thoracic endometriosis syndrome, and last one on outcomes of structured psychotherapy for emotional adjustment in a childless couple diagnosed with recurrent pregnancy loss.