Journal of Human Reproductive Sciences

: 2018  |  Volume : 11  |  Issue : 3  |  Page : 209--211

From the editor's desk

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

Correspondence Address:
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 2018;11:209-211

How to cite this URL:
Patil M. From the editor's desk. J Hum Reprod Sci [serial online] 2018 [cited 2018 Dec 10 ];11:209-211
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Different countries have varying laws and regulations regarding the practice of surrogacy. Lack of stringent laws on surrogacy had made India the hub for surrogacy in the past until November 2015, when a circular was passed by the Ministry of home affairs to assisted reproductive technique (ART) clinics to ban surrogacy for foreign nationals and Overseas Citizens of India. Today, ART clinics in India can provide surrogacy service only for heterosexually married Indian couples staying in India. Such a step was necessary for the prevention of misuse of surrogacy, for the safe and ethical practice of surrogacy services, and to protect the rights of the surrogate mother and the intended parents. This law will help in promoting altruistic and not commercial surrogacy. This issue has a review article which looks at the different aspect of surrogate practice. We are also aware that infertility can be one of the most stressful and life-changing events, a person can face and therefore psychological counseling should be offered to all infertile couples independent of their individual diagnosis or the stage of medical treatment and independent of treatment. Today, infertility counseling has become mandatory and is an integral component of ART. Many couples discontinue treatment due to the emotional distress of ART. This distress could be due to relational strain in between couples as a result of infertility, fear and negative attitudes to treatment, and psychological vulnerability and ability to withstand demands of treatment. There are several screening instruments for identifying patients who probably would require psychotherapy apart from counseling. The review article on the role of mental health practitioners in infertility clinics looks at the various aspects of patient-centered care with structured psychological interventions.

The third review article is on difficult embryo transfer (ET). We are all aware that ET procedure, apart from embryo quality and ER is one of the basic and important factors determining the final outcome of an ART cycle. It is also probably the least successful step in in vitro-fertilization (IVF), and approximately ±30% of failure in ART are due to the poor performance of ET. Optimization of the ET procedure by using soft catheters under ultrasound (USG) guidance improves results by making it less traumatic, standardized, and technically precise. Difficult ETs may be due to anatomical distortion of the cervix by previous surgery or fibroids or due to congenital anomaly, presence of pronounced uterine flexion, or scarring in the lower uterine segment and due to a distorted endometrial cavity. The remedy for difficult ETs apart from USG-guided ET is performing a mock transfer, use of stiffer and more rigid catheter system when resistance is felt at the internal ostium, gently maneuvering the vaginal speculum with partially full bladder, moderate cervical traction straightens the uterus, use of malleable obturator followed by inner catheter with embryo or use of coaxial, or echo tip catheter system. The other two methods that can be used are transmyometrial (vaginal or abdominal) surgical ET or transtubal ET, which is rarely done. The review discusses the effectiveness of cervical dilatation, minimum 3 weeks before the ET for managing difficult transfers with improved pregnancy rate (PR).

Semen analysis, tubal patency testing, and detection of ovulation are the three basic tests in an infertile couple. Although laparoscopy is the gold standard hysterosalpingography (HSG) or saline infusion sonography (SIS) is the principle first-line tool to assess tubal status. The advantage of SIS over HSG is that it eliminates radiation exposure and creates less patient discomfort as compared to HSG; however, it has a disadvantage of being subjective and requires technical competence. Its competitive diagnostic accuracy can be further improved with the use of contrast media and three-dimensional evaluation. At SIS, one can simultaneously evaluate the uterine cavity/contour, ovarian reserve, and myometrial structure and tubal architecture and patency, and it has shown to produces a therapeutic effect as it favors the onset of spontaneous pregnancies. In the original article by Vinita Singh, SIS was found to be much superior to HSG in detecting pelvic pathology regarding sensitivity, specificity, PPV, NPV, and accuracy. They found it to be a useful tool in initial workup of infertility patients with better compliance, low cost, and better results in a single visit. Apart from the detection of tubal patency, uterine pathology, and ovarian reserve USG has a role in predicting response to controlled ovarian stimulation. The original article in this issue has established a correlation between perifollicular vascularity on the day of trigger and the clinical outcome in poor ovarian responders in IVF cycles. This study concluded that follicles with good perifollicular flow can have significantly higher number of MII and good-quality oocytes. There was no difference seen in the oocyte retrieval, fertilization, and implantation rates. The clinical PR, multiple PR, miscarriage rate, and live birth rate were also not influenced by the perifollicular blood flow.

Chromosomal anomalies account for 55% of the occult and early pregnancy losses. The other causes being hormonal or anatomical abnormalities acquired or inherited thrombophilia, immunological problems, or bacterial vaginosis. Karyotyping in both partners in couples with recurrent pregnancy loss (RPL) identifies both structural and numerical chromosomal anomalies. The incidence of chromosomal abnormalities in the study of 172 couples was 9.88% with increasing number of chromosomal aberrations in the female as compared to males. The study by Asoke Pal et al. concluded that cytogenetic analysis in couples with RPL allows genetic counseling with appropriate patient management with the prediction of the success of reproductive option. Apart from RPL, recurrent implantation failure (RIF) is also frustrating for both the couple and the treating physician. One of the causes of RIF in IVF cycles is endometrial pathology which can be seen in the form of thin endometrium at the USG scan. Several treatments, such as estradiol, sildenafil, aspirin, and low-molecular-weight heparin, have been tried to improve the endometrial thickness but have really not helped in improving the implantation rate. Granulocyte colony-stimulating factor (G-CSF) is a new entrant to this list. G-CSF, a natural cytokine and cell signaling protein molecule that can assist in maintaining the immune system, increases the uterine natural killer (NK) cells, which assist embryo attachment. Strict indications of G-CSF supplementation in reproductive field are not established yet, and its safety on early stages of embryogenesis still needs to be demonstrated. The evidence for the use of G-CSF for thin endometrium is contradictory worldwide, and Shivani et al. in their study failed to demonstrate any beneficial effect of G-CSF in improving pregnancy outcomes, endometrial thickness, and endometrial volume in unselected regular IVF cycles. These authors concluded that further RCTs are needed for its regular use in clinical practice.

Intralipid infusions have also been used to improve clinical outcomes in patients with RIF/RPL with evidence of elevated NK cells. Data supporting this practice again are conflicting but suggestive of minimal benefit. Despite this, the patients still inquire about its use based on anecdotal evidence online. The objectives of the study by Anne E. Martini et al. were to determine if intralipid infusion improves live birth rates and if it is a cost-effective therapy. It is been postulated that abnormal immunological response, human leukocyte antigen incompatibility between couples, the absence of maternal leukocytotoxic antibodies, or the absence of maternal-blocking antibodies as a contributory factor in RIF. Few studies reported improved clinical PRs with the use of intralipids in patients with RIF who had an elevated TH1 cytokine response; however, till date, conflicting evidence is available regarding the efficacy and proven benefit. The mechanism by which intralipid modulates the immune system is still unclear though some studies have shown to decrease NK cytotoxic activity, enhancing implantation. Anne Marttini et al. concluded that intralipid does not improve live birth rates and is not a cost-effective intervention in patients with RPL or RIF and should not be routinely offered.

Empty follicle syndrome (EFS) is a lack of retrieval of oocytes at oocyte pick up (OPU) despite apparently normal follicular development and normal E2 levels. There is no way to precisely predict EFS before starting ovarian stimulation and it can be “Genuine” EFS (GEFS) in the presence of optimal blood human chorionic gonadotropin (hCG) levels on the day of OPU or “False” EFS in the presence of low beta-hCG due to error in the administration, or the reduced bioavailability of hCG. The treatment of GEFS is still largely empirical, whereas error in ovulation HCG trigger identified by very low serum HCG levels or a negative urinary HCG test can be treated by an additional dose of hCG. The study by Neeta Singh et al., over a period of 6 years, found it to be very uncommon with an incidence of 2.3% with a higher incidence in antagonist protocol. Although several publications showed a higher incidence in older age or women with diminished ovarian reserve, this study was no association with decreased ovarian reserve.

In India, where many patients cannot afford IVF intrauterine insemination (IUI) is still the first-line treatment for many etiologies as long as the ovarian reserve and total motile fraction of sperms are adequate. Success rates of IUI are contingent upon the procedure being performed for correct indication, avoiding performance of IUI when contraindications exist, and whether the women have ovulatory cycles or not. Results depend largely on the physician, the laboratory, and the embryologist. There are several confounding factors such as age, duration of infertility, semen quality, sperm preparation, timing, number of inseminations, type of stimulation, and indication that influence the results of IUI. Total motile sperm concentration and percentage of abnormal forms are the most important parameter predicting pregnancy. In the study published in this issue found that the probability of clinical PR was greatest for women with age ≤25 years, with a duration of infertility <5 years and having an endometrial thickness between 9 and 11 mm at the time of trigger. Moreover, an association was also found between follicle-stimulating hormone (FSH) value on day 3 of cycle, and ovulatory status with the PR achieved. The PR was higher in women with FSH value below on day 3 of cycle below 10 IU/L and anovulation as a factor of infertility.

We are aware of the fact that retained bony fragments cause secondary infertility by acting such as uterine synechiae or an intrauterine contraceptive device. Apart from mechanical cause, the poor fertility outcome is also attributed to an increase in the local production of prostaglandins that prevent blastocyst implantation. Fetal bone fragments are easily diagnosed with focal echogenic lesions at the USG evaluation of the women presenting with secondary infertility. Most patients benefit with hysteroscopic removal of the fragments which should be done under USG control to ensure that all bone fragments are completely resected. Despite several studies which have documented good PRs after removal of all bony fragments. Shalini Gainder et al. concluded that despite complete removal of the bony fragments, the PRs may still be lower due to the inflammatory damage to the endometrium.

Both endometriosis and periodontal disease are chronic, inflammatory processes and are more common in patients with systemic autoimmune disorders which alter immune modulators. A study by Vidya Thomas et al. have suggested a possible association between endometriosis and periodontal disease and postulated a generalized immune dysregulation as the potential underlying link between the two disorders. We have another original article on “steroidogenesis and vascular endothelial growth factor production does not alter in leydig cells within the homeostatic range of testicular temperature” and two case reports, one on “different endometrial receptivity in each hemiuterus of a woman with uterus didelphys and previous failed ETs” and the other one on “persistent mullerian duct syndrome with testicular seminoma in transverse testicular ectopia.”