Year : 2019 | Volume
: 12 | Issue : 3 | Page : 175--176
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 2019;12:175-176
|How to cite this URL:|
Patil M. From the editor's desk. J Hum Reprod Sci [serial online] 2019 [cited 2019 Dec 8 ];12:175-176
Available from: http://www.jhrsonline.org/text.asp?2019/12/3/175/266887
Adaptation and personalization of fertility therapy may help optimize the efficacy and safety of assisted reproductive technology (ART). The outcome should not only be limited to clinical pregnancy rates and live birth rate but should also include perinatal outcome. The review article in this issue looks at the perinatal outcome in relation to ART procedure. This review reported a higher risk of adverse perinatal outcome with some ART procedures; the absolute rise in the risk is low. There are not many papers which have looked at the long-term risk, although congenital anomalies and neonatal complications have been reported.
Sperm is a very sophisticated toolbox and an optimally elected cell with high-quality DNA, centrosome, RNA species, histone code, and as yet unknown factors. Semen analysis is an essential part of infertility investigations, but its diagnostic value for male infertility and prognostic value for ART outcome is limited. Thus, basic semen analysis gives information about the messenger, whereas sperm DNA integrity tests reveal information about the message. Nuclear DNA anomalies lead to failure of fertilization in in vitro fertilization (IVF), failure to implant after intracytoplasmic sperm injection (ICSI), and increased time to conception. DNA damage can affect the motility of sperm and have a negative influence of blastocyst development. Increased DNA damage can also have impact on the health of the baby born. One of the main causes of sperm DNA damage is increased oxidative stress. One original study from South India looked at the relationship between leukocytospermia and sperm motility and DNA damage. We are aware that leukocytospermia is one of the main causes of oxidative stress. This study concluded that in the presence of a leukocyte count of >1 million/mL, both the sperm motility and DNA integrity are affected. They also found an appositive correlation between seminal adenosine deaminase and increased sperm DNA damage, thus making it a good indicator of male genital tract inflammation and low-quality semen. There was another study which looked at the effect of increased DNA damage on the outcome of intrauterine insemination and ICSI. This study concluded that increased DNA fragmentation index (DFI) decreases the pregnancy rates only in ICSI cycles. It is not only the DFI but also the functionality of accessory glands that is essential for sperm function. The study by Makhadumsab M describes how evaluation of fructose and citric acid can help in understanding the sperm function. We are also aware that increased reactive oxygen species (ROS) is associated with oxidative stress. High oxidative stress levels have a negative correlation with sperm concentration, motility, morphology, and overall normal semen parameters. An inverse relationship has also been noted between ROS and IVF. The oxidative stress results in lipid peroxidation, which when affects the midpiece results in decreased motility. Effect of oxidative stress on acrosome and sperm head can affect the gamete binding and DNA integrity respectively.
The measurement of ROS is not a mainstream investigation in the evaluation of male infertility as normal or reference values are not yet established. Moreover, the standardization of testing and the availability of these tests remain limited; it will be some time before this test will become a part of regular evaluation for male subfertility. The study by Ganeswar Barik looked at the level of malondialdehyde, total antioxidant capacity, and oxidative stress index before and after treatment with antioxidants. This study concluded that oxidative stress is increased in men with abnormal semen parameters, and antioxidant therapy improves sperm concentration, motility, and morphology and decreases oxidative stress with optimal treatment outcome.
In many infertility clinics, ICSI for all has become a norm to prevent failed fertilization but is it justifiable is a question asked frequently. Reeta Biliangady et al. evaluated data on reproductive outcomes between IVF and ICSI in nonmale factor infertility. This study clearly showed no advantage of performing ICSI for patients with normal semen parameters. The literature also does not support ICSI for all, though ICSI may decrease the incidence of unexpected fertilization failure. The numbers needed to treat are 30. This means that thirty couples need to undergo ICSI for one fertilization failure. Moreover, pregnancy rates for ICSI have not been higher than that for conventional IVF.
The incidence of polycystic ovary syndrome (PCOS) is on the rise today, and we find resistance to ovulation induction (OI) therapy in many. We have an article comparing the clinical, metabolic, hormonal, and ultrasound parameters among the clomiphene citrate (CC)-resistant and CC-sensitive PCOS women. Women with significantly higher hyperandrogenism, deranged metabolic profile, high body mass index (BMI), high anti-Müllerian hormone values, and long cycles are associated with CC resistance. One should choose the OI protocols based on these parameters for an optimal outcome.
Priyanka Sinha et al. have shown that laparoscopic ovarian drilling (LOD) has shown to reduce testosterone and luteinizing hormone/follicle-stimulating hormone (FSH) ratio and improve clinical outcome in PCOS. We should keep LOD as the last option as evidence has shown that the results of LOD are not superior to OI with CC or gonadotropins. It may be used in treating PCOS to shorten time to pregnancy and decrease the dose and period of administration of OI drugs. LOD still could be an option in rural population, where regular monitoring may not be possible.
Abhijit A et al. have again endorsed the fact that controlled ovarian stimulation with recombinant FSH is associated with high progesterone levels in the late follicular phase with suboptimal IVF outcome. In this situation, it is best to defer fresh embryo transfer and freeze all embryos. Embryo transfer performed in the subsequent cycle, either natural or artificial, will optimize the pregnancy outcome.
Progesterone levels both on the day of human chorionic gonadotropin (hCG) trigger and oocyte retrieval influence the pregnancy rates. Elevated progesterone levels on the day of retrieval significantly reduce both implantation and pregnancy rates and can be used as an additional component to assess the number of oocytes retrieved and estimate the pregnancy rate and live birth rate indirectly. Srinivas Sangisapu et al. have looked at serum progesterone levels at hCG trigger and at OR. This study concluded that the ratio of rise in progesterone on the day of OR from the day of hCG is associated with the number of oocytes retrieved and IVF outcome.
Socioeconomic factors, health system, addiction, weight, and psychosocial factors are some of the social determinants of reproductive health, which have an association with the likelihood of pregnancy in the infertile population. One of the original studies published in this issue looked at the relationship between fertility/infertility and age; ethnic origin; BMI; dietary intake; physical activity; psychological state; education; work activity; income level; and addiction to alcohol, smoking, and coffee. They found the association to be inhomogeneous and weight control with restriction of calorie intake, greater consumption of healthy foods, regular physical exercise, and lower age to be positively associated with fertility.
There is another original article from Morocco, which showed the benefit of nursing consultation in decreasing the perceived stress and increasing the self-esteem in infertile couples undergoing ART.
We also have four case reports: one on Robertsonian translocation of “21/22” in nonobstructive azoospermia, second on extensive primary male genital tuberculosis, and third on successful pregnancy outcome in two sisters with Swyer syndrome. There is also a case report on India's first successful surrogate birth after percutaneous OR following modified radical hysterectomy and right ovarian transposition to the anterior abdominal wall.