Year : 2019 | Volume
: 12 | Issue : 4 | Page : 271--273
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;12:271-273
|How to cite this URL:|
Patil M. From the editor's desk. J Hum Reprod Sci [serial online] 2019 [cited 2020 Apr 1 ];12:271-273
Available from: http://www.jhrsonline.org/text.asp?2019/12/4/271/273113
Initiation of an effective immune response requires close interactions between innate and adaptive immunity. Unexplained infertility at times can correlate with certain immune aspects such as natural tolerance. The female immune system needs to undergo changes that are directed to protect the fetus from a detrimental immune response. This issue has a review article which looks at the decidual immune system, both innate and adaptive, in couples with unexplained infertility. Altered proportions or levels of T helper 1 cell response (tumor necrosis factor [TNF] TNF-ά, TNF-β, interferon-γ, interleukin [IL] IL-2, IL-12, and IL-18), T helper 2 cell response (IL-3, IL-4, IL-5, IL-6, IL-10, and IL-13), T follicular helper, CD8+ CD28− T, and regulatory T cells, as well as autoantibodies, can result in infertility, implantation failure, or pregnancy loss. The other review article is on T-shaped uterus, which previously has classically been associated with “in-utero” exposure of diethylstilbestrol. The recent American Society for Reproductive Medicine (ASRM) classification of congenital anomalies has not provided a morphometric criterion for T-shaped uterus (2016). Earlier in 2013, the European Society of Human Reproduction and Embryology (ESHRE) and the European Society for Gynaecological Endoscopy (ESGE) has described T-shaped uterus as a subtle uterine variance or dysmorphic uterus. Management of patients with a T-shaped uterus is controversial and the beneficial effect of hysteroscopic metroplasty is questionable with no prospective studies or randomized controlled trials. Most published data on T-shaped uterus which have shown a beneficial effect on live birth rates after lateral metroplasty are only very small case series with no controls. Several side effects of lateral metroplasty have been reported in literature, which include cervical incompetence, endometritis (in 1%–5% of cases), destruction of normal endometrium due to the use of monopolar cautery, development of intrauterine adhesions, uterine perforation at surgery and increased incidence of uterine rupture during pregnancy, increased risk of miscarriage (22%) and premature delivery (20%), adherent placenta, and increased incidence of cesarean section. Moreover, one also needs to differentiate between T-shaped uterus and uterus infantilis. The T-shaped uterus has two-thirds uterine body and one-third cervix, whereas the uterus infantilis has one-third uterine body and two-third cervix. Due to lack of much evidence, lateral metroplasty should not be the first line of treatment and be reserved for symptomatic patients. The challenge in diagnosing and treating T-shaped uterus is that most cases which meet the ESHRE/ESGE criteria for T-shaped uterus also meet the criteria of normal uterus by the ASRM. The review here suggests a centralized database of women with T-shaped uterus with their reproductive outcome, which will enable in establishing clear-cut diagnostic and surgical criteria which will influence the reproductive outcome.
There is an original article from a public hospital which looks at the causes and prevalence of factors causing infertility at a public health facility. Female factor infertility (polycystic ovary syndrome [PCOS] and tubal factor) is more common than male factor infertility. In that public sector hospital, the causes of female factor infertility included pelvic inflammatory disease due to infection, with tuberculosis being the most common cause. Increased age of marriage and unexplained infertility were the other common causes. Body mass index (BMI) did not influence the prevalence of infertility.
Semen analysis is an essential part of infertility investigations, but it has limited diagnostic value for male infertility. Routine semen parameters exhibit high degree of variability; they tell us about the function of testis but fail to predict sperm chromatin quality and sperm function. It also lacks information on subcellular/molecular changes in spermatozoa and is a poor predictor of male fertility potential because 50% of infertile men have normal semen parameters. Moreover, semen analysis has a low prognostic value for the occurrence of pregnancy and the current WHO standards fail to meet rigorous clinical and statistical standard. The clinical dilemma exists on the utility of semen analysis as the only test in male infertility as men with abnormal semen analyses can be fertile and infertile men can have normal parameters. The original paper on the effect of suboptimal semen parameters on male partner's ability to conceive looks at the occurrence of pregnancy in men with semen parameters that are below the generally accepted lower limits of normal. This study concludes that males with poor semen parameters as per the WHO criteria can initiate conception and are not subfertile. Therefore, we need better tests or markers of male fertility potential than conventional semen parameters which will more accurately diagnose male infertility, thus enabling us to stratify correct interventions. Sperm function test may be useful for identifying a male factor contributing to infertility or for selecting therapy, but for whom and which one (s) is unclear at present.
Human fetuin A (HFA) or α2-Heremans-Schmid glycoprotein is a highly pleomorphic protein released mainly by the liver with an important impact on a variety of clinically expressed metabolic and pathological processes. It can thus play a prominent pathophysiological role in numerous diseases and pathophysiological conditions with considerable biomedical significance. Recent advances in diagnostics have led to prospective HFA assays that are based on high-sensitivity immunoassay procedures, surface plasmon resonance, electrochemical detection, and signal enhancement. Its function includes inhibition of the activity of insulin receptors, regulation of response to inflammation, inhibition of calcific matrix metabolism, and ectopic mineralization. The level of fetuin-A in plasma correlates activation biomarkers and chemokines in patients with Type 2 diabetes, metabolic syndrome (MS), obesity, and cardiovascular disease. It is also an important growth and development factor with its action on transforming growth factor beta 1 and innate immunity. Preeclampsia is also associated with decreased serum α2-HS glycoprotein (fetuin-A) concentration. The original article in this issue looked at the association between idiopathic premature ovarian insufficiency and levels of fetuin-A/α2-Heremans-Schmid glycoprotein and concluded that the levels of HFA were not different from that of the controls.
There is also a Phase IV multicentric study to investigate the immunogenicity of recombinant human follicle-stimulating hormone (FSH) and its impact on clinical outcomes in females undergoing controlled ovarian stimulation published. The study drug has low immunogenic potential with overall safety and efficacy profile similar to other recombinant preparations available in the market.
In a prospective, single-center, randomized study, double dose of recombinant human chorionic gonadotropin (r-hCG) (250 μg and 500 μg) for final follicular maturation in in vitro fertilization (IVF) cycles was studied. This study concluded that a double dose of r-hCG for final follicular maturation in IVF cycles resulted in the improvement of mean number of oocytes per follicle but did not result in higher number of MII oocytes retrieved or higher pregnancy rates. However, this study found that double dose of r-hCG resulted in increased number of mature oocytes obtained, fertilization rate, and improved pregnancy rates in poor responders. Although not many studies have been conducted to compare two different doses of r-hCG, an review article has suggested that even the dose of hCG should be individualized for an optimal outcome, with an higher dose being beneficial in poor responders. Most of the studies in this meta-analysis included the comparison of 5000 and 10,000 IU of urinary hCG.
Hydroceles if large and tense can exert considerable hydrostatic pressure on the enveloped testis and may affect the testicular morphology and histology and perhaps its function. Moreover, stretching of the dartos muscle results in loss of its contractility and thereby its ability to contract and alter the testicular position, which is considered important in the thermoregulation of the testis. The FSH and luteinizing hormone levels may be raised and testosterone may be subnormal. The sperm count and motility may also be compromised especially in those patients where the hydrocele was present for longer duration. It was also observed in few publications that patients with a history of hydrocelectomy may have an increased incidence of antisperm antibodies in their serum. There is lack of good-quality evidence and the data available are contradictory on the effect of hydrocele on testicular morphology, histology, and function. It is also not known at present whether changes if any revert to normal with the treatment of hydrocele. In an original study in this issue, the authors looked at the assisted reproductive technique (ART) outcome after intra cytoplasmic injection of sperm (ICSI) in patients with and without hydrocele. They concluded that despite the sperm count and motility being affected by the presence of hydrocele, there was no effect on the ICSI outcome.
A rationale to freeze all embryos and transferring them in a subsequent cycle has become compelling though not proven to improve the outcome of ART. Till date, there is no clear data as to which patient will benefit from frozen embryo transfer (FET) and who will benefit from a fresh embryo transfer. A retrospective analysis by Reeta Biliangady et al. has shown an improved outcome of ART after freeze for all. However, one must consider that replacement protocols may not be physiological and that there could be biological consequences of embryo cryopreservation such as cell loss, arrested/compromised development, altered function/metabolism and absent further cleavage, and blastocyst formation. One needs to take into consideration the patient dynamics when we choose to freeze all embryos in lieu of fresh transfer. Apart from patient dynamics, psychological burden of postponement of embryo transfer, increased cost, and the efficacy of cryopreservation program, which is center specific, also need to be taken into account.
Increased pregnancy complications following FET in a hormone replacement therapy (HRT) cycle is a known fact. Endometrial preparation methods for FET transfer are associated with increased risks of hypertensive disorders of pregnancy and placenta accreta, in patients conceiving after HRT-FET than in those conceiving after natural cycle FET. In an article from France, higher age of the donor and low anti-Mullerian hormone values were identified as predictive factors for preeclampsia in oocyte recipients.
The presence of MS or related metabolic derangements is high in the family members of women with PCOS. It has been observed that PCOS siblings (sisters and brothers) have high androgen levels and are more obese than unaffected sisters. These facts suggest that the same gene defect is responsible for PCOS and the hormonal abnormalities and other symptoms found in the siblings of PCOS-affected women. An original article by Bindu Kulshreshtha has shown that symptomatic sisters and those with a higher BMI, high Homeostasis Model Assessment-Insulin Resistance, and hyperandrogenemia (HA) are at an increased risk of MS. They also observed that asymptomatic sisters with HA also have a higher risk of MS and need to be evaluated for metabolic risk.
This issue has five case reports; one reporting India's first child using preimplantation genetic testing (PGT) PGT-M, PGT-A, and human leukocyte antigen matching for helping a sibling having β-thalassemia major, second reporting a case of Swyer's syndrome with heterotopic adrenal cortical tissue in streak gonads, and third a case of complete androgen insensitivity syndrome. The fourth case reported is a novel method of successfully treating ovarian torsion by using sildenafil citrate and the last one is a successful treatment of heterotopic cervical pregnancy by transvaginal aspiration without disturbing the viable pregnancy.