|Year : 2020 | Volume
| Issue : 2 | Page : 79-81
From the editor's desk
Dr. Patil's Fertility and Endoscopy Clinic, Bengaluru, Karnataka, India
|Date of Submission||24-Jun-2020|
|Date of Acceptance||26-Jun-2020|
|Date of Web Publication||09-Jul-2020|
Dr. Madhuri Patil
Dr. Patil's Fertility and Endoscopy Clinic, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Patil M. From the editor's desk. J Hum Reprod Sci 2020;13:79-81
COVID-19 pandemic is an unprecedented public health emergency. This pandemic when it started resulted in suspension of new treatment cycles of ovulation induction, intrauterine inseminations,in vitro fertilization (IVF) including retrievals and frozen embryo transfers (FETs), as well as nonurgent gamete cryopreservation. We did finish the already started cycles and did those which require urgent stimulation and cryopreservation as in cancer treatment. All elective surgeries and nonurgent diagnostic procedures were also suspended to minimize interpersonal interactions to prevent transmission of COVID-19 to patients, staff, and physicians and to the population at large. As infertility treatment can be delayed for a period of time without undue risk to the patient, it was suspended. However, by the end of May, we realized that living and operating in a society where COVID-19 exists has become a reality for all. Although fertility care does not pose any undue risk, it is an essential health service, especially for those with low ovarian reserve or sperm count, and it was decided to resume assisted reproductive technique (ART) services in a phased out manner. The three main fertility societies in India (Indian Society for Assisted Reproduction, Indian Fertility Society, and Academy of Clinical Embryologists) came together to formulate recommendations to resume ART treatment in a phased out manner which have been published in this issue. Before starting, each unit should ensure that they are adequately prepared to provide patient care in a manner that limits risk to patients, staff, and physicians and other health-care providers by educating the health-care providers and patients and using personal protective equipment. It is important for all health-care providers to stay up to date, as new information is emerging as days pass by, on the risk of disease transmission by symptomatic and asymptomatic individuals. We would be updating these guidelines as and when required.
We have a review article on surrogacy which has made an attempt to encapsulate the varied aspects of this topic from the multiple perspectives of individuals who are involved in the surrogacy cycle. It is very important to study the psychosocial characteristics of triad members involved in this process that is the gestational surrogate, intended parents, and offspring before, during, and after the process. The different social and psychological issues that are involved in surrogate motherhood include the surrogate mother (or couple) relinquishing the baby at or soon after birth, the commissioning or intended couple receiving the commissioned baby, and the long-term outcome for the offspring. Disclosure of this fact is a must for commissioning parents as they cannot get away with a make-believe pregnancy. Different psychological traits and/or different social circumstances of each individual involved may result in psychosocial concerns. Identification of the various psychosocial factors that modulate the process is necessary so that they can be mitigated appropriately for the process to be a success.
CYP19A1 is an aromatase-coding gene and its expression is frequently repressed in polycystic ovary syndrome (PCOS) ovaries due to the promoter hypermethylation, which may play a key role in the pathogenesis of PCOS. CYP19A1 gene expression is regulated by multiple factors as a result of epigenetic modifications in estrogen receptor-beta and changes induced by follicle-stimulating hormone (FSH) in granulosa cells. A study from Indonesia on expression of mRNA CYP19A1 in granulosa cells of PCOS patients concluded that its expression was lower in PCOS women as compared to their non-PCOS counterparts. Probably, if we could have these tests in our clinical armamentarium, we would be able to identify patients with varied response to controlled ovarian stimulation.
Office hysteroscopy (OH) is a part of investigation in many infertile women, regardless of age, though three-dimensional ultrasound and hysterosalpingography (HSG) are first-line investigations. Today, OH is mainly done when ultrasound and HSG suggest an intrauterine abnormality or after recurrent implantation failures in ART cycles. We are aware that hysteroscopy is more accurate as HSG is associated with high false-positive and false-negative rates for intrauterine abnormality. As OH is done without anesthesia, introduction of scope in the uterine cavity may be difficult. In this issue, we have a double-blind randomized control trial (RCT) which demonstrated the effectiveness of 200 mcg of misoprostol applied 4 h before the procedure, which significantly reduced the difficulty encountered in negotiating the cervical canal.
This issue publishes four articles on andrology. The first article looks at the relationship of body mass index (BMI) and semen quality. This study concluded that the semen quality deteriorates with increasing BMI though the mechanism for this negative impact is unknown.
However, definitive conclusion on the effect of increasing BMI on semen quality remains unclear and uncertain due to the contradictory publications. Some studies have shown no association between BMI and semen parameters, whereas the others have shown a negative correlation between BMI with count and motility. Other studies have also shown a significant positive relation between BMI and DNA fragmentation index. The second study is a correlation of testicular size with sperm count in both fertile and infertile population. Several studies have shown a significant correlation between testicular volume and spermatogenesis, sperm density, total sperm count, total motile sperm count, serum FSH, and luteinizing hormone levels. Therefore, testicular volume can be considered to be a reliable indicator of testicular function. The threshold values for testicular volume are varied in different studies and range between 10 and 15 ml. Hence, the critical mean testicular volume necessary for adequate spermatogenesis is still not determined. The testicular volume of 18–20 ml seems to be optimal for optimal spermatogenesis. The original article in this issue concludes that the threshold value for testicular size is 18 ml and 3.8 cm to predict infertility.
There is a study from Italy which compares different sperm separation techniques for ART, through quantitative evaluation of p53 protein. P53 protein is one of the proteins that primarily regulate metabolism, posttranslational modification, and motility of spermatozoa.
Role of protein p53 in the spermatogenesis is to have both appropriate quality and quantity of mature spermatozoa and maintaining sperm DNA integrity. Sperm DNA integrity is an important parameter to assess potential fertility in males. Salvatore et al. conclude that apart from the role of p53 protein in maintaining the sperm DNA integrity, it also could control timing and embryonic development.
Premature ejaculation (PE) is a common male sexual dysfunction and can cause significant personal distress. This may affect the interpersonal relationship of the couple. Apart from psychological and behavioral therapy medical therapy includes use of tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), centrally acting opiates, phosphodiesterase-5 inhibitors, and topical desensitizing creams. Although SSRIs are efficacious, they do have a substantial and prolonged side effect. The original article here compares daily SSRIs such as paroxetine with levosulpiride, an antidopaminergic drug. Levosulpiride is also known to facilitate sexual arousal and lowers the ejaculatory threshold. The study concluded that both paroxetine and levosulpiride are efficacious in patients of PE, but paroxetine is more efficacious than levosulpiride. The limitation of this study was the small sample size and limited evidence on the use of levosulpiride for PE, which is a lesser studied and used drug. Probably, a large RCT would throw light on the use of levosulpiride for PE.
In vitro maturation (IVM) is not a conventional treatment option used and has a lot of controversy regarding its success rate. It is still accepted as an alternative treatment and probably has a role in fertility protection and ovarian hyperstimulation syndrome management, especially in PCOS patients. During IVM, it is the cytoplasmic maturation that is a great concern and not the nuclear maturation. The nuclear maturation and the cytoplasmic maturation are not concordant and result in a lower pregnancy rate compared to conventional IVF. The enrichment of culture media, standardization of the stimulation protocols, and management of cytoplasmic maturity may improve IVM results. We have an RCT which looked at the outcome of rescue IVM in fertilization culture medium with and without human chorionic gonadotropin (hCG). They noted a better outcome when hCG was added to the culture media, but this did not reach statistical significance.
Changes in the intracellular concentration of calcium (Ca2+) regulate diverse cellular processes including fertilization. Calcium signals drive the fundamental events surrounding fertilization, oocyte activation, and later signaling events required for successful preimplantation embryo development. We have a research paper on the effect ofin vitro activation of mouse oocytes through intracellular Ca2+ regulation. This study demonstrated that artificial activation using A23187 could promote meiosis progression of resistant immature mouse oocytes either in germinal vesicle or metaphase I stages to mature oocytes.
Conventional IVF and intracytoplasmic sperm injection (ICSI) when performed on sibling oocyte–cumulus complexes in cases of unexplained infertility and of borderline semen parameters can prevent fertilization failure and rescue a cycle of failed fertilization which can happen when only IVF is performed. In a retrospective study by Goswami et al., higher fertilization rate, cleavage rate, and better quality embryos were seen in the IVF group as compared to ICSI. Split IVF/ICSI in this study could salvage 10% of their cycles where there was complete fertilization failure in the IVF group. Thus, adoption of ICSI-IVF insemination split in cases of unexplained infertility and mild factor infertility may help eliminate total fertilization failures and rescue the ART cycle. There is another RCT published in this issue, which compared follicular flushing with direct aspiration at oocyte retrieval in poor responders. This study also had a similar conclusion as most other studies published till date on follicular flushing, which was supposed to be time-consuming and did not increase the oocyte recovery rate and pregnancy rate in poor responders.
In most cycles, supernumerary embryos are frozen either at cleavage stage or blastocyst stage. Many times, embryos often did not develop to the blastocyst stage on day 5 and, therefore, were not cryopreserved until day 6. There are several studies that have been published which compared the pregnancy rates (PRs) in a FET cycle following transfer of blastocyst frozen either on day 5 or day 6. Some studies have shown no difference in PRs, but others have shown significantly reduced PRs when day 6 vitrified blastocyst was transferred as compared to day 5 vitrified blastocyst, though the morphology was similar. The latter statement confirms that the rate of embryo development to blastocyst is an important indicator of embryo viability. Parnita Sardana et al. compared outcome following transfer of day 5 versus day 6 vitrified blastocyst in three groups of patients. The three groups included FET in self-oocyte cycles with and without preimplantation genetic testing-A (PGT-A) and donor cycles without PGT-A. This study did not find any statistically significant difference in the live birth rate (LBR) in self-oocyte PGT-A cycles, whereas the LBR was significantly higher with day 5 blastocyst transfers in the untested group using both self and donor oocytes. The authors, therefore, concluded that euploid embryos have similar pregnancy outcomes regardless of the day of development. These findings imply that performing a PGT-A on the blastocysts that develop on day 6 will result in better utilization of embryos with delayed development.
We have two interesting case studies: one on isolated Fallopian tube More Details torsion and the other on morphological spectrum of epididymal tubules in obstructive azoospermia.