Year : 2017 | Volume
: 10 | Issue : 3 | Page : 151--153
From the Editor’s Desk
Dr. Patil’s Fertility and Endoscopy Clinic, Bangalore, Karnataka, India
Dr. Patil’s Fertility and Endoscopy Clinic, Bangalore, Karnataka
|How to cite this article:|
Patil M. From the Editor’s Desk.J Hum Reprod Sci 2017;10:151-153
|How to cite this URL:|
Patil M. From the Editor’s Desk. J Hum Reprod Sci [serial online] 2017 [cited 2021 Oct 25 ];10:151-153
Available from: https://www.jhrsonline.org/text.asp?2017/10/3/151/216603
We have two review articles dealing with totally varied subjects in this issue. One article is regarding lean women with polycystic ovaries (PCOS) and the other is regarding oral health and erectile dysfunction (ED). Women with PCOS demonstrate different phenotypes based on their body mass index (BMI), which may vary considerably by geography. We also know that most women with PCOS are obese, and this obesity has a significant impact on the metabolic and reproductive consequences of PCOS. However, one must remember that lean women with PCOS also carry a huge metabolic risk. It has been reported that 5–10% of lean women have PCOS, and 30–50% of women with PCOS are lean. The numbers among the Indian population may be much more, because thin Indian women with PCOS have more fat, less muscle and are sarcopenic with abdominal obesity. Lean Indian women with PCOS are often misdiagnosed and not managed in time. We diagnosed PCOS in lean women when the women had BMI <23 kg/m2with waist circumference (WC) <80 cm. Though obesity has a higher incidence of insulin resistance, 75% of lean women were insulin resistant. luteneizing hormone (LH)/follicle stimulating hormone (FSH) ratios and dehydroepiandrosterone (DHEAS) levels were also higher in lean women with PCOS. Moreover, β-endorphin levels were found to be higher in lean women with PCOS, which correlated with other hormonal parameters. These higher β-endorphins, which stimulate the release of LH, are linked to mood disorders. Lean women with PCOS have a genetic predisposition with insulin resistance and hypersensitivity, as well as higher postprandial insulin levels. These women also have reactive hypoglycemia to carbs, excess hunger and body fat storage. Lean women with PCOS did not report a history of type-2 diabetes among their first-degree relatives. Therefore, the management of lean women with PCOS should deal with handling sarcopenia, building muscle, modifying diet by reducing the intake of carbohydrates and fats and adding proteins. Apart from modifying the diet, one must advise these women to eat less and eat slowly. It is also important to curb stress by various means such as yoga and meditation.
Nowadays, the incidence of ED is on the rise, and most of the time we relate it to stress, the lack of time, exposure to endocrine disruptors and sometimes to pathological conditions such as diabetes and obesity. A reproductive endocrinologist would generally have never thought of the link between chronic periodontitis (CP) and ED. This review article has shown a link between CP and ED, because CP is associated with endothelial dysfunction, and has demonstrated improvement in ED with periodontal treatment.
PCOS is associated with metabolic syndrome, which includes glucose intolerance, increased level of lipids, a higher incidence of hypertension and cardiovascular disease. Usually, women with dyslipedaemia associated with PCOS have low high-density lipoprotein (HDL) and high triglyceride levels. Statins are known to negate some of the adverse metabolic effects caused by PCOS and its treatment with oral contraceptive pill (OCPs). In this issue, we have an original article that looks at the correlation between anthropometric parameters (BMI and WC) and dyslipidaemia. This study demonstrated a significant positive correlation between BMI and WC with regard to triglycerides levels and a negative correlation between BMI and HDL cholesterol level.
We diagnosed unexplained infertility (UI) even when the couple showed no abnormality on being evaluated with routine standard, basic investigations. UI was the most frequent female infertility ‘diagnosis’, with a prevalence of 25–30% among all types of infertility. The diagnostic terminology of UI was not used to describe the presence of a medical condition, but a void – a negative but these negatives are however, practically impossible to prove. Four medical conditions tend to be misdiagnosed as UI and include endometriosis, subtle tubal pathology, premature ovarian ageing and immunological infertility. In the absence of a correctable abnormality, the therapy for UI is, by default, empiric. Proposed treatment regimens include intrauterine insemination (IUI), ovulation induction with oral or injectable medications, a combination of IUI with ovulation induction and assisted reproductive technologies (ARTs). ART is both diagnostic as well as therapeutic, but there is no convincing evidence to indicate that a change in policy to use in-vitro fertilization (IVF) as the first-line treatment, instead of IUI for UI, is justified. IUI is a commonly used treatment strategy for couples with UI. Data have indicated a significantly higher live birth rate with IUI and ovarian stimulation than with IUI alone for UI. Gonadotropin/IUI usage was found superior to the usage of clomiphene citrate (CC) or letrozole/IUI cycle, but gonadotropin therapy increases the cost of therapy. We also have an original article on the use of sequential protocol, which uses CC and human menopausal gonadotropin. Hembram et al. noted this method to be more cost-effective than gonadotropin and that IUI and had the advantage of no significant complications in properly monitored cycles.
Hysterosalpingography (HSG) for tubal patency is the simplest preliminary test to investigate tubal disease. Improvements in HSG as diagnostics modality is due to real-time imaging using the C arm, which helps in utero-tubal manipulation, tubal cannulation and the assessment of tubal pressure. These finding help in choosing the treatment strategy and also prognosticating the different treatment modalities. The original article from Nigeria looked at HSG as the primary method for evaluating uterine and tubal pathology. This study demonstrated a high incidence of tubal disease especially hydrosalpinx and advocated the use of fluoroscopy to improve the sensitivity and specificity.
Sub-mucous and junctional zone (JZ) myomas are associated with decreased implantation and pregnancy rates. Sub-endometrial myomas cause endometrial erosion with subsequent inflammation that alters the nature of the intrauterine fluid, resulting in a hostile environment. They also disrupt the endometrial blood supply, affecting the nidation and sustenance of early embryo. Sub-mucous and JZ myomas also increase intracellular calcium levels, which produce myometrial irritability and hyperactivity resulting in the disruption of the rhythmical contraction process of the JZ. The resection of these sub-mucous and JZ myomas should be undertaken before any infertility treatment. We know that unipolar cautery requires the use of glycine, which may result in complications during hysteroscopy. Being hypotonic and electrolyte-free, an excessive absorption of glycine causes hypervolaemia and hyponatraemia, and its intravasation results in the movement of fluid by osmosis into intracellular and extracellular space. If untreated, it may progress to bradycardia and hypertension and subsequently hypotension, pulmonary oedema, cerebral oedema and cardiovascular collapse. The use of bipolar current with an advantage of using normal saline for distention along with meticulous fluid management might limit the number of serious complications by higher-risk procedures such as myomectomy. The randomized, prospective, parallel, comparative, single-blinded study from Delhi (India) investigated the complication and pregnancy rate following sub-mucous myoma resection either using a mono- or bipolar current for resection. They concluded that the use of bipolar current for resection was much more safer and effective without compromise in the results of reproductive outcome.
Twelve family members including growth differentiation factor 9 (GDF9), bone morphogenetic proteins (BMP 2-16), activins, inhibins and GDF3 belong to the transforming growth factor (TGF) beta family and form the largest family of growth factor ligands expressed in the cumulus. Interactions happen between the oocyte and the surrounding cumulus and granulosa cells. Aberrations in oocyte gene expression have implications on the cumulus and granulosa cell proliferation, differentiation and function. Therefore, it is possible to assess the cumulus or granulosa cells to identify the markers of oocyte and embryo viability. Demiray et al. from Turkey investigated the expression of BMPs, anti mullerian hormone (AMH) and thymus cell antigen 1 (THY1) markers in the cumulus cells (CCs). They concluded that the oocyte and embryo quality could be predicted depending on whether these markers are expressed on the CCs. This study concluded that there is a significant difference in the expression of BMP2 in the CCs of good-quality oocytes and subsequently a good embryo; however, no significant differences were observed for AMH or CD90/THY1.
Preventing multiple pregnancies is of utmost importance, because with multiple pregnancy, ART results shift from success to complications. This is because, both maternal and neonatal morbidity and mortality increases with multiple pregnancy and is higher for triplet pregnancy as compared to twin gestation. No factors specifically predicting twin pregnancies were identified; therefore, single embryo transfer (SET) was supposed to be the order of the day. To increase the pregnancy rate with SET, embryo selection becomes very important. Selection based on blastocyst transfer, time lapse and aneuploidy screening may help in improving the success rates with SET. Uma et al. compared the pregnancy rates of single and double embryo transfer (DET) and found no statistical difference in the pregnancy rates between the two groups. There was significant reduction in the twin pregnancy rate and miscarriage rate in the SET group. The only problem with this study was that it was a retrospective analysis, and there could have been a bias in performing SET in those with good-quality embryos as against DET. Moreover, the sample size was also not equal, with more participants in the DET group as compared to SET group.
Adult stem cells have been identified in the highly regenerative human endometrium on the basis of their functional attributes. They can reconstruct endometrial tissue in vivo suggesting their possible use in treating disorders associated with inadequate endometrium. The role of stem cells in endometrial regeneration is not limited to local endometrial progenitor cells; in fact, haematopoietic and non-haematopoietic bone marrow-derived stem cells are recruited to the endometrium in response to injury. It was also concluded in some studies that CD45 + haematopoietic progenitor cells were able to colonize the uterine epithelium and play an important role in uterine epithelial regeneration. Tandulwadkar et al. instilled autologous platelet-rich plasma into the intrauterine cavity in 68 women aged between 22 and 40 years, over 8 months, with sub-optimal endometrial growth, and in patients with repeated cycle cancellations. They performed frozen embryo transfer when the endometrium reached an optimal thickness with triple layer appearance and good vascularity. They achieved a 45% clinical pregnancy rate.
Sexual dysfunction is on the rise nowadays and may be one of the causes for sub-fertility. It could also be other way round, where attempts to conceive may cause sexual dysfunction. Thus, the relationship between sexual dysfunctions and infertility can be mutual. There is a publication in this issue, which observes sexual functioning in women with infertility problems, their beliefs about sexuality and their quality of life. This study found the incidence of sexual dysfunction to be as high as 50% in the infertile population. Factors contributing to dysfunction included inadequate knowledge about sex, sexual stimulation and sexual communication. There is another article in this issue, which investigates the stress levels in both the partners undergoing infertility treatment. They compared the stress levels according to the treatment modality (IUI or IVF) and found it to be similar. It was also noted in this study that the female partner had more stress compared to the male partner. Therefore, the aim of all reproductive endocrinologists should be primary counselling at the clinic before any treatment is embarked on.
There are three case reports published in this issue and are regarding ‘Ectopic ovary with dermoid cyst as a result of possible asymptomatic autoamputation’, ‘Successful reproductive outcome after laparoscopic Strassmann’s metroplasty’ and ‘Large-volume paracentesis, up to 27 litres, with adjuvant vaginal cabergoline in the case of severe ovarian hyperstimulation syndrome with successful pregnancy outcome’.