Growth disparities in uterine leiomyomas associated with MED12 mutation Uterine leiomyoma is the most common benign estrogen (E)-dependent tumor in women of reproductive age. Approximately 25% of women are affected and the cumulative incidence is 70% of women by the age of 50 years. In addition, this tumor is more prevalent at younger ages, and is more common in African-American women (73%) compared to White women (45%). Uterine leiomyoma comprises smooth muscle cells derived from the myometrium and an extracellular matrix rich in collagen, fibronectin, and proteoglycans.
Commentary: when embryos hit the brakes If we have gleaned any one general principle from the time-lapse literature with regard to embryo selection, it is this: successful outcome from the transfer of a blastocyst depends somewhat upon it reaching that stage but even more so upon how and when it was reached. The simple visualization of an emerging fluid-filled space in a morula belies the underlying workings of a myriad of ordered molecular interactions. Without a doubt, blastulation is a complex process, with the resulting blastocyst representing the successful derivation of divergent cell lineages, a culmination of an ordered sequence of events that begins with the “start signal,” compaction, in mammalian embryos.
Infertility due to ejaculatory duct obstruction can be surgically corrected—a forgotten lesson in male reproductive urology Ejaculatory duct obstruction is a well-defined, potentially correctable cause of male infertility. It is diagnosed infrequently and is found in only up to 5% of infertile men (1). Male infertility due to ejaculatory duct obstruction is often secondary to azoospermia or, rarely, severe impairment of semen parameters even if some spermatozoa are present in the ejaculate. Because spermatogenesis is still normal in most of these men, surgical sperm retrieval for assisted reproduction with intracytoplasmic sperm injection is feasible and often is suggested as the first line of infertility management.
Is hyaluronic acid really ineffective? Asherman syndrome (AS) is a condition defined by the presence of intrauterine adhesions (IUAs) resulting when the bona fide endometrium is replaced by fibrotic tissues, causing the uterine walls to adhere to one another and causing symptoms such as infertility, recurrent miscarriage, menstrual abnormalities, pelvic pain, and abnormal placentation. A successful treatment for AS requires a comprehensive approach and prevention seems to be paramount and starts by optimizing the diagnostic strategy (1–3).
Improving care of our obese patients Although we all know that >50% of the women that we care for are overweight or obese, these numbers cannot be over emphasized (1). At present, overweight and obesity are the most common diseases seen in our patients, and these conditions are less well studied than most other diagnoses, such as polycystic ovary syndrome (PCOS), recurrent pregnancy loss, and thyroid dysfunction. Although many studies have focused their primary objective on the association between body mass index (BMI) and reproductive outcomes (i.e., obesity increases the risk of miscarriage or obesity lowers pregnancy rates [PRs]), there are rare studies focusing on how to better care for these women.
When IUP meets IUD One of the great opportunities to move beyond routine practice comes when patients have medical problems that should not have occurred. Despite being one of the most effective and cost-effective methods of contraception, women still can conceive in spite of an intrauterine device (IUD). If excluding expulsion, approximately 0.02% of women using a levonorgestrel IUD and 0.5% of women using a copper IUD will have an intrauterine pregnancy (IUP) in the first year of use (1). Removal is associated with a 2.7- to 3.2-fold lower risk for spontaneous abortion and a 2.3- to 3.2-fold decrease in risk for preterm delivery (2).
A semen analysis phone app does not replace laboratory testing Laboratory-performed manual semen analysis (SA) is the primary diagnostic test for male fertility. Although the value of laboratory SA has been questioned because of performance variation among testing laboratories, when performed with good microscopic technique and appropriate rigorous quality control (QC), it has been shown to correlate with male fertility and treatment outcomes in multiple studies over decades. As such, it is the criterion standard for SA. In this issue of Fertility and Sterility, Agarwal et al.
Looking for signs of life after thaw Since the earliest days of embryo freezing, two related questions of clinical and practical importance have been the subject of continued investigation and debate: What constitutes viability and determines development potential of embryos after thawing, and how long a culture period does it take to discern it?
Ovarian endometriosis and infertility: in vitro fertilization (IVF) or surgery as the first approach? IVF is commonly applied to all indications for infertility, but increasingly unexplained causes predominate (www.sart.org). Specifically, endometriosis is listed as the primary diagnosis in less than 4% of cases in the United States, primarily because laparoscopy is not performed for the basic infertility workup, as it once was (1). Unexplained cases of infertility show a high prevalence of endometriosis (2, 3). Visible endometriosis such as endometriomas present a special challenge, especially since ovarian reserve may be compromised when ovarian surgery is performed.
Women with endometrioma-related infertility face a dilemma when choosing the appropriate therapy: surgery or in vitro fertilization Endometriosis, particularly ovarian endometriosis, is a disease detrimental to fertility. The exact pathophysiology of endometrioma-related infertility is still a source of debate, however, and a number of mechanisms have been suggested. It has been postulated that it distorts the tubo-ovarian anatomy or induces an inflammatory reaction followed by the so-called burn-out effect, which impacts the follicle reserve (1) and causes oxidative stress (2) resulting in poorer quality oocytes. Indeed, toxic content from an endometrioma may result in local inflammation, elevated oxidative stress levels, increased fibrosis, loss of cortex-specific stroma, smooth muscle cell metaplasia, and a diminished follicle reserve due to greater follicle atresia (1, 2).
Enhancing shared decision making in assisted reproductive technologies through the use of multimedia platforms for informed consent Informed consent embodies the ethical principle of autonomy. The key goal of informed consent is to ensure that patients are making a medical decision in keeping with their goals and values, based on an understanding of the risks, benefits, and alternatives of a recommended treatment. This laudable goal has unfortunately become lost in a formulaic process involving lengthy paperwork that is laden with complex explanations with little room for discourse and dialogue. Informed consent has morphed into “consenting” or signing a piece of paper to avoid liability rather than an ongoing discussion and engagement between clinician and patient.
Ectopic pregnancy—still a challenge Ectopic pregnancy, which accounts for 1%–2% of all pregnancies, is associated with risk of sudden hemorrhage and remains a leading cause of maternal death, although its incidence has fallen during the past 25 years. This has been particularly true for African-American populations (1). The time from conception to tubal rupture is short, often occurring within 6–8 weeks of conception, underscoring the need for doctors of varied specialties, including pediatrics, family medicine, and emergency medicine, as well as obstetrician-gynecologists, to be aware of this possible diagnosis.
Mater semper certa est: motherhood is always certain The development of oocyte donation has led to a reexamination of the facets of motherhood: the genetic, gestational, and psychosocial contributions. In addition, the practice of oocyte donation has prompted a consideration of the unique psychosocial and legal aspects of this form of family building. In this section of Views and Reviews a summary and discussion of the long-term psychosocial adjustment of oocyte donor–conceived children and their parents is presented. Next, the current permeability around donor anonymity is investigated and questions regarding whether donor anonymity can still exist is discussed.
Hysteroscopic removal of intrauterine devices in pregnancy To introduce and demonstrate an approach to the hysteroscopic removal of retained intrauterine devices (IUDs) in pregnancy. Pregnancy risks associated with retained IUDs are also discussed, specifically spontaneous abortion and preterm labor.
Why is growth hormone underutilized for our most difficult IVF couples? In this issue of Fertility and Sterility, Regan et al. (1) present research findings on granulosa cell (GC) receptor density for growth hormone (GH), FSH, bone morphogenetic protein receptor 1B (BMPR1B), and LH in women with varying age and ovarian reserve undergoing in vitro fertilization (IVF). The authors found that GH receptor density was reduced in the poorer responders, and that GH receptor density increased with age in normal responders but not in poor responders. In their subjects aged 39–45 years with antral follicle counts (AFCs) of ≤8, GH treatment was associated with higher densities of all four receptors.
Promising noninvasive microscopy imaging technique evaluates metabolic markers in mouse oocytes Embryo selection represents a major strategic challenge in the assisted reproductive technology (ART) field, because transferring embryos with the highest implantation potential offers obvious advantages for both patients (shorter time to pregnancy, diminished complications, reduced emotional stress) and physicians (efficiency, higher pregnancy rate). The long history of embryo selection (1) has shown both promise and disappointment as numerous techniques have been proposed but did not pass the scrutiny afforded by robust (large) studies and critical evaluation (testing).
New realities for the practice of egg donation: a family-building perspective The practice of egg donation in the United States has been based on assumptions about secrecy, anonymity, and contact among the parties that require reexamination. This article argues for the need to acknowledge that secrecy and anonymity are no longer viable assumptions and that all parties may have a strong interest in contact and connection. A shift in the narrative for the practice of egg donation from a purely medical perspective to a broader family-building perspective is described. Significant practice changes to accommodate the new realities, rooted in a family-building perspective, are outlined in the arenas of medical record retention, informed consent, recipient and donor preparation and counseling, facilitation of contact among the parties, and outreach to other medical professionals, with the goal of promoting not only healthy pregnancy, but also long-term positive family functioning.
Ovarian stimulation for fertility preservation in women diagnosed with cancer The concept of fertility preservation by means of storing embryos and gametes has been entertained for a long time, but its clinical application in women had not been practicable until the early 1980s, owing to technical difficulties of the cryopreservation of embryos and oocytes. The steady progress of cryotechnology (especially vitrification) and advanced cancer treatment with high survival rates, however, have changed the landscape of the clinical practice of fertility preservation. The current consensus is that fertility preservation should be one of the most important topics to consider in young cancer patients of reproductive age.
Assessing assisted reproduction outcomes: sperm are important, too Much research over recent years has centered on whether assisted reproductive technology (ART) pregnancies, those that arise after manipulation of eggs and embryos in vitro, result in adverse outcomes for women and children. The underlying assumption of this research has been that the ART treatment, the underlying infertility, or a combination of the two are responsible for the adverse pregnancy, obstetric, delivery, and neonatal outcomes that have been documented. Far fewer studies have attempted to document the contribution of the male partner to these observations.
Simvastatin and uterine fibroids: opportunity for a novel therapeutic option Uterine fibroids (UF), the most common benign gynecologic tumors, affect up to 50% of all women and 80% of African American women by age of 50. Up to 25% to 50% of affected women develop UF-related symptoms, including abnormal uterine bleeding, anemia, pelvic pain, subfertility, and obstetric complications. Ultimately UFs negatively impact quality of life for many women. Hysterectomy remains the mainstay curative treatment for UFs, but this option is costly, invasive, and prohibits future childbearing.
Legal principles and seminal legal cases in oocyte donation Oocyte donation has played an increasingly important role in assisted reproductive technologies since the early 1980s. Over the past 30 years, unique legal standards have evolved to address issues in the oocyte donation procedure itself as well as the disputes over issues, such as parentage, that inevitably arise with new technologies, particularly for individuals seeking to build nontraditional families. This essay will explore oocyte donation's legal aspects as well as seminal law concerning the procedure, including statutory law (uniform and model provisions and enacted state laws) and selected judicial opinions concerning surrogacy and parentage, testing of oocyte donors, mix-ups of donated oocytes, and donor compensation.
Long-term outcomes of children conceived through egg donation and their parents: a review of the literature This review examines the literature on the long-term outcomes for children and parents in families created through egg donation, focusing on child psychological adjustment, parental psychological health, and parent-child relationship quality. Where possible, outcomes were examined according to family disclosure status (i.e., whether or not the parents intended to tell/had told the child about their method of conception). The small body of empirical literature indicates that children and parents function well throughout childhood and into early adolescence, although there appear to be subtle differences in mother-child relationship quality.
Making evidence-based decisions in reproductive medicine When deciding whether to use a medical intervention, evidence regarding not only effectiveness but also safety and costs must be weighed. Indeed, providing these three cornerstones of evidence is the main task of clinical researchers in any field. In reproductive medicine, although there is a good and long-lasting discussion regarding what is the best outcome for assessing effectiveness (1), safety and particularly costs are frequently overlooked.
The current status of oocyte banks: domestic and international perspectives Two major breakthroughs in the field of assisted reproduction—oocyte donation and oocyte vitrification—have joined forces to create the rapidly emerging phenomenon of commercial egg banks (CEBs). In this review, we examine the history of this concept, the operational models, the geographical variations, and the benefits and pitfalls of CEBs, including the ethical and legal dilemmas arising from gamete mobility. We highlight future directions in the brave new world of third-party reproduction.
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