Techniques For Getting Pregnant

Pregnancy Miracle By Lisa

The Pregnancy Miracle book details a highly unique program for treating infertility using traditional Chinese medicine and holistic methods. The author, Lisa Olson, offers easy-to-follow techniques and remedies involving diet, herbs and acupressure to improve your overall health and well-being, strengthen the organs and systems vital to reproduction, heal specific conditions that may affect fertility and even support reproductive methods such as IVF and hormone therapy. The Pregnancy Miracle system combines five secrets of ancient oriental medicine that restore the bodys balance when it comes to fertility. The book supplies information on how to correct many of the problems that affect both men and women when they are trying to get pregnant. If you are just getting started with your fertility journey, I highly recommend this book to be your first step. Exceptionally rich in information and actionable advice, it will educate and empower you, ultimately increasing the effectiveness of any treatment. Continue reading...

Pregnancy Miracle Overview


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Of Intracytoplasmic Sperm Injection ICSI

Intracytoplasmic sperm injection (ICSI) has been developed as an assisted reproductive technique by which a sperm is mechanically injected into the cytoplasm of an oocyte. This technique was pioneered initially in sea urchin (Hiramoto 1962), then in mouse (Lin 1966) and hamster (Ue-hara and Yanagimachi 1976). Although ICSI has been used successfully in humans throughout the world since it was first introduced clinically in 1992 (Palermo et al. 1992), ICSI in mouse proved extremely difficult, and was unsuccessful until the introduction of the piezo-driven micromanipulator in 1995 (Kimura and Yanagimachi 1995). In theory, ICSI of a single sperm, including sperm DNA and other sperm factors (Wilding and Dale 1997), whether live or amotile, is sufficient to derive a viable mouse. In general, ICSI results in a relatively high percentage (> 50 ) of successfully fertilized embryos and liveborn offspring, all of which are likely to wean and become reproductively sound. ICSI has been used to...

Reasonable Cautions and Concerns Regarding ICSI

ICSI is a remarkably effective ART for male mice with infertility or sperm dysfunction dysmotility due to any cause. However, by injecting a single sperm directly into the ooplasm of oocytes, the ICSI technique bypasses all natural sperm selection processes (cumulus penetration, zona binding, acrosome reaction, zona pellucida penetration, oolemma fusion, etc.). Consequently, the delivery of genetic material into an oocyte during ICSI raises concerns of contamination with pathogens and subsequent infection of the embryo. Another major concern is that of the genetic integrity of the sperm DNA. It is recommended that, whenever possible, motile sperm with normal morphology be used for ICSI. If the sperm has apparently normal morphology and is motile, there is a good chance of successful fertilization and embryo development. If the sperm is of very poor morphology or is largely amotile, then selection of the best sperm for ICSI becomes highly subjective. Structurally abnormal sperm are...

In Vitro Maturation Of Oocytes In Infertility Treatments

The research into maturation of immature oocytes initiated by Pincus and Enzmann (8) and continued by Edwards et al. (23) was not incorporated as a treatment for human infertility until 1991. Cha et al. (24) reported that human follicular oocytes were harvested from unstimulated ovaries during gynecological surgery, matured in vitro, then fertilized, and five embryos were transferred to a woman with premature ovarian failure. The recipient subsequently delivered healthy triplet girls. Trounson et al. (25) further suggested that immature oocyte recovery could be developed as a new method for the treatment of women with infertility due to PCO because the oocytes of these patients retain their maturational and developmental competence. However, the initial reported IVM pregnancy rates were low. Our group demonstrated that priming with hCG 36 hours prior to immature oocyte collection significantly improved the maturation rate, and the pregnancy rate exceeded 30 (26,27). IVM was initially...

Fertility Preservation

Oocytes could be harvested from ovaries of cancer patients after controlled ovarian hyperstimulation. However, there are two major drawbacks associated with conventional IVF first, the time interval needed for IVF ranges from 2 to 6 weeks beginning with the patient's next menstrual period, which may sometimes be too long due to the natural course of the malignant disease without therapy. Second, ovarian hyperstimulation is associated with high estradiol levels which may not be safe in some cases of estrogen-sensitive breast cancer. Ovarian stimulation for oocyte collection could be totally avoided by collecting immature oocytes (51). We recently reported the retrieval of immature oocytes from unstimulated ovaries before gonado-toxic therapy for oocyte vitrification purposes (52). This resulted in the successful preservation of fertility with no delay in chemotherapy, no surgery, and no necessity for hormonal stimulation. Since that report, 26 cancer patients have undergone immature...

Semen Cryopreservation and Assisted Reproduction

Cryostorage of semen has become standard practice and should be offered to all men before undergoing potentially sterilizing therapy. Improvements in the techniques used to store semen (49) and advances in the field of assisted reproduction, such as intracyto-plasmic sperm injection (ICSI), have increased the chance of successful pregnancies using cryopreserved sperm. However, there are some limitations to this method of preserving fertility. First, it is not a feasible option for prepubertal patients. Furthermore, testicular function in adult men with malignant disease is often impaired before treatment (9) resulting in poor sperm quality or difficulty providing semen for storage. Oligospermia is found in a third to a half of patients with Hodgkin's disease, NHL, and testicular cancer before treatment and also occurs in men with leukemia and soft-tissue cancer (7a). Sperm motility is also impaired in these patients, and the process of freezing and thawing semen further reduces the...

Intracytoplasmic Sperm Injection

Under these conditions, however, the importance of another set of factors, some of which were not perceived in the conventional IVF era because of their association with other defects that impeded sperm entry to the oocyte, gains importance. Most of these factors are related to success of oocyte activation or failure and to the early development of the zygote (11).

Intracytoplasmic Sperm Injection History of ICSI

Extremely low sperm counts, impaired motility, and abnormal morphology represent the main causes of failed fertilization in conventional IVF. Today, ICSI is the ultimate option to treat these cases of severe male-factor infertility. One single viable spermatozoon, preferably of good morphology, is selected by the embryologist and injected in each oocyte available. ICSI is based on micromanipulation of oocytes and spermatozoa. Initially, partial zona dissection (PZD) was established to facilitate sperm penetration (4-7). The barrier to fertilization represented by the zona pellu-cida was disrupted mechanically so that the inseminated sperm cells obtained direct access to the perivitelline space of the oocyte. Subzonal insemination (SUZI) represented the next step in micromanipulation techniques (8-11). SUZI enabled the immediate delivery of several motile sperm cells into the perivitelline space by means of an injection pipette. ICSI is even more invasive because a single spermatozoon...

Gamete Handling Prior to ICSI

Germinal Vesicle

A successful ICSI program depends on ovarian stimulation, which is essentially similar to methods used for conventional IVF. Current ovarian stimulation regimens use a combination of gonadotropin-releasing hormone (GnRH) agonists or antagonists, human menopausal gonadotropin (hMG), or recombinant follicle-stimulating hormone (recFSH), and human cho-rionic gonadotropin (hCG), which allows the retrieval of a high number of cumulus-oocyte complexes (43,44). Administration of GnRH agonists Fertilization by means of micromanipulation requires denudation of oocytes (i.e., removal of the surrounding cumulus and corona cells). This strategy allows not only precise injection of the oocytes, but also the assessment of their maturity, which is of critical importance for ICSI. Cumulus and corona cells are removed using a combination of enzymatic and mechanical procedures (20). Both the enzyme concentration and the duration of the exposure to the enzyme should be limited because they can result in...

Female Infertility Is Caused by Endocrine Malfunction and Abnormalities in the Reproductive Tract

Several treatments can alleviate infertility problems,- for example, some success has been achieved in hypothalamic disease with pulsatile administration of GnRH. When hy-pogonadotropism is the cause of infertility, sequential administration of FSH and hCG is a common treatment for inducing ovulation, although the risk of ovarian hyperstimulation and multiple ovulations is increased. Hyperpro-lactinemia can be treated surgically by removing the pituitary adenoma containing numerous lactotrophs (prolactin-secreting cells). It can also be treated pharmacologically with bromocriptine, a dopaminergic agonist that reduces the size and number of the lactotrophs and PRL secretion. Treatment with clomiphene, an antiestrogen that binds to and blocks estrogen receptors, can induce ovulation in women with endogenous estrogens in the normal range. Clomiphene reduces the negative feedback effects of estrogen and thus increases endogenous FSH and LH secretion. When reproductive tract lesions are...

Reproductive technologies help solve problems of infertility

The oldest and simplest reproductive technology is artificial insemination, which involves placing sperm in the appropriate part of the female's reproductive tract. This technique is useful if the male's sperm count is low, if his sperm lack motility, or if problems in the female's reproductive tract prevent the normal movement of sperm up to and through the oviducts. Artificial insemination is used widely in the production of domesticated animals such as cattle. The first successful ART was in vitro fertilization (IVF). In IVF, the mother is treated with hormones that stimulate many follicles in her ovaries to mature. Eggs are collected from these follicles, and sperm are collected from the father. Eggs and sperm are combined in a culture medium outside the body (in vitro, in glass), where fertilization takes place. The resulting embryos can be injected into the mother's uterus in the blastocyst stage or kept frozen for implantation later. The first test-tube baby resulting from IVF...

Fertilization and Embryo Cleavage After ICSI

Fertilisation Polar Bodies Cleavage

After the injection procedure, oocytes are rinsed and cultured in micro-droplets covered with lightweight paraffin oil. The conditions are similar to those employed for IVF inseminated oocytes the oocytes are kept at 37 C in an atmosphere of 5 O2, 5 CO2, and 90 N2. Injected oocytes are examined for integrity and fertilization about 16-18 hours after ICSI (67). An average damage rate of approximately 9 of the injected oocytes can be expected, irrespective of the origin of the sperm used (45). Oocytes are considered normally fertilized when two individualized or fragmented polar bodies are present together with two clearly visible pronuclei (2-PN) that contain nucleoli (Fig. 3). The fertilization rate after ICSI is usually expressed per number of injected oocytes and ranges from 57 to 67 according to the sperm origin (45). As shown in Figure 3, abnormal fertilization may occur, reflected by one-pronuclear (1-PN) oocytes (about 3 of the injected oocytes) (45). These oocytes are likely to...

Modification of the ICSI Procedure

There is a body of evidence indicating that complete absence of pronuclear formation after ICSI is mostly caused by a failure of oocyte activation (55,56 reviewed in Ref. 11). Globozoospermia (round-headed sperm syndrome) is a well-defined condition in which the ability of spermatozoa to activate the oocyte is known to be absent or severely impaired (52), although spermatozoa from some globozoospermic patients fertilize normally (57). Moreover, cases of sperm-oocyte-activating factor deficiency, leading to fertilization failure, without the classical globozoospermia phenotype were also observed (57-60). The oocyte, in its turn, may also be responsible for complete fertilization failure, presumably because of deficiencies of the cyto-plasmic machinery capable of transducing the sperm-derived signals to adequate effector systems (57). Both the sperm-borne and the oocyte-borne abnormalities of oocyte activation can now be alleviated in the ICSI setting. Based on initial observations...

The Center For Human Reproduction

Embryology Andrology

A list of the principal pieces of equipment follows. It should be noted that there are consultants specific to the IVF field who specify equipment and do the laboratory layout, although the embryologist will have considerable input and may, in fact, take entire responsibility for the Medical Gases. There are a large number of medical gas cylinders within this suite. Even if general anesthesia is not used, there will be a need for centrally piped oxygen in the procedure rooms and the recovery room. The IVF culture area and micromanipulation area require vacuum A collection of fertility dolls from various cultures is interesting and relevant. Although not recommended for the waiting room, in a corridor, a large photo wall can be attractively created with photos of parents and their babies. Physicians in this specialty receive hundreds of photos from grateful patients. These range from poorly composed snapshots taken with disposable cameras to professionally posed photos with twins or...

Quality and Treatment of Sperm Used for ICSI

Probably the single most important justification for the development and application of ICSI for mouse colony management is the minimal requirement of sperm amenable to ICSI. Sperm from a male mouse that is fertile, subfertile, or infertile, including a male that either physically cannot mate or cannot produce normal sperm capable of fertilizing oocytes naturally either in vivo or in vitro, can be used successfully for ICSI. Sperm types that have been used successfully include epididymal and testicular sperm, which retains its motility after having been freshly harvested, following complete or hemicastration (Kimura and Yanagimachi 1995), and after having been recovered following cryopreservation ((Wakayama et al. 1998) K.C.K. Lloyd unpublished data). Normal offspring can also be obtained by injection of oocytes with spermatocytes (Kimura and Yanagi-machi 1995) and round spermatids (Sasagawa et al. 1998) from testis after artificial activation. It is this latter source that forms the...

Klinefelters Syndrome And Infertility

Previously, donated sperm or adoption were the only options for men with KS to have children, however, dramatic advances in infertility treatment for individuals with KS have recently occurred. Several reports of births resulting from intracytoplasmic sperm injection (ICSI) of sperm obtained from testicular biopsy specimens in patients with KS have been published (56-58). Although most patients with nonmosaic KS do not have sperm on testicular biopsy (59,60), this technique offers a chance at fertility for those who do. Unfortunately, analysis of spermatozoa obtained by testicular biopsy in individuals with KS has revealed an increased prevalence of sperm with an additional X chro mosome (61), higher rates of aneuploidy (62), and trisomy 21 (63), implying an increased risk of genetic abnormalities in offspring of individuals with KS born using ICSI. Additional selection of sperm from testicular biopsy specimens in individuals with KS may be required to prevent the transmission of...

Principles of ICSI

In ICSI, a single sperm, either intact or sperm head only, is mechanically inserted into the oocyte cytoplasm, bypassing all natural barriers to fertilization, including the cumulus layer, zona pellucida, and oolemma (plasma membrane). ICSI also precludes the natural incorporation of sperm membrane into the oolemma, as occurs during natural (non-assisted) fertilization. Sperm obtained from the epididymis do not need to be capacitated or acrosome-reacted when used for ICSI, although studies indicate that induction of the acrosome reaction may increase male pronuclear formation after ICSI (Kimura and Yanagimachi 1995). Mouse sperm has a hooked head that connects through the neck to a long tail, making it rather difficult to use for ICSI. Fortunately, only the sperm head is necessary for ICSI fertilization and embryo development in the mouse (Kuretake et al. 1996). In most mammals, including humans, centrioles and centrosomes located in the neck region are inherited paternally (Schatten...

Transgenesis by ICSI

Using sperm as a vehicle for delivering exogenous DNA into an egg is an interesting potential application for ICSI in the field of animal transgenesis and biotechnology. The ability of sperm to take up and bind exogenous DNA and then transfer it into an egg during fertilization was first described 30 years ago (Brackett et al. 1971) and was rediscovered in 1989 (Lavitrano et al. 1989). Studies have shown that mouse epididymal sperm can take up 1.5-4 x 106 DNA molecules (average 5 kB). The mechanism of DNA uptake and binding of sperm relies on an ionic interaction that takes place in the subacrosomal segment of the sperm head between DNA and a group of positively charged sperm membrane proteins. Sperm-bound DNA is rapidly internalized into nuclei in 60-65 of sperm (Lavitrano et al. 1992 Francolini et al. 1993 Zani et al. 1995). While the usefulness of this method applied to sperm to be used for transgenesis by IVF remains controversial, exogenous DNA can be delivered successfully into...


Cystic fibrosis is associated with infertility in men. Up to 80 of men with congenital bilateral absence of the vas deferens have mutations in CFTR, although many of them have no obvious other symptoms. The most common of these mutations are AF508, G551D, G542stop, W1283stop, N1303K and

Conventional IVF

As compared with natural fertilization, sperm selection is less stringent in in vitro fertilization (IVF) because the fertilizing spermatozoon does not need to penetrate through the cervical mucus and to make its path along the female genital tract until it meets the oocyte. Hence, the probability of fertilization with less motile and less viable spermatozoa is higher. However, nonprogressively moving and immotile spermatozoa are still excluded as well as spermatozoa with defective function of binding sites for the zona pel-lucida and oolemma on their plasma membrane and those with abnormal acrosomal function.

Indications for ICSI

Before the era of ICSI, attempts were made to modify and refine conventional IVF to achieve increased rates of conception in cases of male-factor infertility. Today, ICSI has clearly overshadowed the use of modified IVF procedures (including high insemination concentration) for the treatment of severe male-factor infertility. ICSI requires only one spermatozoon with a functional genome and centrosome for the fertilization of each oocyte. Indications for ICSI are not restricted to impaired morphology of the spermatozoa, but also include low sperm counts and impaired kinetic quality of the sperm cells. ICSI can also be used with spermatozoa from the epididymis or testis when there is an obstruction in the excretory ducts. Azoospermia caused by testicular failure can be treated by ICSI if enough spermatozoa can be retrieved in testicular tissue samples. Table 1 gives an overview of the current indications for ICSI. Table 1 Current Indications for Intracytoplasmic Sperm Injection...

ICSI Instrumentation

Despite the very successful and multiple applications of ICSI as an effective ART in mice, the complex nature of the procedure and specialized instrumentation required have been cited by some as making ICSI inaccessible to most workers in the field, with the exception of a few highly specialized laboratories. These are unfair assertions, as the instrumentation differs in only a few respects from that used in most transgenic laboratories today, and the procedure can be mastered with concerted daily practice and effort. The instrumentation needed to establish ICSI in the laboratory can be divided into two groups that required for preparation of the microtools, and that required for the ICSI procedure itself. A puller and microforge are necessary to prepare the microtools. The correct settings and use of these instruments are of critical importance in preparing good microinjection pipettes, which in turn is crucial to the ICSI procedure itself. These details are described in Sect. 2.5....

ICSI Procedure

Injection Needle For Oocyte Manipulation

For the ICSI procedure itself, an inverted microscope equipped with micromanipulators and microinjectors should be available (63). Magnification capability of 200 x and 400 x is a prerequisite for precise procedures such as ICSI. A heating stage on the inverted microscope maintains the temperature at 37 C. Ambient temperature control is of vital importance for the survival of oocytes, which are very sensitive to a decrease in temperature that can cause irreversible damage to the meiotic spindle (64). The micromanipulators allow three-dimensional manipulation (coarse and fine movements) of the holding and injection pipette on the left- and right-hand side, respectively. The microinjectors are used to either fix or release the oocyte with the holding pipette, or to aspirate and inject a spermatozoon with the injection The ICSI procedure involves the injection of a single motile spermatozoon into the oocyte. The procedure is carried out in a plastic microinjection dish containing...

Natural History of Infection

To fully appreciate the pathogenic strategies used by L. monocytogenes, or any pathogen for that matter, it is useful to consider how its mechanisms of pathogenesis promote dissemination. L. monocytogenes is ubiquitous in nature and associates closely with animals that feed on plant material (Chap. 6). Human infection is generally traced to ingestion of contaminated ready-to-eat food (Chap. 2) but plays little or no role in the natural history of infection. There are two models that may relate listerial pathogenesis to natural history. First, it is reasonable to assume that the gastrointestinal tract is the primary site of bacterial replication, with invasion, intracellular growth, and cell-to-cell spread leading to increased numbers prior to excretion. In this model, infections of the brain or fetus, although clinically relevant, contribute little to dissemination. The second model is that L. monocy-togenes is primarily a pathogen of pregnant animals causing miscarriage as a means of...

Interplay Between Tolerogenic DCs and Regulatory T Cells

Regulatory T cells are emerging as key players in the downstream effects of tolerogenic DCs. In mice, CD4+ CD25+ Treg expand following stimulation by Ag-loaded mature DC, a process that is dependent, in part, on costimulation, and can be used to block autoimmune diabetes in nonobese diabetic mice (20,21). In vitro maturation of human pDCs with cytosine-poly-guanine oligodeoxynucleotides promotes their ability to prime CD4+ CD25+ Treg (26). Similarly, CD154-stimulated mature human pDCs, but not mDCs, prime naive CD8+ T cells to become IL-10-producing regulatory T cells (57). On the other hand, repeated exposure of human na ve peripheral blood CD4+ T cells to immature, allogeneic monocyte-derived DCs induces Treg (58). Large numbers of alloAg-specific Tr1 cells can be generated in this manner for potential clinical use (59). Recent efforts to render stably immature, human monocyte-derived DCs for the generation of regulatory T cells have focused on inhibition of nuclear factor-kB and...

Clinical Reproductive Endocrinology Stimulation Protocols

The first IVF baby was born as a result of an oocyte picked up in a natural cycle. However, the success rate of this protocol was very low, and the Monash group first reported large numbers of eggs and improved pregnancy rates using a stimulation protocol of clomiphene citrate and human meno-pausal gonadotropin (HMG) together (32). Several other regimens using these two medicines were subsequently reported. The common problems with these protocols were that endogenous gonadotropins led to premature luteinization in 30-40 of the cases, and, in others, ovulation occurred at an inconvenient time of the day. The major step in simplifying IVF induction of ovulation protocols and preventing these unwanted phenomena came with the introduction of GnRH agonists. GnRH analogs were created by a series of modifications in the GnRH molecule that led to the availability of new agonists and antagonists. The agonists initially enhance gonadotropin released from the pituitary but, with continuing...

Breeding for Wildness Rather than Domestication

To keep track of an animal's lineage, and the pairing of appropriate individuals is closely controlled. Many sciences provide knowledge important to the propagation programs, such as veterinary medicine, nutrition, reproductive biology, genetics, and biotechnology. Frozen tissues, artificial insemination, bioengineering, and recombinant deoxyribonucleic acid (DNA) technology play an increasingly important role in modern breeding programs. Breeding wild animals is often more difficult than breeding domestic animals, since unusual breeding behavior is part of the reason some species are endangered. Improved knowledge about the species' social behavior and population biology needs are of assistance in the successful breeding of these difficult wild species, as is biotechnology. Frozen zoos have been established to maintain reproductive and other tissues for artificial insemination. Sometimes this artificial insemination involves the use of related surrogate species for instance, using...

Clomiphene Citrate and Fshhmg Protocol

This protocol used to be the preferred protocol in most IVF units prior to development of GnRH analogs. As mentioned, it was abandoned in our program as the dominant superovulatory regimen because of the high cancellation rate due to untimely LH surges and some reports of the possible adverse effect of clomiphene citrate on the endometrium. In our unit, this

Polycystic Ovarian Syndrome

PCOS is the most common cause of anovulatory infertility. This syndrome was first described by Stein and Leventhal in 1935. The PCOS Rotterdam Consensus Conference recently defined PCOS as a clinical syndrome comprising any two of the three features amenorrhea or oligomenorrhea clinical or biochemical hyperandrogenism, and bilateral polycystic ovaries on ultrasound (45). Although no single biochemical test is diagnostic of PCOS, most patients showed a characteristic ovarian ultrasonographic appearance, namely the presence of > 10 follicles between 2 and 10 mm in diameter. On the other hand, ultrasonographically identified polycystic ovaries are a common finding in apparently normal women, with a prevalence of Infertile women with PCOS represent a difficult therapeutic problem for assisted reproductive techniques because they have a higher incidence of OHSS (refer following section) (49). On transvaginal ultrasound scanning, the prevalence of polycystic ovaries has been reported to...

Oral Contraceptive Pretreatment

The role of GnRH antagonists in human IVF is discussed in Chapter 5. Oral contraceptive pre-treatment for ovarian stimulation in a GnRH agonist or a GnRH antagonist cycle has been recently investigated. Oral contraceptive scheduling of a GnRH agonist or a GnRH antagonist protocol results in fol-licular growth and hormone profile are similar to those observed in GnRH agonist protocols. The number of premature LH rises remains low. Similar numbers of oocytes and high-quality embryos are obtained. This is significant because the use of the oral contraceptive pre-treatment method significantly improves scheduling in a typical IVF program operating Monday to Friday. The greater convenience of oral contraceptive pre-treatment scheduling appears off-set by the need for longer stimulation protocols and more FSH than with a nonschedule regimen.

Ovarian Stimulation And Ovarian Cancer

Concern has been expressed that exposure to fertility drugs might be associated with a risk of ovarian cancer. In particular, pooled analysis of three case-controlled studies by Whittemore et al. (75) suggested an odds ratio of 2.8 (95 CI 1.3-6.1) for invasive ovarian cancer infertile women treated with fertility drugs compared with women with no diagnosis of infertility or infertility drug treatment. This study, suggesting an apparent trebling of risk in infertile women treated with fertility drugs, has been controversial and widely criticized for various biases in the study design. In 1994, Rossing et al. undertook a study that yielded the best data, to this time, examining the role of clomiphene citrate and ovarian cancer. Rossing et al. used record linkage with a population-based cancer register. They identified an increased incidence of ovarian cancer comprising both borderline malignant tumors and invasive disease. They found a standardized incidence rate (SIR) of 2.5 with 95...

Phase Ii Dosefinding Studies Single Dose Protocol

To determine the minimal effective dose, we conducted a dose-finding study. We compared the use of 2 and 3 mg to investigate the protection period,'' the time during which an LH surge is prevented after the antagonist administration. The IVF-ET results were strictly comparable between the two doses and the 2mg dose prevented LH surges for three days in all the patients. However, we observed that the suppression of LH tended to be reduced three days after the injection in the 2mg dose and an LH surge was observed four days after the 2mg Cetrorelix administration. The 3mg dose was therefore selected as a safer choice, as a ''protection period'' of at least four days can be obtained (14). No LH surge was observed in all the patients treated with the 3mg dose. In some patients, an LH rise (LH > 10IU L) was observed on the day of the antagonist administration. The Cetrorelix was able to prevent any further rise in LH, lowering immediately the LH levels and no surge was observed in these...

Multiple Dose Protocol

In all the studies presented, the multiple-dose protocol uses 0.25mg day of Cetrorelix or Ganirelix. To compare the antagonist multiple dose protocol (0.25mg day) to the GnRH-a in IVF cycles, the European Cetrorelix Study Group (21) published the results of an open randomized trial. They studied 188 patients treated with Cetrorelix and 85 patients treated with the long (Buserilin) agonist protocol both groups received hMG. The authors transferred embryos in 83.5 of Cetrorelix group versus 79 of Buserelin group. The clinical pregnancy rate was 22.3 and 25.9 per started cycle in the Cetrorelix and Buserilin groups, respectively these differences were not statistically significant. The duration of treatment with gonadotropins and the estradiol serum levels on the day of hCG were lower in the antagonist The North American Ganirelix Study Group (23) was organized to evaluate the efficacy and safety of Ganirelix (multiple-dose protocol) versus leuprolide (long-protocol) in IVF patients....

GnRHnt In Mild Stimulation

Very few data are available on the use of CC-hMG rec-FSH and antagonists in IVF (29,30). Pregnancy rates appear satisfactory but a high incidence of LH surges was observed (31). It was demonstrated in an animal model that CC increases the sensitivity of the pituitary to GnRH and that the dose of antagonists might need to be increased when CC is used. A prospective study found a lower pregnancy rate in CC-hMG cycles and did not support the interest in this protocol (32). The revival of the natural cycle was proposed as the use of GnRH-nts could prevent premature LH surges. The objective of this regimen is to combine the possible prevention of an LH surge by the administration of the GnRH-nt and the simplicity of the natural cycle with minimal stimulation (Fig. 2). We investigated the administration of the Cetrorelix in the late follicular phase of minimally stimulated cycles in women of good prognosis. These patients had an age between 26 and 36 years old (mean 34.1 1.4), normal...

Remaining Questions On GnRHnt Pregnancy Rates

There is a trend in most of the controlled studies using GnRH-nt (with both compounds and protocols) to find slightly lower pregnancy rates as compared to the GnRH-a long protocol. This led to the questioning of IVF-ET results of GnRH-nts. A meta-analysis concluded there were significantly lower pregnancy rates in GnRH-nt cycles as compared to GnRH agonists (48). However, the difference was very close to being nonsignificant (OR 0.79 95 CI 0.630.99). Adding one study, Ludwig et al. (49) did not find a significant difference in pregnancy rates for Cetrorelix. A recent meta-analysis presented by Daya did not find a difference in ongoing pregnancy rate (unpublished data). Care should be taken in drawing conclusions on these observations. Some population factors were not equivalent in the groups despite randomization. In addition, the learning curve, inherent to the use of new treatment schemes, could have influenced some of the studied outcome. The trend towards higher pregnancy rate...

Effect of IBD on Pregnancy

There is much evidence that any relapse of the disease, especially CD, increases considerably the risk of adverse events such as foetal malformations, premature delivery and miscarriage, emphasising the importance of planning for conception during the quiescence stage and the use of all diagnostic and therapeutical tools available to prevent or intensively treat any relapse of the activity stage during the entire course of pregnancy 16 . As for UC, any activity stage during pregnancy often determines a state of weakness for the expectant mother that frequently affects foetal growth negatively, causing low birth weight and premature delivery. This fact emphasises the importance of thorough and early nutritional therapy and intensive support of the overall conditions of the expectant mother. A recent study revealed the likely association between UC relapse during pregnancy and an increased tendency of foetal malformations 17 . The percentage of miscarriage-premature delivery associated...

Psychic Trauma and the Impaired Recontextualization of Memory

A patient reported that when he was about two or three years old, his mother had a spontaneous miscarriage. He was able to reconstruct that in all probability his mother became hysterical and was emotionally distraught for an undetermined period of time. As a witness to these events, he felt as if his mother had gone crazy. As an adult, he was very tolerant of craziness in women if he was not emotionally attached to them, but any sign of irrational thinking on the part of a woman upon whom he was dependent, such as his wife, made him extremely anxious. The metaphoric process created an unconscious affect category that of irrationality in women upon whom he was dependent. This affective memory was activated and recreated in real time by means of a metonymic association. When he was responding to his wife's irrational behavior, the distinction between past and present was obliterated, as in the previous example. The past invaded the present.

Symptoms of Normal Pituitary Hormone Loss

The next hormones to become deficient are usually the gonadotropins. Prepubertal children have no effects from gonadotropin deficiency, but adults develop oligoamenorrhea, impotence, and or infertility. Deficiencies of TSH, which leads to hypothyroidism, and ACTH, which leads to hypoadrenalism, are less common, even with large tumors. Deficiency of prolactin (PRL) is also uncommon and only presents in the postpartum period as a failure to lactate. Diabetes insipi-

Indications Pcos Patients

Aspects of PCOS patients is the increased LH tone secretion. This group of patients is characterized by anovulation, and ovarian ovulation induction is usually performed using clomiphene citrate, FSH associated or not with GnRH agonists. The rationale for the use of GnRH-nt in PCOS patients is the fact that the LH FSH ratio will be decreased since LH secretion is more affected by the antagonist administration than FSH secretion (2). In IVF, another clear advantage is the reduced incidence of OHSS with the utilization of GnRH-nt. The use of GnRH-nt protocol allows also to induce the oocyte final maturation with GnRH agonist, to elicit an endogenous LH surge and, subsequently, decreasing the risk of OHSS (61). However, a large prospective trial is necessary to confirm these physiological hypotheses (see infra). Lubin et al. (62) described two case reports of PCOS patients treated with GnRH-nt before the treatment with GnRH agonist to induce ovulation. The patients showed a normalization...

Programmation of GnRHnt Cycles

The programmation of GnRH-nt cycles is important to organize the work load of large IVF centers. Programmation could be obtained with progesterone administration in the late luteal phase or oral contraceptive pill (74). A more original way of programming the cycle was proposed by Fanchin et al. (75). The authors proposed luteal administration of estradiol in the late luteal phase as proposed by de Ziegler (76). The administration of estradiol prevents the FSH rise induced by the luteolysis and could synchronize the follicular cohort (75). Some authors (Kolibianakis et al., unpublished data) found lower pregnancy rates when an estro-progestative pill is used. The results of this study are not yet confirmed by other authors. In poor respon-ders, the use of contraceptive pills to program GnRH-nt cycle was found to be associated with increased cancellation rate (77).

Triggering Ovulation with GnRHa in GnRHnts Cycles

A recent study, comparing hCG, Lupron (0.2 mg), and Triptorelin (0.1 mg) to trigger ovulation in IVF patients treated with Ganirelix, found similar IVF-ET results between the three groups of patients (88). Other studies found lower pregnancy rates in patients treated with a combination of GnRH-nts and agonists (89). A small group of high responders were treated with a combination of GnRH-nt and agonists and no OHSS was observed in this preliminary report (90). As mentioned earlier, a study using Antide as GnRH-nt showed an altered luteal phase in cycles combining GnRH-nt and agonist (81). Some authors advocate that the luteal phase needs to be supported by both progesterone and estrogens (Itskowitz, personal communication). In a prospective randomized study, reduced pregnancy rate was found in GnRH-nt cycle in which GnRH-a was used to trigger ovulation, despite using progesterone and estradiol as luteal supplementation (91).

Perinatal Outcome of Pregnancy After GnRHnt for Ovarian Induction

Recently, two papers have been published on the perinatal outcome of IVF pregnancies obtained with GnRH-nt. One report followed 67 pregnant patients after ovarian induction with Ganirelix multiple-dose protocol (95). The miscarriage rate was 9 , and full data on perinatal outcome was obtained in 61 patients. The mean gestational age was 39.4 week for singleton pregnancies and 36.6 week for multiple pregnancies. A birth weight lower than 2500 g was present in 8.7 , one baby had a major congenital malformation, and seven minor malformations were reported in five infants. These results were not different from data available on IVF pregnancies.

Ultrasoundguided Oocyte Retrieval

The most visible use of ultrasound imaging in IVF has been the tremendous advance facilitated by transvaginal retrieval of oocytes (45-55). Oocyte retrieval was a procedure-limiting step when IVF was first done. Retrievals were done laparoscopically or using ultrasound guidance from transurethral, transvesicular, or transabdominal approaches (48,51,55-58). The advent of transvaginal transducers and concerted efforts to develop effective, accurate tracking of the needles used for follicle aspiration was probably the single most important step in making IVF as safe and effective as it is today (Fig. 3) (45,53-55,59-63). Retrieval of oocytes in IVF cycles is now routinely performed under TVUS guidance (49). An aspirating needle is introduced through a guide attached to a transvaginal probe and is inserted into first one ovary, then the other, via the vaginal fornices. Almost all aspiration needles now in common use have a small band of highly reflective surface near the tip of the needle...

Presentation and Diagnosis

The symptoms and signs of CAH depend on the degree of enzyme deficiency. For 21-hydroxylase deficiency, this results in a broad clinical picture complete 21-hydrox-ylase deficiency leads to cortisol and aldosterone absence and salt-wasting crisis in the newborn period. The androgen excess results in prenatal virilization of the external genitalia in women (classic salt-wasting form). Less severe 21-hydroxylase deficiency results in milder cortisol deficiency and milder prenatal androgen excess, with prenatal virilization in women, but no aldosterone deficiency (classic simple virilizing form). Patients with the mildest forms present with symptoms caused by androgen excess only pseudo precocious puberty, hirsutism, menstrual irregularities and infertility, all of which are most readily detected in women (nonclassic form) (1).

Reported Fertility in Men With 21Hydroxylase Deficiency

In summary, there is substantial evidence that fertility can be impaired in male patients with CAH. This finding raises the question to what extent male subfertility in the general population is caused by undiagnosed CAH. Ojeifo et al. (8) investigated basal and ACTH-stimulated serum 17-hydroxyprogesterone levels in a population of 50 males with idiopathic infertility and compared the results with those of 25 controls. No differences in basal or stimulated levels were found, and they concluded that 21-hydroxylase deficiency is a rare cause of idiopathic male infertility.

Three Dimensional Imaging of the Endometrium

Three-dimensional (3D) ultrasonography first became available in the late 1990s and 3D is now a part of almost all high-end imaging systems. There are several methods used to provide 3D information and there are no studies comparing the same endpoints with different imaging systems (105). The prospects for predicting the probability of implantation in IVF programs have now extended into 3D exploration of endometrial receptivity (106).

Ultrasoundguided Embryo Transfer

There is a measure of controversy regarding the usefulness of ultrasonographic guidance during embryo transfer versus non-visually guided clinical touch (131,137,141,149-155). Some clinicians prefer to rely on ultrasound guidance for mock transfers in cycles before IVF and embryo transfer and clinical touch in the actual procedure, others use ultrasound guidance for all procedures, and still others make a decision regarding its use based on whether or not the transfer is likely to be classified as easy or difficult (137,144,155). Two recent meta-analyses and a subsequent randomized controlled trial have been interpreted to mean that transabdominal ultrasound guidance versus clinical touch for embryo transfer significantly increased the pregnancy rate, although the rates of miscarriage, ectopic pregnancy, and multiple pregnancy were not affected (154,156-158).

Introduction Laparoscopy

Before the era of clinical in vitro fertilization (IVF), oocytes were acquired by laparotomy (1). Aside from the escalating scientific interest in fertilizing and culturing human oocytes in vitro, the development of laparoscopic surgery also facilitated the use of IVF in treatment of infertile couples. At the end of 1960, the laparoscopic technique made it possible to retrieve human oocytes quite simply for both research and clinical purposes. The technique played a key role in the start of collaboration between Edwards, the scientist with the knowledge of how to fertilize and culture human oocytes in vitro, and Steptoe, a clinician mastering a technique that could be used to harvest oocytes in women with tubal infertility (2). Subsequently, laparoscopy became the technique of choice for oocyte aspiration during the first 10 years of this clinical IVF era. Different technical aspects surrounding this technique were published at that time by those groups involved in the early clinical...

Technical Aspects Equipment

There are today many different needles that are specially designed for oocyte aspiration. Most companies, like Cook Ltd., Swemed International Lab, and Wallas Ltd., which have specialized in equipment for IVF, offer different types of needles for oocyte retrievals. Our opinion after nearly 20 years of experience with TVOR and having tested most of the available needles on the market is that the sharpness of the needle is the most important factor. A sharp needle means less pain if the puncture is performed in analgesia. Furthermore, it is important that the surface of needle tip has

IVM of Oocytes from Women with PCOS

PCOS is a very heterogeneous syndrome, often first diagnosed when the patient presents complaining of infertility approximately 75 of these women suffer infertility due to anovulation. The majority of women with anovulation or oligo ovulation due to PCOS have menstrual irregularities, usually oligo- or amenorrhea, associated with clinical and or biochemical evidence of hyperandrogenism. In almost all these patients, ultrasonic scan of the ovaries typically reveals numerous antral follicles (28,29). Fertility treatments for women with PCOS include lifestyle management, administration of insulin-sensitizing agents, laparoscopic ovarian drilling, ovulation induction, ovarian stimulation, and IVF. As previously mentioned, this group of patients has an increased risk of severe OHSS from gonadotropin stimulation compared with women who have normal ovaries (5,30). The risk of multiple-follicle ovulation and subsequent multiple pregnancies is also of crucial importance (5,31). However, the...

IVM for High Responders to Gonadotropin Stimulation

Risk can be reduced by withholding the ovulation-inducing trigger of hCG (34). Thus, in conventional ovarian stimulation for IVF where there has been an over-response and there is a high chance of developing OHSS, the cycle would be cancelled. Immature oocyte retrieval followed by IVM and IVF may provide an alternative to cancellation of these cycles. Initially, one live birth was reported from immature oocytes collected from a patient at substantial risk of developing OHSS (35). More recently, Lim et al. (36) reported 17 patients with a high risk of developing OHSS during the course of their IVF cycles. Instead of canceling the cycles, they undertook immature oocyte collection followed by IVM. hCG was administered 36 hours before oocyte collection when the leading follicle had reached a mean diameter of 12-14 mm and indeed 11.6 of the oocytes had already reached the metaphase II stage at collection. Eight out of 17 (47.1 ) clinical pregnancies were achieved in this group of patients....

Diagnosis Of Klinefelters Syndrome

KS is unique because it can be diagnosed at almost any age in utero, in a prepuber-tal boy, in an adolescent, or even in an adult male presenting to either a general practice or an infertility clinic. Chromosomal karyotyping of cells in amniotic fluid obtained from amniocentesis for an abnormal triple screen or for advanced maternal age will reveal KS with great accuracy. KS is suggested in prepubertal children by a testicular length of less than 2 cm after the age of 6 yr (50). Additional clues to the diagnosis of KS in a prepubertal boy are verbal learning disabilities and taurodontism, the unusual enlargement of the pulp of the tooth seen roughly half of men and boys with KS (46). After puberty, individuals with KS will often exhibit tall stature (usually greater than 184 cm) with proportionally long legs and will frequently manifest an arm span that is greater than their height (51). In adults, the diagnosis of KS should be considered in men with gynecomastia, primary...

Androgen Replacement Therapy

Testosterone therapy results in a more male phenotype, with increases in facial and pubic hair, muscle size and strength, libido, and bone mineral density, and improved mood (21,47,52,53). We recommend testosterone therapy beginning at the time of puberty to allow boys with KS to experience pubertal changes in tandem with their peers. In addition, this approach may allow for optimal enhancement of bone mineral density. Even if testosterone therapy is delayed until adulthood, it is still associated with beneficial improvements in mood, behavior, and sense of well-being (53). Testosterone therapy has no beneficial effect on infertility or gynecomastia, which is best treated with surgical resection if bothersome.

Basic Models of Health and Disease

173 Still, consider the following, admittedly somewhat wild, imaginary case. During a regular appendectomy on a woman, the doctor maliciously, and without the patient's consent, implants the in-vitro-fertilised embryo of another woman completely unknown to the patient, thus causing her to become pregnant. It certainly does not seem too far-fetched to call this the intentional infliction of a physical harm.

Sperm Preparation Methods Simple Washing and Dilution

The sperm preparation method used for the first IVF cases involved dilution of the semen with culture medium (usually at 2-10 times the volume) and separation of the spermatozoa by centrifugation. After removal of the supernatant, the pellet is resuspended in another aliquot of culture medium. Repeat centrifugation, usually two or three times in total, is often used to ensure removal of contaminating seminal plasma. The centrifugation is usually performed at 200-300 g and it should certainly be performed at centrifugal forces less than 800 g (8). Advantages of this method are that it is the simplest and the least expensive to perform. One disadvantage of this technique is nonviable, and immotile spermatozoa as well as any leukocytes, squamous epithelial cells, or non-cellular debris that contaminated the original semen sample will still be present in the washed sample. Another disadvantage is the concern about potential damage caused by centrifugation. by significantly diminished...

Evolutionary Consequences of Infanticide

Infanticide is widespread and may reach high frequencies in certain species, but it is not universal. Siblicide and parental neglect are found in a very restricted subset of birds and very few mammals. Local resource competition is more common, found in most classes of animals. Finally, sexually selected infanticide is most common in mammals, but even here there are many orders of mammals that never display infanticide. Species that have a very long period of lactation relative to their gestation period are most vulnerable to sexually selected infanticide. The reason for this is that infanticidal attacks are risky because of maternal defense and counterattacks by allies. Therefore, infanticidal behavior will only evolve when the males gain substantially by shortening lactational infertility of the mother.

Postseparation Treatment Of Spermatozoa Improvement of Motility and Sperm Function

The use of methylxanthine derivatives such as pentoxifylline for the stimulation of sperm functions, especially motility, is well known. Pentoxifylline is a nonspecific inhibitor of phosphodiesterase that has stimulatory effects on sperm motility and motion characteristics like sperm velocity or hyperactiv-ity. The stimulatory effect is attributed to increased intracellular levels of cAMP via inhibition of its breakdown by cAMP phosphodiesterase. Pentoxifylline is also reported to enhance the acrosome reaction (32) presumably due to the increasing levels of cAMP. The results of pentoxifylline treatment in assisted reproduction are equivocal. Depending on the conditions, especially the time of stimulation relative to the capacitative state of the spermatozoa and the concentration of pentoxifylline in the medium, overstimulation can result in a premature acrosome reaction (12). Thus, pentoxifylline tends to be used on a limited basis in IVF programs and some programs choose to use...

Infection Immunity Immunopathogenesis

The occurrence of pathological changes in some infectious diseases varies from individual to individual. Chlamydia trachomatis (which is a major cause of infection in the eyes and genital tract in humans) does not cause pathological changes in most people. However in some individuals, severe disease develops, leading to blindness and infertility.

Prolactinsecreting Pituitary Adenoma Prolactinoma

Prolactin (PRL)-secreting tumors are the most common form of functioning pituitary tumor. Most are microadenomas (< 1 cm in size) and usually present with galactorrhea, disturbance of menstrual regularity, infertility, and, in the male, decreased sexual function (1,2). Diagnosis is made by measurement of circulating PRL and pituitary imaging. Spurious hyperprolactinemia may result from measurement of complexed but bioinactive macroprolactin, and an extraction assay should be considered in all patients who have elevated serum PRL on conventional testing, especially where the level is discordant with the clinical presentation. In general, preservation of normal anterior and posterior pituitary function is the rule in patients with PRL-secreting microadenomas, but assessment of basal hormone levels is recommended in all patients.

Optimal Level of Exposure Aggregation

For example, if we were interested in the possible effect of caffeine on risk of miscarriage, then the ideal measure of caffeine would be comprehensive and include all sources of dietary caffeine, such as coffee, tea, and chocolate, as well as caffeine-containing medications. Under the hypothesis that caffeine is the crit ical agent, study of caffeine from coffee alone would constitute underascertain-ment of exposure, and the exposure that was assigned would be lower to the extent that women were exposed to unmeasured sources of caffeine. A closely related but distinctive hypothesis however, concerns the possible effect of coffee on risk of miscarriage, in which constituents of the coffee other than caffeine are considered as potential etiologic agents. To address this hypothesis, aggregation of caffeinated and decaffeinated coffee would be justified. Under that hypothesis, coffee alone is the appropriate entity to study. Once the hypothesis is clearly formulated, then the ideal...

Outcome And Childrens Health

For all forms of assisted reproductive technology (ART), the most important outcome parameter is the health of the children born after ART. The birth of a healthy singleton birth has to be considered as the most important outcome parameter after ART (79). Even after several decades of ART practice, one has to realize that it is impossible to give an answer with regards to risks for pregnancy and birth complications for ovarian stimulation in view of timed intercourse and intrauterine insemination. Only in IVF and ICSI have enough data been collected to provide a valid estimation of the risks. Even then, there are limitations in the study design of IVF and ICSI follow-up which make it impossible to estimate whether it is the ART procedure or the underlying infertility of the treated couples that influence

Pregnancy Complications

Perinatal outcome of singletons born after IVF have been recently assessed in a meta-analysis (81). The study compared for the period 1978-2002, a cohort of 12,283 IVF and ICSI singletons to a control cohort of 1.9 million spontaneously conceived singletons, matched for maternal age and parity. In comparison with spontaneous conceptions, IVF and ICSI pregnancies were associated with significantly higher odds of each of the perinatal outcome parameters studied perinatal mortality, pre-term delivery, low birth weight, very low birth weight, and small gestational age. In the ART singletons, the prevalence was higher for early pre-term delivery, spontaneous pre-term delivery, placenta praevia, gestational diabetes, pre-eclampsia, and neonatal intensive care admission. IVF patients must be counseled about these adverse perinatal outcomes, and obstetricians should manage these pregnancies as high risk. A systematic review by Helmerhorst et al. of perinatal outcome of singletons and twins...

Possible Causes of Adverse Outcome

The genetics of the male and female partners may influence the outcome. It has been well established that there are more constitutional abnormal karyotypes in infertile males and females. Several studies also indicated that abnormal sperm have more chromosomal abnormalities. In a cohort of 1298 ICSI parents seen for genetic counseling, it was concluded that there was an increased genetic risk for 557 of these children (45). This increased risk was due to maternal or paternal age, chromosomal aberrations, monogenic or multifactorial disease, and consanguinity. Slightly less than 5 of infertile males and 1.5 of tested females had an abnormal karyotype. With regard to fetal karyotypes after ART, there are only systematic data available for ICSI (90). Results on 1586 fetal karyotypes indicated an increased risk related to the chromosomal anomalies in the parents. The majority of cases (17 out of 22) were paternally inherited. There were significantly more de novo anomalies (1.6 ), but the...

Intracytoplasmic Injection of Immature Male Germ Cells

The success of intracytoplasmic sperm injection (ICSI) in cases of extreme deficiency of sperm movement and morphology (12,13) has prompted attempts at using immature male germ cells for fertilization. These efforts were aimed at offering an ART option to men with azoospermia. Term pregnancies were achieved with epididymal and testicular spermatozoa as Immaturity of male germ cell nucleus (incomplete chromatin condensation) and cytoplasm (functional inferiority of developmentally relevant cytoplasmic components centriole and oocyte-activating factor) were suspected to decrease success rates of assisted reproduction with immature male germ cells (15). However, birth rates after fertilization with round spermatids from healthy experimental animals were close to those achieved with spermatozoa (16). Consequently, the relatively low clinical success rates reported after fertilization with round spermatids from infertile men appear to be related to the testicular pathology underlying...

What does the Stem Cell Resource do

The SCR provides a no-cost service to physicians who have patients seeking to donate for research surplus embryos that are otherwise destined for destruction. The SCR provides information for patients to ensure that they understand the ethical and scientific issues surrounding such donations, and supplies Informed Consent documents for the donors to sign. The SCR protects the donor's confidentiality by having researcher-independent blinding of all tissues and samples. If a patient wishes to donate, the SCR provides the IVF physician with transport equipment and ensures the safe delivery of the material to the research facility.

Etiology And Diagnosis Of Abnormal Fertilization

Many abnormalities can be detected by noninvasive examination of zygote pronuclei (also refer to section Predictive Potential of Zygote Noninvasive Evaluation). However, pronuclear alterations are nonspecific and can be caused by both sperm-borne factors (50) and by those derived from the oocyte (51). Hence, the identification of the gamete of origin can only be evaluated indirectly, by putting together observations on zygotes and embryos from the present and the past assisted reproduction trials and analyzing them in the overall clinical context of each case. Sperm-derived, paternal factors are responsible both for abnormalities of fertilization and for defective preimplantation development. The most serious paternal deficiencies can cause complete fertilization failure or a failure of the male pronuclear development. Such conditions can be detected by diagnostic tests using heterologous ICSI with the patient's spermatozoa to mouse, hamster, rabbit, or bovine oocytes (52-54). As...

Family medicine meets the House of Lords

Medical ethics deals, as we have seen, with some of the big issues of life, and death. It faces the extraordinary, both natural and man-made conjoined twins, madness, assisted reproduction, cloning. Were you to base your understanding of medical ethics on the cases that hit the headlines you might think it a discipline concerned almost exclusively with the bizarre.

Sexual behavior transmits many disease organisms

The highly prevalent bacterial diseases chlamydia and gonorrhea are generally not fatal, but when untreated may develop into painful inflammatory diseases and result in infertility. Syphilis is transmitted by a spirochete and is fatal in about half of untreated cases. AIDS, a deadly failure of the immune system, is caused by a retrovirus that is most often sexually transmitted (although other forms of transmission are possible). The retrovirus and the disease are described in Chapters 13 and 18, respectively.

Synchronization and Superovulation of Embryo Donors

Or artificial insemination at 42 and 47 h after the hCG injection. The synchronization of gilts is an advantage in this procedure since the gilts are bred by artificial insemination on a timed basis, irrespective of oestrus behavior. Oestrus is the period during which the female is receptive to mating by the male. When properly stimulated, she assumes a characteristic standing oestrus pose indicating receptivity. Oestrus in the pig lasts for 3 days. Natural mating may result in ovulation occurring during a fairly broad time frame during oestrus. Superovulation with gonadotrophins in prepubertal females sets the system so that we can better predict the time of ovulation. Two inseminations are given to be sure of fertilization. Because oestrous behavior is variable, inseminations are given regardless of behavior. Exceptionally good results have been obtained with this system of reproductive management. Our experience indicates that virtually every donor ovulates using this protocol and...

Occupational Effects on Testicular Function General Aspects

There have been numerous published studies that have retrospectively surveyed the occupations of men attending infertility clinics and or compared occupations of fertile and infertile groups. There is some consensus in showing, for example, that farmers agricultural workers or lorry drivers, painters, or welders may be overrepresented in infertile men (15,16), but overall, the findings of such studies are inconsistent and have failed to identify common occupational causes of male infertility. Occupation is only one of a range of factors that may cause male infertility, and, therefore, searching for such factors in patients at the infertility clinic may not be the most sensitive approach. However, alternative approaches, such as direct investigation of particular working groups, also have various problems (12). Low participation rates are common and may be biased toward those who have experienced, or suspect, a fertility problem (17). These make interpretation of any findings...

Cytoplasmic Component

Regardless of the different types of cytoplasmic inclusions, it has been observed that a deficiency in ooplasmic texture can also reduce reproductive success. Thus, oocytes with impaired fluidity of the cytoplasm, as assessed by the persistence of the injection funnel after ICSI, had a developmental disadvantage compared to MII gametes with regular viscosity (38). However, extensive cytoplasmic granularity is recognized as the most severe form of cytoplasmic texture anomaly since more than half of affected gametes show chromosomal abnormalities (39), which led to minimal rates of implantation (4.2 ) and clinical pregnancy (12.8 ).

Occupational Environmental Exposure to Pesticides FungicidesPCBs

The DBCP example means that in nonscientific circles, the concept that pesticide exposure results in lowered sperm counts infertility has become more or less accepted as dogma. In reality, there are relatively few studies that support this stance (32-35), and many of these are studies in developing countries, where exposure controls may be less vigorous than in developed countries. Furthermore, there are numerous studies in which occupational pesticide exposure is associated with no change in semen quality and or fertility and no effect on testosterone levels (36-40) these include comparative studies of organic and nonorganic farmers. Although it is difficult to draw firm conclusions from these conflicting studies, it is reasonable to expect that occupational exposure to current, nonpersistent pesticides is unlikely to exert major adverse effects on semen quality and fertility in most men, but effects in individuals who might be exposed to unusually high pesticide levels should still...

Self Protection and Resistance

Closely aligned with women's silence is women's enforced inaction. Women are raised to take up less space than men, to yield to men, to avoid contact sports, and when accosted by a rapist, not to resist for fear of making him angry and thus being hurt more, or even killed. In the early part of the twentieth century in the United States it was believed that women's inherently weak physical and emotional constitution made sports participation a health risk if women engaged in sports (especially basketball) they could damage their reproductive organs and perhaps cause infertility (Griffin, 1998). Such social myths were eventually debunked by science. In the United States today there are certain myths about rape resistance and self-defense that are largely believed by a majority of people and these myths persist despite widespread evidence to the contrary. These myths feed on women's fears of rape and their physical insecurity and create a psychology of helplessness. Many women have told...

Day of oocyte retrieval Media preparation

For an IVF case samples will be collected after transvaginal aspiration (TVA) of the female partner, unless it is known that couple must be together to collect the sample, then the sample will be collected before TVA of the female partner. For donor oocyte TVAs, the recipient's male partner will collect the sample during donor TVA to prevent paths from crossing.

Integrated Assessment Of Potential For Bias Due To Disease Misclassification

Marchbanks PA, Peterson HB, Rubin GL, Wingo PA, and the Cancer and Steroid Hormone Study Group Research on infertility definition makes a difference. Am J Epidemiol 1989 130 259-267. Savitz DA, Brett KM, Evans LE, Bowes W. Medically treated miscarriage among Black and White women in Alamance County, North Carolina, 1988-1991. Am J Epidemiol 1994 139 1100-1106. Tielemans E, Burdorf A, te Velde E, Weber R, van Kooij R, Heederik D. Sources of bias in studies among infertility clinics. Am J Epidemiol 2002 156 86-92.

Gonadotropins Regulate Reproduction

The testes and ovaries have two essential functions in human reproduction. The first is to produce sperm cells and ova (egg cells), respectively. The second is to produce an array of steroid and peptide hormones, which influence virtually every aspect of the reproductive process. The gonadotropic hormones FSH and LH regulate both of these functions. The production and secretion of the go-nadotropins by the anterior pituitary is, in turn, regulated by the hypothalamic releasing hormone LHRH and the hormones produced by the testes and ovaries in response to gonadotropic stimulation. The regulation of human reproduction by this hypothalamic-pituitary-gonad axis is dis-

The Brain and Reproduction

The function of the scrotum is to maintain the temperature of the testes at a few degrees lower than average body temperature. The capability to maintain this temperature of the scrotum is rooted in the fact that the muscles within the scrotum are responsive to temperature. Under warm conditions, the scrotum relaxes, allowing the testes to move away from the body and lose heat. In cool temperatures, the opposite occurs The scrotum wrinkles, pulling the testes closer to the body and allowing them to stay warmer. The reduced temperature maintained by the scrotum is mandatory for the production of normal fertile sperm. Fever or other situations that raise the temperature of the scrotum can interfere with sperm production, even resulting in temporary infertility. In a few large mammals (such as elephants, whales, and dolphins), the testes are not located within a scrotum, but instead occupy a position in the abdomen. It is not known why these species apparently do not require a...

Controlling Reproduction

Knowledge of how the male reproductive system functions has allowed scientists to develop technologies for controlling reproduction to enhance or curtail fertility in domestic animals. Knowledge of male reproductive physiology has been applied to the management of domestic breeding populations. Hormone measurements and sperm counts can be used to determine the optimum age at which to begin breeding young stock. Techniques for collecting and storing semen can be combined with artificial insemination of females to increase the number of offspring produced by valuable males, thus resulting in improvement of the population. These methods are particularly valuable to breeders of large animals because maintaining large numbers of males of these species (such as stallions and bulls) can be costly and difficult because of the aggressive behaviors that these males may exhibit.

Effects of mothers implants on offspring

Another issue which has been of continuing concern to women with implants has been the possibility that a woman's implants affect her offspring. Some suggested mechanisms by which this might occur are via placental transmission of siloxanes (the building blocks of silicone), silicone, or other chemicals from breast implants 25 . Another possible source is from breast milk if contaminated with these compounds. Potential maternal-child health issues related to breast implants fall into three main categories (a) female reproduction, including infertility and spontaneous abortion (b) potential teratogenic effects of silicone and other chemicals in implants and (c) lactation quality (purity and safety of milk) and quantity (ability of women with implants to nurse). There is very little published information on any of these issues.

Fecundity and Pregnancy

In comparison with the general population, women in remission under azatioprine have no impairment, either in fecundity or in the capability of having a regular pregnancy without particular risks. In women who underwent restorative proctocolecto-my with ileo pouch-anal anastomosis (IPAA), parturition is normal and IPAA function is not damaged 13 . However, there are reports in the literature that give advice about the critical risk of infertility after IPAA including a decrease of potential fertility up to 80 14,15 . Our female patients should be correctly and tactfully informed about this possible complication, due in most cases to a tubal occlusion from adhesive disease. Would a more diffuse laparoscopic approach ameliorate this data

Some toxins are retained and concentrated in organisms

Lipid-soluble compounds are usually metabolized more slowly than water-soluble compounds, and they are often stored in the body for a long time because they dissolve in adipose tissues. Lipid-soluble compounds can accumulate in the body and reach very high concentrations. Some lipid-soluble toxins, including many pesticides, can bioaccumulate in the environment that is, they can become more and more concentrated in predators that eat contaminated prey. The pesticide load is passed up the food chain from prey to predator, growing increasingly concentrated in the tissues of each consumer in turn. In the top predator, the pesticide may be concentrated thousands or millions of times. Long-lived predators, such as eagles and bears, are particularly at risk for heavy pesticide burdens because they have many years to accumulate them. Bioaccumulated toxins may be responsible for the high rates of cancer and infertility found in some wildlife populations.

Protein Macromolecules

Historically, the most commonly used protein source in human IVF and embryo culture was patient's serum, added to the culture medium at a concentration of 5 to 20 . In some programs, fetal cord serum was used in preference. The use of serum in embryo culture media has several inherent drawbacks the considerable expense and time required for its collection and processing (and screening of the fetal cord serum), the risk of infection to the laboratory staff, as well as the added stress to the patient. Serum contains many components which are poorly characterized. Furthermore, proteins in serum have macromolecules attached, such as hormones, vitamins and fatty acids, as well as chelated metal ions and pyrogens (184,185). As the concentration of such macromolecules and other serum components varies between patients and even within the menstrual cycle, it makes any comparison between batches of medium which contain serum almost impossible. Furthermore, serum from several groups of patients...

Critical Thinking Exercises

Judy Cowan, age 28 years, has been prescribed clomiphene to induce ovulation and pregnancy. Judy is very anxious and wants desperately to become pregnant. Her husband, Jim, has come to the clinic with her. Discuss assessments the nurse would consider important before initiating treatment with clomiphene. Discuss information the nurse would include in a teaching plan for Jim and Judy.

Incubator Incubation Chamber

As discussed above, for optimal development of human embryos in vitro it is important to maintain both the pH of the medium and temperature. The choice and use of incubators is therefore paramount for the success of an IVF program. Several studies have determined that embryo development in vitro is increased by restricting the opening of an incubator (105,274). Furthermore, the use of IR sensor incubators which restore CO2 levels within two to three minutes helps to alleviate the detrimental effect of repeated opening of the incubator (274). Alternatively, the use of modular incubator chambers (MICs) inside the incubator enables the gas phase that embryos are cultured in to remain constant. Mouse embryo development in MIC's at the same gas phase as the incubator (5 CO2 in air) was significantly increased compared to development in the main chamber of the incubator (105). The use of incubators that have multiple chambers within the single incubator chamber can also reduce fluctuations...

Cyclophosphamide Cytoxan

Bone marrow depression, primarily of white cell series, and predisposition to infection, both of which may be life-threatening but reversible with discontinuation of drug. Alopecia, drug-induced infertility with amenorrhea or defective spermatogenesis, hemorrhagic cystitis (in up to 25 of patients), fibrosing cystitis, carcinoma of the bladder, hematopoietic malignancies, anorexia, nausea, vomiting, and pulmonary fibrosis. Antidiuretic hormone-like activity may occur with large doses and result in hyponatremia.

Derivation of stem cells

Production of hESCs from in vitro fertilization (IVF) supernumerary blastocysts hESCs could be derived from blastocysts created for research in at least three ways. These include blastocysts created through IVF or SCNT, altered blastocysts created by alternative nuclear transfer (ANT), and parthogenetic blastocysts. IVF or SCNT. In this area are included embryos that were not created for reproductive purposes but, instead, were created specifically for research or therapeutic purposes. In the case of IVF, both male and female gametes would have to be donated specifically for this purpose (the egg donations are considered below). In the case of SCNT, the requirement is for egg donation and a source of somatic cells, whether it is from the proposed stem cell recipient in the case of therapeutic cloning or for the production of an hESC line with particular genetic characteristics (e.g. a genetic defect). In the latter case, the lines would be used for the study of the genetic defect,...

Suggested Reading

Textbook of Reproductive Medicine. Norwalk, CT Appleton & Lange, 1998. Griffin JE, Ojeda, SR. Textbook of Endocrine Physiology. 4th Ed. New York Oxford University Press, 2000. Johnson MH, Everitt BJ. Essential Reproduction. Oxford Blackwell Science, 2000.

Clinical Focus Box 391

Candidates for in vitro fertilization (IVF) are women with disease of the oviducts, unexplained infertility, or endometriosis (occurrence of endometrial tissue outside the endometrial cavity, a condition that reduces fertility), and those whose male partners are infertile (e.g., low sperm count). Follicular development is induced with one or a combination of GnRH analogs, clomiphene, recombinant FSH, and menopausal gonadotropins (a combination of LH and FSH). Follicular growth is monitored by measuring serum estradiol concentration and by ultrasound imaging of the developing follicles. When the leading follicle is 16 to 17 mm in diameter and or the estradiol level is greater than 300 pg mL, hCG is injected to mimic an LH surge and induce final follicular maturation, including maturation of the oocyte. Approximately, 34 to 36 hours later, oocytes are retrieved from the larger follicles by aspiration using laparoscopy or a

How is it being studied

The procedure require destruction of the organism, or can cells be obtained without causing significant harm If a donor is capable of doing so, has she provided truly informed and voluntary consent If a donor is not capable of giving consent because of age, maturity, mental state, or death, then is it possible to identify an appropriate surrogate and has that surrogate provided truly informed and voluntary consent Is the source of research material incidental to some other purpose (e.g. spare embryos in IVF clinics) or specifically produced for research (e.g. voluntary donation of oocytes and adult somatic cells for the purpose of somatic cell nuclear transfer) Is the material being provided to researchers before or after having been frozen Are cells to be obtained from an entity (such as a blastocyst) that is presumed to be viable for implantation and, if so, is it believed to have a high likelihood of continued development These questions are only examples of the many issues we can...

Vaccines and Toxoids

Immunologic agents are contraindicated in patients with known hypersensitivity to the agent or any component of it. The measles, mumps, rubella, and varicella vaccines are contraindicated in patients who have ever had an allergic reaction to gelatin, neomycin, or a previous dose of one of the vaccines. The measles, mumps, rubella, and varicella vaccines are contraindicated during pregnancy, especially during the first trimester, because of the danger of birth defects. Women are instructed to wait at least 3 months before getting pregnant after receiving these vaccines. Vaccines and toxoids are contraindicated during acute febrile illnesses, leukemia, lymphoma, immunosuppressive illness or drug therapy, and non-localized cancer. See Display 54-6 for additional infor-

Multiple Pregnancies After ART

There is increasing evidence that the major outcome risk after all forms of ART is the occurrence of multiple pregnancies and births. This is the case for ovulation induction, ovarian hyperstimulation with or without intrauter-ine insemination, and IVF or ICSI (102). For IVF-ICSI, the number of children born has been estimated to be about two million. This positive observation is overshadowed by the fact that at least half of these children are not from singleton pregnancies. The occurrence of multiple IVF-ICSI pregnancies and births is, of course, due to the placement of more than one embryo. There is extensive evidence that multiple pregnancies and births generate more problems not only during pregnancy and delivery, but also later in life (102). Therefore, prevention of multiple ART gestation should be considered as a top priority for all infertility treatments. It is obvious that the practice of single embryo transfer may be the answer to this epidemic of multiple births. 3....

Flushing Follicles or

Flushing follicles or not has been debated for years. The rationale is that flushing of the follicle offers an advantage to the patient, with a larger number of oocytes being collected and therefore a higher potential for pregnancy. Kingsland et al. were the first to perform a randomized trial. They demonstrated that when performing transvaginal ultrasonically guided oocyte recovery, there were no significant differences in number of oocytes retrieved, fertilization rate, or pregnancy rate between those where flushing had been used as compared to no flushing. However, they could show that the operating time was significantly shortened in the non-flushing group (33). Similar results were later demonstrated in another prospective randomized study (34). In a recent publication, a study by Bagtharia and Haloob found that 40 of the oocytes were retrieved in the primary aspirate, whereas up to 82 of oocytes were retrieved with two flushes and 97 of oocytes were retrieved in up to four...

GnRH AgonistFSHLong Downregulation Protocol

This protocol (Fig. 2) is currently the protocol of choice for first cycle patients and previously normal or high responders in many IVF programs. A GnRH agonist Leuprolide, 1 mg SC, Buserelin 600 mg SC or Nafarelin acetate (Synarel) , 400 mg nasal spray, is given for 10-14 days before starting gonadotropin treatment (long-protocol), and may be commenced in the mid-luteal phase of the previous cycle or on day 2 of the cycle. We, in addition to other researcher found that pituitary suppression was more effective when the therapy commenced in the mid-luteal phase of the previous cycle The National Collaborating Centre for Women's and Children's Health have reviewed ovarian monitoring during gonadotropin therapy for IVF. NICE found that serum estradiol monitoring provided no additional information compared with ovarian ultrasound and, therefore, do not recommend it. This is different to the above guidelines for basic ovarian stimulation and monitoring. We are comfortable with this...

Secondary Hypogonadotropism

Augarten et al. described a patient who was referred for secondary infertility and was diagnosed with nonclassic 21-hydroxylase deficiency, as was his daughter (58). Serum FSH and LH levels were decreased and unresponsive to GnRH stimulation. Treatment with prednisone resulted in a decrease in the serum levels of 17-hydrox-yprogesterone and of androgens and restored a normal response to GnRH. After 4 mo of treatment, successful conception occurred (58). Bonaccorsi et al. presented three cases of male infertility resulting from 21-hydrox-ylase deficiency with low serum gonadotropin levels that were unresponsive to GnRH stimulation in two patients (12). Unresponsiveness to GnRH was proposed to result

Gernot Sellge and Stephan C Bischoff

Mast cells are bone-marrow-derived tissue cells typically located at barrier sites of the body, such as skin, mucosal barriers, or blood barriers, that is, around blood vessels. This location suggests that mast cells might have a function as immunological gatekeepers or watch dogs and, indeed, some recent functional data support this idea. Mast cells derive from myeloid progenitors, but in contrast to other myeloid cells, they leave the bone marrow in an immature state therefore, mast cells are not found in the blood under normal conditions. For full maturation, the tissue environment is necessary. Thus, mature mast cells can be only isolated from tissue such as skin or mucosal sites, which makes mast cell isolation rather complicated. Alternatively, mast cell progenitors can be isolated from the bone marrow, peripheral blood, or cord blood, which is easier but requires subsequent in vitro maturation of mast cells as far as possible using cytokines. This chapter describes a rather new...

Evaluation and Preparation of the Infertile Couple for In Vitro Fertilization

Thorough evaluation of the infertile couple before in vitro fertilization (IVF) is critical in achieving the best outcomes and avoiding complications. Most IVF centers organize the evaluation by using a checklist that the nurse coordinator and physician assure is complete before proceeding with the cycle. FSH levels also vary from cycle to cycle. A consistently elevated FSH predicts a poorer prognosis than a single elevated level with others being normal. The quality of ovarian stimulation is not improved when IVF is done in a cycle with a more normal FSH level (3). There is an agreement that women with a single elevated FSH level have a high cancellation rate, but studies conflict regarding the extent of reduction of pregnancy outcome (4,5). FSH levels are similar on days 2, 3, and 4. Women with premenstrual spotting should be advised to count the first day of full flow as day 1. It is the antral follicles that respond to stimulation. With a high-quality transvaginal ultrasound scan,...

Pharmacological Therapeutical Management of IBDs During Pregnancy

Of foetal death secondary to cerebral and or pulmonary haemorrhage were found, as well as cardiac malformations such as Fallot's tetralogy and premature delivery, and given the small amount of studies regarding the effect of these drugs during pregnancy, their use is contraindicated in pregnant patients with CD and those planning to become pregnant.

How to rid ESC cultures of contaminating feeder cells

IVF dish aMake a stock suspension of MEF cells at 5 X 105 mL. Make sure the cells are at least 90 viable. Note that the volume of MEF suspension to use does not exactly match the amount of medium normally used for that container. For the small volume containers (96-well, IVF dish, 24-well), you must add additional medium (not cells) to avoid too much evaporation and uneven distribution of feeder cells because of the effect of the meniscus. aMake a stock suspension of MEF cells at 5 X 105 mL. Make sure the cells are at least 90 viable. Note that the volume of MEF suspension to use does not exactly match the amount of medium normally used for that container. For the small volume containers (96-well, IVF dish, 24-well), you must add additional medium (not cells) to avoid too much evaporation and uneven distribution of feeder cells because of the effect of the meniscus.

A toolbox for reasoning

Medical ethics is, in my view, a questioning and a critically reflective discipline. Doctors, nurses, and other health professionals will normally have good reasons for doing what they do. It would be foolish not to give careful consideration to what experienced practitioners do and think is right. But the role of philosophy is to demand reasons and to subject these reasons to careful critical analysis. Socrates saw himself as an intellectual gad-fly irritating the status quo with awkward questions. Medical practice should be continually improving through subjecting itself to the scrutiny of those twin disciplines, science and philosophy. Science asks What is the evidence that this is the best treatment How good is that evidence What evidence is there for alternative treatments Philosophy demands reasons for the moral choices made Is it right to help this single woman to conceive a child using methods of assisted reproduction Should all attempts be made to prolong the

Endometrial Thickness and Pattern for Assessing Endometrial Receptivity

Ovarian Follicle Aspiration Needle

Ultrasonography has been used, with varying degrees of success, to correlate the probability of pregnancy in ovarian stimulation-ovulation induction cycles and IVF cycles (73-77). Most imaging studies have been attempting to predict the probability of implantation. A thicker endometrium was observed on the day of oocyte retrieval in women who conceived during that cycle (74). The IVF pregnancy rate increased in cycles when the endo-metrium was > 9 mm but < 14 mm (75). In another study, no correlation was observed among endometrial pattern or thickness and estradiol levels, number of oocytes retrieved, or progesterone level on the day of embryo transfer however, the authors appeared to appreciate the pattern of the endometrium on the day of hCG administration, but stated that pattern assessment was of no value (78). In another IVF study, the endometrium on the day before embryo transfer was nearly 2 mm thicker in women who conceived (10.2mm) than in those who did not (8.6 mm) (79)....

Endometrial Preparation and Luteal Support

To achieve optimum endometrial growth, exogenous estradiol 17 p (micro-nized) is started on the day of retrieval. The dosage is determined by endometrial thickness measured on the day of retrieval. If the endometrial thickness is less than 6 mm, then 12 mg a day is started if the thickness is between 6 and 8 mm, then 10 mg a day is started and if the thickness is more than 8 mm, then 6 mg is used, all in three divided doses. Recently, we have begun administering the estradiol treatment even before oocyte collection, when an extremely thin endometrium (i.e., < 4mm) is recorded on an ultrasound scan prior to the collection. We are currently investigating an alternative approach whereby the in vitro matured oocyte is vitrified when the endometrial lining is thin. The endometrium is then prepared in an artificial cycle and, once it reaches 8 mm, the oocytes are thawed, fertilized, and transferred. In an IVM treatment cycle, luteal support is started on the day that oocyte maturation is...

Pregnancy Guide

Pregnancy Guide

A Beginner's Guide to Healthy Pregnancy. If you suspect, or know, that you are pregnant, we ho pe you have already visited your doctor. Presuming that you have confirmed your suspicions and that this is your first child, or that you wish to take better care of yourself d uring pregnancy than you did during your other pregnancies; you have come to the right place.

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