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  1. Home
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  3. Infertility and Assisted Reproduction
  • Cited by 8
Publisher:
Cambridge University Press
Online publication date:
August 2010
Print publication year:
2008
Online ISBN:
9780511547287
DOI:
https://doi.org/10.1017/CBO9780511547287
Subjects:
Obstetrics and Gynecology, Reproductive Medicine, Medicine
Information

Book description

Assisted reproductive technology (ART) is available to two-thirds of the world's population, and world-class experts, representing research from 18 different countries, have contributed to this groundbreaking textbook, detailing the techniques and philosophies behind medical procedures of infertility and assisted reproduction. This is one of the most rapidly changing and hotly debated fields in medicine. Different countries have different restrictions on the research techniques that can be applied to this field, and, therefore, experts from around the world bring varied and unique authorities to different subjects in reproductive technology. Encompassing the latest research into the physiology of reproduction, infertility evaluation and treatment, and assisted reproduction, it concludes with perspectives on the ethical dilemmas faced by clinicians and professionals. This book will be the definitive resource for those working in the areas of reproductive medicine world wide.

Reviews

'The future [of medicine] is always difficult, but the authors have made a nice summary of the latest trends and certainly good suggestions to where we are presently moving toward.'

Source: Acta Obstetricia et Gynecologica Scandinavica

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Contents

Page 3 of 3

Contents
  • 52 - The Management of Azoospermia
    pp 478-492
  • View abstract

    Summary

    This chapter deals with the management of azoospermia. It is imperative to pursue in every azoospermic patient a proper diagnostic process, during which one should classify the patients according to the etiology of their azoospermia due to pretesticular, testicular, or post-testicular causes. Methods of surgical sperm retrieval (SSR) include epididymal and testicular sperm retrieval, which can be open, close, or with microdissection. Microepididymal sperm aspiration (MESA), percutaneous epididymal sperm aspiration (PESA), testicular fine-needle aspiration (TEFNA), testicular sperm extraction (TESE) are various sperm retrieval techniques. The underlying etiology of azoospermia could influence the viability of the retrieved sperm cells as well as determine their maturational status being from epididymal or testicular source, in obstructive azoospermia (OA) or nonobstructive azoospermia (NOA), respectively. Cryopreservation of the remaining testicular tissue after sperm extraction or of individual sperm cells isolated after TESE represents a technical challenge.
  • 53 - Spermatid Injection: Current Status
    pp 493-505
  • View abstract

    Summary

    Secretory azoospermia may be primary or secondary, and the absence of sperm in semen is caused by inefficient, deficient, or absent germ cell proliferation, meiosis, and differentiation. Based on the diagnostic testicular biopsy, three major histopathological syndromes are recognized in secretory azoospermia, sertoli cell-only syndrome, maturation arrest, and hypospermatogenesis. Elongating spermatid microinjection is rarely applied as most cases also have elongated spermatids; elongated spermatid microinjection showed to be a very successful approach; and round spermatid microinjection, unfortunately, was proved to be seldom useful. Analysis of world clinical series using elongating and elongated spermatids retrieved by testicular sperm extraction (TESE) shows 28 percent of mean term pregnancy rate. On the contrary, only 3 percent of term pregnancy rate is achieved with round spermatids. In order to avoid any fetal abnormalities, strict criteria should be used to select morphologically normal spermatids for microinjection.
  • 54 - Optimizing Embryo Transfer
    pp 506-517
  • View abstract

    Summary

    This chapter describes the technique of embryo transfer (ET) to evaluate the various modifications proposed in order to maximize the chances of pregnancy, and discusses the different approaches available for managing difficult ETs. Before embarking on an ET, the following factors should be considered: embryo selection, choice of the catheter, performing a trial (mock or dummy) ET, ET medium, ultrasound, flushing the cervical mucus before performing ET. Randomized trials have shown that ultrasound guidance and the use of soft catheters as opposed to firm catheters are associated with higher pregnancy rates. They have also shown that the presence of air in the catheter, its immediate removal, bed rest after ET, sexual intercourse, and the administration of aspirin after ET do not affect the results. Routine use of antibiotics, uterine relaxants, and medication to increase uterine blood flow await further evaluation.
  • 55 - Single Embryo Transfer
    pp 518-530
  • View abstract

    Summary

    Elective single-embryo transfer (SET), combined with subsequent transfer of frozen/thawed embryos, can maintain a high pregnancy rate with a dramatic decrease in multiple pregnancy rates. It has been argued that in the near future, SET should be the default policy for good-prognosis in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) patients. An alternative to elective SET is the use of natural-cycle IVF/ICSI. Although this approach has its attractive sides (easy, cheap, repeatable, and no ovarian hyperstimulation syndrome), its efficacy per cycle is low. The strength of elective SET resides in the fact that ovarian stimulation allows selection of the putative most competent embryo. The impact of SET will depend on the size of the group in whom it is applied. If criteria are very strict, the impact will be small, but the overall pregnancy rate is likely not to decrease. Clinical judgments regarding SET differ between centers and countries.
  • 56 - Blastocyst Transfer
    pp 531-539
  • View abstract

    Summary

    This chapter discusses the advantages of blastocyst transfer and reviews the clinical data. Improvements in the environment and the quality in the embryology laboratory, in culture media, and in the equipment used to produce embryos and embryo selection methods have all had positive impacts on the results of embryo transfers. Parental factors also affect blastocyst development and subsequent implantation rates. In order to optimize embryo culture and blastocyst transfer, one needs to consider all aspects of a treatment cycle. Vitrification is now already the preferred method of cryopreserving embryos of the mouse and cow, and it is only a matter of time before this elegant procedure supercedes slow freezing in the clinical laboratory. Once the blastocyst is biopsied, and therefore collapsed, it is vitrified. Subsequently, a single euploid blastocyst with the highest developmental potential, as determined through morphological grading and noninvasive assays of physiology, is transferred to a natural uterus.
  • 57 - Clinical Significance of Embryo Multinucleation
    pp 540-547
  • View abstract

    Summary

    Embryo multinucleation (MNC) is a common problem in assisted reproductive technology (ART) and should serve as a morphological marker of embryo quality. There may be more than one mechanism to explain embryo MNC; some investigators believe that the pathophysiology involved in binucleation and MNC may be different. Chromosomal defects occurring during early cleavage stages of human embryo development are common and result in embryos with limited developmental capacity and potential to implant when transferred during ART procedures. A comprehensive classification of embryo MNC to help communicate embryologists and clinicians, clinicians and patients, and also as a tool for future scientific reporting on these frequent embryological findings. Embryo MNC is a common event in human clinical embryology. Binucleated embryos appear to have a better prognosis compared to micronucleated embryos in reaching blastocyst stage in vitro, or achieving a pregnancy if transferred.
  • 58 - Quality and Risk Management in the IVF Laboratory
    pp 548-561
  • View abstract

    Summary

    This chapter discusses the quality and risk management principles in the in vitro fertilization (IVF) laboratory. Within the context of the IVF center, services must be made more easily available and provided in a more pleasant environment with more personalized attention. There are two risk management tools: a proactive tool called failure modes and effects analysis (FMEA) and a reactive tool called root cause analysis (RCA). IVF is an area of rapidly advancing technology and so continual training and proficiency testing are imperative. Comprehensive, formal programs are essential for training all embryologists in new techniques and procedures (i.e., novices and more junior staff), and for the orientation, and retraining as necessary, of embryologists coming from other laboratories. While the application of total quality management (TQM) cannot guarantee success, or even improved IVF success rates, it will ensure that the IVF lab systems will operate smoothly and efficiently.
  • 59 - The Nurse and REI
    pp 562-569
  • View abstract

    Summary

    Reproductive endocrinology and infertility (REI) nursing is a growing, evolving, highly specialized field. The REI nurse anticipates the need to make choices, is able to do so without the assistance from others, yet with personal consideration to those the decision effects, and takes responsibility for them. Informed consent in REI nursing warrants special consideration. Good interpersonal skills create a good nurse-patient relationship. This usually translates into daily and sometimes intense interactions with patients as cycles begin, progress, and finish and pregnancy tests are awaited or are completed. Reproductive medicine may present ethical dilemmas for couples and caregivers and will continue to do so as scientific and technological advances extend faster than existing legal and moral frameworks. Supervisors should endeavor to make staff feel valued and appreciated by word and by deed. Recognition and positive feedback are critical to job satisfaction.
  • 60 - Understanding Factors That Influence the Assessment of Outcomes in Assisted Reproductive Technologies
    pp 570-575
  • View abstract

    Summary

    This chapter reviews the current assisted reproductive technology (ART) outcome analysis process in the United States to expand the reader's perspective and understanding of its complexity and explores progress toward meaningful collection, analysis, and interpretation of ART outcomes by clinician and patient in the future. The Society for Assisted Reproductive Technology (SART), an affiliate organization of the American Society for Reproductive Medicine (ASRM), worked with the Centers for Disease Control and prevention (CDC) as the initial purveyor of data collection and publication, representing reproductive specialists and the majority of domestic ART practices. Ovarian reserve, diagnosis-specific therapy, laboratory prowess, practice management philosophies, therapeutic access, and patient demographics play an intricately intertwined role in determining successful outcome. Patient selection/rejection is acknowledged as powerful influences of ART outcome but is practiced to different degrees by any individual physician/practice.
  • 62 - Complications of Assisted Reproductive Technology
    pp 604-618
  • View abstract

    Summary

    This chapter considers each stage of assisted reproductive technology (ART) and discusses its possible complications with options for prevention. The frequency of complications of ART varies among series and depending on whether the complications are reported in single treatment cycles or all treatment cycles. The iatrogenic condition of ovarian hyperstimulation syndrome (OHSS) is the most important complication of ovulation induction and, in its severe form, is a potentially lethal disease. Ovarian cancer and breast cancer are also associated with use of ovulation stimulating drugs. Other unusual side effects of ovulation induction include bloody ascites in a woman with endometriosis and familial Mediterranean fever, pituitary hemorrhage after clomiphene citrate, and hypophyseal hypertrophy in pregnancy after bromocriptine treatment for prolactinomia. Three main groups of complications of oocyte pick up (OPU) are: hemorrhage, pelvic infection, and damage to pelvic structures such as the bowel or ureters.
  • 63 - Ectopic and Heterotopic Pregnancies Following in Vitro Fertilization
    pp 619-628
  • View abstract

    Summary

    The incidence of ectopic pregnancies is increased in assisted reproductive technology (ART) due to a higher number of embryos transferred and a higher prevalence of tubal disease in patients undergoing in vitro fertilization (IVF). The incidence of heterotopic pregnancies increased with increasing number of embryos transferred. Ectopic pregnancy occurs usually within the fallopian tubes. Abdominal pain is the most common clinical manifestation. Other symptoms and signs include vaginal spotting, amenorrhea, and a pelvic mass. The recent advances in ultrasound technology and the higher expertise of sonographers have improved the early diagnosis of ectopic pregnancies. The beta sub-unit of human chorionic gonadotropin (hCG) has been used to differentiate a developing viable intrauterine pregnancy from an abnormal pregnancy. Vascular endothelial growth factor (VEGF) is elevated in ectopic pregnancies. Methotrexate and mifepristone are used in the treatment of ectopic pregnancy. Laparoscopy, laparotomy and salpingectomy are the surgical options for treating ectopic pregnancies.
  • 64 - The Impact of Oxidative Stress on Female Reproduction and ART: An Evidence-Based Review
    pp 629-642
  • View abstract

    Summary

    This chapter discusses the implications of oxidative stress (OS) on female reproduction and assisted reproductive technology (ART). Reactive oxygen species (ROS) such as superoxide, hydrogen peroxide, hydroxyl, and singlet oxygen radicals are capable of producing free radicals leading to OS. Various biomarkers of OS have been studied in the female reproductive tract. ROS is thought to play a regulatory role in oocyte maturation, folliculogenesis, ovarian steroidogenesis, and luteolysis. ROS may play a role in age-related decrease in estrogen production. Superoxide dismutase (SOD) and glutathione peroxidase expression decreases in the ovary from the premenopausal to menopausal period. The effects of follicular OS on oocyte maturation, fertilization, and pregnancy have also been studied. Follicular fluid ROS and lipid peroxidation levels may be markers for success with in vitro fertilization (IVF). Successful management of infertility in the ART scenario depends on overcoming OS in the in vitro conditions.
  • 65 - PGD for Chromosomal Anomalies
    pp 643-656
  • View abstract

    Summary

    This chapter describes the data on pre-implantation genetic diagnosis (PGD) for aneuploidy screening (AS), focusing in two main topics: the chromosomal status of human gametes and embryos and the clinical application of PGD-AS in assisted reproductive technology (ART) and its controversies. In oocytes, the most frequent abnormalities detected were single chromosome trisomy and monosomy. The maternal origin of aneuploidy is prevalent in abnormal human conceptuses, and reproductive maternal aging is the important factor affecting the frequency of aneuploidy. Previous history of spontaneous abortions is a risk factor of pregnancy loss even in patients with normal karyotype. New evolving technologies will be able to significantly increase the sensitivity of PGD and reduce the diagnostic errors. Biological events such as mosaicism, postzygotes aneuploides, and trisomic rescue can cause diagnostic errors. With the view that efficiency can be significantly improved, PGD-AS has to be considered as a tool to implement ART procedure.
  • 66 - Preimplantation Genetic Diagnosis for Single-Gene Disorders
    pp 657-676
  • View abstract

    Summary

    There is a wide range of single-gene disorders that could be screened for using preimplantation genetic diagnosis (PGD). These mostly include Mendelian disorders like autosomal or X-linked disorders, whether recessive or dominant. The most common autosomal dominant diseases include myotonic dystrophy, Huntington disease, neurofibromatosis, and adenomatous polyposis coli. The aim of genetic counseling is to enable couples and families with genetic disadvantages to live and reproduce as normally as possible. Couples undergoing PGD should be advised to have protected intercourse or to abstain from sex to avoid the risk of spontaneous pregnancy during that cycle. Polar body biopsy is also known as preconception or pre-fertilization biopsy, and in some countries, it is the only form of PGD that is legally approved. Fluorescent in situ hybridization (FISH) is particularly useful when examining interphase nuclei, as with blastomeres.
  • 67 - Epigenetics and ART
    pp 677-683
  • View abstract

    Summary

    This chapter provides background information about basic epigenetic mechanisms, the phenomenon of genomic imprinting, and human imprinting syndromes. An overview of the epigenetic reprogramming events during gametogenesis and in the early embryo is presented as well. The chapter reviews epidemiological data on epigenetic risk in assisted reproductive technology (ART) children and discusses the significance and implications of these findings. Modifications at the histone-DNA interface may have a direct impact on chromatin, whereas modifications in the histone tails may alter chromatin structure indirectly by recruitment of chromatin-associated proteins that will modulate chromatin structure. Epigenetic patterns are imposed on the genome during embryonic development and differentiation through predetermined programs. When considering epigenetic risks, long-term continuous follow-up of ART children is necessary, with assessment of the neonatal outcome as well as monitoring of imprinting disorders, cancer incidence, and neurobehavioral development.
  • 68 - Congenital Anomalies and Assisted Reproductive Technology
    pp 684-692
  • View abstract

    Summary

    This chapter discusses the implications of assisted reproductive technology (ART) in formation of congenital anomalies. Examples of congenital anomalies with ART include anencephaly, spina bifida, cardiovascular defects, orofacial clefts, and alimentary tract atresia. Imprinting disorders examined with regard to in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) conception are Angelman syndrome and Beckwith-Wiedemann syndrome, and recent reports have suggested a higher risk of these specific disorders after ART. Women receiving IVF treatment face a twentyfold increased risk of twins and a 400-fold increased risk of higher order births. Preimplantation genetic diagnosis (PGD) is ever evolving with fluorescent in situ hybridization (FISH) for sexing, aneuploidy screening, and structural chromosomal abnormalities and fluorescent and multiplex PCR as the most recent developments for monogenic diseases. Infertility itself is likely to be an important factor in congenital anomalies after ART.
  • 69 - Stem Cell Research
    pp 695-705
  • View abstract

    Summary

    Human embryonic stem cells (hESCs) are invaluable research tools to study embryonic development and can serve as a platform to develop and test new therapies. The main sources of embryos for hESC derivation are those obtained from assisted reproductive techniques at the in vitro fertilization (IVF) clinics. Supernumerary frozen embryos have been successfully used for the generation of hESC lines. An alternative xenobiotic-free feeder system for the growth of hESCs involves their growth on human foreskin cells obtained from newborn males following circumcision. The field of hESC research will center its efforts on overcoming three main obstacles in the hESC derivation process: the need to develop consistent "feeder-free and xeno-free systems, embryo-friendly approaches and the somatic cell nuclear transfer (SCNT) techniques which will seek to avoid immune rejection at the clinical level, with or without the use of oocytes as host cell.
  • 70 - Fertility Preservation in Female and Male Cancer Patients
    pp 706-716
  • View abstract

    Summary

    This chapter discusses fertility preservation and reviews the recent evidence on the pathophysiology of chemotherapy/radiotherapy-induced gonadal toxicity and the recent data on the indications and the outcomes of techniques used for fertility preservation in female cancer patients. The exact incidence of premature ovarian failure (POF) following chemotherapy is difficult to establish since many factors contribute to ovarian failure. Several reproductive-age malignancies afflicting pelvic organs can be cured with radiotherapy. These include cervical, vaginal, and anorectal carcinomas, some germ cell tumors, Hodgkin's disease, and central nervous system tumors. A wide variety of strategies have been assessed for fertility preservation in females which includes chemoprotection, ovariopexy, and assisted reproductive technologies. Keeping the testicles outside the field of radiation or being shielded has been shown to be an effective strategy to prevent radiation-induced testicular damage. Semen cryopreservation and testicular tissue cryopreservation are fertility preservation measures in male using assisted reproductive technologies.
  • 71 - Ethical Dilemmas in ART: Current Issues
    pp 717-722
  • View abstract

    Summary

    This chapter highlights the main ethical concerns of IVF. Two main issues surround gamete donation: the traditional and more recently questioned anonymity of the gamete donor and when donation becomes scarcer should donors be paid. In most countries where gamete donation is used as a means of solving infertility problems, those who recruit the donors have difficulties matching the supply to the demand, especially in the case of oocytes. A newer dilemma is that of choosing by preimplantation genetic diagnosis (PGD) an embryo free of a disease to facilitate the birth of a savior sibling, a child who would be a human leukocyte antigen (HLA) match for a very sick older sibling. There are also specific ethical considerations according to source of cells and especially regarding the creation of embryos specifically for research. According to Bernard Dickens, "Ethics frames the law within which law is voluntarily obeyed".
  • 72 - Infertility Treatment in Perimenopausal Women: Ethical Considerations
    pp 723-727
  • View abstract

    Summary

    This chapter reviews the literature on the effects of age on fertility in the perimenopausal woman. The effect of age on female fertility is difficult to assess because of confounding variables such as coital frequency and other biological causes associated with infertility, the use of contraception and the social and economical constraints that limit family size. The most effective assisted reproductive technology (ART) treatment for perimenopausal women is oocyte donation. Infertility treatment in the perimenopausal woman raises many ethical questions. All fertility centers should establish guidelines based on the literature and their success rates to appropriately counsel patients about the likelihood of live birth based on age. These guidelines would also allow both the physician and the patient to justify treatment in those cases when the odds of success are low but are not nonexistent.
  • 73 - Religious Perspectives of Ethical Issues in Inferility and ART
    pp 728-746
  • View abstract

    Summary

    This chapter discusses various religious views on infertility and assisted reproductive technology (ART) based upon the presentations of a symposium at the 59th American Society for Reproductive Medicine (ASRM) annual meeting in San Antonio October 2003. It discusses the views of the Coptic orthodox church, Islamic and Jewish perspectives on ART. The Jewish legal system was derived via logic, extrapolation, and argumentation based on the basic commandments in the Torah that were considered incontrovertible and irrefutable axioms and postulates. Therefore, in vitro fertilization (IVF) is absolutely obligatory when it is medically indicated in order for a couple to have children. The spread of technologies of intervention in the processes of human procreation raises very serious moral problems in relation to the respect due to the human being from the moment of conception, to the dignity of the person, of his or her sexuality, and of the transmission of life.
  • 74 - The Future of Assisted Reproduction
    pp 747-758
  • View abstract

    Summary

    The future of assisted reproduction lies in optimization of each treatment phase starting with ovarian stimulation through laboratory procedures, selecting the best embryo for transfer, embryo transfer, luteal phase support leading to pregnancy, and the birth of a healthy single ton baby. Gonadotropin-releasing hormone (GnRH) agonists have changed the course of ovarian stimulation for in vitro fertilization (IVF). GnRH antagonists have been introduced recently in ovarian stimulation for pituitary suppression. High implantation and pregnancy rates in oocyte donation cycles irrespective of acceptors' age imply that ovarian stimulation impairs endometrial receptivity in stimulated cycles. Embryo transfer procedure plays a pivotal role in the success of assisted reproduction. Improving embryo implantation continues to pose a major challenge to clinicians. The future developments in assisted reproduction should encompass individualized approach to ovarian stimulation, vitrification, single blastocyst transfer, and development of new tools for genetic testing.

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