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Current
Women's Health Reviews
ISSN: 1573-4048
Current Women’s
Health Reviews
Volume 6, Number 3, August 2010
Contents
Current Concepts in Assisted Reproduction and Fertility
Preservation (Part II)
Guest Editors: Sajal Gupta and Ashok Agarwal
Biography
of Contributors Pp. 197-199
Assisted Reproduction:
Evidence-Based Management of Infertile Couples with Repeated
Implantation Failure Following IVF Pp. 200-218
Kim D. Ly, Nabil Aziz, Joelle Safi and Ashok
Agarwal
[Abstract]
Single Blastocyst Transfer: Contemporary Experience
Pp. 219-226
Chin-Kun Baw, Kim Dao Ly, Amr Kader, Ali Ahmady and
Ashok Agarwal
[Abstract]
The Role of Oxidative Stress and Antioxidants
in Assisted Reproduction Pp. 227-238
Sajal Gupta, Lucky Sekhon, Yesul Kim and Ashok
Agarwal
[Abstract]
Coasting: What is the Cost? Pp. 239-244
Mohamed Aboulghar
[Abstract]
PGD and Prenatal Diagnosis: Comparison and Review
in Different Genetic Disorders Pp. 245-249
Ling Sun, Lian Liu, Man Li, Nikoo Afifiyan and
Ali Ahmady
[Abstract]
Options to Prevent Multiple Pregnancies with
ART Pp. 250-253
James M. Goldfarb and Nina Desai
[Abstract]
Metabolomic Profiling for Selection of the Most
Viable Embryos in Clinical IVF Pp. 254-260
George A. Thouas and David K. Gardner
[Abstract]
Fertility Preservation:
Creating A Standard of Care for Fertility Preservation
Pp. 261-266
Kathryn D. Coyne, Amr Kader and Ashok Agarwal
[Abstract]
Prognostic Role of Ovarian Reserve Testing
Pp. 267-272
Jashoman Banerjee, Mona H. Mallikarjunaiah and
John M. Murphy
[Abstract]
Whole Ovarian Vitrification: A Viable Option
for Fertility Preservation? Pp. 273-275
Bruno Salle and Jacqueline Lornage
[Abstract]
Emerging Technologies for Fertility Preservation
in Female Patients Pp. 276-286
Ahmed Nasr and Mohamed Ali Bedaiwy
[Abstract]
Abstracts
[Back to top]
Evidence-Based Management of Infertile Couples
with Repeated Implantation Failure Following IVF
Kim D. Ly, Nabil Aziz, Joelle Safi and Ashok
Agarwal
Embryo implantation depends on both embryo quality and
the endometrial environment. Implantation failure has a complex,
variable pathophysiology and is detrimental to the outcome
of in vitro fertilization (IVF). Thus, patients with
multiple implantation failure require an individualized approach
to diagnosing and managing treatment options for future IVF
cycles. These options should be based on concrete, unambiguous,
consistent scientific evidence with randomized, controlled
trials.
We review and discuss 14 treatment options: (i) blastocyst
transfer, (ii) assisted hatching, (iii) co-culture, (iv) preimplanta-tion
genetic screening, (v) hysteroscopy, (vi) sildenafil, (vii)
salpingectomy for tubal disease, (viii) oocyte donation, (ix)
transfer of six or more embryos, (x), intratubal embryo transfer,
(xi) natural cycle IVF, (xii) antiphospholipid antibodies
(APA) testing and treatment, (xiii) allogenic lymphocyte therapy,
and (xiv) IV immunoglobin therapy. The approaches were evaluated
based on available information from studies, expert opinions,
consensus, etc.
We conclude that blastocyst transfer, assisted hatching, salpingectomy
for tubal disease, and hysteroscopy in IVF procedures are
clinically effective. This review serves as a summary of current
treatment options for clinicians to counsel patients and manage
their expectations based on strong and reliable evidence.
[Back to top]
Single Blastocyst Transfer: Contemporary Experience
Chin-Kun Baw, Kim Dao Ly, Amr Kader, Ali Ahmady and
Ashok Agarwal
Recent studies demonstrated an overwhelming success in
single blastocyst transfer (SBT): implantation rates (IR)
were 60.9%-70.5% and pregnancy rates (PR) were 60.9%-76% while
the multiple pregnancy rates (MPR) were 0%-3.2%. Most of these
studies involved good prognosis patients not more than 37
years of age. The results indicated that SBT decreased the
number of multiple pregnancies while maintaining desirable
pregnancy outcomes. However, SBT and cryopreserved single
blastocyst transfer (cSBT) in the field of in vitro
fertilization (IVF) are still in their infancy. Guidelines
for the number of blastocysts being transferred and the techniques
have not yet been standardized. The method to estimate the
most viable blastocyst has not yet been proposed. The success
of SBT also was found to be highly associated with the technique
and patients’ and clinicians’ perceptions toward
it.
[Back to top]
The Role of Oxidative Stress and Antioxidants
in Assisted Reproduction
Sajal Gupta, Lucky Sekhon, Yesul Kim and Ashok
Agarwal
Aim: Oxidative stress contributes to the high rate of
failure seen in assisted reproductive techniques in achieving
fertilization and pregnancy. Many studies have been done to
elucidate the sources of oxidative stress in the setting of
assisted reproductive technology (ART) and interventions to
overcome its negative influence on the outcome of IVF and
ICSI. This article explores the utility of metabolomics as
a novel, non-invasive method of accurately and efficiently
quantifying oxidative stress. The aim of this study was to
review the current literature on the effects of various interventions,
including the use of antioxidants supplementation of IVF culture
media and patients to improve fertilization and pregnancy
rates in subfertile patients undergoing ART.
Methods: Review of recent publications through Pubmed
and the Cochrane data base.
Results: Oxidative stress is correlated with negatives
ART outcomes. Both exogenous and endogenous sources of reactive
oxygen species during IVF/ICSI are well established in the
literature. Compared to IVF, ICSI is known to minimize the
exposure of gametes to endogenous sources of oxidative stress.
Strategies to control exogenous sources of oxidative stress
within the ART setting include reducing visible/near UV light
exposure, the addition of metal chelators to culture media,
maintenance of low oxygen tension in the environment and the
use of antioxidant therapy. Antioxidant supplemen-tation of
culture media with vitamin C, vitamin E, and melatonin has
been investigated and yielded conflicting results. Whereas
oral antioxidant supplementation of male patients has been
accepted and is currently practiced, there is a lack of consensus
regarding the effectiveness of supplementation of vitamin
C, vitamin E and melatonin in females undergoing ART.
Conclusion: There is a need for further investigation
with randomized controlled studies to confirm the efficacy
and safety of antioxidant supplementation of culture media
and patients as well as the need to determine the dosage required
to improve fertilization rates and pregnancy outcome with
IVF/ICSI.
[Back to top]
Coasting: What is the Cost?
Mohamed Aboulghar
The objective of this article is to review the current
literature on the value of coasting for the prevention of
ovarian hyperstimulation syndrome (OHSS). Coasting is a common
procedure that is performed in ovarian stimulation cycles
at risk of OHSS. Coasting is done by stopping FSH injections
and monitoring E2 daily until it drops below 3000 pg/mL then
hCG is given. Depriving granulosa cells of the FSH stimulus
results in their apoptosis, thus reducing levels of E2 and
vascular endothelial growth factor (VEGF linked to the pathogenesis
of OHSS). Meanwhile, the small follicles that are dependent
on FSH will undergo atresia, while large follicles will not
be affected. Coasting is effective in reducing the OHSS rate,
but complete prevention is not possible. Prolonged coasting
is associated with a significantly lower pregnancy rate.
[Back to top]
PGD and Prenatal Diagnosis: Comparison and Review
in Different Genetic Disorders
Ling Sun, Lian Liu, Man Li, Nikoo Afifiyan and
Ali Ahmady
Pre-implantation and prenatal testing provide genetic
information and detect birth defects or abnormalities in an
embryo/fetus before implantation/born. In this review, the
process and details of the two testing are discussed.
[Back to top]
Options to Prevent Multiple Pregnancies with
ART
James M. Goldfarb and Nina Desai
Multiple pregnancies have been and remain the most common
and serious complication of assisted reproductive technologies
(ART). Prematurity is the major complication of multiple pregnancies
although there are other problems affecting the children and
parents also increase significantly. The scope of the problem
of ART and multiple pregnancies is discussed as well as the
specific issues involving children and parents. Progress in
decreasing ART multiple pregnancies and suggested steps to
further decrease ART multiple pregnancies are also discussed.
[Back to top]
Metabolomic Profiling for Selection of the Most
Viable Embryos in Clinical IVF
George A. Thouas and David K. Gardner
Along with standard morphological indicators of preimplantation
embryo development, information gained from novel “Omics”
platforms is providing more detailed functional characterizations
of embryo phenotype. Since embryo metabolism is a critical
driver of development and implantation, it is proposed that
analysis of the embryo metabolome may reveal several physiologically
relevant markers. Metabolomics analysis is currently showing
significant promise in this context, providing a systematic
method of screening for low molecular weight metabolic by-products,
in isolated cell extracts and biological fluids. Correlations
between in vitro development and pregnancy outcomes
have already been described after retrospective data comparison
with metabolomic profiles. This article summarizes progress
and current findings of metabolomic analysis as a new and
complimentary technology for screening embryo cohorts in clinical
IVF, to facilitate prognostic selection of a single embryo
for transfer.
[Back to top]
Creating A Standard of Care for Fertility Preservation
Kathryn D. Coyne, Amr Kader and Ashok Agarwal
Fertility preservation options for women are currently
only routinely offered to patients who face iatrogenic fertility
loss, and most options are considered experimental. The most
common modalities for female fertility preservation are embryo
cryopreservation, oocyte cryopreservation, and ovarian tissue
cryopreservation, the later two of which remain in the experimental
arena. Natural fertility loss is affecting women as significantly
as premature fertility loss. Increasing cancer survival and
the modern reproductive trend of delaying childbearing are
indications for the need and demand for fertility preservation.
Advances in the field are necessary to respond to this demand
and include superior cryopreservation techniques and fertility
preservation technologies, customized guidelines, comprehensive
care plans, and availability of more cost-efficient procedures.
The obstacles to creating a standard of care for fertility
preservation are as broad as the field itself. Lack of patient
awareness, limited physician experience and knowledge, inadequate
counseling, costs, and ethical issues are some examples of
the many challenges to establishing a standard of care. With
continued research and multidisciplinary collaboration, a
higher quality of care may be provided to a larger patient
population who wishes to maximize their fertility potential
in the future.
[Back to top]
Prognostic Role of Ovarian Reserve Testing
Jashoman Banerjee, Mona H. Mallikarjunaiah and
John M. Murphy
The existing quantity of follicles and their response
to stimulation at a particular age predicts the ovarian reserve.
In vitro fertilization is emerging as a common method
of treatment of infertility. This technique is not 100% accurate
and puts the patient and the couple in both physical and financial
burden. It is important to predict the outcome of a cycle
of IVF to counsel a patient prior to proceeding. The ovarian
reserve is the main functional component which might guide
the outcome. There may be many factors affecting ovarian reserve
but the age of the patient is the most important one. Various
markers have been utilized to determine ovarian reserve in
women which are endocrine, radiological or dynamic tests.
No perfect marker has been identified yet but some have proven
to be better than the other. This review will discuss the
different methods of testing ovarian reserve and the current
research that might help the clinician to predict outcome
prior to initiating IVF.
[Back to top]
Whole Ovarian Vitrification: A Viable Option
for Fertility Preservation?
Bruno Salle and Jacqueline Lornage
Ovarian transplantation may be the future of fertility
preservation. Although ovarian fragments graft is known to
restore fertility, but a large number of primordial follicles
are lost during the neo vacularisation period and the life
span of the transplant is usually short. Whole ovary transplantation
may restore ovarian function immediately and during long time.
Nevertheless results of whole transplantation are still disappointing.
Only one gestation in animal had been reported.
[Back to top]
Emerging Technologies for Fertility Preservation
in Female Patients
Ahmed Nasr and Mohamed Ali Bedaiwy
A wide variety of fertility preservation options in women
is available; however, most of the currently available strategies
are still experimental and do not guarantee subsequent fertility.
The only established method is in vitro fertilization
with embryo cryopreservation prior to cancer therapy. Other
proposed strategies to preserve fertility in women with cancer
include: storage of frozen ovarian tissue or the whole ovary
for future transplantation, storage isolated follicles for
in vitro growth and maturation and ovarian transposition before
radiotherapy. The effectiveness of ovarian protection during
chemotherapy with GnRH analogs is yet to be shown.
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