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  1. Home
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  3. Human Assisted Reproductive Technology
  • Cited by 5
Publisher:
Cambridge University Press
Online publication date:
May 2011
Print publication year:
2011
Online ISBN:
9780511734755
DOI:
https://doi.org/10.1017/CBO9780511734755
Subjects:
Obstetrics and Gynecology, Reproductive Medicine, Medicine
Information

Book description

Human Assisted Reproductive Technology: Future Trends in Laboratory and Clinical Practice offers a collection of concise, practical review articles on cutting-edge topics within reproductive medicine. Each article presents a balanced view of clinically relevant information and looks ahead to how practice will change over the next five years. The clinical section discusses advances in reproductive surgery and current use of robotic surgery for tubal reversal and removal of fibroids. It looks into the refinement of surgical procedures for fertility preservation purposes. Chapters also discuss non-invasive diagnosis of endometriosis with proteomics technology, new concepts in ovarian stimulation and in the management of polycystic ovary syndrome, and evidence-based ART. The embryology section discusses issues ranging from three-dimensional in-vitro ovarian follicle culture, and morphometric and proteomics analysis of embryos, to oocyte and embryo cyropreservation. This forward-looking volume of review articles is key reading for reproductive medicine physicians, gynecologists, reproductive endocrinologists, urologists and andrologists.

Reviews

'… educational, well written and comprehensive …'

Source: Acta Obstetricia et Gynecologica Scandinavica

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Contents

Page 1 of 2

Contents
  • Chapter 9 - Non-invasive diagnosis of endometriosis with proteomic technologies
    pp 88-100
  • View abstract

    Summary

    Robotic surgery is emerging as a viable option for gynecological surgeons in general gynecology, urogynecology, oncology, and reproductive surgery. The ZEUS was the first robotic system utilized in gynecological surgery. It is replaced by the robotic system used currently in gynecological surgery: the da Vinci immersive telerobotic system. The da Vinci surgical system consists of three components: a surgeon's console, a patient-side cart with four interactive arms, and a vision cart. The surgeon experiences several benefits while utilizing the da Vinci surgical system. Urogynecologists have started to adopt the new robotic technology. Three studies have examined short-term outcomes, long-term outcomes, and feasibility of robotic-assisted sacrocolpopexy. There are potential uses of robotic-assisted laparoscopic surgery in the field of reproductive medicine. The ability to perform surgery from a remote location can have a significant impact on patient care and access to care, and should be incorporated into future robotic models.
  • Chapter 10 - Antiangiogenic agents for endometriosis
    pp 101-109
  • View abstract

    Summary

    This chapter addresses the controversies surrounding the impact and surgical management of hydrosalpinges and uterine leiomyoma on in vitro fertilization (IVF) cycle outcome. Evidence accumulated over the last 15 years suggests that either unilateral or bilateral hydrosalpinges may exert deleterious effects on IVF cycle outcome. Hydrosalpinx fluid may have a direct embryotoxic effect and may also inhibit fertilization. This deleterious effect may be mediated by the presence of inflammatory cytokines present within hydrosalpinx fluid. Several groups have reported that only large hydrosalpinges, visible on ultrasound, resulted in reduced implantation and pregnancy rates. The impact of uterine leiomyomata specifically on the outcome of assisted reproductive technologies has been evaluated with conflicting results. Evaluation of the uterine cavity by hysteroscopy or sonohysterography should be a routine part of the pre-cycle evaluation. The accuracy of routine ultrasound evaluation and hysterosalpingography is more limited.
  • Chapter 11 - New concepts in the management of polycystic ovary syndrome
    pp 110-118
  • View abstract

    Summary

    Ovarian endometriomas are a common and specific manifestation of the disease endometriosis. In vitro fertilization (IVF) treatment in the words of the European Society of Human Reproduction and Embryology (ESHRE) Special Interest Group (SIG) on Endometriosis appears to be appropriate in patients with advanced endometriosis, which is frequently associated with adhesions, ovarian endometriomas, and tubal obstruction. Ovarian responsiveness to hyperstimulation plays a crucial role in determining the success rate of IVF. There are currently insufficient data to clarify whether the endometrioma-related damage to ovarian responsiveness precedes or follows surgery. Elucidation of this point is of utmost interest since it would strongly impact on the decision of whether to operate on women with endometriomas and who are selected for IVF. At present, there appears to be evidence supporting both an endometrioma-related injury and a surgery-mediated damage. The physiological mechanisms leading to ovulation are abnormal in ovaries with endometriomas.
  • Chapter 12 - Adjuvant therapy to increase implantation rates
    pp 119-126
  • View abstract

    Summary

    This chapter examines the evidence and methods of uterine cavity evaluation and the structural abnormalities that may compromise in vitro fertilization (IVF) success. The gold standard method for the evaluation of the uterine cavity is direct visualization with hysteroscopy. One of the most commonly encountered uterine cavity abnormalities is endometrial polyps. Müllerian anomalies are structural developmental abnormalities of the female reproductive system. The American Society for Reproductive Medicine (ASRM) staging system classifies these abnormalities into hypoplastic/agenesis, unicornuate, didelphus, bicornuate, septate, arcuate, and DES-related. Uterine septae form from incomplete absorption of the intervening tissue as the two Müllerian ducts fuse. The arcuate uterus occurs when there is a mild extension from the uterine fundus caudally. Myomas are the most common benign tumor of the female reproductive system. Finally, the chapter describes a comprehensive diagnostic and treatment algorithm for patients with Asherman's syndrome (AS).
  • Chapter 13 - Ovarian hyperstimulation syndrome
    pp 127-151
  • View abstract

    Summary

    This chapter describes surgical methods for retrieval of epididymal and testicular spermatozoa in men with obstructive azoospermia (OA) or non-obstructive azoospermia (NOA). Either percutaneous epididymal sperm aspiration (PESA) or microsurgical epididymal sperm aspiration (MESA) can be successfully used to retrieve sperm from the epididymis in men with OA. If PESA fails to retrieve motile sperm for intracytoplasmic sperm injection (ICSI), testicular sperm aspiration (TESA) is performed at the same operative time. TESA may be performed in either OA or NOA cases. The chapter also describes sperm retrieval rates using different methods and in several clinical conditions. It presents clinical outcomes of ICSI using testicular and epididymal sperm. The clinical outcomes of ICSI using testicular sperm extracted by TESA or micro-testicular sperm extraction (TESE) in NOA are significantly lower than those obtained with either ejaculated or epididymal/testicular sperm from men with OA.
  • Chapter 14 - The evidence-based practice of assisted reproduction
    pp 152-166
  • View abstract

    Summary

    Increased understanding of the intricacies of the follicular development and selection processes has been critical to the development of many of the new developments in ovarian stimulation in clinical practice. This chapter reviews these clinically related physiological aspects of ovarian stimulation, and discusses the resulting new concepts of ovarian stimulation. Recent studies have indicated that anti-Mullerian hormone (AMH) may be a more reliable and robust predictor of ovarian response during ovarian stimulation. The long ovarian stimulation protocol combining GnRH agonist with exogenous gonadotropin administration has been the most popular treatment regime for the past 20 years. The objectives of ovarian stimulation in assisted reproductive technology (ART) are evolving. A further development which promises to further reduce the burden of ovarian stimulation is the introduction of a long-acting follicle stimulating hormone (FSH) preparation which greatly reduces the number of injections required during an in vitro fertilization (IVF) treatment cycle.
  • Chapter 15 - Three-dimensional in vitro ovarian follicle culture
    pp 167-176
  • View abstract

    Summary

    The availability of gonadotropin releasing hormone (GnRH) antagonists did not only offer clinicians an alternative to GnRH agonists but, more importantly, has led to the development of new concepts aiming to increase safety and simplicity in ovarian stimulation. These include the modified natural cycle, mild in vitro fertilization (IVF), the use of GnRH agonist for triggering of final oocyte maturation with elective cryopreservation in patients at risk of developing ovarian hyperstimulation syndrome (OHSS), the administration of antagonists during the luteal phase for management of severe OHSS, as well as control of endogenous luteinizing hormone (LH) with GnRH antagonists in intrauterine insemination (IUI) cycles. Administration of GnRH antagonists can be performed by either a single dose or by using a daily scheme. The need to simplify ovarian stimulation led to the development of long-acting follicle stimulating hormone (FSH).
  • Chapter 16 - Artificial gametes
    pp 177-185
  • View abstract

    Summary

    Discovering the genetic variants associated with ovarian response to gonadotropins is an important step towards individualized pharmacogenetic protocols of ovarian stimulation. More than 90% of the genetic variability is caused by the presence of single nucleotide polymorphisms (SNPs). Pharmacogenetics is the science that describes the relationship between genetic variability and drug response and studies how to tailor pharmacological therapy to the genetic features of the individual patient and how to improve desired actions and minimize side effects. Different genes have been studied in relation to the characteristics of the normal ovarian cycle or different individual responses to controlled ovarian hyperstimulation (COH). The follicle stimulating hormone receptor gene (FSHR) is crucial in follicular maturation: inactivating FSHR mutations almost always leads to amenorrhea and activating mutations can cause a spontaneous ovarian hyperstimulation syndrome or predispose to iatrogenic ovarian hyperstimulation syndrome (OHSS).
  • Chapter 17 - Current status and future trends of the clinical practice of human oocyte in vitro maturation
    pp 186-198
  • View abstract

    Summary

    This chapter focuses on the non-invasive approaches which largely concentrate on proteomics analyses. Proteins are generated from the genome with signal sequences that direct them to the cell membrane or are secreted in the extracellular environment. Secreted proteins are often post-translationally modified, in particular by glycosylation. These proteins are then released into the interstitial environment where they may enter body fluids such as the blood system and, in the case of endometriosis, be detected in endometrial, peritoneal, or follicular fluids. In most proteomic approaches, mass spectrometry (MS) plays a part in the analyses. Electrospray ionization (ESI) is the most common method for sample introduction into the MS. Matrix assisted laser desorption ionization (MALDI) is also be used as an alternative to ESI. Two-dimensional gel analyses have traditionally been used for the differential analysis of proteomes and differences may be observed and selected visually or using image analysis of scanned gels.
  • Chapter 18 - Oocyte and zona imaging
    pp 199-208
  • View abstract

    Summary

    Medical treatment of endometriosis is a necessary step in the management of the disease due to its high rate of recurrence and different clinical situations. Women with endometriosis present a peritoneal environment with increased angiogenic activity. Angiogenesis involves the formation of new blood vessels released by pre-existing vessels. Several antiangiogenic agents have been successfully tested in experimental models of endometriosis inhibiting new vessel formation. These compounds target specifically the endothelial cells without penetration in the tissues. Several anticancer drugs with antiangiogenic potential have been found to have a detrimental effect on reproductive function in both animal models and patients. The studies in experimental oncological models demonstrated that dopamine agonists (DA) have an antiangiogenic effect promoting the vascular endothelial growth factor receptors (VEGFR)-2 endocytosis in endothelial cells, preventing the VEGF-VEGFR-2 union and avoiding receptor phosphorylation and signal cascade.
  • Chapter 19 - Granulosa cells and their impact on human ART
    pp 209-222
  • View abstract

    Summary

    The majority of women with anovulation or oligoovulation due to polycystic ovary syndrome (PCOS) often have clinical and/or biochemical evidence of hyperandrogenism. This chapter describes the treatment with clomiphene citrate (CC), aromatase inhibitors (AIs), gonadotropins, and metformin followed by a discussion on the management of women with PCOS undergoing in vitro fertilization (IVF). It deals with the combined treatment of clomiphene with metformin. In women with PCOS, metformin is said to lower fasting insulin concentrations but also probably acts directly on theca cells and attenuates androgen production. The aim of the chronic low-dose step-up protocol is to obtain the ovulation of a single follicle. While results of IVF for women with PCOS are generally satisfactory compared with those with normal ovaries, ovarian stimulation protocols must be adapted accordingly to avoid the major pitfall of ovarian hyperstimulation syndrome (OHSS) in these women.
  • Chapter 20 - Sperm diagnosis:
    pp 223-231
  • selecting the best sperm for IVF/ICSI treatment
  • View abstract

    Summary

    Several medications have been found to increase implantation rates with in vitro fertilization (IVF) when given as adjuncts to follicle stimulating hormone (FSH) stimulation of the ovaries in preparation for oocyte retrieval. Gonadotropin-releasing hormone (GnRH) agonists, oral contraceptives (OCs), and estrogen pretreatment help to synchronize the follicular cohort resulting in an improved ovarian response. Metformin (MET) increases implantation in PCOS women having IVF and dramatically reduces the incidence of ovarian hyperstimulation syndrome (OHSS) in these women. Growth hormone (GH) markedly increases implantation in poor-responding women having IVF. Small doses of human chorionic gonadotropin (hCG) are used to provide LH activity allowing use of pure FSH products and the pen devices that deliver graduated FSH doses. Low-dose aspirin (ASA) increases ovarian response and implantation, and reduces the incidence of severe OHSS. Drugs such as letrozole that increase androgens may prove to be useful agents to increase ovarian response in poor responders.
  • Chapter 21 - Embryo culture in the twenty-first century
    pp 232-247
  • View abstract

    Summary

    This chapter deals with the classification, pathophysiology, prediction, prevention, and treatment of ovarian hyperstimulation syndrome (OHSS). OHSS is characterized by bilateral cystic ovarian enlargement and third-space fluid shift resulting in ascites and pleural effusion. It may be moderate or severe in severity, early or late in onset, spontaneous or iatrogenic in etiology. Prediction of OHSS is the cornerstone of prevention. It is based on identifying the characteristics of the patients who would be high responders as well as the use of ultrasonography and estradiol assessment. The pathophysiology of OHSS suggests the involvement of an inflammatory mechanism during the development of the fluid leakage associated with OHSS. Therefore, investigators hypothesized that glucocorticoids could possibly prevent OHSS in patients at high risk. Laparoscopic ovarian drilling has been used successfully for prevention of OHSS in patients with polycystic ovaries. The medical treatment of OHSS consists of correction of circulatory volume and electrolyte imbalance.
  • Chapter 22 - Morphometric analyses of embryos
    pp 248-259
  • View abstract

    Summary

    This chapter reviews the current status of assisted reproduction techniques in the light of the best evidence available. In order to optimize the results of assisted reproduction, various laboratory modifications have been suggested. These include performing Intracytoplasmic sperm injection (ICSI) rather than in vitro fertilization (IVF) for all oocytes, using co-culturing techniques, assisted hatching techniques, as well as selecting the embryos with the best potential for implantation based on their morphology, their metabolism, or by prolonging their culture in vitro to the blastocyst stage. Embryo transfer (ET) is arguably the most critical step in assisted reproduction and the least successful. Various attempts have been made to improve endometrial receptivity in order to increase the clinical outcome of IVF and ICSI. These include various regimens of luteal support, the use of corticosteroids, the removal of hydrosalpinges, diminishing uterine contractions as well as enhancing the endometrial blood flow.

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