Fertility research and practice最新文献

Background: In vitro fertilization (IVF) and pre-implantation genetic diagnosis (PGD) are becoming increasingly common techniques to select embryos that are unaffected by a known genetic disorder. Though IVF-PGD has high success rates, 7.5 % of blastocysts have inconclusive results after testing. A recent case involving a known BRCA-1 carrier was brought before our Assisted Reproductive Technology Ethics Committee in order to gain a better appreciation for the ethical implications surrounding the transfer of embryos with indeterminate testing.

The case presentation: Thirty-nine year old G0 BRCA-1 carrier requiring IVF for male factor infertility. The couple elected for PGD to select against BRCA-1 gene carrier embryos. However, several embryos were returned with inconclusive results. The couple wished to proceed with the transfer of embryos with an unknown carrier status. The case was presented before our Assisted Reproductive Technology Ethics Committee.

Conclusion: Many considerations were explored, including the physician's duty to protect patient autonomy, the physician's duty to act in the best interest of the future child, and the physician's duty towards society. Transferring both embryos with unknown carrier status and known-carrier status was debated. Ultimately, the transfer of inconclusive embryos was felt to be ethically permissible in most cases if patients had been adequately counseled. However, the re-biopsy of embryos with inconclusive testing results was encouraged. The transfer of known-carrier embryos was felt to be unethical for certain disease-states, depending on the severity of illness and timing of disease onset. We strongly encourage physicians to create an action plan in advance with their patients, prior to testing, in the event that embryos are returned with inconclusive PGD results. The committee's decision, though helpful in guiding practice, should not overshadow the individual physician-patient relationship, and the need for thorough counseling.

Background: Couples are considered infertile if they do not conceive over a 12-month period of unprotected intercourse. Studies have shown that female causes accounted for between 25 to 37 percent of infertility worldwide (with larger proportions in sub-Saharan Africa and Southeast Asia) and male causes accounted for between 8 to 22 percent. Both male and female causes accounted for between 21 to 38 percent. Although the majority of ART children are normal, there are concerns about the increased risk for adverse pregnancy outcomes. More than 30 % of ART pregnancies are twins or higher-order multiple gestations (triplets or greater) and more than one half of all ART neonates are the products of multifetal gestations, with an attendant increase in prematurity complications. The aim of this study was to evaiuate the outcome of pregnancies conceived by In-vitro fertilisation compared to those conceived naturally in two hospitals in Douala, Cameroon.

Methods: This was a prospective study carried out from October 1, 2011 to September 30, 2012. Participants were recruited from two hospitals: the Douala General Hospital (DGH) and the Clinique de l' Aéroport (CDA), also in Douala. A total of 102 women were recruited for study: 51 who conceived by IVF (cases) and 51 who conceived naturally (controls). Of the 102 women, 52.9 % were between 31 - 39 years of age, while 21.6 % were above 40.

Results: Participants who conceived through IVF-ET were 4.1 times more likely to undergo cesarean delivery than those who conceived naturally [OR 4.10, 95 % CI 1.78-9.42]. Similarly, a higher percentage of patients in the IVF group than those in the control group have never given birth (33.3 % vs 2.0 %) (P < 0.0001). The percentage of multiple pregnancies was 7.5 times higher in the IVF group than in the control group (14.7 % vs.1.96 %) (P = 0.000). The leading indication for cesarean delivery was advanced maternal age (27.3 %) followed by IVF or precious pregnancy (18.2 %).

Conclusions: Cesarean delivery was more frequent amongst the IVF group than in the control group. The leading indications for cesarean delivery were advanced maternal age and IVF or precious pregnancy. The long-term neonatal outcomes of IVF babies beyond 5-min Apgar scores should be studied in Cameroon and follow-up beyond 1 year encouraged.

Background: The causes of female infertility are multifactorial and necessitate comprehensive evaluation including physical examination, hormonal testing, and imaging. Given the associated psychological and financial stress that imaging can cause, infertility patients benefit from a structured and streamlined evaluation. The goal of such a work up is to evaluate the uterus, endometrium, and fallopian tubes for anomalies or abnormalities potentially preventing normal conception. To date, the standard method for assessing these structures typically involves some combination of transvaginal sonography (TVS), hysterosalpingography (HSG), and hysteroscopy (HSC). The goal of this review is to compare the diagnostic accuracy of TVS, HSG, and HSC for diagnosing abnormalities in infertility patients to determine if all studies are necessary for pre-treatment evaluation.

Results: We identified infertility patients prior to initiation of assisted reproductive technology who had baseline TVS, HSG, and HSC within 180 days of each other. From medical record review, we compared frequencies of each finding between modalities. Of the 1274 patients who received a baseline TVS over 2 years, 327 had TVS and HSG within 180 days and 55 patients had TVS, HSG and HSC. Of the 327, TVS detected fibroids more often than HSG (74 vs. 5, p < .0001), and adenomyosis more often than HSG (7 vs. 2, p = .02). HSG detected tubal obstruction more often than TVS (56 vs. 8, p = .002). Four (1.2 %) patients had endometrial polyps on both HSG and TVS. In the 55 patients with HSG, TVS, and HSC, HSC identified endometrial polyps more often than TVS (10 vs. 1, p = .0001) and HSG (10 vs. 2, p = .0007). TVS detected more fibroids than HSC (17 vs. 5, p < .0001). Tubal obstruction was identified more often by HSG than HSC (19 vs. 5, p < .0001).

Conclusions: TVS is superior for evaluation of myometrial pathology. HSG is superior for evaluation of tubal pathologies. Endometrial pathologies are best identified with HSC.

Background: Conventional single-incision laparoscopic surgery has been successfully employed for treatment of ovarian endometriomas. However, this technique presents surgeons with formidable ergonomic challenges, that make its widespread adoption unlikely. Robotic assistance in single-incision laparoscopic surgery provides adequate instrument triangulation through a single fulcrum, while eliminating ergonomic challenges to the surgeon. The objective of this video is to describe a novel technique of laparoscopic excision and ablation of ovarian endometriomas with single-site robotic assistance. Footage from a single surgical case is shown in our video. The da Vinci Si surgical system with da Vinci Single-Site platform was utilized. A flexible CO2 laser fiber was employed as the main energy tool. To describe a technique of single-incision laparoscopic excision and ablation of endometriomas with robotic assistance. Footage from a single surgical case is shown in this video. The da Vinci Si surgical system with da Vinci Single-Site platform was utilized. A flexible CO2 laser fiber was employed as the main energy tool.

Results: Our technique achieved excellent surgical, clinical and cosmetic results, with complete excision and ablation of the endometriomas and no complications. The procedure was completed in day-surgery setting.

Conclusion: Our step-by-step video tutorial shows how the dedicated single incision laparoscopy technology for the da Vinci Si surgical system can be safely and effectively applied to the excision and ablation of ovarian endometriomas.

Background: Fertility is one of the three principal components of population dynamics. High fertility and rapid population growth exert negative influences on economic and social development. This study was aimed to estimate the level and trends of fertility among (15-49 years) old women in kersa demographic surveillance and health research center, kersa district Eastern Ethiopia.

Methods: The study was conducted at kersa demographic surveillance and health research center in kersa district, Eastern Ethiopia. The study utilized five years follow up data (2008-2012). All women (15 to 49 years old) who have been living at kersa demographic surveillance and health research center in kersa district from 2008 to 2012 were included in the analysis to estimate the level and pattern of fertility. Descriptive statistics was computed to determine level and pattern of fertility.

Results: Age specific fertility rate was highest in women of the age group 25-29 years old (233.2 per 1000 women in 2008; 205.8 per 1000 women in 2009; 279.0 per 1000 women in 2010; 186.6 per 1000 women in 2011 and 198.5 per 1000 women in 2012) in five consecutive years from 2008 to 2012. Total fertility rate didn't show any significant decline during the study period, i.e., 4.3, 4.5, 4.9, 3.5, 4.0 live births per woman throughout her reproductive period (15-49) years old in 2008, 2009, 2010, 2011 and 2012, respectively. On the other hand, general fertility rate declined from 110.3 births per 1000 women in 2008 to 95.9 per 1000 women in the reproductive age in 2012.

Conclusion: The total fertility rate was found to be relatively high. Fertility rate is higher in rural residents and illiterate women than in urban residents and literate women. Strong information, education, communication and behavior change communication on family planning should be designed and implemented to prevent unwanted fertility.

Background: Glycosylation is the most common and structurally diverse of all the post-translational modifications of proteins. Lipids and extracellular matrices are also often glycosylated. The mammalian uterus is highly enriched in glycoconjugates that are associated with the apical surfaces of epithelial cells and the secretions released by both epithelial and stromal cells. These glycoconjugates interact primarily with sperm, the implanting embryo, the fetus, and any pathogen that happens to gain entry into the uterus. Secretions of the endometrial glands increase substantially during the luteal phase of the menstrual cycle. These secretions are highly enriched in glycoproteins and mucins that promote specific uterine functions.

Findings: Lectins and antibodies have been employed in the majority of the studies focused on uterine glycosylation have employed to define the expression of carbohydrate sequences. However, while these studies provide insight about potential glycosylation, precise information about glycan structure is lacking. Direct sequencing studies that employ biochemical or mass spectrometric methods are far more definitive, but have rarely been employed with uterine glycoproteins. Both lectin/antibody binding and direct carbohydrate sequencing studies that have been focused on the mammalian uterus are reviewed. The primary functional role of the eutherian uterus is to facilitate fertilization and nurture the developing embryo/fetus. Trophoblasts are the primary cells that mediate the binding of the embryo and placenta to the uterine lining. In mammals that utilize hemochorial placentation, they invade the decidua, the specialized endometrial lining that forms during pregnancy. Trophoblasts have also been analyzed for their lectin/antibody binding as a complement to the analysis of the uterine cells and tissues. They will also be reviewed here.

Conclusions: The functional roles of the glycans linked to uterine and trophoblast glycoconjugates remain enigmatic. Another major question in the human is whether defects in placental or uterine glycosylation play a role in the development the Great Obstetrical Syndromes. More recent findings indicate that changes in glycosylation occur in trophoblasts obtained from patients that develop preeclampsia and preterm birth. The functional significance of these changes remain to be defined. Whether such shifts happen during the development of other types of obstetrical syndromes remains to be determined.

Background: While recent studies have indicated that fertility has remained high in Uganda, no systematic attempt has been made to identify the factors responsible for this persistent trend and to quantify these factors. This paper uses the Uganda Demographic and Health Surveys (UDHS) of 2006 and 2011, to examine the contribution contraceptive use, marriage and postpartum infecundability on one hand and Total Fertility Rate (TFR) on the other. We constructed a database using the Woman's Questionnaire from the UDHS 2006 and 2011. We then apply Bongaarts aggregate fertility model procedures to derive estimates of total fertility rate for the different socioeconomic groups.

Results: The findings indicate that a woman's contraceptive behavior; marriage status and postpartum infecundability (also referred to as postpartum insusceptibility due to postpartum amenorrhea, which is intended to measure the effects on fertility breastfeeding), are important predictors of fertility outcomes. The results also show that higher education levels and urban residence are consistently associated with lower fertility rates and are positively associated with contraceptive use. Other key predictors of fertility include: wealth status, and region of residence.

Conclusion: The country needs to scale-up target interventions that are aimed at uplifting the education status of women and improving their economic wellbeing, because such interventions have a positive impact on fertility reduction and on improving maternal and reproductive health outcomes.

Background: Ectopic pregnancy is a potentially life-threatening condition occurring in 1-2 % of all pregnancies. The most common ectopic implantation site is the fallopian tube, though 10 % of ectopic pregnancies implant in the cervix, ovary, myometrium, interstitial portion of the fallopian tube, abdominal cavity or within a cesarean section scar.

Findings: Diagnosis involves a combination of clinical symptoms, serology, and ultrasound. Medical management is a safe and effective option in most clinically stable patients. Patients who have failed medical management, are ineligible, or present with ruptured ectopic pregnancy or heterotopic pregnancy are most often managed with excision by laparoscopy or, less commonly, laparotomy. Management of nontubal ectopic pregnancies may involve medical or surgical treatment, or a combination, as dictated by ectopic pregnancy location and the patient's clinical stability. Following tubal ectopic pregnancy, the rate of subsequent intrauterine pregnancy is high and independent of treatment modality.

Conclusion: This review describes the incidence, risk factors, diagnosis, and management of tubal and non-tubal ectopic and heterotopic pregnancies, and reviews the existing data regarding recurrence and future fertility.

Background: Persistent high fertility is associated with mother and child mortality. While most regions in the world have experienced declines in fertility rates, there are conflicting views as to whether Uganda has entered a period of fertility transition. There are limited data available that explicitly detail the fertility trends and patterns in Uganda over the last four decades, from 1973 to 2011. Total fertility rate (TFR) is number of live births that a woman would have throughout her reproductive years if she were subject to the prevailing age specific fertility patterns. The current TFR for Uganda stands at 6.2 children born per woman, which is one of the highest in the region. This study therefore sought to examine whether there has been a fertility stall in Uganda using all existing Demographic Health Survey data, to provide estimates for the current fertility levels and trends in Uganda, and finally to examine the demographic and socioeconomic factors responsible for fertility levels in Uganda. This is a secondary analysis of data from five consecutive Ugandan Demographic Health Surveys (UDHS); 1988/1989, 1995, 2000/2001, 2006 and 2011. Using pooled data to estimate for fertility levels, patterns and trends, we applied a recently developed fertility estimation approach. A Poisson regression model was also used to analyze fertility differentials over the study period.

Results: Over the studied period, fertility trends and levels fluctuated from highs of 8.8 to lows of 5.7, with no specific lag over the study period. These findings suggest Uganda is at the pre-transitional stage, with indications of imminent fertility rate reductions in forthcoming years. Marital status remained a strong predictor for number of children born, even after controlling for other variables.

Conclusions: This study suggests there is no evidence of a fertility stall in Uganda, but demonstrates an onset of fertility transition in the country. If this trend continues, Uganda will experience a low fertility rate in the future-a finding pertinent for policy makers, especially as the continent and the country focus on harnessing the demographic dividend.

Background: Rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) are disorders that commonly impact reproductive aged women.

Findings: Both women with RA and SLE have smaller sized families than do controls. In the case of RA factors other than fertility contribute, while in women with SLE there may be diminished ovarian reserve due to cyclophosphamide therapy and advanced maternal age. RA pregnancies can be complicated by preterm birth and small-for-gestational aged infants. SLE pregnancies have higher rates of fetal loss, in particular in those patients with co-existing antiphospholipid syndrome. SLE pregnancies are also more likely to be complicated by pre-eclampsia and hypertension and to result in preterm birth and small-for-gestational aged infants.

Conclusion: Appropriate fertility evaluation and careful pregnancy planning with coordinated obstetrical care help ensure better outcomes in these patient populations.