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Breastfeeding involves a loss of nutrients through the milk that will require special nutritional needs, even greater than during pregnancy. Therefore, in general, during lactation, intake should be increased, avoiding diets of less than 1800 cal per day.
Both the maternal nutritional status and the adequate nutrition of the infant will depend on this. However, even in cases of maternal malnutrition such as famine, breast milk will have an excellent nutritional and immunological value with stable levels of iron, zinc, folate, calcium, etc., since the energy, proteins, and nutrients in the milk come both from the diet and from the mother's own reserves.
In short, a varied diet rich in fruits, vegetables, and foods of animal origin is recommended, as well as the supplements indicated by scientific societies.
Although traditionally importance has been given only to the role of vitamin D in bone health, its possible role in fertility is gaining increasing interest. This vitamin has receptors throughout the body, including the ovary, endometrium and placenta, and has been linked to reproductive and obstetric outcomes.
Optimal vitamin D levels have been shown in several studies to improve the likelihood of pregnancy. However, the mechanism by which it increases the rate of gestation is still not very clear.
In a study carried out in recipients of donor eggs, in which it is assumed that all the embryos will be of good quality, it was observed that those patients with correct vitamin D levels had a greater chance of becoming pregnant. However, in another study performed with euploid embryo transfer (chromosomally healthy), this effect was not observed. Thus, although the evidence seems to indicate that vitamin D does improve endometrial receptivity, its role is probably more complex than it appears at first glance.
Another possible mechanism by which vitamin D could increase pregnancy rates is by improving oocyte quality. It has been shown that blood levels of vitamin D are proportional to follicular fluid levels, and it is thought that vitamin D may alleviate ovarian aging, although it has not been studied directly in oocytes.
La hormona antimulleriana (AMH) es una hormona cuyo valor se puede determinar en una analítica de sangre para valorar la reserva ovárica de la mujer. Esta hormona es producida por los folículos antrales, por lo que es proporcional al recuento de folículos antrales y al número de óvulos que podremos conseguir en una estimulación ovárica.
En general, se considera que la AMH es el parámetro más fiable a la hora de valorar la reserva ovárica. Sin embargo, a veces nos encontramos que los valores difieren entre una extracción y otra, e incluso nos podemos encontrar con incrementos de su valor con el tiempo. Este aumento no va en relación con un aumento en la reserva ovárica, ya que esta disminuye con el paso del tiempo.
La AMH puede tener una gran variabilidad debido a factores como los cambios estacionales, el momento del ciclo, el consumo de tabaco o determinadas enfermedades. En un estudio que valoró la variabilidad de la AMH en diferentes días del ciclo encontró una media de variación de hasta un 20%, siendo mayor en aquellas mujeres con niveles bajos de AMH.
Por ello, se debe siempre contrastar la información dada por la AMH con una ecografía de recuento de folículos antrales, y ser cautos a la hora de interpretar una única determinación de AMH, sobre todo en caso de mujeres con baja reserva ovárica.
An empty puncture is a situation in which no oocytes are retrieved during an ovarian punction even though there is a correct growth in the follicles. When we encounter this situation we refer to it as Empty Follicle Syndrome.
Some studies show this can occur in up to 7% of patients that undergo IVF, even though the vast majority of cases can be explained by problems in the hormonal treatment (incorrect administration, outdated HCG...). It is estimated that True Empty Follicle Syndrome is only present in 0.02% of patients.
The causes for this Syndrome are unknown but it is thought that alterations in the folliculogenesis (formation of the follicles and ovules) could be the main cause. These alterations can be caused by advanced maternal age, bad ovarian quality, or genetic factors.
This could cause:
- An early degeneration of the oocytes explaining the lack of them in the punction.
- Lack of detachment of the oocyte from the follicle wall. During ovulation, the luteinizing hormone triggers a series of mechanisms that imply the softening of the follicle´s adhesive tissue, allowing the oocyte to detach from the follicle wall.
Another suggestion we can find is the repetition of the cycle with recombinant hCG, luteinizing hormone, or the trigger of ovulation with the liberation of an agonist of the gonadotropin hormone. If after all of these suggestions the problem persists, ovodonation could be an option.
The AFR or antral follicle count is one of the most widely used markers of ovarian reserve, together with AMH (Antimullerian Hormone). It consists of assessing the number of antral follicles in each of the ovaries by vaginal ultrasound, a normal value being considered to be around 8-12 follicles in total.
In general, ovarian reserve decreases with age, and therefore the RFA, however, not all women of the same age have the same ovarian reserve and it is therefore important to assess it for any assisted reproduction treatment and in patients who are infertile or wish to preserve their fertility.
The AFR can help us to predict the chances of success in IVF, but it is not the only parameter to take into account, since it tells us about quantity, but not oocyte quality.
Oocyte quality is mainly associated with the woman's age, and refers to the possibility of her oocytes giving rise to a healthy embryo with the capacity for evolutionary pregnancy. It has been established that in patients up to 35 years of age, each embryo generated with their oocytes has a 65-70% chance of giving rise to a healthy embryo. This percentage decreases as the years go by, and at 38 years of age we are talking about 30%, at 40 years of age 25% and at 42 or 43 years of age less than 20-10%.
There are also other factors that can have a negative influence on oocyte quality, such as the consumption of toxic substances, concomitant illnesses, ovarian endometriosis, stress and unhealthy lifestyle habits.
The impact of paternal age on reproductive and neonatal outcomes has always been underestimated, as the focus has been on maternal age, which is much more determinant. However, paternal age has also been negatively related to fertility.
Firstly, age decreases the chances of achieving pregnancy naturally, as the number of spermatozoa decreases after the age of 40, and in addition, the sperm will have a greater fragmentation of their DNA. It is true, however, that these factors will not affect pregnancy rates using techniques such as in vitro fertilisation.
There are also studies that have shown an increased risk of premature births or low birth weight in children born to fathers aged 35 or older, although these findings are not entirely clear. Another aspect is the relationship between paternal age, especially after the age of 50, with a slight increase in the risk of autism and schizophrenia.
Therefore, it could be said that in general the ideal age to be a father would be below 40. From this point onwards, the chances of conceiving naturally start to decrease and there will be an increase, albeit minimal, in the genetic risks for the offspring. However, this does not mean that parenthood is discouraged above this age. Assisted reproduction techniques can compensate for this decrease in fertility and the risks involved will be very low.
Ovodonation with vitrified eggs has very similar pregnancy rates to fresh eggs. The only difference may be in the number of eggs from which the eggs are retrieved. In addition, it is also vitally important to have the survival rate of devitrification of the eggs.
Sterility and infertility are different concepts; to understand fertility, one of the key concepts to know is that, in general conditions, the human species has a low reproductive efficiency with only between 20 and 25% of monthly pregnancy possibility in fertile couples and without any problem, reaching 80% of accumulated pregnancy rate throughout a year of searching and 90% after 2 years of searching for gestation.
Sterility is defined as the inability of a couple to conceive naturally within one year. Within this term, a distinction can be made between primary sterility, if the couple has never become pregnant, and secondary sterility, if the couple has already achieved a pregnancy previously, but at the present time is unable to become pregnant.
Infertility, on the other hand, is understood as the inability to achieve a live birth, this being the case of couples who achieve pregnancy but subsequently miscarry.
Therefore, although sterility and infertility are often referred to interchangeably, they are different concepts, although they have in common the inability to achieve an evolving pregnancy and a newborn.
The Fertile Chip uses the microfluidic technique to filter the male sample to obtain a larger number of spermatozoa lacking DNA double-strand fragmentation. These selected spermatozoa could be used in ICSI, thus decreasing the probability of microinjecting spermatozoa with a fragmented double strand.
It is true that in order to obtain a sufficient quantity of spermatozoa after performing the Fertile Chip technique it will be necessary to have minimum values of sperm concentration, motility and morphology.
As a general rule, a minimum concentration of 5 million spermatozoa per milliliter, 20% of spermatozoa with A+B motility and 2% of spermatozoa with normal morphology has been established. However, it is true that at the time of performing the technique, if some parameters were lower and others higher, they could compensate each other and finally sufficient sperm could be recovered for ICSI.
Ovarian stimulation aims to achieve the growth of multiple eggs. This will mean that the ovaries will reach a much larger size than usual. This increase in size will be maintained from almost the beginning of the ovarian stimulation until several days after the puncture and ICSI.
The fact that the ovary is larger than usual is a risk factor for possible ovarian torsion. This consists of a complete or partial rotation of the ovary on its supporting elements, with the consequent loss of its blood supply, which is a medical emergency requiring early surgical intervention to avoid necrosis and loss of the ovary.
For this reason, it is advisable to rest after the puncture, avoiding above all exercise with impact and sexual relations until some time has passed and the ovaries have returned to their normal size. In addition, on the day of the puncture, this rest should be carried out more strictly due to the side effects that the anesthesia used for the intervention may have.
Although traditionally only the role of vitamin D in bone health has been emphasized, its potential role in fertility is becoming increasingly important. This hormone has receptors throughout the body, including the ovary, endometrium, and placenta, and has been linked to reproductive and obstetric outcomes.
Studies have shown that optimal levels of vitamin D improve the chance of pregnancy. However, the mechanism by which the rate of gestation increases is not yet very clear.
In a study carried out on donor egg recipients, where it is assumed all the embryos will have a good quality, it was observed that those patients with correct vitamin D levels had a greater chance of becoming pregnant. However, in another study carried out with the transfer of euploid (chromosomally healthy) embryos, this effect was not observed. Thus, although the evidence seems to indicate that vitamin D does improve endometrial receptivity, its role is probably more complex than it appears at first glance.
Another possible mechanism by which vitamin D may increase pregnancy rates is by improving egg quality. Blood levels of vitamin D have been shown to be proportional to levels in follicular fluid, and it is believed that vitamin D may palliate ovarian aging, although it has not been possible to study it directly in eggs.
Both the Fertile Chip and the columns of adnexins or MACS are filters used in the embryology laboratory to try to select the best spermatozoa to microinject the oocytes. In general, it is said that both filters are used to select spermatozoa with less DNA fragmentation. However, this is not exactly the case.
Therefore, the Fertile Chip is better for men with sperm DNA fragmentation, especially double-stranded. On the other hand, the MACS technique will help us to reduce the number of spermatozoa with fragmentation.
Single stranded fragmentation produces different problems than double stranded fragmentation. While single stranded breaks are related to male sterility, double stranded breaks are related to a higher risk of abortion.
Single stranded fragmentation is mainly caused by oxidative stress (tobacco, alcohol...), and is a much more extensive error, affecting a large part of the spermatozoid DNA. This makes it very difficult to repair by the oocyte and, therefore, not even gestation occurs.
In the case of double-stranded fragmentation, breaks are produced at specific points that are unprotected by an enzyme called nuclease, so the damage is not so extensive and can even be repaired by a young egg. Otherwise, if this fragmentation is not repaired, it will give rise to an embryo with chromosomal alterations that will most probably end in a miscarriage.
Therefore, depending on the problem of the patients, we may find it more interesting to study one or another type of fragmentation. However, the ideal would be to study both types of fragmentation, given that there could be problems in both.
As possible advantages of the use of the PICSI we could talk about the following:
- It is a complete, accurate and alternative sperm selection method. Complete because the sperm sample to be used for PICSI has already been improved with techniques such as Swim-up or Gradient; precise because the basis of the technique involves molecular components and alternative because it represents a different option to other means of sperm selection.
- It seems to be associated with a reduction in the abortion rate: the different studies state that the use of PICSI does not increase the live birth rate compared to the use of ICSI but reveal that there is a lower abortion rate in the PICSI group. Why is it that if it reduces abortions it is not found in the studies that it increases the live birth rates? Because this decrease in the abortion rate is so low that in studies it has no influence on live birth rates.
- It is an objective and simple method that does not require much experience to develop, unlike ICSI where there is a subjective component in the choice of sperm to microinject.
The best option to achieve a pregnancy after having had a tubal ligation is to resort to in vitro fertilization (IVF). Another possible option would be to try to repair the fallopian tubes by an operation called tubal reanastomosis, i.e. joining the ends of the cut tubes together again.
Ovarian hyperstimulation is characterized by an increase in the size of the ovaries. In the most severe cases there may be sudden changes in body fluids, with fluid leaking out of the blood vessels into, for example, the abdominal cavity.
In this type of situation, it is always recommended to avoid physical exercise and sexual relations. The main reason will be to avoid possible ovarian torsion. This consists of a complete or partial rotation of the ovary on its supporting elements, with the consequent loss of its blood supply. The fact that the ovary is larger than usual is a risk factor for this type of incident.
In fact, after carrying out an in vitro fertilization, even if there is no ovarian hyperstimulation syndrome, sexual relations are not recommended until some time has passed, as to a greater or lesser extent, the ovaries will always be larger than usual due to the growth of multiple follicles, and therefore, an increased risk of ovarian torsion.
Most chronic diseases will be at risk of worsening during pregnancy, so close monitoring before, during and after pregnancy will be essential.
In some cases, pregnancy may even be contraindicated because of the risks to the mother.
There are two groups of patients in whom a deficit of the LH hormone may prevent proper follicular development:
- Women over 35: As the years go by, the LH produced by the body is less powerful and the LH receptors are less functional.
- Women who, in spite of having good ovarian reserve parameters, have shown a low response in a previous ovarian stimulation cycle. One of the causes, among others, that can provoke this unexpected low response is a genetic variant of LH that makes the hormone biologically inactive. Thus, if we measure the LH levels in the blood they will be normal, but the hormone will not be able to exert its function.
These are the patients in whom it will be necessary to add LH activity in ovarian stimulation, since they do not have enough endogenous LH to complement FSH in folliculogenesis.
Firstly, it is necessary to define very well what these spermatozoa obtained from the testicle are going to be used for and what type of azoospermia we are talking about.
In cases of secretory azoospermia, as it is more difficult to obtain sperm, microinjection can be attempted even if the number is very low, always informing the patients of the prognosis. There is no defined minimum number of sperm but there must be at least two or three times the number of oocytes to be microinjected to ensure a certain margin of safety. Normally, freezing samples in these cases is very difficult due to the shortage.
In contrast, in obstructive azoospermia, the scenario is usually different. Embryologists assess that the concentration of sperm present is as before, 2-3 times more than the number of oocytes to be microinjected, and if the sample has a higher concentration it can be frozen for future use. As long as the sample can be frozen, it will be the most convenient to avoid future surgeries if the in vitro fertilization treatment fails.
The cause of Kallman syndrome is genetic, with different genes involved. Therefore, there is no cure as such. Treatment consists of exogenously giving the body the hormones it needs for proper pubertal development. In women estrogens are administered and in men testosterone, in both cases they will be maintained indefinitely.
In addition, if there comes a time when the patient wishes to have children, the hypothalamic pituitary gonadal axis must be activated with medication. GnRH or FSH and LH can be administered to activate the ovaries and testicles.
Serological study of hepatitis B, hepatitis C, HIV and syphilis should be performed prior to any treatment.
This aims to avoid transmission between partners, from mother to fetus and even contamination in the laboratory with possible infection of the staff of the same or other uninfected partners.
Ideally, fetal DNA testing should be the method used in all pregnant women. However, most health care providers only cover the costs for high-risk patients.
In general, we could say that this test would be especially recommended in the following groups of women:
- Women who underwent first trimester screening and are considered high-risk patients(≥1/270)
- Women who presented aneuploidies in chromosomes 21, 18 or 13 in their previous pregnancy.
- Women who are pregnant at ≥ 38 years.
A woman is considered to have POF if she has deteriorated ovarian function under 40 years of age. Some time ago this was also known as early ovarian failure or early menopause. However, these terms are not entirely accurate, because at menopause there is a total or almost total depletion of the ovarian reserve, so menstruation disappears completely. In early ovarian failure patients may continue to ovulate occasionally.
50% of the testosterone in a woman's body comes from the conversion of other androgens, while the other 50% is produced directly in the ovary and the adrenal glands in equal parts.
Specifically, women produce between 0.1 and 0.4 mg of testosterone daily, while men produce between 5 and 7 mg daily.
99% of a woman's testosterone is bound to a protein called sex hormone-bound globulin (SHBG), which does not allow it to function. Therefore, only 1% of testosterone will be in free form and may have an effect on the body.
As menopause approaches, there is a decrease in androgen levels. However, the ovaries of menopausal women will continue to produce testosterone constantly.
In addition to menopause, other situations that may decrease androgen concentrations include anorexia nervosa, medications such as contraceptives (due to increased SHBG concentrations), HIV, bilateral oophorectomy (surgical excision of both ovaries), and endocrine pathologies such as a failure of the adrenal glands or hypopituitarism.
On the contrary, there are circumstances in which higher levels of androgens are observed, such as polycystic ovary syndrome (PCOS)
Testosterone is sometimes used in assisted reproduction in an attempt to improve the response in women with low egg reserves.
Testosterone or DHEA pre-treatment appears to be associated with better live birth rates, although the quality of evidence is moderate.
FISH is a cytogenetic analysis technique that allows the identification of sperm chromosomes in an ejaculate or testicular biopsy sample. It determines the chromosomal endowment, expressing the percentage of spermatozoa that present alterations.
Usually 5 chromosomes are analyzed, 13, 18, 21, X and Y, as they are the most frequently affected chromosomes that can give rise to viable gestations. However, this study can be extended to other chromosomes.
Multiple indications have been proposed for performing sperm FISH, including repeated miscarriages, implantation failure, advanced paternal age, history of chemotherapy treatment, seminal alterations, infertility of unknown origin, genetic anomalies, etc. However, not all of them are linked to a high percentage of patients with an altered FISH.
There's quite a bit of controversy about that. In general, there is no clear evidence that time-lapse incubators improve success rates. However, there are studies that claim that more embryos will be able to reach the blastocyst stage due to better culture conditions and that higher gestation rates can be achieved by better embryo selection.
The first incubators for embryo culture were large and the embryos of all patients were stored in the same space. Therefore, when a patient's embryos had to be removed for microscopic viewing or transfer, the temperature and gas conditions were temporarily altered, and this could affect all the embryos.
More recently, "benchtop" or "sandwich" type incubators have been developed. These have individualized compartments for each patient, so that opening one does not affect the others. In addition, the culture conditions are much better than with the first incubators, as they work at low oxygen pressures, so they imitate the conditions of the human body much better. The difference between these incubators and the Embryoscope® or other types of time-lapse incubators is that they do not have a built-in camera, so if you want to monitor the development of the embryos you need to remove them from the incubator to look at them under the microscope.
Ovaleap's main advantage is its administration device.
In a recent study, 402 patients from different countries were surveyed to evaluate what they considered to be the most important characteristics of devices for self-administration of medication in assisted reproduction treatments. Of the 6 most valued characteristics, Ovaleap has the device with the highest number of them, 5 in total (type of device: multi-dose pen, with dial-back function, possibility of increasing the dose in small amounts, release button for injection and visibility of the remaining medication in the cartridge).
Only the Puregon device outperformed it in one feature, the daily injection volume, being 0.18ml while with Ovaleap it is 0.25ml.
Turner syndrome is one of the most common chromosomal abnormalities in humans, and represents an important cause of early menopause. It is caused by the total or partial loss of one of the X chromosomes (women usually have 2 X chromosomes).
The vast majority of women with Turner syndrome will be sterile due to ovarian failure. However, there is a small percentage of women (about 5%) who will be able to achieve natural gestations. It will be more likely if you have had spontaneous menstruations or if you have a mosaic Turner syndrome (when some cells have one X chromosome and two other X chromosomes).
Some adolescent women or Turner mosaics will have enough ovarian function to respond to ovarian stimulation and may vitrify oocytes to become mothers later or perform in vitro fertilization. However, the vast majority of women with this chromosomal alteration will have to resort to ovodonation.
In addition, for these women there is an increased risk of aortic dissection during pregnancy and postpartum, which will require a complete medical evaluation before seeking gestation, paying special attention to cardiovascular and renal function.
Only in a minority of cases of salpingitis does peritonitis or pelvic abscess develop, manifesting itself with more intense pain and general symptoms such as fever. If this degree is reached, surgery is sometimes necessary to cure the disease, and the tubes and even the ovaries have to be removed.
In the most severe cases, the process can extend to other abdominal organs such as the liver or even pass into the blood (sepsis), posing a risk to the woman's life.
There are several types of analogs, which differ by small variations of components of the molecule. These would be leuprorelin acetate, triptorelin, nafarelin, buserelin, and goserelin. There are several presentations (daily, monthly, quarterly ...), indicating at each time the most appropriate for the effect you want to achieve. Each type of analog also has its route of administration, which may be subcutaneous, intramuscular, or intranasal.
It has not been demonstrated that any of the agonists marketed is superior to another, although the subcutaneous route provides constant bioavailability and little variation between patients, while intranasal or inhalation absorption may be more variable.
Cancer treatment may occasionally require removal of the ovaries or administration of chemotherapy or radiation therapy. This often results in a loss of fertility. However, in many situations, with adequate planning it will be possible to preserve the fertility of these patients so that they can become mothers in the future. The most important thing in this sense is to consult a fertility specialist as soon as the malignant pathology is diagnosed.
There exist no differences between a natural pregnancy and a pregnancy that has been achieved using reproductive technologies such as IVF. After the embryo transfer, fetal development will be the exactly the same.
Neither the risk of malformations nor the risk of miscarriage increase when using a fertility treatment. Some studies have discovered a slightly higher risk of preterm birth or low birth weight. Anyway, these complications do not seem to be directly linked to the use of fertility treatments, but with the cause of infertility: women aged 40 or older, uterine anomalies and other pathologies... This type of pregnancies must be monitored very closely.
Follicular puncture or oocyte retrieval is a mild procedure that involves little risk of complications.
The most severe risks that can occur during or after this procedure are damage to pelvic organs (intestines, bladder...), bleeding, or infections. These complications are very rare, as it is an ultrasound-guided procedure, which means that the gynecologist can monitor the sites being approached.
Other side effects, though less severe, include dizziness and vomiting due to anesthesia, or abdominal pain during the first days after the procedure.