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The AFC 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 AFC, 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.
After a study of the couple as a whole, female infertility may be detected. Some of the most common causes of female fertility problems are PCOS, endometriosis, tubal obstruction, low ovarian reserve and advanced maternal age.
Depending on the reason for female infertility, there are several treatment options. For example, clomiphene could be used to induce ovulation in women with PCOS, assisted reproductive techniques such as AI or IVF could be used, donor eggs could be used, and so on.
Human chorionic gonadotropin or hCG is the biomarker used to detect pregnancy, as it is produced exclusively by the trophoblast (which is what gives rise to the placenta). This hormone can be detected in both blood and urine before pregnancy can be detected by ultrasound.
HCG begins to be secreted into the maternal circulation after implantation, which normally occurs 8 to 10 days after ovulation, and its concentration doubles approximately every 48 hours during the first 30 days after implantation.
Normally, urine pregnancy tests will be able to detect hCG at 4 weeks gestation, as they will only be positive when the hCG concentration is at least 20mIUI/ml. It should be borne in mind that pregnancies are counted from the last menstrual period, so that 4 weeks of gestation will actually be 2 weeks from ovulation, which is when fertilization has occurred and the embryo has been created. In other words, the hCG concentration will be easily detected about 8-10 days after implantation.
The determination of hCG in the blood will be much more sensitive and can be positive when the urine test does not yet detect the hormone. According to studies, at 8 days after ovulation it would be possible to detect concentrations of around 10MUI/ml of hCG in the blood.
Scientific evidence seems to indicate that it is better to transfer embryos at the blastocyst stage, as they will achieve higher gestation rates than embryos at day 3. This increase in implantation rates is due, in part, to a better synchronization between embryo and endometrium, but above all, to a better selection of embryos. Not all day 3 embryos will make it to the blastocyst stage, so if we can discard these embryos by long culture, we will be avoiding useless transfers.
The first studies that were performed on day 3 and 5 embryo freezing seemed to find worse results with embryos at the blastocyst stage. This was because the freezing technique used was slow freezing, which decreased embryo survival to thawing, especially for blastocyst stage embryos. Nowadays, the technique used is vitrification, with embryo survival close to 100%, both for embryos at day 3 and embryos at day 5.
Thus, seeing that blastocysts will give us higher gestation rates than day 3 embryos and that they have a very high survival rate to freezing (using vitrification), it seems clear to deduce that it would be better to freeze day 5 embryos.
It is true that studies have failed to find significant differences in cumulative gestation rate by freezing and transferring embryos at day 3 or 5 of development. What has been shown is that by freezing the embryos at day 5 a smaller number of embryos are frozen and the number of transfers necessary to achieve pregnancy will also be lower.
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.
After the embryo transfer, it is normal for patients to be especially attentive to any symptoms that may indicate that pregnancy has been achieved. However, the most common is not to notice any symptoms in these first days. Pregnancy symptoms are mainly caused by the elevation of the hCG hormone, and in these first days after the transfer the levels will be very low or undetectable.
In fact, many times the symptoms reported by patients are due to the medication we use to facilitate embryo implantation. Thus, progesterone can produce drowsiness, nausea, etc. The administration of hCG at the end of an IVF cycle can produce an increase in urinary frequency and the increase in the size of the ovaries due to the growth of multiple follicles or the medication used for an endometrial preparation can produce discomfort similar to that of menstruation.
Thus, we can conclude that there is no specific symptom of pregnancy at this early stage. Neither the absence of symptoms nor the presence of any of them can indicate whether the transfer has been effective. We have to wait for the beta-hCG test to be certain.
If there is fluid inside the uterus (hydrometra), it would be best not to perform the embryo transfer, since the presence of this fluid can prevent embryo implantation. It would be best to freeze the embryos and transfer them in another cycle with a suitable endometrium. In any case, even if for some reason it is decided to perform the transfer, it is not advisable to introduce cannulas unnecessarily into the uterus, since this increases the possibility of injuring the endometrium.
The embryo transfer is critical for the success of the assisted reproduction treatment. If we have a good embryo and a receptive endometrium, but the transfer is not performed correctly, we can lose the possibility of achieving pregnancy. During the transfer, it is essential to avoid trauma to the uterus as much as possible. These would produce uterine contractions that would hinder embryo implantation.
The most frequent cause of male infertility is a defect in sperm production (spermatogenesis), resulting in seminograms with low sperm count or low sperm motility. This is the problem in 65-80% of men who present with difficulties in achieving pregnancy.
Celiac women on a gluten-free diet have the same pregnancy rates as the general population.
However, it has been observed that untreated celiac patients may have late menarche, early menopause, secondary amenorrhea.
These patients are more at risk of developing spontaneous miscarriages, recurrent miscarriages and, if they do achieve gestation, of having preterm deliveries and newborns with lower birth weight.
Infertility in untreated celiac women is related to malabsorption of minerals such as iron and deficiency of vitamins such as folic acid, vitamin D and B12.
A deficit of zinc and/or selenium implies an alteration in the synthesis and secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), and folic acid is essential for the metabolism of nucleic acids and for the neuronal development of the embryo. Its deficiency can cause alterations at both levels.
Antiphospholipid syndrome or APS is an autoimmune disorder characterized by thrombotic events and/or problems in pregnancy associated with the presence of antiphospholipid antibodies in the blood, such as anticardiolipin antibodies, anti-beta2-glycoprotein antibodies or lupus anticoagulant. It can occur in isolation or in the context of other autoimmune diseases such as lupus erythematosus sitematosus.
Complications in pregnancy include miscarriages (especially those after 10 weeks), preeclampsia or placental insufficiency. The mechanism by which PAS produces these adverse events could be a defect in placentation. Thus, in women with APS, the risk of thrombombolism during pregnancy or postpartum is 5-12% (in the general population it would be <0.10%).Treatment of APS during pregnancy reduces the likelihood of thrombosis and pregnancy complications. The medication that is prescribed will depend on the problems that the woman has presented, but normally consists of acetylsalicylic acid or ASA (low-dose aspirin) and heparin, although sometimes other drugs such as hydroxychloroquine may be used. If thrombosis has occurred, lifelong treatment with anticoagulants will probably be necessary, not only during pregnancy. If the PBS has only been expressed as complications of pregnancy it can probably be withdrawn 6 weeks after delivery.
The ideal for a woman seeking pregnancy is to quit smoking as soon as possible. The deleterious effect on the eggs will not be recoverable, so that, if assisted reproduction techniques are required, the number and quality of the eggs obtained will most likely be lower than would correspond to a woman of the same age.
However, there are studies that postulate that smoking also has an effect on endometrial receptivity. It is possible, although there is no clear evidence, that this effect can be reversed by quitting smoking, so it would make sense to stop smoking at least one cycle before you start looking for pregnancy.
What is clear is that once pregnant, smoking should be avoided as much as possible, in order to facilitate proper placentation and not expose the baby to risks.
Gestational diabetes is a common endocrine pathology in pregnancy that develops due to an increase in placental hormones that can block the action of insulin resulting in a metabolic state of insulin resistance that will lead to an increase in blood glucose levels. Therefore, the treatment of gestational diabetes is focused on maintaining normal blood glucose levels, which is determined by blood glucose testing before and after meals.
Treatment must be individualized according to the characteristics of each patient. In most cases, blood glucose levels can be controlled with moderate physical exercise and a specific diet with a menu focused on avoiding sudden increases in blood glucose levels. Likewise, in overweight and obese patients, exercise and a healthy diet will improve the metabolic environment, reducing the risk of suffering this pathology.
Finally, in cases where blood glucose levels cannot be controlled with diet and exercise, the patient will be evaluated by an endocrinology team to begin treatment with injectable insulin, regulating the dose and type of insulin necessary to avoid episodes of hyperglycemia.
The prevalence of CD56+ NK cells in blood is approximately 10% of all peripheral blood lymphocytes. Some studies have reported that percentages as high as 12% may be related to poor reproductive outcomes.
For this reason, different treatments have been proposed over time, although there is still no clear scientific evidence of their efficacy. Among the different options, corticosteroids would be the most widespread treatment given their immunomodulatory role and a profile with fewer associated risks than the other treatments.
It is essential that this treatment be prescribed and controlled by a specialist in reproductive immunology.
The fetal heartbeat should appear between 5 and 6 weeks of pregnancy, so at 7 weeks it should be possible to detect the fetal heartbeat without problems by Doppler ultrasound.
There is a circumstance that could explain a delay in the detection of the heartbeat. This would occur when the actual time of pregnancy is less than that calculated on the basis of the last menstrual period. Ovulation is normally calculated to occur mid-cycle in women with regular cycles between 25 and 35 days. However, especially in women with irregular cycles, ovulation may be delayed, so that pregnancy would occur later than calculated. Therefore, if we do an ultrasound at 7 weeks of pregnancy and we observe an embryo of smaller size and without a heartbeat, the most prudent thing to do would be to wait a while and repeat the ultrasound to evaluate if the embryo has grown and has developed a heartbeat.
Another situation to take into account would be the case of women with obesity in which the visualization of the embryo can be more difficult due to the interposition of fat. In these women it is sometimes necessary to wait until the size of the embryo is somewhat larger to be able to detect the fetal heartbeat clearly.
However, if we are visualizing a 7-week embryo, with a corresponding size (about 8mm) and it does not have a fetal heartbeat, it is most likely that we are dealing with a miscarriage.
Embryo implantation is a complex process in which several factors are involved. It is a dialogue that takes place between the transferred embryo and the properly prepared endometrium at that time. Most of the research on the interaction between emotional stress and infertility over the last 30 years has shown that, although infertility causes stress, stress does not necessarily cause infertility. However, acute and chronic stress can reduce the success rate of fertility treatments.
Stress acts by different mechanisms and its correct assessment requires a collaboration between gynecology, biology and psychology. The available evidence determines that the fertility treatment protocol should include stress management and stress reduction as factors of major importance.
For this purpose, there are various psychological methods such as cognitive behavioral therapy or adequate training in relaxation techniques that help to reduce stress levels. Therefore, it is important to have an initial psychological assessment to evaluate stressors that may interfere with the reproductive health of both members of the couple, whether to initiate assisted reproduction treatment, or in any couple with infertility, whatever its origin.
BRUDYFERTY AOX is a vitamin supplement used to reduce oxidative stress, which can have consequences on sperm DNA. This vitamin supplement contains DHA, among other elements, and has an antioxidant effect.
Small randomized studies have shown the antioxidant effect of DHA supplementation in relation to a decrease in sperm DNA single-stranded fragmentation.
In the evolution of this damage there are factors that can be modified, such as eliminating smoking, alcoholism, obesity, treating seminal infections, limiting testicular overheating, avoiding the ingestion of oxidants and including in the diet the ingestion of antioxidant systems in the regular diet.
During the first few days of pregnancy (before the absence of menstruation), the embryo undergoes rapid changes in its development until it forms a blastocyst. This is the name given to embryos that manage to develop up to day 5-6 of development and form a specific structure. It is at this stage that it should implant in the uterus. When this happens, the gastrulation process begins, in which the cells of the embryo have to differentiate into three layers (endoderm, mesoderm, and ectoderm) and begin to form rudimentary organs.
This period is particularly sensitive to any type of toxicant, including exposure to alcohol. Any aggression could alter this evolutionary process of the embryo and produce problems in the embryo.
Most of the studies carried out on the effect of alcohol in these early stages have been carried out in mice, and have shown that alcohol intake is clearly detrimental. Placental volume and proper functioning of the placenta in exposed mice was found to be much lower than in mice that did not ingest alcohol.
In addition, one study showed that a single dose of alcohol at this stage could cause craniofacial malformations similar to those of fetal alcohol syndrome.
Therefore, total abstinence from all alcoholic beverages is recommended to all pregnant women or women who are trying to become pregnant.
Natural childbirth is almost always the best, both for the mother and the baby.
Cesarean section is a surgical intervention, and therefore carries more risks for the mother (bleeding, infection...). In addition, children born by natural childbirth adapt better respiratorily than those born by cesarean section.
Therefore, natural childbirth will be the ideal type of delivery. However, if there is a maternal illness, fetal distress or if the dilatation does not progress correctly, it will be better to opt for a cesarean section.
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.
Antimullerian hormone (AMH) is a hormone whose value can be determined in a blood test to assess a woman's ovarian reserve. This hormone is produced by the antral follicles, so it is proportional to the antral follicle count and the number of eggs that can be obtained in an ovarian stimulation.
In general, AMH is considered to be the most reliable parameter for assessing ovarian reserve. However, sometimes we find that the values differ from one retrieval to another, and we can even find increases in its value over time. This increase is not related to an increase in ovarian reserve, as this decreases over time.
AMH can be highly variable due to factors such as seasonal changes, timing of the cycle, smoking or certain diseases. A study that assessed the variability of AMH on different days of the cycle found an average variation of up to 20%, being higher in women with low AMH levels.
Therefore, the information given by AMH should always be contrasted with an ultrasound of antral follicle count, and caution should be exercised when interpreting a single AMH determination, especially in the case of women with low ovarian reserve.
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 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.
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.