(BQ) Part 2 book Textbook of clinical embryology presents the following contents: Treatment of male and female infertility, social aspects of using reproductive technology, Assisted peproductive technology (ART), ART - skills, techniques and present status,...
Chapter 17 Treatment of male and female infertility Tim Child Once a couple experiencing fertility problems have undergone appropriate and timely investigations then, in the majority of cases, a diagnosis can be made A minority will have the rather unsatisfactory diagnosis of exclusion, ‘unexplained infertility’ A treatment plan can then be made The patients should attend the consultation together Pre-pregnancy counselling Women who are trying to become pregnant should be informed that drinking no more than one or two units of alcohol once or twice a week, and avoiding episodes of intoxication, reduce the risk of harming a developing fetus Men who drink up to three or four units of alcohol per day are unlikely to affect their fertility Excessive alcohol intake can affect semen quality Women who smoke should be informed that this is likely to reduce their fertility and should be offered referral to a smoking cessation programme Passive smoking may also affect female fertility While there is an association between male smoking and reduced semen quality, the impact of this on fertility is unclear Dietary supplementation with folic acid before conception and up to 12 weeks’ gestation reduces the risk of having a child with a neural tube defect The recommended dose is 0.4 mg per day, though for women with diabetes, on anti-epileptic medication or who have previously had a child with a neural tube defect, a dose of mg per day is recommended A female body mass index (BMI) over 29 is associated with a longer time to conception and a higher rate of miscarriage Women who are not ovulating, and who have a BMI over 29, are likely to improve their chances of conception by losing weight Similarly there is a correlation between male obesity and reduced fertility Women with low BMI of less than 19 and who have irregular or absent menstruations are likely to improve their fertility by increasing their weight While there is an association between elevated scrotal temperature and reduced semen quality, it is not clear whether wearing loose-fitting underwear improves fertility Some occupations involve exposure to hazards that can reduce male or female fertility, and appropriate advice offered A number of prescription, over-the-counter and recreational drugs interfere with male and female fertility and so should be enquired about, and appropriate advice given Vaginal sexual intercourse every 2–3 days through the cycle optimizes the chance of conception For couples with a diagnosed cause of infertility, the treatment will depend on the cause Ovulation disorders Following investigation, the cause of ovulatory dysfunction should be classified (see Chapter 20): WHO Group I Ovulation disorders (hypogonadotrophic hypogonadism) Women with WHO Group I anovulatory infertility can improve their chances of conception and an uncomplicated pregnancy by moderating high exercise levels and increasing the body weight if the BMI is less than 19 Pulsatile subcutaneous administration of gonadotrophin releasing hormone via a pump is a physiological and successful way of inducing monoovulatory cycles However, the need to wear the pump constantly limits the use of this technique Ovulation induction with once daily sub-cutaneous gonadotrophin injections for two weeks or so is more commonly used The absence of endogenous LH pituitary Textbook of Clinical Embryology, ed Kevin Coward and Dagan Wells Published by Cambridge University Press © Cambridge University Press 2013 161 Section 2: Infertility production means that a gonadotrophin with LH activity should be used in addition to FSH The ovarian response needs to be closely monitored with ultrasound to reduce the risk of hyperstimulation and multiple pregnancy An hCG injection will be required to induce ovulation, followed by timed intercourse WHO Group II Ovulation disorders (PCOS) Women with WHO Group II ovulation disorders who are overweight should be encouraged to normalize their BMI This may promote spontaneous ovulation or increase the response to ovulation induction drugs and also reduce risks during pregnancy Clomifene citrate The anti-estrogen clomifene citrate has for decades been the first-line ovulation induction drug for PCOS Clomifene blocks the estrogen feedback from the ovaries to the pituitary and hypothalamus, ‘tricking’ the pituitary into releasing more FSH which may be sufficient to result in follicular development Clomifene is taken as a tablet, usually at an initial dose of 50 mg once daily for days from day of the menstrual cycle Side effects include headaches and visual disturbances If these occur then clomifene must be stopped and an alternative treatment used The most important side effect is a 10% multiple pregnancy rate, nearly always twins, though the author has seen two sets of quadruplets following clomifene treatment It is good practice to offer ultrasound monitoring in the first cycle to recognize the development of too many dominant follicles, cycle cancellation and dose reduction in the next cycle Failure to respond at all to clomifene (‘clomifene resistance’) leads to a step increase in the clomifene dose each cycle to a maximum of 150 mg daily If still clomifene resistant even at the maximum dose then second-line treatments as discussed below are used Clomifene is licensed for a maximum of six cycles of treatment Very prolonged use (over 12 months) has been linked with a possible increase in the risk of developing ovarian cancer Metformin 162 As discussed in Chapter 20, PCOS appears to be a condition of insulin resistance Obese women with anovulatory PCOS, who reduce their weight by 5% or more, will also reduce their insulin resistance and may begin to ovulate spontaneously If not then the insulin sensitizing agent metformin can be used Metformin is taken in multiple doses every day, unlike clomifene which is only taken for days per cycle Metformin’s side effects include nausea, vomiting and other gastrointestinal disturbances It does not promote weight loss A number of RCTs have compared clomifene against metformin against combined clomifene and metformin for first-line ovulation induction in women with PCOS A recent NICE (National Institute for Health and Clinical Excellence) meta-analysis suggests similar cumulative live birth rates with the different treatments An advantage of metformin is that it promotes mono-ovulation so there’s no need for ultrasound follicular tracking In addition, metformin may normalize testosterone levels and consequently reduce hirsutism, thus having additional non-fertility benefits The need for daily multiple doses and the gastrointestinal side effects are disadvantages The main disadvantage of clomifene is the multiple pregnancy rate Hence, the options should be discussed with women to enable them to make an informed choice Women who are clomifene resistant can undergo one of the following second-line treatments: laparoscopic ovarian drilling, gonadotrophin therapy, or combined treatment with clomifene and metformin if not already used first line Success rates appear similar between the options Laparoscopic ovarian drilling (LOD) During a laparoscopy the ovaries are each ‘drilled’ using a diathermy electrical current for a few seconds in multiple places This technique has replaced the now obsolete ‘wedge-resection’ procedure An advantage of LOD is that other pathology such as endometriosis or adhesions can be diagnosed and treated during the same procedure Tubal patency can also be tested (‘lap and dye’) Also, if successful, then the resulting mono-ovulation is consequently not associated with an increased risk of multiple pregnancy or the need for ultrasound follicular tracking Furthermore, if successful, the effect can last for many years after a single procedure Disadvantages include the need for surgery and the associated risks of anesthesia and intra-abdominal organ damage There is a risk of causing the formation of peri-ovarian adhesions which could reduce fertility Rarely, premature ovarian failure has been reported secondary to the ovarian trauma It is not clear how LOD has its effect The ‘drilling’ disrupts the ovarian stroma and appears to reset the milieu allowing folliculogenesis to commence Chapter 17: Treatment of male and female infertility Gonadotrophin therapy Gonadotrophins are administered by daily subcutaneous injection and are either recombinant or urinary derived Disadvantages of gonadotrophin treatment include the need for frequent ultrasound follicular tracking and the risk of multiple pregnancy, which occurs with rates of up to 20% or more The multiple rate depends on the threshold maximum ‘safe’ follicle number set by the doctor for inducing ovulation For instance, some clinics will cancel the treatment cycle if there are four or more mature follicles, which will clearly mean there is a triplet risk if all three dominant follicles ovulate The use of ‘low-dose step-up’ gonadotrophin regimes for ovulation induction in PCOS patients results in multiple pregnancy rates of < 10% (i.e similar to clomifene) The gonadotrophins are started at a low dose of between 25 to 75iu and held at that dose for 10 days before the first ultrasound monitoring scan If a dominant follicle >10 mm diameter has developed, then the same dose is continued for a few days A further scan is arranged to confirm the presence of a preovulatory follicle, at which time an hCG trigger is given to induce ovulation followed by timed intercourse If on the initial day 10 scan there is no follicular response, then the gonadotrophin dose is increased by a small amount and the scan repeated every seven days and the dose increased until a follicular response is achieved and ovulation can be induced Meta-analysis suggests that patient satisfaction and cumulative success rates are similar between LOD and gonadotrophin therapy The ‘one-stop’ nature of LOD, the avoidance of ultrasound monitoring, daily injections and multiple pregnancy risk are clear advantages However, many women prefer to avoid surgery and to move on to more immediate treatment using gonadotrophins rather than wait and see whether ovulation results after LOD Assisted conception The third-line treatment for infertility due to PCOS is assisted conception, the standard method being IVF In summary, IVF involves gonadotrophin ovarian stimulation followed by transvaginal oocyte retrieval, in vitro oocyte fertilization and culture, and transcervical embryo transfer In long-protocol IVF, the hypothalamo-pituitary axis is suppressed by administration of a GnRH-agonist for a few weeks before commencing gonadotrophins In short-antagonist protocol IVF, a GnRH-antagonist is commenced around day to of gonadotrophin stimulation without prior suppression Live birth rates are similar between long- and short-antagonist protocol IVF for women with PCOS However, the risk of developing ovarian hyperstimulation syndrome (OHSS), the main health risk to women undergoing IVF, is significantly lower with the short-antagonist protocol If longprotocol IVF is used, then co-treatment with metformin tablets will also significantly reduce the risk of developing OHSS It is not known whether the use of metformin co-treatment during short-antagonist IVF is of additional benefit Risk factors for developing OHSS during IVF include younger age (< 33 years), previous OHSS and the presence of ovaries of polycystic morphology OHSS can be mild, moderate or severe Mild or moderate OHSS may cause ‘only’ discomfort, nausea and diarrhea However, severe OHSS is potentially, though rarely, fatal and requires hospital admission for intravenous rehydration and thromboprophylaxis, along with close monitoring of fluid balance and blood haematology, clotting and biochemistry factors The rate of severe OHSS is about 1% of all IVF cycles Women with PCOS undergoing long-protocol IVF have a severe OHSS rate of 2–10%; this is reduced to 1–3% with the use of metformin co-treatment or by using a short-antagonist protocol A number of other strategies are also available to reduce the risk of developing OHSS and are reviewed elsewhere The only way of absolutely avoiding the risk of developing OHSS is to not stimulate the ovaries Oocyte in vitro maturation (IVM) involves the transvaginal aspiration of immature oocytes from unstimulated ovaries, followed by their in vitro maturation and fertilization Embryos are then cultured in vitro and transferred trans-cervically IVM is fully reviewed in another chapter IVM is most successful for younger women with ovaries of polycystic morphology (i.e two of the main risk factors for OHSS) While clearly there is zero risk of developing OHSS in a woman undergoing IVM, and the treatment is very ‘easy’ and acceptable from a patient perspective, the success rate is currently significantly less than IVF, which limits its desirability WHO Group III Ovulation disorders (ovarian failure) Anovulation due to ovarian failure is detected by high levels of FSH, or low levels of AMH or a low AFC The 163 Section 2: Infertility woman may have a family history of premature ovarian failure, a personal history of chemo-radiotherapy or removal of ovarian tissue, for example while removing endometriotic cysts, or have a genetic disorder such as Turner syndrome There are no drugs that can be given to boost fertility in cases of ovarian failure The treatment is oocyte donation or moving on from fertility treatments to other options such as adoption or accepting childlessness Potential recipients of donor oocytes are offered counselling regarding the physical and psychological implications of treatment for themselves and their potential children In the UK, children born from gamete (oocyte and sperm) or embryo donation are able to trace the donor from the age of 18 years Oocyte donors are screened for both infectious and genetic diseases and undergo a full stimulated IVF cycle Their oocytes are collected and fertilized in vitro with the recipient’s partner’s sperm The recipient’s endometrium is prepared with exogenous oestrogen and progesterone in coordination with the donor’s cycle and embryo transfer then takes place The success rate is related to the age of the donor This must be taken into account when deciding how many embryos to transfer Pregnancy rates of around 50% per cycle are common WHO Group IV (hyperprolactinaemia) Women with ovulatory disorders due to hyperprolactinaemia should be offered treatment with a dopamine agonist such as bromocriptine under the care of an endocrinologist hydrosalpinx is present Even if tubal patency results, the patient must be warned that the blockage may recur and that, if she conceives, she is at significantly increased risk of developing a tubal ectopic pregnancy Early ultrasound in pregnancy is required to confirm an intrauterine position If the disease is more severe or involves the whole tube, then surgery is unlikely to be of benefit IVF was developed as a treatment for tubal disease and remains the most successful form of therapy The presence of an ultrasound-visible hydrosalpinx is associated with a halving of the IVF success rate due to leakage of the fluid into the uterine cavity Removal of the affected tube(s) restores the IVF success rate to what it would have been if there were no hydrosalpinx (Figure 17.1) Some women with a hydrosalpinx note a watery brown vaginal loss off and on throughout the menstrual cycle Ultrasound can often demonstrate the fluid within the endometrial cavity The hydrosalpinx fluid contains embryo-toxic substances There is also the purely mechanical effect of the fluid flushing the embryo Some women may, however, be resistant to the suggestion, particularly with bilateral hydrosalpinges, that their fallopian tubes are removed, leaving them permanently sterile If there are extensive adhesions in the pelvis, then removal of the tubes can be difficult, so sometimes a clip is applied laparoscopically at the cornu, where the tube enters the uterus, to prevent fluid leakage into the endometrial cavity A newer hysteroscopic technique involves insertion, via the uterine cavity, of an implant through the tubal ostia into the proximal part of the tube (‘Essure’) The product was developed as a form of contraception and is unlicensed for this indication Tubal and uterine disease Tubal damage 164 Hysterosalpingogram, HyCoSy or laparoscopy may demonstrate the presence of tubal disease If one fallopian tube is patent then the cumulative chance of conception is satisfactory and no particular treatment is required If both tubes are blocked then treatment options depend on the position of the block (proximal vs distal) and severity of the disease Mild distal (at the fimbrial end) tubal disease can be treated by laparoscopic fimbrioplasty in which the blocked (‘clubbed’) tubal ends are surgically opened and ‘flowered-back’ There is little role for this if the rest of the tube is damaged, particularly if a Figure 17.1 Laparoscopic view of bilateral hydrosalpinges Chapter 17: Treatment of male and female infertility Treatments such as ovulation induction or IUI are inappropriate for women with tubal disease Intrauterine adhesions An uncommon cause of amenorrhea is extensive intrauterine adhesions (‘Asherman’s syndrome’) usually due to endometrial curettage for a miscarriage or retained placental tissue after delivery The basal endometrial layer is damaged to the extent that proliferation and endometrial thickening does not occur and so neither does menstruation, despite there being ovulatory cycles Sometimes less extensive intrauterine adhesions are found in women who are menstruating but who have fertility or recurrent miscarriage problems The presence of intrauterine adhesions can be suspected on ultrasound scan but is confirmed on HSG or hysteroscopy Hysteroscopic resection of the adhesions is undertaken and an intrauterine coil left in place for a month to try to reduce adhesion reformation Often, since the basal endometrial layer is damaged, the result is relatively poor Under these circumstances surrogacy may be required Fibroids (leiomyomas) Fibroids which are distorting the endometrial cavity may be removed, a procedure called myomectomy The method of removal depends on the site and size of the fibroid(s) Fibroids within the endometrial cavity are removed using a hysteroscope inserted through the cervix under general anaesthesia (Transcervical Resection of Fibroid, TCRF) The cavity is irrigated with glycine and electrical current passed through a semi-circular loop which is used to cut away the fibroid in strips for removal through the cervix The same method is used for sub-mucosal fibroids of up to cm diameter Risks of TCRF include perforation of the uterine wall and intrauterine adhesion formation Larger fibroids distorting the endometrial cavity are removed abdominally, preferably by laparoscopy rather than open surgery Risks of myomectomy, by any route, also include bleeding requiring blood transfusion or further surgery, and rarely, to save a life, hysterectomy While it is generally accepted that myomectomy is appropriate for fibroids distorting the endometrial cavity, the situation for intramural fibroids that are not distorting the cavity is not so clear It is accepted that such fibroids reduce the implantation rate; however, whether removal of the fibroids improves the rate is not known since sufficiently powered RCTs have not been undertaken Certainly if the woman has symptoms attributable to her fibroids, such as heavy menstrual bleeding or bladder-bowel pressure symptoms, then surgery is probably indicated Endometriosis Laparoscopic removal of minimal to mild endometriosis is associated with a statistically significant increase in the rate of natural conception and so should be offered The endometriosis is removed by cutting away using scissors or laser, or is ablated using electric diathermy Laparoscopic removal of endometriotic ovarian cysts (cystectomy) is associated with an increase in the subsequent rate of natural conception There are two methods of treating cysts The first step is to open and drain away the ‘chocolate’ cyst fluid within the cyst The wall can then either be stripped away or an attempt made to ablate it Stripping has the advantage of allowing the tissue to be sent for histopathological analysis Occasionally cysts thought to be endometriotic are found to be malignant or borderline in character Stripping of the cyst wall is also associated with a higher natural cumulative conception rate and a lower chance of cyst recurrence However, cystectomy can cause further damage to the ovary, which may reduce the response to ovarian stimulation during IVF It is unclear whether endometriomas should be removed prior to IVF No sufficiently powered RCTs have been undertaken Cystectomy does not improve the ovarian response to stimulation (and, if the ovary is further damaged, may have the opposite effect) (Figs 17.2 and 17.3) It may improve ovarian accessibility for transvaginal oocyte recovery Certainly during oocyte recovery it is important to avoid passing the needle into an endometrioma, as this can lead to pelvic infection and possible ovarian abscess formation Surgery may be required to treat a pelvic abscess and the ovary may be permanently damaged If an endometrioma is entered during oocyte recovery, intravenous antibiotics are given Women with moderate to severe endometriosis may benefit from surgical removal of disease and adhesions to improve their fertility and/or pain symptoms, though no randomized studies have been undertaken to test this hypothesis However, very often the most appropriate treatment is IVF Prolonged GnRH-analogue down-regulation for two 165 Section 2: Infertility transferred into a ‘host surrogate’ If the woman does not have functioning ovaries then her partner’s sperm can be used to inseminate the surrogate, known as ‘straight surrogacy’ Clearly there are a number of legal and ethical issues surrounding surrogacy, though it is a successful (and only) form of treatment for many couples Unexplained infertility Figure 17.2 Laparoscopic view of a cyst within the right ovary Figure 17.3 The cyst has been stripped from the right ovary or three months before long-protocol IVF in women with severe endometriosis has been shown to improve the live birth rate, possibly through improving endometrial receptivity Whether or not the same outcome can be achieved by using prolonged oral contraceptive pill pretreatment is not currently known Absent or severely abnormal uterus 166 Women may have an absent uterus due to a congenital abnormality such as Rokitansky syndrome or following hysterectomy for malignancy The uterus may be severely abnormal due to extensive fibroids or endometrial abnormalities such as Asherman’s syndrome If the woman’s ovaries are still functioning then she can undergo a stimulated IVF cycle, produce embryos with her partner’s sperm and have the embryos For couples with unexplained infertility there is no place for ovarian stimulation treatment using oral drugs such as clomifene citrate, or the lesser used drugs tamoxifen, anastrozole or letrozole Patients, and doctors, often presume that the boost clomifene gives to ovulation, potentially resulting in multiple ovulation, will increase the chance of conception in women who are already ovulating spontaneously A number of studies have shown this not to be the case The explanation may be that the anti-estrogenic effects of clomifene have deleterious effects at the endometrium Expectant management for a period of time may be appropriate This involves giving advice on lifestyle factors, as initially described in this chapter, and excluding pathology that would require immediate recourse to fertility treatment It is helpful to agree on a time frame with the couple, for instance to continue trying naturally for another six months before review and potentially moving on to active treatment It is also helpful for the couple to have access to the fertility clinic nurse, counsellor or dietician for consultations Expectant management is often also appropriate for couples with a diagnosis of minimal-mild endometriosis or mild male factor when there continues to be a reasonable monthly chance of conception for infertility durations of up to or years Expectant management may be the only option for couples who cannot afford IVF or where the woman’s ovarian reserve is so diminished (despite still ovulating regularly) that IVF is not possible Intrauterine insemination (IUI) has been used as a treatment for unexplained fertility for many years There is no evidence that unstimulated (i.e during a natural menstrual cycle) IUI results in a higher conception rate compared to no treatment IUI is consequently often combined with ovarian stimulation using clomifene or gonadotrophins While this approach is associated with a higher success rate, it also comes with an increased risk of multiple pregnancy The clinical Chapter 17: Treatment of male and female infertility pregnancy rate will be increased with more aggressive stimulation regimes, for instance a higher gonadotrophin dose, or allowing women with many mature follicles to undergo the IUI procedure rather than cancel the cycle In UK practice, triplets are viewed as a major complication and so clinics often cancel the IUI cycle if there are more than two mature follicles This will accordingly limit the IUI success rate The IUI success rate per cycle is generally in single figures and the need for patent fallopian tubes, and sufficient sperm, limits its applicability to those who have a chance of natural conception anyway Many couples are better off moving on to IVF, which has a significantly higher success rate with the benefit of having control over the rate of multiple pregnancy, particularly when elective single embryo transfer is used IVF is the most successful treatment for couples with unexplained infertility Importantly, the success rate is not generally related to the duration of infertility, unlike IUI where couples with more than three years of infertility have a very low pregnancy rate Consequently, the longer the duration of unexplained infertility, the greater the difference in success rates between IUI and IVF and more appropriate IVF becomes Advanced maternal age As women age, the chance of conception, whether natural or with fertility treatment, reduces To an extent this can be overcome during IVF treatment by replacing greater numbers of embryos Currently, in the UK, the HFEA permit a maximum of two embryos to be replaced in women under the age of 40, but three in women older than this Clearly this carries a risk of triplet pregnancy, though the absolute risk is very low for women approaching their mid-forties IVF has a success rate in very low single figures for women aged 44–45 years and, for this group and beyond, oocyte donation may be indicated Preimplantation genetic screening (PGS) during IVF has been suggested as a method of attempting to overcome the increased rate of oocyte aneuploidy, which is the cause of the lower success rate in older women However, many older women produce insufficient embryos of suitable quality for biopsy and genetic analysis There is controversy over the extent to which PGS is of benefit in increasing the live birth rate per cycle started (rather than per embryo transfer) when advanced maternal age is the indication Male infertility The most appropriate treatment depends on the degree of semen abnormality and cause, and also the situation with the female partner, for example her age, ovulatory and tubal status For men with azoospermia the treatment will depend on the cause For primary testicular failure (raised serum FSH and low testicular volume), surgical sperm retrieval (SSR) is associated with a 30–50% chance of retrieving sperm There is an inverse correlation between the FSH level and the likelihood of retrieving sperm with percutaneous needle biopsy The sperm is usually cryopreserved and used during a subsequent IVF-ICSI cycle, or the SSR can be performed on the day of oocyte collection and used fresh for ICSI However, this approach risks not having sperm available for insemination and either needing to use donor sperm, or freezing or discarding the uninseminated oocytes For men with normal FSH levels and testicular volumes (obstructive azoospermia) the likelihood of retrieving sperm on SSR is 75–95% It is possible that such men have an epididymal block that is potentially reversible with surgery Referral to a urologist is required for contrast studies, though very often the site of the obstruction is not found or cannot be repaired The exception is men who have had a vasectomy The success rate of vasectomy reversal is related to the length of time since the vasectomy was performed Successful reanastomosis is less likely beyond seven years Antisperm antibodies may be present in the ejaculate following reversal which may affect the chance of natural conception Many men will opt to move straight to SSR followed by IVF-ICSI rather than attempt vasectomy reversal If the man has diabetes, a neurological condition or has had prostate surgery, then it is possible he has retrograde ejaculation A post-ejaculation urine sample is examined for the presence of sperm Some men with a neurological condition, such as paraplegia, may have erectile failure which responds to electro-ejaculation Alternatively they may undergo SSR Other men with erectile failure may respond to a drug such as Viagra Men with low levels of FSH and a diagnosis of hypogonadotrophic hypogonadism, possibly due to Kallman’s syndrome, are offered induction of spermatogenesis using gonadotrophins Different regimes exist, though most utilize two or three subcutaneous injections each week of hCG and FSH The response 167 Section 2: Infertility rate is high, though this can take many months and may not be complete Donor sperm treatment is used by many couples with an infertility diagnosis of azoospermia This may be because sperm is not found on SSR or the couple does not want to, or cannot (for instance for financial or female factor reasons) undergo the procedure followed by the required IVF-ICSI Furthermore, men with a translocation or other genetic cause of their male factor infertility may prefer to use donor sperm rather than consider preimplantation genetic diagnosis during IVF Donor sperm can be used for intrauterine insemination or during IVF Men with mild male factor and a partner with patent fallopian tubes can consider IUI, though success rates are limited just as they are for couples with unexplained infertility At least million motile sperm per ml are needed after sperm washing IVF may be more appropriate and cost-effective As the severity of male factor increases, IVF is indicated along with ICSI as the severity worsens further There continues to be debate over the benefits of zinc, vitamins and other supplements to improve male fertility Some studies suggest improved semen quality and/or reduced DNA fragmentation Furthermore, a recent Cochrane review has suggested improved live birth rates in the partners of men taking anti-oxidants However, the optimal dose and duration of antioxidants is unclear Further study is warranted there is tubal damage, then IVF using donor sperm is indicated Single women or same-sex female couples Management of Infertility for the MRCOG and Beyond, 3d edn, edited by S Bhattacharya and M Hamilton (London: RCOG Press, 2012) Single women or lesbian couples may be referred to the fertility clinic for treatment A full fertility history, as described in the previous chapter, is taken to try to determine underlying pathology which may affect the success of donor sperm treatment If tubal disease is thought to be unlikely, then donor insemination treatment is commenced The pregnancy rates are < 15% per cycle depending on female age Ovarian stimulation is used if there is ovulatory dysfunction If pregnancy does not result after three treatment cycles, or if tubal or pelvic abnormality is thought possible, then an HSG or laparoscopy and dye is performed Up to six donor insemination cycles are appropriate, though the majority of successes occur during cycles one to three If insemination treatment is unsuccessful, or if 168 Conclusion Completion of appropriate and timely investigations allows the physician to discuss and offer suitable fertility treatments with the couple These may range from expectant management up to IVF-ICSI with PGD It is vital to be realistic with the chance of success and to explain the risks and any financial costs of treatment to allow the couple to make an informed decision Further reading Current Management of Polycystic Ovary Syndrome, edited by A Balen, S Franks, R Homburg and S Kehoe (London: RCOG Press, 2010) D De Ziegler, B Borghese and C Chapron Endometriosis and infertility: pathophysiology and management Lancet 376 (2010): 730–8 R Homburg and C M Howles Low-dose FSH therapy for anovulatory infertility associated with polycystic ovary syndrome: rationale, results, reflections and refinements Hum Reprod Update (1999): 493–9 T Z Jacobson, J M Duffy, D Barlow, C Farquhar, P R Konickx and D Olive Laparoscopic surgery for subfertility associated with endometriosis Cochrane Database Syst Rev (2010): CD001398 National Institute for Health and Clinical Excellence Assessment and Treatment for People with Fertility Problems Clinical Guidelines, 2012 http://www.NICE org.uk J Pundir, S K Sunkara, T El-Toukhy and Y Khalaf Metaanalysis of GnRH-antagonist protocols: they reduce the risk of OHSS in PCOS? Reprod Biomed Online 24 (2012): 6–22 A Swanton, A Itani, E McVeigh and T Child Azoospermia: is sample centrifugation indicated? A national survey of practice and the Oxford experience Fertil Steril 88 (2007): 374–8 The Subfertility Handbook: AClinician’s Guide, 2d edn, edited by G Kovacs (Cambridge: Cambridge University Press, 2011) Chapter 18 Social aspects of using reproductive technology Renate Barber and Alison Shaw Social aspects of fertility and infertility The milestones of marriage, parenthood and grandparenthood are taken for granted during a normal life span in most human societies Couples are expected to have children and grandparents expect to have grandchildren It is often a personal and social tragedy if, after some years of marriage, there are no offspring; childlessness may detract from a person’s self-respect and social standing, besides inviting questions from other members of the family and community Moreover, these questions are very often aimed at the woman more than at the man Although infertility, as one of the main reasons for a lack of children, is understood by the medical profession to arise from either the man or the woman, in many societies the woman was, and continues to be, blamed for a couple’s childlessness In fact, in predominantly male-oriented societies the very concept of male infertility has often been totally alien and the phenomenon may still scarcely be recognized, with the blame for childlessness tending to be laid at the woman’s door In societies that permit a man to have more than one wife, it is relatively easy for a woman to observe that her husband does not have children with his other wives either, but the responsibility for childlessness would never be attached to the husband; a wife in this situation might clandestinely contrive to get pregnant by another man (such as a relative) It is only modern investigative technologies including that of the sperm count that have enabled the onus of some infertility cases to be placed firmly on the male Concern about fertility is universal and ancient It is reflected in rituals that in many societies originally centred on the agricultural year and are concerned with producing good yields and fertile earth and fauna [1] Pagan and Christian rituals, for example, include Easter, which marks the start of sowing and growing of crops, autumn harvest festivals to give thanks for the crops and Christmas, the winter solstice, to mark the ending of the dark season Almost universally in human history, human fertility has been desired and valued, while barrenness has been feared and disapproved, for powerful socioeconomic and cultural reasons In subsistence societies, children are valuable economically, by providing labour power Among some African cattle herders, for example, there is a delicate balance between the size of the herds and the size of the families, because there must be enough people to look after the animals, but there can only be a limited number of people who can live off the herd In societies lacking systems of social security and insurance for old age and sickness, children are also the only guarantee that the elderly will be taken care of Where there is high infant mortality, it is thus good policy to have many children to ensure that some will survive into adulthood Children also represent perhaps the only visible means of continuity in many traditional societies, by perpetuating a line of inheritance and by enabling property to be inherited by descendants Societies vary worldwide in whether they are patriarchal (investing power and authority in males), matriarchal or allow both males and females to hold positions of power and influence They also vary as to whether they calculate inheritance patrilineally (in the male line), matrilineally (in the female line) or along both lines of descent (bilaterally) However, a majority of societies worldwide are or tend to be patriarchal and patrilineal In such societies, having sons is especially important For example, in certain forms of male ancestor Textbook of Clinical Embryology, ed Kevin Coward and Dagan Wells Published by Cambridge University Press © Cambridge University Press 2013 169 Section 2: Infertility 170 worship, only men may officiate at the rituals and the rituals themselves must be performed by the man’s sons As a result, there is often considerable pressure not just to have children but to have sons rather than daughters The social pressure on a couple, and usually particularly on a woman, to have children is particularly acute in societies in which reproduction is understood to be a female domain and where a traditional division of labour by gender provides the central principles around which family life and the wider society is organized If, after a few years of marriage or even sooner, a new wife does not become pregnant, she may be vulnerable socially and emotionally, for she is failing to fulfil her expected role as a wife and mother Moreover, her childlessness may provide grounds for divorce or for the husband to take a second wife, or for the husband’s relatives to insist that he takes a second wife In many other parts of the world today, including at least until recently in the West, the structure of society and the subordinate position of women within it has been derived to a large extent from the fact that women bore and reared children Indeed, some feminist scholars have argued that men were envious of women’s creative power as well as in awe of it, and thus branded women of childbearing age as impure and polluting, particularly during menstruation This distinction may be marked by rituals of gender separation and isolation, and in consequence of this women have been barred from sacred offices such as the priesthood and other positions of power and authority [2] The relegation of women to the domestic sphere, which is congruent with the exclusion of ritual impurity brought on by menstruation and childbirth (most Christian churches still ‘church’ a woman six weeks after childbirth), was largely responsible for the low position of women in many societies and for their general disempowerment This is underlined by the fact that older, postmenopausal women tended to enter public life to a greater degree, could become highly influential and, in some situations, could adopt socially male roles Mothers of important men are admired, though their status really derives from that of their sons The very fact of being the bearer of sons and heirs gave women of reproductive age and capacity a certain position of power, in that their noncooperation would be a serious threat to a man, but the corollary of this is that women who failed in the childbearing role were at a serious disadvantage and subject to stigma and abuse The preoccupation with virginity, which has been and often still is so pronounced in the Judeo/ Christian/Muslim world, is due to the need within patriarchal and patrilineal societies to be quite sure that the begetter of children is the mother’s husband Hence women must be under the guardianship of their fathers, brothers, husbands or sons With a sedentary lifestyle and ownership of property, it became vital that heirs should be of the blood line, and so women had to be closely guarded, their sexuality controlled The danger of a woman bearing a child conceived from outside the lineage drops away with the menopause and cessation of childbearing In these societies, women who not fulfil their biological roles by being barren, or by only having daughters and no sons, are permanently disadvantaged and discriminated against – throughout their lives – unless their childlessness is part of an allotted role such as that of vestal virgin, sworn virgin or nun The status of a young woman may remain negligible, but the role of ‘mother’ is honoured Young as well as older mothers have status by virtue of having given birth, and there is ambiguity as to whether childless women, even those in important positions, are not held in lower esteem than women who are mothers (or mothers as well as having a profession) Under certain circumstances, mothers of many children enjoy greater veneration than young starlets may garner, for example In the Soviet Union, for instance, ‘heroines of the soviet union’ were mothers of 12 or more children Moreover, in patrilineal societies, brides are strangers in their husband’s kin group and they will only become full members of their marital family when they have borne children, and thereby become well known and respected for their knowledge and experience Techniques and technologies enabling the separation of sexual activity from procreation have had very far-reaching consequences for women’s roles which are still working themselves through in the modern world By being able to control family size, women may choose to relegate childbearing to a relatively brief span in the life cycle In principle this means that age is no longer a defining factor in role allocation and that motherhood ceases to be a way of life but becomes instead a stage in life Indeed, gender roles in the modern world are less rigidly determined by such facts as ascribed sex at birth, which no longer must dictate whether we are men or women, mothers or fathers or even whether we must marry people of opposite gender In relation to women’s roles, the Section 4: ART: skills, techniques and present status that of the unborn baby, although legally the mother’s well-being takes priority over that of the embryo / fetus The ethical considerations become more equal once the baby has been born, and so when one is considering the ethical implications for novel treatments for infertility, the beneficence of the child that is ultimately born as a result of these must be brought into the equation To give an extreme example, if a new treatment enables a mother to conceive and have a longed-for baby, but that treatment inherently causes the baby to live for only a couple of years due to some inevitable genetic alteration, the beneficence of the child would outweigh the beneficence of the mother (beneficence to conceive) when this treatment is being considered ethically constraints of the NHS are also increasingly stretching the ability to deliver these original ideals There is often now clear variation in treatment availability in different parts of the country, with those areas of social deprivation often most affected The whole premise for ‘justice’ and ‘fairness’ is that people are of equal worth and have equal rights Clearly with a limited healthcare budget, priorities of healthcare spending are inevitable However, these should be based on patient need, rather than patient status, and the same rationalization of treatments should be available to all When offering the range of fertility treatments, clinical embryologists must ensure that justice and fairness are maintained Confidentiality Truth and integrity Confidentiality is perhaps the most familiar of all the ethical duties in medicine Indeed, the doctor-patient relationship is centred on trust Unfortunately, confidentiality is often breached inadvertently Classic examples of this are when medical staff speak to the relatives of a patient without that patient’s prior permission, or when medical staff discuss details of a patient’s conditions in hospital corridors or other public areas of the hospital It must be remembered that for a patient with mental capacity, any medical practitioner should seek the permission of the patient before discussing confidential aspects of treatment with the patient’s relatives, or with healthcare professionals not directly involved in that patient’s care Although children are of a different legal status, those dealing with paediatric patients should still respect the confidentiality of the child and their family This includes restricting access of patient records to those directly treating the patient Confidentiality is of paramount importance in the field of assisted fertilization, and not only involves the couple being treated, but also the confidentiality of sperm or egg donors if they are involved Truth and integrity are central to the relationship between a healthcare worker and the patient, and the basis for the patient’s trust However, not very long ago it was common practice for some doctors to routinely alter histology reports to ensure that the patient was given a more favourable diagnosis! Interestingly, the driving force for such actions was to protect the patient and it was thought to be ‘in the patient’s best interests’ Patients, however, have the right to know the truth about their illness, and such behaviour would nowadays correctly result in major sanctions for a doctor in most countries Healthcare workers need to be truthful about prognosis, and about the true benefits / outcomes of any given treatment ‘Truth’ and ‘integrity’ also need to be paramount in the field of surgical research or the development / testing of novel treatments, where ‘conflicts of interest’ abound, and the temptation to exaggerate the benefits of a new treatment all too common Justice and fairness 378 In the UK, we often take it for granted that an integral part of the Beveridge Report that formed the blueprint for the National Health Service (NHS) was that there should be ‘a health service providing full preventive and curative treatment of every kind to every citizen without exceptions’ Sadly this is not the case in all countries around the world, and the financial Ethical decisions in practice One of the important things to appreciate with medical ethical decision-making is that in most difficult ethical situations, the ethical principles described above are competing with each other rather than existing in isolation Integral to any ethical decision, therefore, is the important step of deciding precisely which ethical principles are involved, and then to determine which principles take priority over the others For example, in clinical embryology, the autonomy of the mother, the autonomy of the father, the autonomy of the unborn child, and the autonomy of the doctor may Chapter 36: Ethical considerations for clinical embryology all need to be considered Clearly, in treatments where multiple embryos are produced, but only small numbers implanted, the ethical principles of autonomy and beneficence may be distinctly different and competing for the mother and the non-implanted embryo Treatments that are unduly expensive for the healthcare providers may involve difficult ethical considerations of the autonomy of the couple wanting a baby, versus the justice for patients with other conditions also needing to be treated from the same limited budget The examples of conflicting ethical principles are numerous It is therefore vital that a clear ethical pathway is formed in order to address a particular ethical scenario and come to an ethical decision The pathway includes the following important questions: Can the competition be resolved by changing the method or technique of the treatment? What value system undergirds the ethics? Those considering the ethical problem need to evaluate whether the proposed treatment (or clinical study) will result in predictable side effects or long-term consequences that can be predicted, and to determine whether these are acceptable or not We have already seen that different value systems influence ethical decisions There must be clarity from the outset, therefore, as to what value systems are being followed by each individual involved in the decision-making process Is the overall aim of the treatment being considered ethical? Usually this is clear, but sometimes a particular therapy may in itself be unethical from the outset Are there any myths or misunderstandings? This enables the precise issues involved to be clearly defined, and ensures that all parties involved are in agreement as to what the issues are Who and what are involved? Many ethical problems involve many different groups of people As with the myths and misunderstandings, these need to be clearly defined from the outset In the field of assisted conception, an example would be to restrict IVF and embryo transfer to one embryo, in which the ethical dilemma of storage and disposal of multiple embryos ceases to be an issue Often, however, it is not possible to modify the treatment Should one ethical principle take priority? Occasionally it is clear that one ethical principle takes absolute priority over the others However, frequently we are dealing with relative priorities, or the situation of ‘lesser of two evils’ What are the likely long-term consequences that an ethical decision will have? Is there already professional guidance about this ethical problem? In the field of clinical embryology, the Human Fertilisation and Embryology Authority (HFEA) has produced clear guidance on different aspects of treatment Is there already legal guidance about this ethical problem? As outlined in the section above on ‘Ethics and law’, sometimes clear legal rulings / guidelines exist for a particular ethical problem Does this ethical problem need to be referred to a research or clinical ethics committee? All the ethical principles that are involved with the particular ethical problem need to be identified so that they can be included in the ethical evaluation Often more principles are involved in a particular ethical situation than initially thought All clinical research projects involving human subjects need to be submitted to an ethics committee for approval before the study can be conducted Also, nowadays, all new operations or procedures being introduced to a particular hospital (even if that procedure is being performed elsewhere) need to be evaluated by that hospital’s committee responsible for ‘New Treatments and Innovations’ Are any of these in competition with each other? Will a particular decision start a precedent? As outlined above, they frequently are, and identifying this clearly is central to any ethical decision Any ethical decision has the potential to provide a precedent for future ethical problems This needs to Which ethical principles are involved? 379 Section 4: ART: skills, techniques and present status 380 be taken into account when any new decision is being made, and all decisions need to be taken responsibly to remember at all times that the patient is at the centre of the ethical decision-making process Is the rest of the healthcare team in agreement with the ethical decision? Conclusions Clearly there are times when different members of the multidisciplinary healthcare team (or the patients themselves) come to different conclusions when considering an ethical dilemma However, in order to be able to implement an ethical decision for a particular clinical scenario, consensus has to be reached ‘Opt out’ or ‘conscience clauses’ exist for healthcare workers who feel that their personal beliefs not permit them to participate in particular treatments While the tendency is for these to be eroded, it is imperative that these clauses be maintained, so that the autonomy and values of healthcare workers are respected The field of clinical embryology requires all who are involved in it to be able to think and practice ethically The field is changing rapidly, and ethical frameworks are becoming challenged with ethical dilemmas of ever-increasing complexity The aim of this chapter has been to provide the background, framework and basic principles of how to address specific ethical dilemmas, and to outline how an ethical decision can be made in clinical practice The reader is now encouraged to study the ethical aspects of specific treatments in more detail For further discussion regarding the ethical and legal implications of ART, please refer to Chapter 20 Once the decision has been reached, has this been communicated to the patient? Further reading Surprisingly this important aspect is frequently delayed and sometimes even forgotten It is important A G Johnson and P R V Johnson Making sense of medical ethics – a hands on guide (London: Hodder Arnold, 2007) Index abortion legal status 136–8 spontaneous see miscarriage unsafe 136–8 acid Tyrode’s, zona drilling 287, 288 acrosome 99 acrosome reaction (AR) 93, 98–100 activins 61 ADAM proteins 100 adrenal cortex, steroid hormones 65–6 disorders of synthesis 66 regulation of synthesis 66, 68 adrenocorticotropic hormone (ACTH) 66 adverse incidents, reporting 195 age, advanced female fertility decline 54, 153, 154 infertility treatment 167 agouti-related peptide 60 air quality, laboratory 207–8, 275–6 air-cushion pipettes 223–4, 225 albumin culture media 282, 306 intravenous infusions 257 alcohol consumption 161, 240 aldosterone 66 allantois 117 allele drop-out (ADO) 351–2 altricial offspring 5–6 amenorrhoea 73–5 causes 73–4 medical treatment 74–5 modified WHO classification 73 outflow tract defects 74, 75 physiological 73 primary 73 secondary 73 amnion 112 amniotic cavity 112 androgen receptors (AR) 25, 45 androgens 67, 75 see also testosterone androstenedione 75 aneuploidies frequency and impact 357 IVF embryos 292, 293 PGD 349 PGS 357–62 Angelman syndrome (AS) 271 angiopoietins 43–4 Angler fish 3–4 anovulation see ovulatory disorders antibodies placental transport 85 production in pregnancy 85 anti-Müllerian hormone (AMH) 10, 49, 337 antioxidant supplements 168 antisperm antibodies (ASA) 155, 159, 243–4 anti-tumour necrosis factor-α (TNF-α) antibodies 86–7 aortic arches, embryonic 124, 125–6 apical ectodermal ridge (AER) 119, 120 Aristotle 178–9 ARP protein 100 array-CGH see microarray comparative genomic hybridization arterial system, development 124, 125–6 artificial insemination by donor see donor sperm treatment Asherman’s syndrome 165, 345 aspermia 245 asthenozoospermia 245 atrial septal defects 126 atrial septum, development 124, 125 atrio-ventricular valves 125 audits 204–5 autonomy 377, 378–9 azoospermia 245 investigations 159 obstructive 154–5, 167, 263 treatment 167, 168, 263 Baer, Karl Ernst von 180, 182 Barr body 112 basal body temperature (BTP, BBT) 145, 156–7 Beckwith-Wiedemann syndrome (BWS) 271 beneficence 377–8 biliary system, development 128 birth defects, ICSI offspring 271 blastocyst 111, 112 cryopreservation 330–1, 332 implantation 112–14 marsupial morphological assessment 321–2, 324 PGD 347–8 trophectoderm biopsy 293–7 blastomeres 111–12 biopsy 291–3 multinucleation 292, 320–1, 322 unequally sized 319 Blood, Diane 214 blood borne viruses (BBV) 222 blood islands 114, 123 blood vessels, development 114, 123, 124, 125–6 body mass index (BMI), female 161 bone morphogenetic proteins (BMPs) 34 bones, development 119 Bonnet, Charles 181 Bourn Hall Clinic, Cambridge 188 Boveri, Theodor 182, 183 brain, development 121, 122 branchial arches 125–6 breast cancer 148, 257–8 brightfield illumination 232 Brinster, Ralph 186, 187 Brown, Louise 187–8, 210 bulbourethral glands 21 cabergoline 257 calcium (Ca2+) activation by PLCζ 103–4 egg activation 101–3 calcium (Ca2+) conduit model, egg activation 102 campomelic dysplasia (CD) 13 cancer fertility preservation 257–8, 263, 307, 332 predisposition syndromes, PGD 353 capacitation, sperm 92–3, 98–100 caps, contraceptive 146–7 caput epididymidis 89 cardiovascular disease 77, 148 cardiovascular system congenital defects 126 development 123–6 Care Quality Commission 213, 216 cartilage, development 119 β-catenin (Ctnnb1) 14, 16 CD9 protein 100 cell theories 181–4 cell-mediated immunity, in pregnancy 85–6 central nervous system (CNS), development 121, 122 381 Index 382 centrifuge techniques 221–2 centriole 183 Cerazette 149 cervical cancer 31, 148 cervical mucus 31 peri-ovulatory changes 145, 157 sperm passage through 92 cervix 31 sperm filtration system 92 cetrorelix 253, 255 Chang, M C 182, 185–6 chemotherapy 258, 263, 307 children IVM, outcomes 307–8 right to have 198–9 social aspects 169–70 welfare considerations 194–5, 199 cholesterol 24–5, 44, 65, 66, 67, 319 chorionic cavity 113, 114 chorionic villi 79–80, 114 chromosome abnormalities arising during female meiosis 54–5 ICSI safety 270–1 IVF embryos 292, 293 morphological features 317, 319 see also aneuploidies chromosome model of inheritance (Boveri–Sutton) 183 chromosome rearrangements, PGD 348–9 chromosomes, history of discovery 183 circulation, changes at birth 126 citrate synthase 103 cleavage divisions 111–12 rate and timing alterations 317–19 cleavage-stage embryo biopsy 291–3 cryopreservation 328–9, 332 morphological assessment 317–21, 322–3 PGD 347 cleft lip 123 climacteric 75 clinics see fertility clinics/centres cloaca 128 cloacal membrane 115, 130 clomifene citrate 162, 166, 251–2 cloning, therapeutic 369–70 clothing, protective 221, 350 coelom, intraembryonic 116 coelomic vessel 12 coercion 198 coitus interruptus 146 colloids 229–30 colorectal cancer 148 combined oral contraceptive (COC) 147–8 benefits 147 emergency (COEC) 150 polycystic ovary syndrome 256, 257 risks 147–8 communication 201–2, 219–20 compaction, early embryo 112, 321 comparative genomic hybridization (CGH) 289 conception rates 152, 153 condoms female 146 male 141, 146 confidentiality, patient 143, 201, 378 congenital adrenal hyperplasia (CAH) 66 congenital bilateral absence of vas deferens (CBAVD) 271 congenital heart defects 126 connexins 34 conotruncal ridges 124, 125 consanguinity 173 consent 194, 213–15, 377 consequentialism 198, 376 constitutional delay of growth and puberty 70 consumables, embryo viability and 280 contraception 143–51 barriers to access 138 fertility awareness methods 145–6 girls under 16 years 143, 377 post-coital 150 strategies for improving access 138–9 unmet needs 135–6 See also family planning contraceptive methods effectiveness/failure rates 144 eligibility criteria 144 features of ideal 143 hormonal 147–9 injectables and implants 149 intrauterine 149–50 male 105–6, 146 vaginal 146–7 cornual polyps 340 coronary heart disease (CHD) 77 corpora cavernosa 21 corpus albicans 30 corpus epididymidis 89 corpus luteum (CL) 30, 43–4 corpus spongiosum 21 cortical reaction 100 corticosteroid-binding globulin (CBG) 68 corticotropin-releasing hormone (CRH) 60 cortisol 66, 68 CRISP proteins 100 cryo-machine 328 cryopreservation 327–35 embryo 190, 328–9, 330–2 frozen embryo replacement 334 history 185, 190 oocyte 332–3 safety 335 slow freezing 328–9 sperm 185, 333–4 techniques 327–31 theory 327 See also vitrification cryoprotectants 327 cryptozoospermia 245 cultural influences 196–7 culture media embryo 276–8, 281–2 oocyte maturation 306 cumulus cell-oocyte complex (COC) 43, 301–2, 303 immature oocytes 314–15 IVM procedure 302–3, 309 cumulus oophorus development 33–4, 41 LH surge 34 mature oocytes 314 removal techniques 264, 290 sperm penetration 93 customer satisfaction questionnaires 205 cystic fibrosis (CF) 159, 271 cytotrophoblast 112 darkfield illumination 232–3 DE protein 100 deferent duct see vas deferens density gradient centrifugation, sperm 247–8, 263 deontology 198, 376 depot medroxyprogesterone acetate (DMPA, Depo-Provera™) 149 depression, menopausal women 76 dermamyotome 118, 119 desmolase 65 diaphragms, contraceptive 146–7 diethylstilbestrol (DES)-related anomaly 339 differential interference contrast (DIC) microscopy 233–4 differentiation, cell 110 digyny 317 dihydrotestosterone (DHT) 67 dilution series, linear 229 disinfection 222 DNA amplification failure 351–2 amplification using PCR 349–50 contamination 350, 351 fragmentation, sperm 244 methylation, sperm 95 documentation, ART clinics 202–3 donor sperm treatment 168 history 185 legal aspects 195–6 religious aspects 174–5 Index social aspects 171 sperm cryopreservation 333 See also sperm donors dopamine 60 drugs, causing male infertility 155 Duchenne muscular dystrophy (DMD) 199 ductus venosus 125 duodenum development 127–8 ectoderm 114, 120 ectogenesis 184–5 ectopic pregnancy 341–2 Edwards, Robert (Bob) 182, 183, 185, 186, 187–8, 190, 366 egg (ovulated oocyte) activation 100–5 failure 106–7, 317 models 102 PLCζ as sperm factor 103–5 role of calcium 101–2 cryopreservation 190 donation 164, 171 ethical issues 198 legal aspects 195–6 religious aspects 174–5 retrieval 189 selection 1–2, 34–5 sperm interaction see sperm–egg interaction transport in oviduct 30 See also oocyte, zygote ejaculation 20, 21 retrograde 167, 333 embryo assisted hatching 286, 321 axes, formation 115 biopsy 190, 286–97 blastocyst trophectoderm 293–7 breaching zona pellucida 286–9 cleavage stage 291–3 microscopes 235 PGD 289–90, 291, 346–8 PGS 291, 357–8 polar bodies 289–91 vitrification after 297 cryopreservation 190, 328–9, 330–1, 331–2 culture 275–83 chemical factors 280–3 environmental factors 275–9 group and embryo:volume ratio 282–3 history 186–7 media 276–8, 281–2 physical factors 279–80 extraembryonic structures 114 folding 116–17 fragmentation 319, 320, 322 hatching 112 implantation 112–14 legal cases 215 metabolism 280–1 microscopy 234–5 organizer 115 organogenesis 118–30 preimplantation development 110–12 preservation quality assessment 313, 323 clinical value 323, 324 morphological methods 189, 316–23 objective methods 313 research 188, 196, 197, 210–11, 212–13 selection for IVF 199, 313–23 storage, legal aspects 195 transfer 183–4, 187–8, 217, 334 See also blastocyst; cleavage-stage embryo; morula; zygote embryogenesis, early 110–17 embryoid bodies (EBs) 365 embryonal carcinoma (EC) cells 365 embryonic disc bilaminar 112–14 trilaminar 114–15, 118 embryonic stem cell-like stem cells (ESLSCs) 366, 367, 368, 369, 370 embryonic stem cells (ESCs, ES cells) 112, 364–72 biology 366–8 clinical potential 365–6 discovery 364–5 therapeutic potential 368–72 EmbryoScope system 236 endocardial cushions 125 endocrinology, reproductive 65–78 endoderm 114, 116 endometrial cancer 148 endometriosis 154, 343–5 treatment 165–6, 345 endometrium 31 cyclical changes 39, 44–5 placental interface 79–80 receptivity, IVM cycles 308 endorphins 61 endothelial cells, developing gonads 11, 12 endothelin-1 44 epiblast 112, 366–7, 368, 370 epiblast stem cells (EpiSCs) 367, 370 epidermal growth factor (EGF) 34, 306 epididymis 19–20 sperm maturation 19–20, 89–91 sperm storage 91 epididymosomes 90 epigenesis, Aristotle’s theory 179–80 epigenetics, sperm 93–5 erectile failure 167 erection, penile 21 Essure 164 estradiol feedback loops 39, 61 IVM culture media 306 IVM cycles 255–6, 305–6 menstrual cycle 39, 40, 43, 59, 72 estrogen childhood and puberty 68–71 CNS effects 76 combined oral contraceptive (COC) pill 147 frozen embryo replacement 334 menopause and 75–6 menstrual cycle 41, 42–43, 44, 45 estrogen receptors (ER) 45 estrone 75–6 ethics 197–9, 374–80 definitions 374 foundation values 375 framework for guidance 376 law and 376 myths and misunderstandings 374–5 PGD 199, 353–4 practical decision-making 378–80 principles 377–8 theories 376–7 evacuation of retained products of conception (ERPC) 345 Evans, Natallie 215 external genitalia, development 129, 130 face, development 123 fairness 378 fallopian tubes (oviducts) 30–1, 339–40 surgery 340–1 see also tubal damage family planning 135–9 importance 136 natural methods 145–6 strategies for improving access 138–9 See also contraception female couples, same sex 168 female infertility causes 152–4 examination 156 history taking 155–6 investigations 156–8 treatment 161–6, 168 female reproductive tract 27–36, 337 development 8–11, 129, 130, 337, 338 developmental abnormalities 337–9 investigations, in infertility 157–8 sperm in 91–3 surgery 337–45 female sterilization 150–1 reversal 340 383 Index 384 Femidom 146 fertility age-related decline, in women 153, 154 control 143–51 global perspectives 133–42 history 155–6 natural regulation 145–6 social aspects 169–72, 197 symbols 177–8 See also infertility fertility awareness methods 145–6 fertility clinics/centres 188, 193 communication 201–2 documentation and records 202–3 infrastructure and work environment 201 legal responsibilities 194–6 licencing and inspection 194, 211–12 organization 201, 219, 220 quality management 200–9 regulation see regulatory aspects resource management 203 resource-poor countries 139 See also laboratory fertilization 30, 98–107, 316–17 capacitation and acrosome reaction 98–100 egg activation 100–5 failure 105–7, 317 clinical relevance 105–6 and infertility 105 PLCζ defects 106–7 history of discovery 182–3 species specificity 4–5 sperm–egg fusion 93, 100 sperm motility and chemotaxis 98 See also sperm–egg interaction fetal cells, in mothers 5, 80 fetus anatomical separation 79–81 immune relationship with mother 79–87 fibroblast growth factor (FGF8) 120 fibroblast growth factor (FGF9) 13–14, 15, 16 fibroblast growth factor 10 (FGF10) 120 fibroblast growth factor receptor (FGFR2) 14 fibroids, uterine 153–4, 165, 342–3 fimbrioplasty 164, 341 fluorescent in situ hybridization (FISH) 289, 348–9, 358 Fol, Hermann 180, 182–3 folic acid supplements 161 follicles, ovarian see ovarian follicles follicle-stimulating hormone (FSH) 58, 59 follicular development 41, 41, 49, 72–3, 251 IVM cycles 305 menopausal changes 75 menstrual cycle regulation 38–9, 40, 44, 59, 72 mid-cycle peak 42, 43 ovulation induction 252, 253–4 puberty 69 recombinant human (rFSH) 252 regulation of secretion 58, 61 serum, infertility 156, 159 signal (premenstrual rise) 60 spermatogenesis regulation 24–5 follicular fluid 33, 42 follicular phase 41–3, 59 folliculogenesis see ovarian folliculogenesis follistatin 61 foramen ovale 125 foregut development 126, 127–8 FOXL2 14–15, 16 Fraser Guidelines 143, 377 frozen embryo replacement 334 FSH see follicle-stimulating hormone gallbladder development 128 gamete donation legal aspects 195–6, 217 religious aspects 174–5 sociocultural aspects 171, 173 gametes generation and selection 1–3 identification 208–9 social and behavioural selection 3–4 storage, legal aspects 195 ganirelix 253, 255 gap junctions 34 gastrointestinal system, development 126–8 gastrulation 114–15 GDF-9 see growth differentiation factor genetic disorders ICSI safety 270–1 sociocultural aspects 173 genetic testing male infertility 159 see also preimplantation genetic diagnosis; preimplantation genetic screening genital ridges 9, 116, 130 genomic imprinting disorders 271 germ cells developing gonads 11, 12, 21–2 primordial 9, 21–2, 39–40, 50, 116 spermatogenesis 22–3 germ layers, primary 114–15, 118 germ theories 181–4 germinal vesicle (GV) 53, 54, 264, 303, 304, 314–15 germinal vesicle breakdown (GVBD) 303, 304 gestation length ghrelin 60 Gillick competence 143, 377 glial cells, development 121–2 glioblasts 122 global perspectives 133–42 globozoospermia 105, 106, 245, 270 gloves 221, 280, 350 glycosyl phosphatidylinositol (GPI)anchored protein 100 GnRH see gonadotrophin-releasing hormone gonadotrophin-regulated testicular RNA helicase (GRTH) 24 gonadotrophin-releasing hormone (GnRH) 58, 62 male reproductive function 24, 25 menstrual cycle regulation 38–9, 42, 71 puberty 69 pulsatility 58, 60, 71 pulse generator 58–9 structure 62 gonadotrophin-releasing hormone (GnRH) agonists 62–3, 188–9 IVF protocols 253–5 ovulation induction 161, 252–3 polycystic ovary syndrome 256, 257 gonadotrophin-releasing hormone (GnRH) antagonists 62–3, 253 breast cancer 258 ovulation induction 255 polycystic ovary syndrome 256–7 gonadotrophins control of spermatogenesis 24–5 IVM culture media 306 IVM cycles 255–6, 305 menstrual cycle regulation 38–9, 44 ovulation induction 161–2, 163, 252 breast cancer 258 IVF protocols 253–5 polycystic ovary syndrome 256–7 spermatogenesis induction 167–8 gonads cell biology of developing 11–12 development and differentiation 8–10 genetic control of development 12–15 regulation of function 58–63 sex determination steroid hormones 66–7 See also ovaries; testes Graafian follicles 29, 51–2 granulosa cells 27, 42 connections with oocytes 33, 34 differentiation into cumulus cells 33–4, 41 follicle development 33 luteinized 43 origins 11–12 Index growth differentiation factor (GDF-9) 32, 34 gut tube, primitive 116, 126, 127 haematopoietic stem cell transplantation 369 haemolytic disease of newborn 85 Haldane, J B S 184 Hartsoeker, Nicholaas 181 Harvey, William 179–80 hCG see human chorionic gonadotrophin head and neck, development 123 Health and Social Care Information Centre 213 Heape, Walter 183–4 heart congenital defects 126 development 123–5 heart tube, primitive 116–17, 123, 124 Hertwig, Oskar 183 Heuser’s membrane 112, 113 hindgut development 127, 128 histones, sperm nucleus 93–5 historical perspective 177–90 HIV infection 142 HLA tissue matching, embryos 195, 353 HLA-C 82, 83 HLA-E 82 HLA-G 82–3 Hoffman modulation contrast (HMC) 233 hormone replacement therapy (HRT) 77–8 hot flushes 76 HOX genes 120 human chorionic gonadotrophin (hCG) 44 ectopic pregnancy 342 IVM cycles 255–6, 305 ovulation induction 253 Human Fertilisation and Embryology (HFE) Act 1990 (1990 Act) 193–6, 211 Human Fertilisation and Embryology (HFE) Act 2008 (2008 Act) 213 Human Fertilisation and Embryology Authority (HFEA) 193, 200, 210–13, 349, 379 future 213 licencing and inspection 194, 211–12 research regulation 212–13 rules with unintended consequences 217, 218 human menopausal gonadotrophin (hMG) 252, 253–4 human papillomaviruses (HPV) 31, 140 Huxley, Aldous 184 hyaluronic acid (HA) 93, 266 hydrosalpinx 164, 340 hymen, imperforate 75 hyperprolactinaemia 74, 75, 153, 164 hypoblast 112 hypogonadotrophic hypogonadism female 152, 161–2, 250 male 155, 167–8 hypo-osmotic swelling test (HOST) 244 hypothalamic–pituitary dysfunction 74, 250 hypothalamic-pituitary failure 73, 74 hypothalamic-pituitary-gonadal axis, puberty 69 hypothalamic-pituitary-ovarian (HPO) axis 58–63, 71 control of GnRH pulses 60 feedback loops 61 GnRH pulse generator 58–9 menstrual cycle regulation 38–9, 40 pharmacological manipulation 62–3 puberty 69 hypothyroidism 74, 75 hystero-contrast-ultrasonography (HyCoSy) 158 hysterosalpingogram (HSG) 157 ICSI see intracytoplasmic sperm injection immune cells, fetal–maternal interface 81, 82, 83 immunology, reproductive 79–87 immunotherapy, pregnancy immune disorders 86–7 Implanon™ 149 implantation 112–14 failure 82–3, 86–7 implants, contraceptive 149 in vitro fertilization (IVF) embryo selection 199, 313–23 history 182, 184–90 male infertility 168, 189 natural cycle, with IVM 255–6 older women 167 polycystic ovary syndrome 163 religious aspects 173–5 social aspects 171–2, 173 sperm cryopreservation 333–4 success rates 300 superovulation protocols 253–6 tubal disease 164 unexplained infertility 167 in vitro maturation (IVM) of oocytes 163, 300–10 availability of immature oocytes 301–4 benefits over other ARTs 300–1 causes of lower success rates 308–10 culture media 306 duration of culture 306–7 endometrial preparation 255–6, 305–6 gonadotrophin priming 255–6, 305 historical perspective 301 ICSI 263, 305 indications 307 laboratory procedure 309 methods 305–7 obstetric and perinatal outcomes 307–8 oocyte retrieval 305 predictors of outcome 307 stages of maturation 302–4 success rates vs IVF 307, 308 treatment protocol 255–6, 304–5 incubators, embryo culture 275–6, 279–80 indoleamine 2,3-dioxygenase (IDO) 83 infectious risks 222, 335 infertility 152–9 causes 152–5 defined 152 diagnosis of cause 155–9 fertilization failure 105 global perspectives 139 history and examination 155–6 investigations 156–9 social aspects 169–72 treatment 161–8 unexplained 155, 166–7 See also female infertility; male infertility inheritance Boveri–Sutton chromosome model 183 social aspects 169–70, 172–3 inhibin 61 A 43, 44, 61 B 25, 61, 75 injectable contraceptives 149 inner cell mass (ICM) 112 inositol triphosphate (IP3) 102, 103 Institute of Reproductive Sciences (IRS), Oxford 219, 220 insulin-like protein (INSL3) 10–11, 25 integrity 378 intermediate mixtures 229–30 International Organization for Standardization (ISO 9001:2008) 200–1, 216 intracytoplasmic morphologically selected sperm injection (IMSI) 235–6, 268 intracytoplasmic sperm injection (ICSI) 189, 262–72 clinical results 106–7, 269–70 embryo biopsy and 289, 290 equipment 264–5 IVM 263, 305 microscopes 235, 236, 264 oocyte preparation 264 patient selection 262–3 PGD 350 385 Index intracytoplasmic sperm injection (ICSI) (cont.) rig 264–5 safety 270–1 setup and procedure 265–9 sperm preparation 263–4 intrauterine adhesions 165, 345 intrauterine devices (IUDs), copper 149–50 intrauterine insemination (IUI) 166–7, 168 intravenous immunoglobulin (IVIg) 86 IVF see in vitro fertilization IVM see in vitro maturation Izumo protein 100 Jadelle™ 149 Jewish societies 172, 173–4 Jost, Alfred justice 198, 378 Kallmann’s syndrome 58–9, 73, 167–8 kangaroos 5–6 karyomapping 352, 354–5, 360 key performance indicators (KPIs) 205 kidneys, development 129–30 kinship 172–3 KIR receptors 82, 83 kisspeptin 60 Klinefelter’s syndrome 270 386 laboratory 219–37 air quality 207–8, 275–6 communication within 219–20 decontamination and disinfection 222 liquid handling techniques 222–5 microscopy techniques 230–7 organization 219 protective clothing 221 quality management 200–9 safety procedures 220 signage/labelling 221 skills, fundamental 221–37 solutions, preparing 225–30 laboratory equipment handling 221–2 monitoring and measuring 207–8 validation 206–7 lactation intermittent male lactational amenorrhoea method (LAM) 145 laparoscopic ovarian drilling (LOD) 162, 163 laparoscopy and dye procedure 157–8 ectopic pregnancy 342 large offspring syndrome 282 lasers, zona drilling 287–9 law 193–7, 376 See also regulatory aspects LDL-cholesterol 44 Leeuwenhoek, Anton van 179, 181, 182 leiomyomas, uterine see fibroids, uterine leptin 60 lesbian couples 168 letrozole 252, 258 leucocyte immunization, paternal and third party 86 leuprolide acetate 253, 254–5, 257 levonorgestrel emergency contraception (LNG-EC) 150 levonorgestrel-releasing intrauterine system (LNG-IUS) 150 Leydig cells 18–19 hormonal regulation 24–5 origins 11, 12 secretory functions 24–5 LH see luteinizing hormone light, embryo culture 276 limb development 119, 120 linkage analysis 351–2 liver development 128 tumours, oral contraceptive users 148 long-acting reversible contraceptives (LARCs) 149 lung development 126–7 luteal phase 43–4, 59, 60 luteinization inhibitor (LI) 42 luteinizing hormone (LH) 58, 59 control of spermatogenesis 24–5 follicular development 41 menstrual cycle regulation 38–9, 40, 44, 72 ovulation induction 253–4 puberty 69 recombinant human (rLH) 252 regulation of secretion 58, 61 serum tests, infertility 159 surge 34, 39, 42–3, 59–60, 72 urine sticks 156 male infertility causes 154–5 examination 156 fertilization failure 105–6 history taking 155–6, 239, 240 investigations 158–9 PLCζ as potential therapeutic 107 social aspects 169, 171 treatment 167–8, 189 male reproductive tract 18–22 development 8–11, 21–2, 129, 130 structure and function 18–21 marsupials 5–6 mate choice maternal deaths 133–5 causes 134–5, 136, 341 prevention 135 maternal-to-zygotic transition (MZT) 111 matrix metalloproteinases (MMPs) 43, 44, 45 Mayer–Rokitansky–Kuster–Hauser (MRKH) syndrome 338 meiosis female 50–1, 52–4 abnormalities arising during 54–5 metaphase II (MII) 53 prophase I 52–4 resumption after sperm–egg fusion 100 history of discovery 183 male 23 meiotic spindle, oocyte 54, 236, 269, 278, 315–16 membrane receptor model, egg activation 102 menarche 38, 68–70 menopause 75–8 cardiovascular risk after 77 hormone replacement therapy (HRT) 77–8 skeletal changes 76–7 symptoms 76 menstrual cycle 38–46, 59–60 duration 38 endocrinology 71–3 endometrial changes 39, 44–5 follicular phase 41–3, 59 hypothalamic and pituitary control 38–9, 40 luteal phase 59, 60 stages 41–4 menstruation 44–5 mesenchymal tissue 119 mesoderm 114 axial 116 derivatives 116 extraembryonic 113–14 intermediate 116, 129 lateral plate 116, 118, 119, 126 paraxial 116, 118 splanchnopleuric 126 mesonephric duct see Wolffian duct mesonephros 9, 10, 12, 116, 129 metanephric blastema 129 metanephros 9, 10, 116, 129 metformin 162, 163 MHC antigens 81–2 class I 81 class II 81–2 trophoblast 82–3 microarray comparative genomic hybridization (array-CGH) 289, 349, 358–9 microsatellite analysis 350 Index microscopes 230–5 compound 230–1 dissecting (stereomicroscopes) 231, 232 illumination systems 231–4 maintenance 236–7 selection 234–5 microscopy 230–7 midgut development 126, 127, 128 Million Women Study 77 mineral oil 187, 264–5 miscarriage immune mechanisms 82–3 PGD and 349 surgical management 345 mitosis phase, spermatogenesis 23 molar concentration 227–7 morula 111–12 morphological assessment 321–2 mosaicism, chromosomal 358 motile sperm organellar morphology examination (MSOME) 268 M-phase promoting factor (MPF) 100 mRNA oocyte 55, 101 sperm 95 Müllerian anomalies, congenital 337–9, 339 Müllerian duct (paramesonephric duct) 9, 10, 129, 130 Müllerian-inhibiting substance see anti-Müllerian hormone multinucleation, blastomere 292, 320–1, 322 multiple births 195 multiplex-polymerase chain reaction (PCR) 349–50 musculoskeletal system, development 118–20 Muslim societies 172, 174–5 myomectomy 343 myometrium 31 myotomes 118, 119 nafarelin acetate 253 natural killer cells, uterine (uNK cells) 81, 82, 83 necrozoospermia 245 neo-oogenesis 51 nervous system cytodifferentiation 121–2 development 120–2 neural crest cells 115–16, 121, 122 neural plate 115, 121 neural tube 115, 121 neural tube defects 122, 161 neuroblasts 122 neurons, development 121–2 neuropeptide Y (NPY) 60 neurulation 115–16, 120–1 next generation sequencing (NGS) 361 nodal vesicular parcels 115 Nomarski illumination 233–4 non-conformances, ART clinics 203–4 non-disjunction 54 noradrenaline 60 norethisterone enanthate (Noristerat™) 149 notochord 115 nucleoli, fertilized eggs 316, 317 oil overlays embryo culture 187, 276 ICSI manipulations 264, 266 older parents 198–9 See also age, advanced female oligomenorrhoea 73–5 causes 73–4 medical treatment 74–5 modified WHO classification 73 oligozoospermia 159, 245 OMICs methods, assessing embryo and egg quality 313 oocyte apoptosis (elimination) 51, 54 control of follicular development 32 cryopreservation 332–3 development 32–6, 50–6 LH surge 34 molecular signalling 34 zona pellucida 33, 55 See also oogenesis diameter 55, 314, 315 granular area 314, 316 granulosa cell connections 33, 34 growth in size 32, 49, 55 health 34–6 immature, availability 301–4 in vitro maturation see in vitro maturation manipulation during ICSI 269 maturation 303–4, 308–10, 313–14 mature normal 314 microscopy 234–5 morphological assessment 313–16, 322–3 nests 51 ovulated see egg prenatal 48, 50, 51 preparation for ICSI 264 primary 32, 48 quality ageing changes 54 assessment 35–6, 313–16, 322–3 early oogenesis events and 48–56 effects of IVM 308–10 retrieval, IVM 305 secondary 32 selection 1–2, 34–5 oocyte maturation inhibitor (OMI) 42 oogenesis 48–56 mechanism of meiosis 52–4 timeline 50–2 See also oocyte; development oogonia 50–1 oogonial stem cells (OSCs) 301 oolemma rupture during ICSI 269 sperm binding/fusion 93, 100 opiates, endogenous 61 oral contraceptive pill see combined oral contraceptive organogenesis, human 118–30 oropharyngeal membrane 115 osteoporosis, postmenopausal 76–7 ovarian cancer 148 ovarian failure 73–4, 153, 250 treatment 74, 163–4 ovarian follicles 27–30, 72 age-related decline in numbers 75 atresia 40, 49 basal lamina 33 cell origins 11–12 development see ovarian folliculogenesis dominant 41, 73 Graafian (ovulatory) 29, 51–2 growth 32, 48–50, 55 pool see ovarian reserve pre-ovulatory 42 primary 40 primordial see primordial follicles rupture/oocyte release see ovulation secondary (pre-antral) 33, 40–1 tertiary (antral) 33–4, 41, 49 ultrasound tracking 157 vascularity 27 ovarian folliculogenesis 28, 29, 32–4, 39–41, 250–1, 301–2 control by oocytes 32 molecules regulating 34, 35 ovulatory cycle 72–3 timeline 50, 51–2 ovarian hyperstimulation, controlled see ovulation induction ovarian hyperstimulation syndrome (OHSS) 163, 257, 300, 305 ovarian reserve 51, 156, 301 ovaries 27–30 cyclical changes 72 development 8–10 genetic control of development 14–15, 16 regulation of function 58–63 steroidogenesis 67, 68 vascularization 27 oviducts see fallopian tubes ovulation 42–3, 71 indicators 145 LH surge 42–3 387 Index ovulation induction 161–2, 250–9 breast cancer patients 257–8 complications 300 history 186 indications 250 IVF protocols 253–6 antagonist 255 antagonist during luteal phase 255 long 253–4 mini-dose 254–5 new 255–6 short 254–5, 305 medications 251–3 polycystic ovary syndrome 256–7 poor responders 257 ovulatory disorders 152–3 investigations 156–7 treatment 161–4 oxygen (O2) concentration, embryo culture 278–9 oxytocin 25 388 P450-linked side chain cleaving enzyme (P450ssc; desmolase) 65 pancreas, development 127, 128 paraffin oil 187 paramesonephric duct see Müllerian duct parents, legal definitions 196 partial zona dissection (PZD) 262, 286 parts per million (ppm) 228–8 Pasteur, Louis 178, 180 patrilineal societies 169–70, 172–3 pelvic inflammatory disease (PID) 340 penis 21 peripheral nervous system (PNS), development 122 peritubular myoid cells (PMC) 12 perivitelline space (PVS) 315, 316 person responsible 194 Persona 146 Petri dish 186–7 pH, embryo culture media 276–8 pharyngeal arches 123 phase contrast microscopy 232–3 phosphatidylinositol 4,5-bisphosphate (PIP2) 103 phospholipase Cζ (PLCζ) defects, andegg activation failure 106–7 egg activation 103–5 localization within sperm 104–5, 106 therapeutic potential 107 piezo-mediated zona drilling 288 Pincus, Gregory 182, 185, 190, 301 pipettes 222–5 cleaning and inspection 224–5 dispensing techniques 223–4, 225, 226 embryo biopsy 290–1, 295 ICSI micro-injection 265, 269 tips 224 pituitary adenomas, prolactin-secreting 74, 75 pituitary gland, anterior 59 placenta antibody transport 85 maternal interface 79–81 plasminogen activator (PA) 43 plasticware, embryo viability and 280 pluripotent cells 110, 364 pluripotent stem cells 364–5 induced (iPSC) 370 purification 371 see also embryonic stem cells polar bodies (PB) abnormalities 315, 317, 318 biopsy 289–91 formation 52, 303, 304, 313–14 PGD 346–7, 348 polarized light microscopy (PLM) 236 polycystic ovaries (PCO) 300, 301 IVM 304–5, 307, 308 polycystic ovary syndrome (PCOS) 73, 152–3 diagnostic criteria 153 IVM 305, 307, 308 ovarian hyperstimulation syndrome 257, 300, 305 ovulation induction protocols 256–7 treatment 74, 162–3 polymerase chain reaction (PCR) 349–52 multiplex 349–50 quantitative 359–60 polyspermy blocking mechanisms 93, 100 morphological features 317, 319 population dynamics positive-displacement pipettes 224, 226 post-acrosomal sheath WW domainbinding protein (PAWP) 103 post-coital contraception 150 precocial offspring prednisolone 87 preeclampsia 82–3, 85–7 preformation theory 179, 180–1 pregnancy feto-maternal immune relationship 79–87 immune function 84–6 woman’s right to a safe 133–5 preimplantation genetic diagnosis (PGD) 190, 346–55 chromosome rearrangements 348–9 efficacy 354 embryo biopsy 289–90, 291, 346–8 ethical issues 199, 353–4 extension of indications 352–4 ICSI 263 legal aspects 195 single gene disorders 347, 349–52 transport 354 preimplantation genetic haplotyping (PGH) 352 preimplantation genetic screening (PGS) 357–62 accuracy and outcomes 361 alternative methods 359–61 embryo biopsy 291, 357–8 FISH 358 microarray CGH 358–9 older women 167 pre-pregnancy counselling 161 primitive node 115 primitive streak 114–15 primordial follicles 32, 40, 48–9, 51 age-related decline 75 atresia (apoptosis) 40, 49 growth resumption 32, 48–9, 51, 301–2 coordinated oocyte growth 55 regulation 32–3, 49 See also ovarian folliculogenesis primordial germ cells 9, 21–2, 39–40, 50, 116 process validation 207 progesterone endometrial effects 45 frozen embryo replacement 334 hypothalamic feedback 61 luteal synthesis 44 menstrual cycle 39, 42, 43, 60, 72 serum mid-luteal 156 progesterone receptors (PR) 45 progestogen-only pill (POP) 148–9 progestogens combined oral contraceptive (COC) pill 147 implants 149 injectable 149 progress zone (PZ) 120 prolactinoma 74, 75 pronephros 9, 10, 116, 129 pronuclei, fertilized eggs 316, 317, 318 proopiomelanocortin (POMC) 61 prostaglandin F2α (PGF2α) 43–4 prostaglandins 43 prostate gland 20–1 protamines 93–5 protein kinase A (PKA) 44 psychosexual problems 154 Pten 32–3 puberty 68–71 delayed 70–1 hypothalamic-pituitary-gonadal axis 69 precocious 70 stages 70 Purdy, Jean 187 PVP (polyvinylpyrrolidone) media 266 Pythagoras 178–9 Index quality indicators 205 objectives 202, 205 policy 202 quality control and assurance, sperm preparation 248 quality management system (QMS) 200–9 quality manual 202 quantitative polymerase chain reaction (PCR) 359–60 radiotherapy 258, 263 reactive oxygen species (ROS) 93, 244 reciprocal translocations 348, 349 records, ART clinics 202–3 rectal atresia 128 recurrent miscarriage 82–3, 86–7 Redi, Francesco 178–9, 180 regenerative medicine 368–72 regulatory aspects 193–7 international 196–7 UK 193–6, 200, 210–18 regulatory T cells (Tregs) 83 religion 173–5, 196, 375 renin-angiotensin-aldosterone system 66 reproductive endocrinology 65–78 reproductive health 133–42 defined 133 factors influencing 133, 134 importance 133 women’s rights 133–42 reproductive immunology 79–87 reproductive strategies 5–6 reproductive surgery 337–45 reproductive system, development 8–11, 129, 130 reproductive tourism 197 rete testis 18, 19 retinoic acid (RA) 12, 120 rhesus disease 85 risk assessment, laboratory 220 Robertsonian translocations 348, 349 Rock, John 184–5 Rokitansky syndrome 338 R-spondin (RSPO1) 14 salpingitis isthmica nodosa 340 saviour siblings 195, 353 Schenk, S L 182–3 sclerotomes 118, 119 seals semen 91–2 dilution 246 emission 21 liquefaction 240 pH 241 sperm preparation 245–8 viscosity 241 volume 241 semen analysis 158–9, 239–45 interpretation of results 245 microscopic techniques 235 patient history 239 reference values 159, 241 sample production 239–40 seminal plasma 91–2 seminal vesicles 20 seminiferous tubules 18 serial dilution 228–9, 230 Sertoli cells 18 hormonal regulation 25 origins 11–12 role in spermatogenesis 23–4, 25 serum, in culture media 282, 306 sex cords, primitive 130 sex determination antagonism between male and female genes 15, 16 genes 12–15 XY system, discovery 183 sex hormone-binding globulin (SHBG) 68 sex reversal, gonadal 11 sex selection 195, 197 sexual development 8–17, 130 disorders of 130 genetic control 12–15, 16 sexual history 144 sexual reproduction 1–6, 98 sexually transmitted infections (STIs) 139–42, 143–4 burden 139–40 consequences 140–1 interventions 141–2 Sheehan’s syndrome 73 short tandem repeats (STRs) 350, 351 SI units 228 single gene disorders PGD 347, 349–52 SNP microarrays 360 single nucleotide polymorphism (SNP) microarrays 352, 354–5, 360 situs inversus 115 situs solitus 115 skeletal health, postmenopausal 76–7 skeletal system, development 119 smoking 161, 240 social aspects 169–75, 196–7 soluble sperm factor model, egg activation 102 solutions, laboratory 225–30 concentrations 227–8 definitions 226–7 preparing 228–30 somites 116, 118, 119 somitomeres 118, 119 Sonic Hedgehog (SHH) 115, 120 sons 169–70, 171 SOX9 gene 13, 14, 15, 16 Spallanzani, Lazzaro 180, 181 sperm(atozoa) 3, 89–95 acrosome reaction (AR) 93, 98–100 autoantibodies see antisperm antibodies capacitation 92–3, 98–100 chemotaxis 98 concentration (count) 242–3 cryopreservation 185, 333–4 density gradient separation 247–8, 263 DNA fragmentation 244 egg interaction see sperm–egg interaction epididymal storage 91 in female genital tract 4, 91–3 histones, protamines and epigenetics 93–5 hyperactivation 92–3 immobilization, for ICSI 268–9 legal cases 214, 215–17 markers of function 105–6 maturation in epididymis 19–20, 89–91 migration (swim up) 246–6 morphological evaluation 243 motility acquisition 90, 92, 93, 98 analysis 241–2 hyperactive pattern 92 PLCζ localization 104–5, 106 preparation 245–8, 263–4 commercial products 248 methods 245–8 quality assurance and control 248 witnessing 248 production see spermatogenesis selection 1, 2, 3–4, 267–9 surgical retrieval (SSR) 167, 333 transport vitality testing 244 washing 246, 263–4 sperm donors 171, 195–6 See also donor sperm treatment sperm–egg interaction 93, 99–100 chemotaxis 98 cumulus penetration 93 membrane fusion 93, 100 sperm factor triggering egg activation 102–5 zona binding 4–5, 90–1, 93, 99–100 See also fertilization sperm survival test, human 280 spermatids 22, 23 spermatocytes 23 spermatogenesis 2–3, 22–5 cellular, genetic and chromatin changes 94 genes and proteins regulating 24 hormonal regulation 24–5 389 Index 390 spermatogenesis (cont.) phases 22, 23 testicular temperature and 2, 19 therapeutic induction 167–8 spermatogenic cycle 23 spermatogenic wave 23 spermatogonia 23 spermatogonial stem cells (SSCs) 23, 24 spermicides 147 spermiogenesis 22, 23 spermism, theory of 178–9, 181 spinal cord, development 121, 122 spiral arterioles 45, 79–80 spontaneous generation 178–9 SRY gene/SRY protein 11–13, 14, 22, 130 staff 219 communication 201–2, 219–20 fundamental laboratory skills 221–37 management 203 occupational hazards 222, 335 protective clothing 221, 350 standard operating procedures (SOP) 202 stem cells 110, 364, 370 adult 369 research 197 See also embryonic stem cells; pluripotent stem cells Steptoe, Patrick 182, 187–8 stereomicroscopes 231–1, 232 sterilization female 150–1, 340 male 146 microbiological 222 steroid binding proteins 67–8 steroid hormones 65–8 adrenal cortex 65–6 biosynthesis see steroidogenesis gonadal 66–7 steroidogenesis 65 adrenal disorders of 66 regulation 66, 68 ovarian 67, 68 testicular 24–5, 67, 68 steroidogenic cells, gonadal 11, 12 stomach development 127 subfertility 152 See also infertility subzonal insemination (SUZI) 262, 286 suckling of young superovulation 250–9 See also ovulation induction suppliers, fertility clinics 203 supporting cells developing gonads 11–12 testicular see Sertoli cells surgery, reproductive 337–45 surgical sperm retrieval (SSR) 167, 333 surrogate motherhood 166, 171 legal aspects 196, 197 religious aspects 174 Sutton, Walter 182, 183 Swammerdam, Jan 179, 181 syncytiotrophoblast 112, 114 T cells 81, 83 tammar wallaby temperature control during microscopy 230 embryo culture 278 ICSI manipulations 264 sperm production 2, 19 teratomas/teratocarcinomas 364–5, 366 teratozoospermia 245 testes development 8–10, 22, 130 genetic determination 12–14, 15, 16 steroidogenesis 24–5, 67, 68 structure and function 18–19 temperature 2, 19 testicular failure, primary 154, 167 testis-determining factor (TDF) 13, 130 See also SRY gene/SRY protein testosterone biosynthesis 25, 67 childhood and puberty 68–71 functions 25 male reproductive tract development 10, 22 menopausal women 75 regulation of production 24 serum, male infertility 159 tetralogy of Fallot 126 Th1/Th2 balance 84–5, 86 Th17 cells 83 theca cells 27 follicle development 33, 40 luteinized 43 origins 11, 12 theca interna 41, 42 tissue inhibitors of proteinases (TIMPs) 44, 45 tissue plasminogen activator (tPA) 43 totipotent cells 110, 364 traceability 208, 335 trained birth attendants (TBA) 134 training, using human embryos 196 translocations 348, 349 transvaginal ultrasound ectopic pregnancy 342 follicular tracking 157 hystero-contrast-ultrasonography (HyCoSy) 158 infertility assessment 158 transzonal processes (TZPs) 29, 33, 34 trophectoderm biopsy, blastocyst 293, 294, 295, 296 trophoblast antigen expression 81–3 differentiation 112, 114 formation 112 maternal interface 79–81 MHC antigens 82–3 trust 378 Tsc1 32–3 tubal damage 153, 339–41 diagnosis (patency tests) 157–8 pathophysiology 340 results of surgery 341 treatment 164–5, 340–1 tumour necrosis factor (TNF) 43, 44 tunica albuginea 18, 19 Turner’s syndrome 74 twins, monozygotic 112 U, Mrs (2002 case) 214 ultrasonography egg retrieval 189 transvaginal see transvaginal ultrasound umbilical cord 117 unsafe abortion 136–8 unsafe sex 139–42 urethra, male 20 urinary system, development 129–30 urogenital system development 9–11, 129–30 menopausal symptoms 76 urokinase plasminogen activator (uPA) 43 uterine artery embolization (UAE) 342–3 uteroplacental circulation 114 utero-tubal junction (UTJ), sperm interactions 92 uterus 31 congenital abnormalities 338–9, 342 disorders causing infertility 153–4, 166, 342–3 fibroids 153–4, 165, 342–3 implantation of blastocyst 112–14 sperm interactions 92 vagina 31–2 validation 206–7 varicocele 155 vas deferens (deferent duct) 19, 20 congenital bilateral absence (CBAVD) 271 vascular endothelial growth factor (VEGF) 43 vasectomy 146 reversal 167 vasopressin (AVP) 60 venous system, development 124, 125 venous thromboembolism (VTE) 147, 148 Index ventricular septal defects 126 ventricular septum, development 124, 125 virtue ethics 376–7 viruses 222, 335 vitelline duct 126 vitelline veins 125 vitrification 329–31 biopsied blastocysts 297 volatile organic compounds (VOCs) 275, 280 v/v concentrations, % 228 Wolff, Casper Friedrich 180, 181–2 Wolffian duct (mesonephric duct) 9, 10, 22, 129, 130 women reproductive health rights 133–42 single, or same sex couples 168 social status/roles 170–1 Women’s Health Initiative (WHI) trial 77 w/v concentrations, % 227 w/w concentrations, % 227 Warnock Committee 210 whole genome amplification (WGA) 354–5, 359 Wilson, E B 182, 183 witnessing procedures 208–9, 248, 335 WNT4 14, 15, 16 Wnt7A 120 Wnt/β-catenin signalling pathway 14 X chromosome 21 X chromosome inactivation (XCI), female embryo 112 X-linked disorders 349 XX males 14 XY females 13 Y chromosome 8, 21, 22, 349 Yearworth and Others v North Bristol NHS Trust 215–17 yolk sac 117, 126 primary 112 secondary/definitive 114 Zn21-dependent metalloprotease 100 zona pellucida (ZP) abnormalities 316, 321 development 33, 55 drilling/dissection 189, 262, 286–9, 321 embryo hatching 112 glycoproteins (ZP1, ZP2 and ZP3) 99–100 sperm binding 4–5, 90–1, 93, 99–100 thickness 314, 321 zone of polarizing activity (ZPA) 119, 120 zygote 27, 110–12 cleavage divisions 111–12 abnormalities 317–19 cryopreservation 332 morphological assessment 316–17, 318, 323 391 ... 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