Reproductive Endocrinology and Infertility (eBook)

Editors 3
We dedicate this book to our mentors, students, residents, and fellows who have continually refreshed our excitement for reproductive medicine as we learn with them, and to our families who have sacrificed much to assist us in our professions. 5
Preface 6
Contents 7
Contributors 11
Part I Management of the R.E.I. Clinic and Laboratories 18
Characteristics of a Successful R.E.I. Clinic and Laboratory 19
1.1 Introduction 19
1.2 Successful Leadership Principles 20
1.3 Effective Management 20
1.4 Skill 21
1.5 A Focus on Patients 21
1.6 A Focus on the Staff 1.7 Conclusions 22
References 22
Assisted Reproductive Technology Practice Management 23
2.1 AIM 2.2 Revenue Cycle 23
2.2 Revenue Cycle 23
2.3 Employment Cycle 24
2.4 Site of Service Designation 31
2.5 Optimizing Practice Outcomes Through Quality Improvement 33
2.6 Uniform Laws, Regulations, and Case Law Pertaining to Art 34
2.6.1 Case Law Regarding Sperm Donation 34
2.6.2 Egg Donors 34
2.6.3 Traditional Surrogacy 35
2.6.4 Gestational Surrogacy 35
2.6.5 Disposition of Frozen Genetic Material 35
2.6.6 Same-Sex Issues 36
2.6.7 Posthumous Use of Genetic Material 36
2.6.8 Uniform Laws 36
2.7 Resolving Problems 37
2.7.1 Six Sigma 37
2.7.2 Root Cause Analysis 38
2.7.3 Ishikawa Fishbone Analysis 38
2.7.4 Lean Process 39
2.8 Capital, Capital Management and Capital Expenditures 40
2.8.1 Capital Expenditures 42
2.9 Employee Requirements 43
2.10 Conclusion 43
References 47
Appendix 48
Collaboration Within the Reproductive Endocrinology and Infertility Practice: Integration of Laboratory and Clinic Operations 54
3.1 Introduction 54
3.2 Developing an Integrated Practice 54
3.3 Conclusions 57
References 57
Informed Consent in Advanced Reproductive Technology 58
4.1 Introduction 58
4.2 Informed Consent for IVF/ICSI 58
4.2.1 Specific Informed Consent Domains 60
4.2.2 Special Issues for Informed consent in IVF/ ICSI 62
4.3 Informed Consent Issues for Preimplantation Genetic Diagnosis and Preimplantation Genetic Screening 63
4.4 Informed Consent for Egg Donations 64
4.5 Oocyte and Ovary Tissue Cryopreservation 65
4.6 Informed Assent for Minors 65
4.7 Embryo Cryopreservation: Advanced Directives and Intent 66
4.8 Posthumous Donation: When There Can Be No Informed Consent 66
4.9 Storage of Informed Consent Documents 67
4.10 Conclusion 67
4.11 Summary 67
References 69
Reproductive Laboratory Regulations, Certifications and Reporting Systems 70
5.1 Introduction 70
5.2 The Clinical Laboratory Improvement Amendments 71
5.2.1 Proficiency Testing 71
5.2.2 Patient Test Management 72
5.2.3 Quality Control 72
5.2.4 Personnel Requirements and Responsibilities 72
5.2.5 Quality Assessment 73
5.2.6 Inspections and Sanctions 73
5.3 The Fertility Clinic Success Rate and Certification Act of 1992 74
5.3.1 Personnel Qualifications and Responsibilities 74
5.3.2 Facilities and Safety 75
5.3.3 Quality Management 75
5.3.4 Maintenance of Records 75
5.3.5 Sanctions and Enforcement 76
5.3.6 American Society for Reproductive Medicine Guidelines 76
5.4 FDA 76
5.4.1 General Provisions and Establishment Registration 76
5.4.2 Donor Eligibility and Specimen Labeling 77
5.4.3 Current Good Tissue Practice and Inspections 78
5.5 The College of American Pathologists Reproductive Laboratory Accreditation Program 79
5.5.1 Performance Standards and Checklist 79
5.5.2 Inspections and Accreditation 79
5.6 The Joint Commission Accreditation Program for Assisted Reproductive Technology Laboratories 80
5.6.1 Standards 80
5.6.2 Survey Process 80
5.7 Laboratory Personnel Certification 80
5.8 Laboratory and Clinic Data Reporting Systems 81
References 83
Successfully Integrating the FDA Regulations into Your Practice 86
6.1 Introduction 86
6.2 Overview of the 21 CFR part 1271 Regulations 88
6.2.1 Registrations Final Rule 88
6.2.2 Donor Eligibility Final Rule 89
6.2.3 Current Good Tissue Practice: Final Rule 100
6.3 Summary: Evidence-Based Guidelines 102
6.4 Case Studies 104
6.4.1 Example 1: Anonymous Oocyte Donor 104
6.4.2 Example 2: Directed Sperm Donor 104
6.4.3 Example 3: Gestational Carrier/ Anonymous Oocyte Donor Fresh Cycle
6.4.4 Example 4: Embryo Donation Third- party Mixed Embryos
6.5 Conclusions 106
References 106
Psychosocial Consequences of Infertility and Treatment 108
7.1 Introduction 108
7.2 Distress and Marital Benefit 108
7.3 Predictors of Stress 110
7.4 Stress and Treatment Outcome 111
7.5 Social Stigmatization 111
7.6 Mental Well-Being after Having Achieved Pregnancy/ Delivery 111
7.7 Long-Term Adjustment to Childlessness 111
7.8 Fertility Patients’ Needs 112
7.9 Drop-Out of Fertility Treatment 113
7.10 Effects of Psychosocial Interventions 113
7.11 Clinical Recommendations 113
References 114
A Live Baby or Your Money Back: The Marketing of In Vitro Fertilization Procedures 116
8.1 Introduction 116
8.2 The Prevalence and Practice of IVF 117
8.3 Money-Back Guarantees: Economics for a Typical Patient and Clinic 118
8.3.1 Marginal Cost vs. Average Cost 119
8.3.2 Patient Selection: Aggressive Screening 119
8.3.3 Breakthrough in IVF Success Rates 119
8.3.4 Risk Transfer 119
8.3.5 Heterogeneity 120
8.4 Variation in Performance Across IVF Clinics 120
8.5 Patient Outcomes Across Successive IVF Attempts 121
8.6 Perseverance and the House Money Effect 125
8.7 Abandoning the “No First Use” Policy 126
8.8 Conclusion 129
8.8.1 Patients 129
8.8.2 Clinic Managers 130
8.8.3 Public Policy Advocates 130
8.8.4 The Simple Model Works 130
References 130
Part II Female Reproductive Physiology and Medicine 132
Ovulation: A Molecular View 133
9.1 Introduction 133
9.2 Dynamics of Ovulation 133
9.3 Endocrine Signal and Second Messengers 134
9.4 Transcriptional Regulation 134
9.5 Progesterone 135
9.6 Eicosanoids 136
9.7 Angiogenic Factors 136
9.8 Epidermal Growth Factor like Factors 137
9.9 Proteases and Their Inhibitors 137
9.9.1 Matrix Metalloproteinases 137
9.9.2 The Plasmin/Plasminogen Activator System 138
9.9.3 ADAMTS 139
9.10 Immune Cells 139
9.11 Cytokines and Chemokines 140
References 141
Clinical Evaluation of Female Factor Infertility 147
10.1 Introduction 147
10.2 Medical History and Physical Examination 148
10.3 Assessment of Oocyte Reserve 149
10.4 Assessment of Ovulation 150
10.5 Assessment of Patency of the Female Reproductive Tract 151
10.6 Assessment of Endometrial Receptivity 155
10.7 Assessment of the Abdominal Pelvic Cavity 157
10.8 Conclusions 157
References1 158
Polycystic Ovary Syndrome 161
11.1 Introduction 161
11.2 Polycystic Ovary Syndrome: Diagnostic Criteria 161
11.3 Classical Clinical Manifestations of PCOS 162
11.4 Pathology 162
11.4.1 Radiologic Studies in PCOS 162
11.4.2 Pathophysiology and Laboratory Findings 162
11.5 Long-Term Risks OF PCOS 163
11.6 Genetic Origins 164
11.6.1 Cautions Regarding the Genetic Studies of PCOS 165
11.7 The Mevalonate Pathway and PCOS 165
11.7.1 Statin Effects on Ovarian Function 165
11.7.2 Clinical Trials of Statins in PCOS 165
11.8 Insulin Resistance in PCOS 166
11.9 Hyperandrogenism in PCOS 168
11.9.1 Hirsutism 168
11.9.2 Hypertrichosis and Virilization 169
11.9.3 Androgen Biosynthesis 170
11.9.4 Laboratory Evaluation of Hirsutism 172
11.10 Treatment of Hyperandrogenism and PCOS 173
11.10.1 Weight Reduction 173
11.10.2 Oral Contraceptives 175
11.10.3 Medroxyprogesterone Acetate 175
11.10.4 Gonadotropin-Releasing Hormone Agonists 176
11.10.5 Glucocorticoids 176
11.10.6 Ketoconazole 176
11.10.7 Spironolactone 176
11.10.8 Cyproterone Acetate 176
11.10.9 Flutamide 177
11.10.10 Cimetidine 177
11.10.11 Finasteride 177
11.10.12 Ovarian Wedge Resection 177
11.10.13 Laparoscopic Ovarian Diathermy 178
11.10.14 Physical Methods of Hair Removal 178
11.10.15 Insulin Sensitizers 178
11.10.16 Orlistat 179
11.11 Adrenal Conditions to Be Considered When Diagnosing PCOS 179
11.11.1 Cushing’s Syndrome 179
11.11.2 Congenital Adrenal Hyperplasia 183
11.12 Androgen-Secreting Ovarian and Adrenal Tumors 186
11.13 Virilization During Pregnancy 188
11.14 Virilizing Adrenal Neoplasms 188
11.15 Evidence-Based Guidelines in PCOS 188
References 190
The Current Status for Metformin Use in Reproductive Medicine 197
12.1 Metformin Pharmacology 197
12.2 Metformin and Effects on the PCOS Phenotype 197
12.3 Metformin and Ovulation Induction 198
12.4 Metformin and Infertility 198
12.4.1 Metformin vs. Clomiphene 199
12.4.2 Combination Therapy vs. Single Agent Therapy 200
12.4.3 Metformin and Gonadotropins and Laparoscopic Ovarian Diathermy 201
12.5 Metformin and Multiple Pregnancy 201
12.6 Metformin and Miscarriage 201
12.7 Metformin for Later Pregnancy Complications 201
12.8 Summary: Evidence-Based Guidelines 202
References 202
Clinical Aspects of Endometriosis 204
13.1 Pathogenesis 204
13.1.1 The Ectopic Transplantation 204
13.1.2 The Transformation (Metaplasia) of Coelomic 205
13.1.3 The Induction Theory 205
13.1.4 Genetic Basis 205
13.1.5 Immunologic Mechanisms 205
13.1.6 Environmental Factors 206
13.1.7 Future Research 206
13.2 Prevalence 206
13.3 Diagnosis 206
13.3.1 Pain 206
13.3.2 Subfertility and Infertility 207
13.3.3 Spontaneous Abortion 207
13.3.4 Endocrinologic Disorders 207
13.3.5 Clinical Examination 207
13.3.6 Imaging and Endometriosis 208
13.3.7 Laboratory Tests 208
13.4 Spontaneous Evolution During Pregnancy 209
13.5 Prevention 210
13.6 Therapy 210
13.7 Preoperative and Postoperative Hormonal Treatment 211
13.8 Results of Surgical Treatment 211
13.9 Medical Treatment 212
13.9.1 Empirical Therapy 212
13.9.2 Hormonal Medical Therapy 212
13.9.3 Aromatase Inhibitors 214
13.9.4 Nonhormonal Medical Therapy 214
13.9.5 Effícacy of Medical Treatment 214
13.10 Adolescent Endometriosis 214
13.11 Recurrence 215
13.12 Assisted Reproduction for Treatment of Endometriosis 215
13.12.1 Intrauterine Insemination 215
13.12.2 In Vitro Fertilization (IVF) 215
13.12.3 Intracytoplasmic Sperm Injection ( ICSI) 215
13.12.4 Gamete Intrafallopian Transfer 215
13.13 Coping with Disease 215
13.14 Summary-Treatment/Evaluation Algorithm 216
References 216
Common Endocrinopathies in Reproductive Endocrinology 221
14.1 Thyroid Disorders 221
14.1.1 Thyroid Hormones 221
14.1.2 Iodide Metabolism 222
14.1.3 Factors Affecting Risk for Autoimmune Thyroid Disorders 223
14.1.4 Evaluation 223
14.2 Prolactin Disorders 233
14.2.1 Prolactin Secretion 233
14.2.2 Hyperprolactinemia 235
14.3 Conclusion: Evidence-Based Case Studies 241
References 242
Acquired Uterine Factors and Infertility 247
15.1 Endometrial Polyps and Infertility 247
15.2 Leiomyomata 251
15.2.1 Diagnosis 251
15.2.2 Leiomyomata and Fecundity 252
15.2.3 Treatment Options 253
15.2.4 Planning Myomectomy 254
15.2.5 Considerations Favoring Myomectomy 254
15.2.6 Disadvantages of Myomectomy 255
15.2.7 Myomectomy 256
15.2.8 Minimizing Blood Loss During Myomectomy 257
15.3 Adenomyosis and Infertility 258
15.3.1 The Etiology 258
15.3.2 Patient Characteristics 259
15.3.3 Manifestations 259
15.3.4 Prevalence 259
15.3.5 Diagnosis 259
15.3.6 Magnetic Resonance Imaging of Adenomyosis 260
15.3.7 Postulated Mechanisms of Adenomyosis in Infertility 260
15.3.8 Possible Involvement in Infertility 261
15.3.9 Studies of Adenomyosis Therapy and Subsequent Fertility 261
15.4 Asherman Syndrome and Infertility 262
15.4.1 Definition 262
15.4.2 Clinical Presentation 262
15.4.3 Pathophysiology 262
15.4.4 Classification 263
15.4.5 Prevalence 264
15.4.6 Diagnosing Asherman syndrome 264
15.4.7 Therapy 265
15.4.8 Surgical Procedures 265
15.4.9 Prevention of Adhesion Reformation 267
15.4.10 Therapeutic Outcomes 269
15.4.11 Prevention of Intrauterine Adhesions 270
15.5 Conclusions 270
References 271
Müllerian (Paramesonephric) Anomalies and Associated Wolffian ( Mesonephric) Duct Malformations 277
16.1 Introduction 277
16.2 Incidence/Prevalence 277
16.3 Embryologic Origin 278
16.3.1 Embryology of the Fallopian Tubes, Uterus, and Uterine Cervix ( Fig. 16.1) 278
16.3.2 Embryology of the Vagina and Hymen ( Fig. 16.2) 280
16.4 Theories for the Etiology of Reproductive Malperformance 288
16.5 Diagnostic Evaluation and Treatment 288
References 288
References Table 2 289
Recurrent Miscarriage 293
17.1 Background and Introduction 293
17.1.1 Conceptus Development and Miscarriage 293
17.1.2 Epidemiology of Miscarriage and Recurrent Miscarriage 294
17.2 Etiologies of Recurrent Miscarriage 294
17.3 Genetic Factors 296
17.4 Structural Uterine Abnormalities 297
17.5 Endocrinologic Factors 298
17.6 Antiphospholipid Syndrome and Other Autoimmune Disorders 300
17.7 Genetic Thrombophilias and Recurrent Miscarriage 302
17.8 Alloimmunity, Pregnancy, and Miscarriage 302
17.9 Idiopathic Recurrent Miscarriage 304
17.10 Recommendations for Practice in Recurrent Miscarriage 305
References 305
Laparoscopy in the Diagnosis and Treatment of Female Infertility 309
18.1 Indications for Laparoscopy 309
18.2 Equipment 309
18.2.1 Imaging Systems 309
18.2.2 Insufflation 310
18.2.3 Surgical Instrumentation 310
18.2.4 Uterine Manipulators 310
18.2.5 Laparoscopic Applications of Energy 311
18.2.6 Mechanical Energy 311
18.2.7 Basic Electrosurgical Principles 18.2.8 Glossary of Electrosurgical Terms 312
18.3 Patient Positioning 313
18.4 Entering the Abdominal Cavity 313
18.4.1 Umbilical Site Veres Needle Technique 313
18.4.2 Open Laparoscopy 314
18.4.3 Direct Trocar Insertion 314
18.4.4 Left Upper Quadrant Entry 314
18.4.5 Vaginal Approaches to Insufflation 314
18.5 Secondary Trocar Placement 18.6 Tissue Removal 315
18.7 Operative Laparoscopy 316
18.8 Laparoscopic Myomectomy 317
18.9 Laparoscopy Using Local Anesthsia or Conscious Sedation 317
18.10 Conclusion 318
References 318
Turner Syndrome 319
19.1 Introduction 319
19.2 Diagnosis 320
19.3 Care for Girls and Women with TS 326
19.4 Summary: Evidence-based Guidelines 332
References 333
Errors in Chromosome Segregation During Oogenesis and Early Embryogenesis 337
20.1 Introduction 337
20.2 Investigation of Meiotic Chromosome Behaviour in Fetal Ovaries 339
20.2.1 Analysis of Meiotic Crossovers in Fetal Oocytes 340
20.2.2 Oocyte Crossover Patterns 340
20.2.3 Natural Elimination of Abnormalities 341
20.3 Meiotic Crossover Errors Detected by Family Linkage Analysis 341
20.3.1 Linkage Analysis of Trisomy 21 341
20.3.2 Linkage Analyses of Trisomy 13 and 18 343
20.4 Direct Evaluation of Oocyte Aneuploidy 343
20.4.1 Analysis of Oocyte Aneuploidy by Karyotyping 344
20.4.2 Analysis of Oocyte Aneuploidy Using Fish and CGH 344
20.4.3 Analysis of Oocyte Aneuploidy Using CGH 345
20.4.4 The Aneuploidy Rate in Human Oocytes 346
20.4.5 Aneuploidy in Early Human Embryos 348
20.5 Preimplantation Genetic Diagnosis for Chromosomal Disorders 349
20.5.1 Specific PGD for Carriers of Chromosomal Rearrangements 349
20.5.2 Preimplantation Genetic Screening for Aneuploidy 349
20.5.3 First Polar Body or Blastomere for the Diagnosis of Aneuploidy? 349
20.5.4 Problems with First PB Analysis 349
20.5.5 Problems with Single Blastomere Analysis 351
20.5.6 Controversies Over PGS 351
20.5.7 Screening the Whole Chromosome Complement 351
20.6 Conclusions 352
References 352
Part III Male Reproductive Physiology and Medicine 355
An Overview of Sperm Production 356
21.1 Introduction 356
21.2 General Features of Testicular Histology 356
21.3 Spermatogenesis 356
21.3.1 The Cycle of the Seminiferous Epithelium 357
21.3.2 The Wave of the Seminiferous Epithelium 358
21.3.3 Spermatogonial Stem Cell Renewal 358
21.3.4 Spermatocyte Development 359
21.3.5 Spermiogenesis: Associated Processes Involved in the Formation of Spermatids 359
21.4 The Spermatozoon 360
21.4.1 Role of the Golgi Apparatus in Acrosome Formation 360
21.4.2 Endoplasmic Reticulum 360
21.4.3 Chromatoid Body: Structure and Functions 361
21.4.4 Intercellular Bridges 361
21.4.5 Sperm Head and Nuclear Modifications 361
21.4.6 Structure of the Flagellum 362
21.5 Conclusions 363
References 363
Meiotic Recombination and Errors During Spermatogenesis 367
22.1 Introduction 367
22.2 Meiosis 367
22.2.1 Techniques Used to Study Genetic Recombination 368
22.2.2 Identification of Key Proteins Involved in Mammalian Chromosome Synapsis and Recombination 368
22.2.3 Timing and Progression of SC Formation 369
22.2.4 Fidelity of Meiotic Chromosome Synapsis 369
22.2.5 Variation in Meiotic Recombination Frequencies 369
22.2.6 Meiotic Recombination and Chromosome Synapsis in Infertile Males 371
22.3 Conclusions 372
References 373
Clinical Evaluation and Treatment of Male Factor Infertility 376
23.1 Introduction 376
23.2 History 376
23.3 Physical Examination 379
23.4 Laboratory Assessment 379
23.5 Development of a Differential Diagnosis 380
23.5.1 Low Seminal Volume 381
23.5.2 Azoospermia 382
23.5.3 Oligospermia 383
23.5.4 Asthenospermia 384
23.5.5 Teratozoospermia 385
23.5.6 Oligoasthenoteratospermia 385
References 385
Semen Analysis: Essentials for the Clinician 387
24.1 Introduction 387
24.2 Problems in Conducting the Semen Analysis 24.2.1 Biological Variability Affecting Semen Analysis 388
24.2.2 Causes for Technical Variability in Semen Analysis 388
24.3 Components of Basic Semen Analysis 389
24.3.1 Sample Collection: Preanalytical Issues 389
24.3.2 Semen Volume 389
24.3.3 Sperm Motility 389
24.3.4 Sperm Vitality 389
24.3.5 Sperm Concentration 390
24.3.6 Sperm Morphology 390
24.4 Other Investigations 390
24.4.1 Semen Biochemistry 391
24.4.2 White Blood Cells and Bacteria 391
24.4.3 Antisperm Antibodies 391
24.4.4 Hyperactivation 392
24.4.5 Zona Binding 392
24.4.6 Acrosome Reaction 392
24.4.7 Sperm–Oocyte Interaction and Penetration 392
24.4.8 Reactive Oxygen Species 392
24.4.9 Sperm DNA Integrity 393
24.4.10 Stem Cells 393
24.5 Aspects of Evaluation and Identification of Clinical Pathologies 393
References 394
Sperm Capacitation, the Acrosome Reaction, and Fertilization 397
25.1 Introduction 397
25.2 Gamete Transport and Recognition 397
25.2.1 Sperm Interactions with the Vaginal Environment, Cervix, and Uterus 398
25.2.2 Uterotubal Junction, Oviductal Transport, and Oviductal Sperm Reservoir 399
25.2.3 Sperm Capacitation 399
25.2.4 Sperm Hyperactivation 400
25.2.5 Ovulation, Oocyte Pickup, and Sperm– Egg Recognition 400
25.3 Sperm–Egg Coat Binding and Acrosomal Exocytosis 401
25.3.1 Oocyte Zona Pellucida Composition and Assembly 401
25.3.2 Sperm Acrosome Biogenesis and Structure 25.3.3 Sperm–Zona Binding 402
25.3.4 Sperm Acrosomal Proteins Implicated in Sperm– Zona Interactions 403
25.3.5 Acrosomal Exocytosis (AE) 404
25.3.6 Sperm–Zona Penetration 405
25.4 Sperm–Oolemma Binding, Sperm Incorporation and Oocyte Activation 406
25.4.1 Sperm–Oolemma Binding and Fusion 407
25.4.2 Sperm Incorporation 407
25.4.3 Solubilization of Sperm Perinuclear Theca and the Release of SOAF 407
25.4.4 Oocyte Activation and the Identity of SOAF 409
25.4.5 Antipolyspermy Defense 410
25.5 Zygotic/Pronuclear Development 411
25.5.1 Sperm Chromatin Remodeling and Formation of Pronuclei 412
25.5.2 Early Transcriptional Activity 412
25.5.3 Sperm Aster Formation and PN Apposition 413
25.5.4 Degradation of Sperm Accessory Structures 415
25.5.5 Differences Between Natural Fertilization and ICSI 415
25.6 Conclusions 417
References 418
26.1 Introduction 430
Advanced Tests of Sperm Function 430
26.1 Introduction 430
26.1.1 Sperm DNA Damage 431
26.1.2 Sperm FISH for Chromosomal Aneuploidy 431
26.2 Hypo-osmotic Swelling Test 432
26.3 Cervical Mucus/Sperm Interaction Assay 432
26.4 Sperm Capacitation Assays and Acrosome Reaction Assays 433
26.5 Hemizona and Zona-PellucidaBinding Assay 433
26.6 Sperm Penetration Assay (or Zona-Free Hamster Oocyte Penetration Assay) 434
26.7 Conclusions 435
References 435
Genetic Testing of Male Infertility 437
27.1 Introduction 437
27.2 Pretesticular (Congenital Endocrine) Forms of Male Infertility Due to Genetic Factors 437
27.3 Posttesticular Forms of Male Infertility Due to Genetic Factors 440
27.4 Testicular Forms Due to Genetic Factors 441
27.5 Genetic Tests with Potential Clinical Interest 444
27.6 Conclusions 446
References 447
Varicocele and Male Infertility 451
28.1 Introduction 451
28.2 Pathophysiology 451
28.3 Diagnosis 452
28.4 Indications for Treatment 453
28.5 Modalities of Treatment 453
28.5.1 Surgery 454
28.5.2 Percutaneous Embolization 454
28.5.3 Complications 454
28.6 Outcomes of Varicocele Repair 28.7 Conclusions 455
28.8 Summary: Evidence-Based Guidelines 455
References 455
Sperm Retrieval Techniques 458
29.1 Introduction 458
29.1.1 Vasal Sperm Aspiration 458
29.1.2 Epididymal Sperm Aspiration 460
29.1.3 Testicular Sperm Aspiration and Extraction 461
29.1.4 Laboratory Effort and Timing of Sperm Retrieval 467
29.1.5 Sperm Cryopreservation 29.2 Conclusions 468
References 469
The Clinical Utility of the Evaluation of Sperm Chromatin 471
30.1 Introduction 471
30.2 Sperm DNA Structure 472
30.3 Mechanisms of Sperm DNA Damage 472
30.3.1 Apoptosis 473
30.3.2 Oxidative Stress 473
30.3.3 Defective Sperm Chromatin Packaging 473
30.4 Methods of Sperm DNA Evaluation 474
30.4.1 Assessment of Sperm DNA Damage or Fragmentation 474
30.4.2 Assessment of Sperm DNA Packaging or Condensation 476
30.5 The Clinical Utility of Sperm DNA Assessment 477
30.6 Reduction of Sperm DNA Damage 480
30.6.1 Oral Antioxidants 481
30.6.2 Sperm Separation 481
30.6.3 High-Magnification ICSI 481
30.6.4 ICSI with Testicular Spermatozoa 481
30.7 Conclusions 482
References 483
Part IV Assisted Reproductive Therapies: Artificial Insemination 488
Artificial Insemination: Intrauterine Insemination 489
31.1 Introduction 489
31.2 History 489
31.3 Techniques of Intrauterine Insemination 490
31.3.1 Controlled Ovarian Hyperstimulation 490
31.3.2 Analogs 491
31.3.3 Monitoring, Timing, and/or Induction of Ovulation 491
31.3.4 Modalities of Insemination 492
31.4 Effectiveness of Intrauterine Insemination 492
31.4.1 Intrauterine Insemination in Unexplained Subfertility 492
31.4.2 Intrauterine Insemination in Cervical Factor Subfertility 492
31.4.3 Intrauterine Insemination in Male Subfertility 493
31.5 Risks of Intrauterine Insemination 494
31.6 Patients’ Preferences for Intrauterine Insemination 494
31.7 Intrauterine Insemination or Expectant Management 495
31.8 Conclusion 495
31.9 Cases 31.9.1 Case 1 495
31.9.2 Case 2 496
References 496
Sperm Preparation for Artificial Insemination 499
32.1 Introduction 499
32.2 Patient Education 500
32.3 Laboratory and Physician Communication 500
32.4 Employee Training 500
32.5 Sample Handling and Safety 500
32.6 Sample Identification and Documentation 501
32.7 Equipment and Reagents 501
32.8 Sperm Preparation Worksheets and Records 502
32.9 Overview of Sperm Preparations 502
32.9.1 Basic Wash Preparation 502
32.9.2 Density Gradient Preparation 503
32.9.3 Swim-Up Preparation 503
32.9.4 Refrigeration Incubation Preparation 504
32.9.5 Heparin Incubation Preparation 505
32.9.6 Retrograde Wash Preparation 505
32.9.7 Preparation of Cryopreserved Sperm 506
32.9.8 Sample Handling After Preparation 507
32.10 Special Considerations 507
32.11 Conclusions 508
References 508
Sperm Banking, Donation, and Transport in the Age of Assisted Reproduction: Federal and State Regulation 510
33.1 Introduction 510
33.2 Sperm Banking 510
33.3 Donor Sperm 511
33.4 Sperm Donor Testing 512
33.5 Laboratory Procedures for Sperm Cryopreservation 512
33.6 Laboratory Techniques for Sperm Cryopreservation 513
33.7 Storage of Cryopreserved Semen 514
33.8 Cross Contamination 514
33.9 Transport of Cryopreserved Semen 515
33.10 Clinical Aspects of use of Frozen Semen in Artificial Insemination and Art 515
References 516
Reproductive Treatment of HIV-1 Discordant Couples 518
34.1 Introduction 518
34.2 HIV in Semen 518
34.3 Semen Processing and Sperm Washingwith Swim-Up 520
34.4 Assisted Reproduction 521
34.5 Conclusion 524
References 524
Ovulation Induction 526
35.1 Induction of Ovulation for Specific Disorders 526
References 537
Transvaginal Sonography in Reproductive Endocrinology and Infertility 545
36.1 History of Transvaginal Sonography 545
36.2 Limitations of TVS 545
36.3 Practical Physics 545
36.4 Ultrasound Equipment 547
36.5 The Examination 547
References 562
Part V Assisted Reproductive Therapy: In Vitro Fertilization 566
Establishing the IVF Laboratory: A Systems View 567
37.1 Introduction 567
37.2 Key Parameters of Maternal Systems 567
37.2.1 Temperature 567
37.2.2 pH Control 568
37.2.3 Waste Products 568
37.2.4 Detoxification Mechanism 568
37.2.5 Sterilizing and Fixing Agents 568
37.2.6 Pollutants as Possible Biological Signals 569
37.2.7 Mineral Oil and Embryo Culture System 569
37.3 Key Characteristics of Modern IVF Facilities 569
37.3.1 HEPE Filtration 570
37.3.2 Material Selection for Construction 571
37.4 Performance of Traditional IVF Laboratory Architecture 571
37.5 Modern IVF Facilities 572
37.5.1 100% Outside Air vs. 50% Outside Air 572
37.5.2 Chemical Filtration 572
37.5.3 Laboratory Layout 573
37.5.4 Casework for IVF Laboratories 573
37.5.5 Flooring 573
37.5.6 Paint 573
37.5.7 Lighting 573
37.6 The Modern IVF Laboratory 573
37.7 The Reality of Building an IVF Laboratory 574
37.8 Performance of Modern IVF Laboratories 575
References 576
Preparation and Selection of Sperm for IVF and ICSI 577
38.1 Introduction 577
38.2 Semen Collection 578
38.3 Sperm Processing Techniques 578
38.3.1 Simple Washing and Dilution 578
38.3.2 Swim-Up from Pellet 578
38.3.3 Swim-Up from Nonpelleted Samples 579
38.3.4 Density Gradient Centrifugation 579
38.3.5 Density Gradient and Swim-Up Combination 580
38.3.6 Glass Wool Filtration 580
38.3.7 Sephadex Columns 580
38.3.8 Microfluidics 581
38.3.9 Viral Sperm Processing 582
38.4 Postseparation Treatment of Spermatozoa 583
38.5 Selection Criteria 583
38.6 Conclusions 585
References 585
The Genetic and Epigenetic Contributions of Sperm to Early Embryogenesis 589
39.1 Introduction 589
39.2 Aneuploidy of Paternal Origin 589
39.3 Y Chromosome Microdeletions 591
39.3.1 Phenotypes Associated with Y Chromosome Microdeletions 591
39.3.2 Y Chromosome Microdeletions in Fertile and Infertile Man 591
39.3.3 Y Chromosome Microdeletions and ART Outcome 592
39.3.4 Indications for Y Chromosome Microdeletion Testing in a Clinical Setting and the Need for Standardization 592
39.4 Epigenetic Factors 593
39.5 DNA Methylation in Gametes and Embryos 593
39.5.1 Implications of Altered Gamete and Early Embryo DNA Methylation 594
39.5.2 Imprinting in Spermatozoa of Men with Abnormal Semen Parameters 595
39.6 Conclusions 595
References 596
Micromanipulation of Human Oocytes and Embryos: Applications of Intracytoplasmic Sperm Injection and Assisted Hatching in Infertility Treatment 598
40.1 Introduction 598
40.2 Intracytoplasmic Sperm Injection 599
40.3 ICSI Methods 600
40.3.1 Cumulus Cells and ICSI 600
40.3.2 ICSI Tools 600
40.3.3 Artificial Activation Following ICSI 600
40.3.4 Sperm Selection 601
40.3.5 ICSI with Nonejaculated Sperm 601
40.4 Indications for the Use of ICSI 603
40.5 ICSI Efficiency 603
40.6 ICSI Safety 603
40.7 Assisted Hatching 604
40.8 Methods 605
40.9 Conclusions 606
References 606
Embryo Culture Techniques 610
41.1 Introduction 610
41.2 Historical Perspective on Development of Embryo Culture Techniques 610
41.3 Advances in IVF Technologies 612
41.4 Culture Methods 612
41.4.1 Air Quality 613
41.4.2 Temperature 613
41.4.3 Light 613
41.4.4 Incubator Gas Phase 614
41.4.5 pH 615
41.4.6 Media 615
41.4.7 Plating Considerations 620
41.5 Oocyte and Embryo Handling Strategies 623
41.6 Developing Embryo Culture Techniques 625
41.7 Conclusions 625
References 626
In-Vitro Maturation of Human Oocytes 630
42.1 History and Development of IVM of Human Oocytes 630
42.2 Oocyte Maturation 631
42.3 IVM in Practice 632
42.4 Gonadotropin Priming in IVM Cycles 636
42.5 Overview of an IVM Cycle 639
42.6 Outcome of IVM Cycles 640
42.7 Conclusions: Evidence-Based Guidelines 640
References 641
Integrating Preimplantation Genetic Diagnosis into the ART Laboratory 644
43.1 Introduction 644
43.2 Rationale for PGD 645
43.3 PGD vs. PGD-AS 645
43.4 Requirements for In-House PGD 646
43.4.1 What Kind of Program Requires In- House PGD? 646
43.4.2 IVF Laboratory Micromanipulation Technology 646
43.5 Referral PGD 647
43.6 Setting up PGD-AS 647
43.6.1 How to Obtain a Blastomere for Analysis 647
43.6.2 Blastomere Fixation and Techniques 648
43.6.3 Extended Culture and Tracking Individual Embryos 649
43.6.4 Paperwork 649
43.6.5 Chromosomal Diagnosis Using FISH 649
43.6.6 Laboratory Space 652
43.6.7 What’s the Setup Cost? 652
43.6.8 Qualified Personnel 652
43.7 Personnel Training 652
43.7.1 In-House Training 653
43.7.2 Workshop Training 653
43.7.3 Certification: State, National, and Federal 653
43.8 Is There A Cost Breakeven Point? 653
43.9 Ethical Considerations 654
43.10 Government Involvement 654
43.11 Genetics and Public Policy 654
43.12 Practice Controversy and Philosophical Polarization 654
43.13 Summary and Conclusions 655
43.14 Appendix A 655
References 655
Evaluation and Selection of Preimplantation Embryos for Transfer 659
44.1 Introduction 659
44.2 Gamete Scoring 659
44.2.1 The Spindle 661
44.2.2 Oocyte Respiration 661
44.3 The Fertilized Oocyte 662
44.4 Scoring the Cleaving Embryo 664
44.5 Blastocysts Formation and Scoring 668
44.6 Conclusions 668
References 669
Embryo Transfer in IVF: Evidence-Based Clinical Practice 672
45.1 Ease of Transfer 672
45.2 Trial Transfers 673
45.3 Ultrasound Guidance Versus Clinical Touch 673
45.4 Preparing the Patient 674
45.5 Preparing the Catheter 674
45.6 Depositing the Embryos 675
45.7 After the Procedure 676
45.8 Alternative Methods 676
45.9 Number of Embryos to Transfer 676
45.10 Blastocyst Versus Cleavage Stage Embryo Transfer 678
45.11 Summary: Evidence-based guidelines 678
References 679
Cryopreservation of Human Oocytes and Embryos 683
46.1 Basics of Cryopreservation 683
46.1.1 Cryoprotectant Agents 683
46.1.2 Slow Freezing 684
46.1.3 Cryodamage 685
46.1.4 Vitrification 686
46.2 Cryopreservation of Human Embryos 686
46.2.1 Cryopreservation of Cleavage Stage Embryos 687
46.2.2 Blastocyst Cryopreservation 688
46.3 Cryopreservation of Human Oocytes 689
46.4 Storage of Cryopreserved Oocytes and Embryos 691
46.5 Conclusions 692
References 692
Preserving Fertility 696
47.1 Facts About Cancer 696
47.3 Chemotherapy Agents: Ovarian Toxicity 697
47.4 Ovarian Damage Induced by Radiation 698
47.5 Other Reproductive Harms Associated with Chemotherapy and Radiation 698
47.6 Strategies to Preserve Reproductive Function 699
47.7 Ovarian Tissue Freezing 699
47.8 Ovarian Transplantation 699
47.9 Embryo Cryopreservation 700
47.10 Oocyte Freezing 700
47.11 Ovarian Transposition (Oophoropexy) and Other Options 701
47.12 Conclusion: Evidence-Based Guidelines 701
References 702
Ovarian Hyperstimulation Syndrome 704
48.1 Introduction 704
48.2 Risk Factors 704
48.3 Classification 704
48.4 Prevention of OHSS 705
48.5 Treatment 705
48.5.1 Outpatient Management 705
48.5.2 In Patient Management 705
48.6 Treatment/Evaluation Algorithm 706
References 706
Pregnancy Outcomes in Infertile Couples 707
49.1 Introduction 707
49.2 Competing Risks 707
49.3 Pregnancy Outcomes 710
49.4 Counseling 713
49.4.1 Multiple Gestations 714
49.4.2 Obstetric Complications 714
49.4.3 Congenital Malformations and Chromosomal Abnormalities 714
49.4.4 Other Risks 714
References 714
The Impact of Complementary Medicine on In Vitro Fertilization 718
50.1 Introduction 718
50.2 Physiological Changes: Beta-Endorphin 719
50.2.1 Physiological Changes: Autonomic Nervous System and Regulation of Blood Flow 720
50.2.2 Psychological Changes: Anxiety and Depression 720
50.3 Clinical Outcome Data: Non-IVF Studies 721
50.3.1 Clinical Outcome Data: IVF 721
50.4 Summary: Evidence-Based Guidelines 725
References 725
Part VI Research in the REI Practice and Laboratories 729
Designing a Clinical Research Infrastructure 730
51.1 Introduction 730
51.2 Patient Population 730
51.2.1 Specialty- or Subspecialty-Based Recruitment 731
51.2.2 Population-Based Recruitment 732
51.3 Protocols 733
51.4 Personnel 733
51.5 Finances 735
51.6 IRB/Compliance 736
51.6.1 Basic Ethical Principles 737
51.6.2 Research Regulations 737
51.7 Conclusions 738
References 738
Integrating Research into a Clinical Practice 739
52.1 Introduction 739
52.2 Benefits of Integrating Research into a Clinical Practice 739
52.2.1 An Improved Knowledge Base and Critical Thinking Skills 740
52.2.2 Improved Job Satisfaction 740
52.2.3 Service to Patients and Community 740
52.3 Tools to Implement Research into a Clinical Practice 740
52.3.1 Review the Literature 740
52.3.2 Discuss Ideas with Colleagues 740
52.3.3 Involve Staff in a Journal Club 741
52.3.4 Evaluate Your Situation and Utilize Your Assets 741
52.3.5 Delegate 741
52.3.6 Use Your Quality Assurance Program 741
52.3.7 Build on Small Successes 742
52.3.8 Collaborate 742
52.3.9 Establish a Research-Oriented Team 742
52.3.10 Consistently Monitor Progress 742
52.4 Conclusions 743
References 743
Research Regulations: The Role of the Institutional Review Board 744
53.1 Background 744
53.2 Finding and Choosing an Institutional Review Board 745
53.3 The Application Process 745
53.4 Patient Privacy and Sample Storage 748
53.5 Summary References 749
Technology Transfer and Its Role in the Practice of Reproductive Endocrinology and Infertility 750
54.1 Technology Transfer 750
54.2 A Brief History of Technology Transfer in the United States 750
54.3 The Impact of Technology Transfer 751
54.4 Intellectual Property 752
54.5 Who Owns Your Invention? 752
54.6 The Invention 753
54.7 Obtaining a Patent 753
54.7.1 Novelty 753
54.7.2 Utility 753
54.7.3 Nonobviousness 753
54.7.4 Adequately Described 753
54.7.5 Patent Systems 754
54.8 Types of Patent Application 754
54.8.1 Provisional Patent Application 754
54.8.2 Utility Application 755
54.8.3 PCT Application 755
54.8.4 National Phase Patent Applications 755
54.8.5 European Patent Office 755
54.9 Prosecuting a Patent Application 755
54.10 How Much Does it Cost to Get a Patent? 756
54.11 Licensing The Patent 757
54.11.1 Types of Licensee 757
54.11.2 Finding a Licensee 757
54.12 Forming a Start-Up Company 760
54.12.1 Finding a Business Partner 760
54.12.2 Working with Students 761
54.12.3 Communicating the Idea 761
54.12.4 Forming the Company 762
54.12.5 The Initial Funding 763
54.13 Case Study 54.13.1 CALM 767
References 767
The Environment and Reproduction: Endocrine Disruption, Reproductive Impairment, and Epigenetics 768
55.1 Introduction to Endocrine Disruption 768
55.2 The Chemical Substance Inventory 769
55.3 Identified Environmental Chemicals and Contaminants 769
55.4 Reproductive Concerns Regarding Environmental Chemicals and Contaminants 769
55.5 Endocrine Disruption Study Design Challenges 775
55.6 Endometriosis: A Marker for Endocrine Disruption 775
55.7 Altered Enzyme Pathways and/or Gene- Dependent Activities 776
55.8 Reproductive Health Effects of Environmental Chemical Exposure 780
55.9 Actions 781
55.10 Conclusion 781
References 781
Index 791