First-trimester Down syndrome screening following assisted conception

19 12 2013

To the Editor:

We would like to comment on the article written by Dr. Bellver and colleagues (1) regarding the need for adjustments of first-trimester Down syndrome screening parameters following assisted conception. Although we greatly appreciate their work, which confirms earlier data in the field, we would like to issue some additional remarks.

The Bellver et al. study suggests a reduced maternal serum pregnancy-associated plasma protein A (PAPP-A) and increased false positive rates (FPR) in singleton pregnancies achieved by in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), compared with naturally conceived pregnancies. However, the latter showed to be significant when including only ICSI cycles using non-donor oocytes. The authors discuss several other groups according mode of conception (IUI with partner or donor sperm, IVF, non-donor versus donor oocytes, fresh versus frozen embryo transfer), which veils the main message of the article, namely that (at least in their cohort) only in ICSI non-donor cycles serum PAPP-A level at first-trimester Down screening is significantly different from that seen in natural pregnancies. In their manuscript the authors describe a « diminished » PAPP-A level, even in cases where these levels are not significantly different, which is confusing. Read the rest of this entry »

The postreproductive salpingectomy

13 12 2013

To the editor:

Findley et al. report (1) that simultaneous salpingectomy performed at the time of hysterectomy has no short-term negative effects on ovarian reserve. To add plausibility to this finding, we would like to point to the vascular connections: In the ovaries, blood supply is mainly secured via the arteria ovarica from the aorta and via the ramus ovaricus from the arteria uterina. These two arteries naturally anastomose with each other. A further branch of the arteria uterina, the ramus tubarius, connects the fallopian tube. During hysterectomy, the arteria uterina is ligated. Nevertheless, the central branch of the arteria ovarica in the infundibulopelvic ligament still guarantees sufficient blood flow from the aorta to the ovaries. A collateral connection of the remaining branch of the ramus tubarius from the anastomosis with the arteria ovarica also secures the vascular supply of the fallopian tube. However, when salpingectomy is performed concomitant to hysterectomy, the ramus tubarius will be removed. Accordingly, all the blood passing through the ligamentum infundibulo pelvicum will now become available to the ovaries. Blood circulation through the ovaries should thus remain unaffected or even increase when hysterectomy is combined with salpingectomy.

The few available studies support the hypothesis that removal of both uterus and fallopian tubes causes a redistribution of the blood flow in favor of the ovaries. Moreover, hormone production by the ovaries was also found to be unaffected even months after the intervention (2, 3). Read the rest of this entry »

Microdissection testicular sperm extraction in older men

10 12 2013

To the Editor:

Women experience a notable decrease in oocyte production in their late thirties; however, the effect of age on spermatogenesis is less well described. Indeed, while there are no known limits to the age at which men can father children, the effects of advanced paternal age are incompletely understood. Reproductive concerns related to advanced paternal age are less well defined (1) with a recent whole-genome sequencing study suggesting an increased risk for rare de novo mutations for older fathers (2). Whether the risk for major birth defects from de novo mutations is greater than the risk from assisted reproduction remains unknown (3).

Our retrospective study showed that sperm retrieval rates in men undergoing microdissection testicular sperm extraction (TESE) was not negatively affected by age (4). Despite the limited number of men in this study as pointed out by Kim (5), it remains the largest study to evaluate the effect of male age on sperm retrieval in nonobstructive azoospermia (NOA). The sperm retrieval rates were similar in men <30 years of age, 30 to 50 years of age, and older than 50 years of age (~50 – 60%). We identified that most men over 50 years of age who had successful sperm retrieval had hypospermatogenesis histology on previous diagnostic biopsy. It is possible that some older men with NOA may have secondary azoospermia with sperm detectable in the ejaculate at an earlier age. Therefore, it is likely that older men may be more likely to have acquired NOA (i.e., secondary infertility), whereas younger men may be more likely to have congenital NOA. Read the rest of this entry »

Response to commentary on manuscript: “The impact of fresh versus cryopreserved testicular sperm on intracytoplasmic sperm injection (ICSI) pregnancy outcomes in men with azoospermia due to spermatogenic dysfunction: a meta-analysis”

9 12 2013

To the Editor:

We appreciate the insightful comments of Dr. Kim (1). As he correctly states, the use of fresh versus cryopreserved sperm has been controversial. While the use of frozen sperm from men with obstructive azoospermia appears to yield equivalent outcomes to fresh sperm, the application to men with nonobstructive azoospermia (NOA) is less certain (2). However, if proven equivalent, Dr. Kim correctly emphasizes the significant logistical and economic burdens that could be improved for couples. Additionally, we agree with his assessment on the importance of methodology. We as male reproductive specialists do not have a standardized, evidence-based protocol for the cryopreservation of sperm. As such, we believe that there should be some caution in mentioning an established detrimental effect of cryopreservation. The analyses that produced such findings suffer the same methodological dependence that is inherent within essentially any cryopreservation data to date (3). Moreover, as data from men with obstructive azoospermia suggest equivalent outcomes, it appears that cryopreservation does not irreparably impact sperm function (2). Read the rest of this entry »

Regarding “Medical treatment of ectopic pregnancy: a committee opinion”

6 12 2013

To the Editor:

We welcome the recently published article by the Practice Committee of the American Society for Reproductive Medicine on the medical treatment of ectopic pregnancy (EP) (1). In selected patients, Methotrexate (MTX) is an effective treatment for unruptured EP and helps to avoid surgical intervention.

We are however concerned about some aspects of the committee’s opinion. The document advocates the use of single measurements of serum human chorionic gonadotropin (hCG) as a discriminatory zone to separate abnormal from normal gestations at the first presentation, if a transvaginal ultrasound scan (TVS) fails to identify the location of a pregnancy. This approach is not without risk. For example, it does not take into account the possibility of a multiple pregnancy where for a given gestational age serum hCG levels are higher than in a singleton. Consequently, hCG levels in multiple pregnancies are usually much higher before the pregnancy reaches a size that may be visualized on TVS (2). This could result in the administration of MTX to a woman with a pregnancy of unknown location (PUL) who has a developing twin pregnancy rather than an underlying EP. Such an outcome would in all likelihood lead to major congenital abnormalities in the developing fetuses. We recommend that the diagnosis of EP be based on the positive identification of an EP mass if inappropriate use of MTX is to be avoided. In the event of a PUL, waiting 48 hours to determine the hCG ratio has been shown to be a safe management approach, which offers further reassurance if the ratio is incompatible with a viable IUP (3). Read the rest of this entry »