Microbiota of the seminal fluid

22 01 2014

To the Editor:

I read with great interest the article by Hou et al. (1) regarding the microbiota of the seminal fluid from sperm donors and infertile subjects. This study aimed to explore potential causes of male infertility and showed that increased number of bacteria were present in semen samples from infertile subjects as well as sperm donors. The topic of infections and infertility is extremely interesting, and there are still a lot of aspects to be covered.

The significance of bacteriospermia in subfertile men is controversial. When dealing with a sperm sample the possibility of contamination is always probable since the presence of normal flora cannot be overlooked. Moreover, it is quite challenging to evaluate which microorganisms significantly affect male fertility potential. However, bacteriospermia and leukocytospermia have a negative effect on male fertility through multiple proposed mechanisms (2). In the largest study to evaluate bacteriospermia, Domes et al. (2) commonly diagnosed in subfertile men bacteriospermia and leukocytospermia, which were associated with a significantly increased DNA fragmentation index. Read the rest of this entry »





Examining the ovaries by ultrasound for diagnosing hyperandrogenic anovulation: updating the threshold for newer machines

9 01 2014

To the Editor:

We enjoyed reading the article by Christ et al. (1). The discussion about ultrasound criteria, specifically where to put the threshold to distinguish between a polycystic and a normal ovary, has been ongoing for some time and will surely continue for a while yet. Although the results are somewhat predictable since this report is a reassessment of partial data from a previous study (2), the timing of this publication is important because it reinforces a recently published task force report (3). Change is long overdue, but we believe the recommendation of using ≥ 25 follicles per ovary (3) should be adopted promptly as it is clear that the former threshold of 12 follicles is obsolete due to the improvement in the resolution of ultrasound. However, physicians should be aware that a much lower threshold should be used when trying to identify women at high risk of having an excessive response to exogenous gonadotropins used in in vitro fertilization/intracytoplasmic sperm injection cycles. Women with a total antral follicle count (AFC) > 20, considering both ovaries, are already at a higher risk of ovarian hyperstimulation syndrome (4). Another important point to consider when choosing the best threshold are the differences observed in AFC during reproductive age (5). The question of using the same threshold or different thresholds depending on a woman’s age should be balanced between diagnostic test accuracy and ease of implementation. Read the rest of this entry »





The lack of clinical congruence in diagnosis and research in relation to subclinical hypothyroidism

8 01 2014

To the Editor:

We have just read a publication by Bernardi et al. on the topic of subclinical hypothyroidism and recurrent early pregnancy loss (1). Going through the paper we found that the opposite situation was being described, that is, no impact of subclinical hypothyroidism on recurrent early pregnancy loss. This puzzling situation motivated us to dissect the concepts presented by the authors.

One central point of misconception on thyroid function can be tracked down to a 2007 publication cited by Bernardi which recommended a “desirable TSH level” of 2.5 mIU/ml for pregnant women. In that original publication the authors had admitted that this recommendation was done on the basis of a poor level of evidence. Although this recommendation does not fulfill the principles of evidence-based medicine, it has very unfortunately found its way into clinical practice. Choosing a low cut-off value for the upper range of TSH, as Bernardi et al. have done, will result in a misclassification of normal subjects by which the apparent subgroups, euthyroids and women with subclinical hypothyroidism, are not truly subgroups but belong to a same group of subjects having TSH values within the normal range. Therefore it is logical that one cannot expect to find any difference between these artificial subgroups in relation to recurrent early pregnancy loss. Read the rest of this entry »





The effect of methotrexate injection for treatment of an ectopic pregnancy on ovarian reserve

7 01 2014

To the Editor:

We read with great interest the paper “Does methotrexate administration for ectopic pregnancy after in vitro fertilization (IVF) impact ovarian reserve or ovarian responsiveness?” by Boots et al. (1). In the article, the authors evaluated the effects of methotrexate (MTX) on the future fertility of women undergoing IVF by comparing markers of ovarian reserve (day 3 FSH, antral follicle count), measures of ovarian responsiveness (duration of stimulation, peak E2 level, total dose of gonadotropins, number of oocytes retrieved, fertilization rate), and time from MTX administration to subsequent IVF cycle, in the IVF cycle before and after an ectopic pregnancy (EP) treated with MTX. They concluded that MTX treatment of an EP does not compromise ovarian reserve or ovarian responsiveness in subsequent cycles. However, other studies have demonstrated that when gonadotropin stimulation dose remains unchanged, fewer oocytes may be collected after MTX is taken as management of an ectopic pregnancy, suggesting a decrease in ovarian reserve (2). Read the rest of this entry »





The Playing Field is Changing . . .

7 01 2014

To the Editor:

The clinical practice of assisted reproductive technology (ART) has continued to evolve rapidly. The Practice Committee of the American Society for Reproductive Medicine (ASRM) in collaboration with the Society for Assisted Reproductive Technology (SART) in October 2012 e-published a guideline indicating that the cryopreservation of oocytes should no longer be experimental (1). As a direct result, the current system of data collection for SART and the Center for Disease Control and Prevention (CDC) requires revision. Additional data collection is required to comply with the Fertility Clinic Success Rate and Certification Act (FCSRCA) of 1992 (Wyden Law).

Moreover, other trends in ART practice have been identified. The freezing of embryos following blastocyst biopsy is often necessary to allow adequate time to obtain results of genetic testing prior to embryo transfer (2). Some clinics also freeze eggs or embryos from multiple stimulations/retrievals prior to transfer as a strategy to manage low responder patients (3). Critiques of our current reporting system together with suggested changes have recently been published by SART members (4, 5). SART has been well aware of these practice trends and the inability of our current reporting system to handle them. Read the rest of this entry »