Consideraciones éticas y científicas del inicio de la vida sobre el aborto eugenésico en enfermedades genéticas incapacitantes en Perú

El artículo expone conceptos actuales biológicos, así como algunos planteamientos filosóficos acerca del inicio de la vida, que se examinarán en relación con la necesidad del aborto eugenésico. Se presenta el concepto de "exdurantismo", en el que la combinación del nuevo genoma nuclear y mitocondrial hacen único al individuo; además, se concibe al complejo genómico como "integrador somático" que dirige el desarrollo embrionario, y se muestra la problemática en el caso de las violaciones que provocan embarazos, el aborto eugenésico en enfermedades genéticas incapacitantes o la utilización de embriones posterior a la fertilización in-vitro. Se plantea que la dignidad de la persona comienza desde la concepción. Frente a la detección de una enfermedad genética, grave o letal, se debe ofrecer soporte económico y social, de diagnóstico y tratamiento; además, desde la salud pública, una mayor inversión para plantear estrategias de tamizaje, diagnóstico, manejo e investigación.

The article presents current biological concepts, as well as some philosophical approaches to the beginning of life, which will be examined in relation to the need for eugenic abortion. The concept of "exdurantism" is presented, in which the combination of the new nuclear and mitochondrial genome makes the individual unique; furthermore, the genomic complex is conceived as a "somatic integrator" that directs embryonic development, and the problematic is shown in the case of rape that causes pregnancies, eugenic abortion in incapacitating genetic diseases or the use of embryos after in-vitro fertilization. The dignity of the person begins at conception. When a serious or lethal genetic disease is detected, economic and social support, diagnosis and treatment should be offered; in addition, public health should invest more in screening, diagnosis, management and research strategies.

O artigo apresenta conceitos biológicos atuais, bem como algumas abordagens filosóficas sobre o início da vida, que serão examinados em relação à necessidade do aborto eugênico. É apresentado o conceito de "exdurantismo", no qual a combinação do novo genoma nuclear e mitocondrial torna o indivíduo único; além disso, o complexo genômico é concebido como um "integrador somático" que dirige o desenvolvimento embrionário, e é mostrada a problemática no caso de estupro que resulta em gravidez, aborto eugênico em doenças geneticamente incapacitantes ou o uso de embriões após a fertilização in vitro. Argumenta-se que a dignidade da pessoa começa na concepção. Diante da detecção de uma doença genética, grave ou letal, devem ser oferecidos apoio econômico e social, diagnóstico e tratamento, bem como maior investimento em saúde pública em estratégias de triagem, diagnóstico, gestão e pesquisa.

Malformação arteriovenosa uterina: um relato de caso / Uterine arteriovenous malformation: a case report

O presente estudo tem como objetivo relatar o caso de uma paciente com malformação arteriovenosa uterina, efetivamente tratada com embolização seletiva e com fertilidade preservada. A malformação arteriovenosa uterina é uma alteração vascular rara até então pouco descrita na literatura. A paciente do sexo feminino apresentou quadro de sangramento uterino anormal, com início 30 dias após um abortamento, sem realização de curetagem, de uma gestação resultante de fertilização in vitro. Foram, então, realizados exames de imagem, que levaram ao diagnóstico de malformação arteriovenosa uterina. O tratamento de escolha foi a embolização arterial seletiva, com resolução do caso. Após sete meses, nova fertilização in vitro foi realizada, encontrando-se na 36a semana de gestação. São necessários mais estudos sobre essa malformação a fim de que sejam estabelecidos os métodos mais eficazes para o manejo de casos futuros, especialmente quando há desejo de gestar.

The present study aims to report the case of a patient with uterine arteriovenous malformation, effectively treated with selective embolization and with preserved fertility. Uterine arteriovenous malformation is a rare vascular disorder that has so far been rarely described in the literature. Female patient presented with abnormal uterine bleeding, starting 30 days after an abortion without subsequent curettage, of a pregnancy resulting from in vitro fertilization. Imaging tests were then performed that led to the diagnosis of uterine arteriovenous malformation. The treatment of choice was selective arterial embolization, with successful results. After seven months, a new in vitro fertilization was performed, being in the 36th week of pregnancy. Further studies on this pathology are needed in order to establish the most effective methods for the management of future cases, especially when there is a desire to become pregnant.

Manejo del Síndrome de Hiperestimulación Ovárica / Management of Ovarian Hyperstimulation Syndrome

INTRODUCCIÓN: El síndrome de hiperestimulación ovárica es una respuesta exagerada del ovario a los tratamientos hormonales para estimular la formación de óvulos. OBJETIVO: Describir el caso clínico de una mujer con síndrome de hiperestimulación ovárica; revisar el abordaje, manejo, tratamiento y cómo prevenirlo. CASO CLÍNICO: Paciente femenina de 37 años, multigesta, en tratamiento con metformina por Síndrome de ovario poliquístico , que presenta infertilidad secundaria a factor tubárico, que desarrolló un cuadro moderado de síndrome de hiperestimulación ovárica como consecuencia de la aplicación de las técnicas de fertilización in vitro (Folitropina alfa humana recombinante (GONAL-F®) y Cetrolerelix (CETROTIDE®); al cuarto día del procedimiento de aspiración folicular presenta dolor pélvico intenso, disuria, deposiciones diarreicas, ecografía abdominal y vaginal evidencia líquido libre en cavidad alrededor de 1000cc, además de ovarios tanto derecho e izquierdo con volumen de 102 mL y 189 mL respectivamente. Paciente es ingresada para realizar tratamiento hidratación parenteral, Enoxaparina 40mg subcutánea, Cabergolina 0.5mg vía oral, alta a las 72 horas. DISCUSIÓN: Las claves para la prevención del síndrome de hiperestimulación ovárica son la experiencia con la terapia de inducción de la ovulación y el reconocimiento de los factores de riesgo para el síndrome de hiperestimulación ovárica. Los regímenes de inducción de la ovulación deberían ser altamente individualizados, monitorizados cuidadosamente y usando dosis y duración mínimas del tratamiento con gonadotropinas para conseguir la meta terapéutica. CONCLUSIONES: El síndrome de hiperestimulación ovárica constituye la complicación más temida durante el uso de inductores de la ovulación; el conocimiento de factores de riesgo, puede prevenir o evitar que llegue a ser de un caso severo, lo cual puede causar mayor morbilidad o hasta mortalidad. La vitrificación se convierte en la técnica que permite prevenir el síndrome de hiperestimulación ovárica, junto con esta técnica hay 2 alternativas: la inducción con análogo de la hormona liberadora de gonadotropina o el uso de agonistas dopaminérgicos.

INTRODUCTION: Ovarian hyperstimulation syndrome is an exaggerated response of the ovary to hormonal treatments to stimulate egg formation. OBJECTIVE: To describe the clinical case of a woman with ovarian hyperstimulation syndrome; to review the approach, management, treatment and how to prevent it. CLINICAL CASE: 37-year-old female patient, multigestation, under treatment with metformin for polycystic ovary syndrome, presenting infertility secondary to tubal factor, who developed a moderate picture of ovarian hyperstimulation syndrome as a consequence of the application of in vitro fertilization techniques (recombinant human follitropin alfa (GONAL-F®) and Cetrolerelix (CETROTIDE®); On the fourth day of the follicular aspiration procedure she presents intense pelvic pain, dysuria, diarrheic stools, abdominal and vaginal ultrasound shows free fluid in the cavity of about 1000cc, in addition to right and left ovaries with a volume of 102 mL and 189 mL respectively. Patient was admitted for parenteral hydration treatment, Enoxaparin 40mg subcutaneous, Cabergoline 0.5mg orally, discharged after 72 hours. DISCUSSION: The keys to prevention of ovarian hyperstimulation syndrome are experience with ovulation induction therapy and recognition of risk factors for ovarian hyperstimulation syndrome. Ovulation induction regimens should be highly individualized, carefully monitored, and using minimal doses and duration of gonadotropin therapy to achieve the therapeutic goal. CONCLUSIONS: Ovarian hyperstimulation syndrome constitutes the most feared complication during the use of ovulation inducers; knowledge of risk factors, may prevent or avoid it from becoming a severe case, which may cause increased morbidity or even mortality. Vitrification becomes the technique that allows preventing ovarian hyperstimulation syndrome, along with this technique there are 2 alternatives: induction with gonadotropin-releasing hormone analog or the use of dopaminergic agonists.

Fertility Does not Quarantine: Coronavirus Disease 2019 Pandemic Impacts on in Vitro Fertilization Clinical Pregnancy Rates / Fertilidade não fica em quarentena: impacto da pandemia COVID-19 nas taxas de gravidez clínica em fertilização in vitro

Abstract Objective To understand the impact of the coronavirus disease 2019 pandemic on in vitro fertilization (IVF) clinical pregnancy rates and analyze factors that may have influenced their outcome. Methods This was a retrospective observational study conducted at a tertiary-care Brazilian fertility center. All fresh IVF and embryo warming cycles performed from March 11 to December 31, 2018-2021 were analyzed, and their data were used to calculate fertilization, embryo cleavage, cycle cancellation, embryo transfer (ET), and clinical pregnancy rates. Statistical tests were used to evaluate the alterations found. Logistic regression models were used to explore the association of the categorical variables with the observed clinical pregnancy rates. Data from 2018 and 2019 (prepandemic) and 2020 and 2021 (pandemic) were grouped. Results A total of 756 cycles were analyzed (n = 360 prepandemic and n = 396 pandemic). The age group of the patients, fertilization rates, and cleavage rates did not have significant differences (p > 0.05). There was a reduction in the percentage of fresh IVF and an increase in embryo warming cycles (p = 0.005) during the pandemic. There was also an increase in fresh cycle cancellations (p < 0.001) and a reduction in ET rates (p < 0.001). The pandemic had a negative impact on clinical pregnancy rates (p < 0.001) especially due to the increase in fresh cycle cancellations (p < 0.001). Conclusion Embryo warming cycles with subsequent frozen-thawed ET were presented as a viable alternative to continue assisted reproductive treatments against pandemic restrictions on fresh cycles, ensuring clinical pregnancy, albeit at a lower rate than that of the prepandemic period.

Resumo Objetivo Compreender os impactos da pandemia de COVID-19 nas taxas de gravidez clínica em fertilização in vitro (FIV) e analisar fatores que possam ter influenciado seu resultado. Métodos Foi realizado um estudo observacional retrospectivo em um centro brasileiro de reprodução assistida. Todos os ciclos de FIV com embriões frescos e descongelados realizados entre 11 de março e 31 de dezembro, 2018-2021 foram analisados, e seus dados utilizados para cálculo das taxas de fertilização, clivagem embrionária, cancelamento de ciclos, transferência de embriões (TE) e gravidez clínica. Testes estatísticos avaliaram significância das alterações encontradas e modelos de regressão logística exploraram associação das variáveis categóricas estudadas com as taxas de gravidez clínica observadas. Os dados de 2018 e 2019 (pré-pandemia) e 2020 e 2021 (pandemia) foram agrupados. Resultados Foram analisados um total de 756 ciclos (n = 360 na pré-pandemia e n = 396 na pandemia). A faixa etária das pacientes e as taxas de fertilização e de clivagem não tiveram alterações significativas (p > 0,05). Na pandemia, houve redução da porcentagem de ciclos de FIV com embriões frescos e aumento dos com descongelamento (p = 0,005). Também foi notado aumento das taxas de cancelamentos de ciclos com embriões frescos (p < 0,001) e redução do número de TEs (p < 0,001). A pandemia exerceu impacto negativo na taxa de gravidez clínica (p < 0,001), especialmente devido ao aumento de cancelamentos dos ciclos a fresco (p < 0,001). Conclusão Frente às limitações pandêmicas impostas aos ciclos com embriões frescos, os ciclos de descongelamento de embriões se apresentaram como alternativa viável à continuidade dos ciclos de FIV, garantindo gravidez clínica ainda que em taxas inferiores às do período pré-pandêmico.

Effect of protection of enoxaparin against experimental ischemia/reperfusion injury in the rat ovary on in vitro fertilization outcomes

SUMMARY OBJECTIVE: The study aimed to investigate the protection of enoxaparin (E) against experimental ischemic (I) and ischemic-reperfusion (I/R) injury in rat ovaries on in vitro fertilization outcomes. METHODS: In total, 56 adult female Sprague-Dawley albino rats were randomly assigned to 6 groups of 8 animals each: Sham, Ischemia, I/R, Sham+E, I+E, and I/R+E. Ischemia groups were subjected to bilateral adnexal torsion for 3 h. In contrast, I/R and I/R+E groups received subsequent detorsion for 3 h. Enoxaparin (0.5 mg/kg s.c.) was administered 30 min prior to ischemia (I+platelet-rich plasma) or reperfusion (I/R+I+platelet-rich plasma). Ovaries were stimulated through intraperitoneal injection of 150-300 internal units IU/kg pregnant mare serum gonadotropin. Anti-Müllerian hormone levels were measured before and after surgery in all groups. RESULTS: When the number of metaphase II oocytes was evaluated, statistically significant differences were observed between the I and I+E (p=0.001) and I/R and I/R+E (p=0.000) groups. When both I and I+E groups and I/R and I/R+E groups were compared, it was found that E application increased the number of fertilized oocytes. The number of embryos on the second day was higher in the I/R+E group than that in the I/R group. Statistically significant differences were found in the number of grade 1 embryos between the I/R and I/R+E groups (p=0.003). In comparing anti-Müllerian hormone values within the group, the highest decrease was observed in the I and I/R groups. CONCLUSION: Enoxaparin effectively minimizes ovarian damage and preserves ovarian reserve following ovarian torsion.

Cryopreservation as a strategy for prevention of ovarian hyperstimulation syndrome in a public assisted reproduction service in São Paulo - Brazil

SUMMARY OBJECTIVE: This study aimed to evaluate the prevalence of ovarian hyperstimulation syndrome (OHSS) and associated risk factors in patients undergoing fertilization cycles at risk of OHSS (≥15 antral follicles or ≥15 oocytes aspirated) and submitted to cryopreservation of all embryos in the Human Reproduction Service of the Pérola Byington Hospital (Referral Center for Women's Health) in São Paulo, SP, Brazil. METHODS: This cross-sectional, institutional, descriptive study of secondary data from patients' charts enrolled in the Assisted Reproduction Service of the Pérola Byington Hospital at risk of OHSS after controlled ovarian stimulation and submitted to cryopreservation of all embryos was conducted between January 2015 and September 2017. RESULTS: OHSS occurred in 47.5% of cycles, all with mild severity, and there were no moderate or severe cases of OHSS. CONCLUSION: The cryopreservation of all embryos is associated with a reduction in moderate and severe forms of OHSS. Risk factors for OHSS should be evaluated prior to initiation of treatment, with less intense stimulation protocols accordingly.

Algunos dilemas éticos presentes y futuros ante los avances en fecundación in vitro / Some present and future ethical dilemmas surrounding advancements in in vitro fertilization

RESUMEN El creciente campo de la reproducción humana asistida ha alcanzado hitos inimaginables. Su continuo desarrollo y las innovaciones que genera, en ocasiones, plantean dilemas tanto éticos como jurídicos. El presente ensayo trata de exponer los cambios progresivos que se están viviendo en el ámbito del origen de la vida debido al desarrollo de nuevas opciones y estrategias en reproducción humana asistida. En primer lugar, se realiza una reflexión interdisciplinar desde la ciencia, la ética y el derecho, sobre la naturaleza humana y los cambios a los que la sociedad se enfrenta, en particular, desde la perspectiva española. En segundo lugar, recoge una breve aproximación en torno a las técnicas biomédicas presentes o futuras en el campo de la reproducción humana. Concluye sobre la necesidad de reflexionar ante el vertiginoso avance de la ciencia en materia de reproducción humana asistida.

ABSTRACT The growing field of assisted human reproduction has achieved unimaginable milestones. Its continuous development and the innovations it generates at times pose both ethical and legal dilemmas. This essay aims to elucidate the progressive changes occurring in the realm of the origin of life due to the development of new options and strategies in assisted human reproduction. First, it constructs an interdisciplinary reflection on human nature and the changes society faces from the perspectives of science, ethics, and law, particularly from the perspective of Spain. Second, it provides a brief overview of current or future biomedical techniques in the field of human reproduction. It concludes with a discussion of the need to reflect on the rapid advancement of science in assisted human reproduction.

Effect of laparoscopic ovarian cystectomy on ovarian reserve and the outcomes of in vitro fertilization patients with benign ovarian cysts / 中华妇产科杂志

Objective:To investigate the effect of laparoscopic ovarian cystectomy on anti-Mullerian hormone (AMH) level, ovarian response to gonadotropin stimulation and pregnancy rate for in vitro fertilization (IVF) patients with benign ovarian cysts.Methods:Patients with benign ovarian cysts who were admitted for cystectomy and had undergone IVF treatment were enrolled in the study. There were 373 participants with ovarian cysts underwent laparoscopic ovarian cystectomy in the experimental group. According to duration of post-surgery, there were four sub-groups: 1 year post-surgery (1Y POST), 2 years post-surgery (2Y POST), 4 years post-surgery (4Y POST) and ≥5 years post-surgery (≥5Y POST) in the experimental group. According to histopathologic types of ovarian cysts, there were two sub-groups: ovarian endometriotic cysts and ovarian non-endometriotic cysts. Two hundreds and three patients with no history of ovarian cysts and ovarian surgery were in the control group. The level of AMH and basic concentrations of follicle stimulating hormone (FSH), luteinizing hormone (LH), progesterone (P), estradiol (E 2) were measured. Antral follicle counts (AFC) were calculated. There were other study variables: total dose of gonadotropins, duration of ovarian stimulation, the number of oocyte retrieved, the number of embryo obtained, blastocyst transfer rate and pregnancy rate. Results:The control group was matched as closely as possible to the experimental group, including age, body mass index and menstrual cycle (all P>0.05). Compared to the women in control group, the women in ovarian endometriotic cystectomy sub-group had significantly higher levels of basal FSH and basal P, lower level of AMH (all P<0.05); the women in ovarian endometriotic cysts sub-group had significantly higher dose of gonadotropins (all P<0.05); the women in ovarian endometriotic cysts ≥5Y POST sub-group had significantly lower number of oocyte retrieved, lower number of embryo obtained, lower blastocyst transfer rate, and lower pregnancy rate (all P<0.05). Compared to the women in control group, the women in ovarian non-endometriotic cysts sub-group had a significantly higher level of basal FSH and basal P (all P<0.05). The women in ovarian non-endometriotic cysts sub-group had lower level of AMH, higher dose of gonadotropins, lower number of oocyte retrieved, lower number of embryo obtained, lower rate of blastocyst transfer and lower rate of pregnancy than the control group but there were no statistically significant differences among them (all P>0.05). The women with unilateral ovarian endometriotic cysts had significantly lower number of oocyte retrieved on the side of surgery than another side ( P<0.05). Conclusions:In short term laparoscopic ovarian cystectomy has no significant effect on ovarian reserve. But with long-term follow-up ovarian reserve, ovarian response to gonadotropin stimulation and pregnancy rate are decreased. The effect of laparoscopic ovarian cystectomy in benign cysts on ovarian is associated with whether or not it is the surgical side.

Analysis of reproductive outcomes in the first IVF-ET cycle after laparoscopic treatment in patients with endometriosis / 中华妇产科杂志

Objective:To explore the effect of endometriosis (EM) on reproductive outcomes of young patient with EM after laparoscopic treatment in the first in vitro fertilization-embryo transfer (IVF-ET) cycle.Methods:The clinical data and reproductive outcomes of 394 infertile patients with EM after laparoscopic treatment (EM group) and 3 242 infertile patients caused by gamete transport disorder (control group) in the first IVF-ET cycle were collected in Chongqing Health Center for Women and Children from January 2016 to June 2021. The information included baseline characteristics, oocyte retrieval, embryo development, clinical pregnancy, miscarriage, and live birth. Propensity score matching (PSM) method was used to perform 1∶2 matching between EM group and control group. The impact of EM on reproductive outcomes was analyzed in the retrospective observational study.Results:In the initial data, compared with control group, the number of two pronucleus (2PN) zygotes (9.7±4.8 vs 9.0±4.4), the number of transferable embryos (6.2±3.6 vs 5.5±3.4) and the rate of transferable embryos (64.0% vs 60.8%) on the third day were significantly lower in EM group, and the differences were statistically significant (all P<0.05). After PSM was performed, there were 394 and 787 cases in EM group and control group, respectively. Compared with control group, the number of 2PN zygotes (9.7±4.9 vs 9.0±4.4), the 2PN fertility rate (77.1% vs 75.3%), the number of transferable embryos on the third day (6.2±3.6 vs 5.5±3.4), the transferable embryos rate on the third day (63.8% vs 60.8%) were significantly lower in EM group, and the differences were statically significant (all P<0.05). The study did not find the effect of EM on embryo implantation rate, pregnancy rate, early miscarriage rate, live birth rate and preterm birth rate (all P>0.05). Conclusions:EM might interfere with the development of oocytes and embryos. Obtaining top-quality embryos may be an effective way to improve the prognosis of patients with EM after laparoscopic treatment.

Determination of endometrial receptivity by three-dimensional power ultrasound for evaluation of pregnancy outcome after in vitro fertilization and embryo transfer / 中国基层医药

Objective:To investigate the clinical value of endometrial receptivity determination by transvaginal three-dimensional power ultrasound in the prediction of pregnancy outcome after in vitro fertilization and embryo transfer. Methods:A total of 220 infertile patients who underwent in vitro fertilization and embryo transfer in Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine from July 2018 to July 2021 were included in this study. Before in vitro fertilization and embryo transfer, all patients were tested for endometrial receptivity by transvaginal two-dimensional and three-dimensional power ultrasound. Pregnancy outcomes were followed up. Anatomical indexes (endometrial thickness, endometrial volume, and endometrial morphology) and endometrial blood flow indexes [endometrial blood flow type, pulsation index, resistance index (RI), ratio of peak systolic velocity to end-diastolic velocity (S/D), vascularization index (Vl), blood flow index (FI) and vascular blood flow index (VFI)] were compared between different pregnancy outcomes. Results:There were no significant differences in endometrial thickness, endometrial volume, and endometrial morphology between successful pregnancy and failed pregnancy groups ( t or χ2 = 0.23-0.54, P = 0.523-0.890). There was no significant difference in endometrial blood flow typing between successful pregnancy and failed pregnancy groups ( χ2 = 0.217, P = 0.897). PI, RI, and S/D in the successful pregnancy group were (2.46 ± 0.29), (1.07 ± 0.21), and (0.57 ± 0.10), respectively, which were significantly lower than (2.71 ± 0.34), (1.35 ± 0.24), and (0.66 ± 0.11) in the failed pregnancy group ( t = 4.51, 5.27, 3.43, all P < 0.001). VI, FI, and VFI values in the successful pregnancy group were (23.04 ± 2.95), (32.26 ± 3.17), and (6.59 ± 0.94) respectively, which were significantly higher than (16.85 ± 2.17), (28.42 ± 3.04), and (4.88 ± 0.86) in the failed pregnancy group ( t = 10.94, 6.25, 8.37; all P < 0.001). Conclusion:Endometrial blood flow parameters such as PI, RI, S/D, VI, FI, and VFI determined by transvaginal three-dimensional power ultrasound have a certain predictive value for pregnancy outcomes after in vitro fertilization and embryo transfer. They can be used as sensitive indexes for evaluating endometrial receptivity.

Commercial Surrogacy: An Overview / Gestação de substituição comercial: Uma visão global

Abstract Objective Surrogacy is the process in which a woman carries and delivers a baby to other person or couple, known as intended parents. When carriers are paid for surrogacy, this is known as commercial surrogacy. The objective of the present work is to review the legal, ethical, social, and cultural aspects of commercial surrogacy, as well as the current panorama worldwide. Methods This is a review of the literature published in the 21st century on commercial surrogacy. Results A total of 248 articles were included as the core of the present review. The demand for surrogate treatments by women without uterus or with important uterine disorders, single men and same-sex male couples is constantly increasing worldwide. This reproductive treatment has important ethical dilemmas. In addition, legislation defers widely worldwide and is in constant change. Therefore, patients look more and more for treatments abroad, which can lead to important legal problems between countries with different laws. Commercial surrogacy is practiced in several countries, in most of which there is no specific legislation. Some countries have taken restrictive measures against this technique because of reports of exploitation of carriers. Conclusion Commercial surrogacy is a common practice, despite important ethical and legal dilemmas. As a consequence of diverse national legislations, patients frequently resort to international commercial surrogacy programs. As of today, there is no standard international legal context, and this practice remains largely unregulated.

Resumo Objetivo A gestação de substituição é o processo no qual uma mulher engravida e entrega um bebê a outra pessoa ou casal, conhecidos como pais pretendidos. Quando as gestantes são pagas, isto é conhecido como gestação de substituição comercial. O objetivo do presente trabalho é rever os aspectos legais, éticos, sociais e culturais da gestação de substituição comercial, bem como o panorama atual em todo o mundo. Métodos Trata-se de uma revisão da literatura publicada no século XXI sobre a gestação de substituição comercial. Resultados Um total de 248 artigos foi incluído nesta revisão. A demanda por tratamentos com gestação de substituição por mulheres sem útero ou com distúrbios uterinos importantes, homens solteiros e casais masculinos está aumentando constantemente em todo o mundo. Este tratamento reprodutivo tem dilemas éticos importantes. Além disso, a legislação é amplamente adiada em todo o mundo e está em constante mudança. Portanto, os pacientes procuram cada vez mais por tratamentos no exterior, o que pode levar a importantes problemas legais entre países com leis diferentes. A gestação de substituição comercial é praticada em vários países, na maioria dos quais não há legislação específica. Alguns países tomaram medidas restritivas contra esta técnica por causa de relatos de exploração destas mulheres. Conclusão A gestação de substituição comercial é uma prática comum, apesar de importantes dilemas éticos e legais. Como consequência de diversas legislações nacionais, os pacientes frequentemente recorrem a programas de gestação de substituição comercial internacionais. Atualmente, não existe um contexto jurídico internacional padrão e esta prática permanece em grande parte não regulamentada.

El anillo vaginal de progesterona como soporte de la fase lútea en fertilización in vitro

Objetivo. Comparar la efectividad del anillo vaginal y las cápsulas vaginales de progesterona en el soporte de la fase lútea en procedimientos de fertilización in vitro. Métodos. Estudio retrospectivo que evaluó los resultados de embarazo en mujeres receptoras de embriones logrados de donación de ambos gametos al comparar la efectividad del anillo vaginal y las cápsulas vaginales de progesterona en el soporte de la fase lútea en procedimientos de fertilización in vitro. Resultados. 38 mujeres usaron el anillo vaginal y 46 aplicaron las cápsulas vaginales como soporte de la fase lútea. Se halló tasas similares de implantación (36,5% versus 36,9%), embarazo clínico (52,6% versus 50,0%) y nacido vivo (50,0% versus 45,7%). Conclusiones. Se halló tasas similares de implantación, embarazo clínico y nacido vivo con el empleo del anillo vaginal y las cápsulas vaginales de progesterona en el soporte de la fase lútea en procedimientos de fertilización in vitro. Debido a la comodidad de su uso y a las adecuadas tasas de embarazo, el anillo vaginal de progesterona se constituye como una alternativa importante en el soporte de la fase lútea en la fertilización in vitro.

Objective: To compare the effectiveness of the vaginal ring and vaginal progesterone capsules in supporting the luteal phase in in vitro fertilization procedures. Methods: Retrospective study that evaluated pregnancy outcomes in female recipients of embryos obtained from donation of both gametes by comparing the effectiveness of the vaginal ring and vaginal progesterone capsules in supporting the luteal phase in in vitro fertilization procedures. Results: Thirty-eight women used the vaginal ring and 46 applied vaginal capsules as luteal phase support. Similar rates of implantation (36.5% versus 36.9%), clinical pregnancy (52.6% versus 50.0%) and live birth (50.0% versus 45.7%) were found. Conclusions: Similar implantation, clinical pregnancy and live birth rates were found with the use of the vaginal ring and vaginal progesterone capsules in the support of the luteal phase in in vitro fertilization procedures. Due to the convenience of its use and adequate pregnancy rates, the progesterone vaginal ring is an important alternative in the support of the luteal phase in in vitro fertilization.

The Pathway of Female Couples in a Fertility Clinic / O percurso de casais homossexuais femininos em uma clínica de fertilidade

Abstract Objective The present study aims to describe the main characteristics of female couples resorting to a fertility clinic, to understand whether these patients have clear previous plans concerning procreation and how they end up completing their family planning, and to briefly describe the main outcomes of the recepción de ovocitos de pareja (ROPA, in the Spanish acronym: in English, reception of partner's oocytes) method. Methods This is a descriptive retrospective study of the pathway and outcomes of female couples in a fertility clinic during a 2-year period. Results A total of 129 couples were treated. Only one third of the couples had no condition potentially affecting fertility or advanced age. Most couples were decided to undergo artificial insemination or in vitro fertilization and the majority kept their plans, as opposed to 38% of the couples who decided to the ROPA method (lesbian shared in vitro fertilization) who changed plans. Live birth rates per treatment (including frozen embryo transfers) for artificial insemination, 58% for in vitro fertilization, 80% for treatments with donated oocytes or embryos, and 79% for ROPA. Four in five couples achieved live births. Conclusion The present study highlights the importance of a thorough medical workup in same-sex couples resorting to assisted reproduction. Despite the higher-than-expected rates of fertility disorders, the outcomes were good. Most couples end up in a single parented method. Furthermore, the results of the ROPA method are reassuring.

Resumo Objetivo O presente estudo tem como objetivo descrever as principais características dos casais femininos que recorrem a uma clínica de fertilidade, perceber se estas pacientes têm planos prévios claros sobre a procriação, como acabam por completar o seu planejamento familiar e descrever sucintamente os principais resultados do método fertilização in vitro compartilhada lésbica (ROPA, na sigla em espanhol). Métodos Trata-se de um estudo retrospectivo descritivo da trajetória e dos resultados de casais femininos em uma clínica de fertilidade durante um período de 2 anos. Resultados Um total de 129 casais foram tratados. Apenas um terço dos casais não apresentava nenhuma condição que afetasse potencialmente a fertilidade ou idade avançada. A maioria dos casais optou pela inseminação artificial ou fertilização in vitro e a maioria manteve seus planos, ao contrário dos 38% dos casais que decidiram se submeter ao método ROPA que mudaram de planos. As taxas de nascidos vivos por tratamento (incluindo transferências de embriões congelados) - 22% para inseminação artificial, 58% para fertilização in vitro, 80% para tratamentos com oócitos ou embriões doados e 79% para ROPA. Quatro em cada cinco casais conseguiram nascidos vivos. Conclusão O presente estudo destaca a importância de um acompanhamento médico em casais femininos que recorrem à reprodução assistida. Apesar das taxas mais altas do que o esperado de distúrbios de fertilidade, os resultados foram bons. A maioria dos casais acaba em um método monoparental. Além disso, os resultados do método ROPA são tranquilizadores.

Estrategias para mejorar los resultados reproductivos tras síndrome del folículo vacío: a propósito de un caso clínico

El síndrome del folículo vacío (SFV) es el fracaso total para recuperar los ovocitos después de la estimulación ovárica, a pesar de un desarrollo folicular aparentemente normal y una esteroidogénesis folicular adecuada. Se han descrito dos variantes de SFV: la forma genuina, que ocurre en presencia de niveles adecuados de hCGβ circulante o de LH en el momento de la aspiración de ovocitos, y la forma 'falsa', que se asocia a niveles séricos de hCG/LH por debajo de un umbral crítico. En nuestra paciente, tras un protocolo aceptado de estimulación ovárica con gonadotropina menopáusica humana y folitropina alfa y posterior maduración folicular con coriogonadotropina alfa no se obtuvieron cúmulos ovocitarios en la punción ecoguiada, con lo que se trató de emplear otras estrategias encaminadas a corregir esta situación. El tratamiento y el pronóstico de estas pacientes aún no se conocen bien. Se necesitan grandes estudios multicéntricos y revisiones sistemáticas para aumentar la comprensión del SFV y así, su manejo, diseñando mejores estrategias como tratamos de hacer con nuestra paciente con el empleo de doble descarga para maduración ovocitaria.

Empty follicle syndrome (EFS) is the complete failure to retrieve oocytes after ovarian stimulation, despite apparently normal follicular development and adequate follicular steroidogenesis. Two variants of EFS have been described: the genuine form, which occurs in the presence of adequate circulating βhCG or LH levels at the time of oocyte aspiration, and the 'false' form, which is associated with serum hCG/ LH levels below a critical threshold. In our patient, after an accepted protocol of ovarian stimulation with human menopausal gonadotropin and follitropin alfa and subsequent follicular maturation with choriogonadotropin alfa, no oocyte clusters were obtained in the ultrasound-guided puncture, so an attempt was made to use other strategies aimed at correcting this situation. The treatment and prognosis of these patients are still poorly understood. Large multicenter studies and systematic reviews are needed to increase understanding of EFS and thus its management, designing better strategies as we tried to do with our patient with the use of double discharge for oocyte maturation.

Oral dydrogesterone in frozen-thawed embryo transfer cycles

SUMMARY OBJECTIVE: The aim of this study was to compare the use of micronized vaginal progesterone and oral dydrogesterone in the endometrial preparation for frozen-thawed embryo transfer. METHODS: This was a randomized, controlled, open, two-armed clinical trial, with women undergoing frozen-thawed embryo transfer along with hormone replacement therapy for endometrial preparation, between September 2019 and February 2021. A total of 73 patients were randomly selected and orally administered 40 mg/day dydrogesterone (dydrogesterone group, n=36) or 800 mg/day micronized vaginal progesterone (micronized vaginal progesterone group, n=37), after endometrial preparation with transdermal estradiol. The main outcome was a viable ongoing pregnancy with 12 weeks of gestation as evaluated by ultrasound. RESULTS: The reproductive outcomes in frozen-thawed embryo transfer cycles were similar, with pregnancy rates in the dydrogesterone and micronized vaginal progesterone treatment groups being, respectively, 33.3 and 32.4% at 12 weeks pregnancy (confidence interval= -22.4-20.6, p=0.196). CONCLUSIONS: The use of oral dydrogesterone may be a more patient-friendly approach to endometrial preparation in frozen-thawed embryo transfer cycles, avoiding undesirable side effects and discomfort resulting from vaginal administration, while also providing similar reproductive results.

Analysis of related factors and prediction of poor ovarian response in patients with controlled ovarian stimulation / 中华妇产科杂志

Objective:To explore the related factors of poor ovarian response (POR) in patients receiving controlled ovarian stimulation (COS) and to establish the nomogram for predicting POR in patients who received in vitro fertilization or intracytoplasmic sperm injection (IVF/ICSI).Methods:In this retrospective research, clinical data of 17 164 cycles of patients who received IVF/ICSI treatment at Henan Provincial People′s Hospital from September 1st, 2016 to September 1st, 2020 were analyzed. Independent correlative factors affecting the occurrence of POR were screened by logistic regression, which were the model enrollment variables in the prediction model. Totally 13 266 cycles with well-record of enrollment variables were screened, and these data were randomly divided into model group (9 896 patients) and validation group (3 370 patients) according to 3∶1. The nomogram was established according to the regression coefficient of the relevant variables. The prediction accuracy of the nomogram was evaluated by calculating area under the receiver operating characteristic curve (AUC).Results:Multivariate logistic regression analysis showed age, infertility type, body mass index, anti-Müllerian hormone, basal follicle stimulating hormone, basal estrogen, antral follicle number, previous times of POR, history of ovarian surgery, ovulation stimulation protocol and average amount of gonadotropin were independent correlative factors affecting the occurrence of POR (all P<0.05). In the model group, according to the above factors, the prediction model and nomogram of POR risk were constructed and the validation group verified the model. The AUC of the model group was 0.893 (95% CI: 0.885-0.900), and the AUC of the validation group was 0.890 (95% CI: 0.878-0.903). Conclusion:The influencing factors of POR after COS in patients treated by IVF/ICSI are screened, and the nomogram for predicting POR established in this study is proved to be effective, simple, intuitive and clear in predicting the occurrence of POR.

Clinical characteristics of severe late-onset ovarian hyperstimulation syndrome and its impact on the live birth outcome of IVF-ET / 中华妇产科杂志

Objective:To investigate the correlation between different clinical features and live birth in patients with severe late-onset ovarian hyperstimulation syndrome (OHSS) after in vitro fertilization-embryo transfer (IVF-ET).Methods:The clinical information of 330 patients who were pregnant after IVF-ET and referred to medical treatments diagnosed as late-onset severe OHSS in Peking University Third Hospital from January 2016 to December 2020 was retrospectively analyzed. The patients were divided into live birth achieved group ( n=287) and non-live birth achieved group ( n=43) according to pregnancy outcomes, and live birth achieved group was further divided into two subgroups, full-term birth group ( n=222) and early-term birth group ( n=65) according to gestational week at delivery for better analysis. Single factor and multi-factor analysis were utilized to clarify the influencing factors of both live birth and early-term birth. Results:Among all the patients who received IVF-ET, the incidence of severe OHSS was 0.67% (673/100 758). Among 330 severe late-onset OHSS patients, 42.4% (140/330) had pleural effusion, the incidence of abnormal liver function was 69.4% (229/330), and the live birth rate was 87.0% (287/330). Among the 287 patients who achieved live birth, 55.4% (159/287) had no pleural effusion, 18.5% (53/287) had a small amount of pleural effusion, and 26.1% (75/287) had medium or massive pleural effusion; in the non-live birth achieved group, there were more patients without pleural effusion and less patients with a small amount of pleural effusion; the difference was statistically significant ( χ2=6.213, P=0.045). The rate of selective fetal reduction in live birth achieved group was 16.0% (46/287), which was significantly higher than that in the non-live birth achieved group, which was 2.3% (1/43; χ2=5.749, P=0.017). Multivariate logistic regression analysis revealed that moderately abnormal liver function was an independent risk factor for live birth ( OR=3.15, 95% CI: 1.60-6.19), while selective fetal reduction was an independent protective factor for live birth ( OR=0.13, 95% CI: 0.02-0.96). Additionally, subgroup analysis suggested that twin birth was an independent risk factor for preterm birth ( OR=8.54, 95% CI: 4.31-16.91). Conclusions:Moderate hepatic dysfunction may be associated with adverse pregnancy outcomes in patients with severe late-onset OHSS. Selective fetal reduction and singleton pregnancy are recommended to ameliorate live birth rate, full-term delivery rate, also the maternal and neonatal prognosis for patients with multiple pregnancies.

Relationship between the level of anti Mullerian hormone and antral follicle count and oocytes number in patients undergoing in vitro fertilization / 中国医师杂志

Objective:To investigate the relationship between the level of anti Mullerian hormone (AMH) and antral follicle count (AFC) and oocytes number in patients with in vitro fertilization (IVF). Methods:372 patients with primary infertility who received IVF and embryo transfer (IVF-ET) treatment in the Affiliated Hospital of Guizhou Medical University from January 2020 to December 2020 were prospectively selected as the study subjects. According to the oocytes obtained, the patients were divided into low ovarian response group (LOR group, the number of oocytes obtained ≤5, n=37), normal group (NOR group, the number of oocytes obtained was 6-15, n=292) and high ovarian response group (HOR group, the number of oocytes obtained >15, n=43). The levels of AMH and AFC in the three groups were observed. The relationship between AMH, AFC with LOR and HOR was observed by multivariate logistic analysis. The sensitivity, specificity, optimal cut-off value and area under the curve (AUC) of AMH and AFC for predicting LOR and HOR were calculated by receiver operating characteristic (ROC) curve. Results:There were significant difference in AMH, AFC and oocyte number among the three groups (all P<0.05). The AMH, AFC and oocyte number in NOR group were higher than those in LOR group, and AMH, AFC and oocyte number in HOR group were higher than those in LOR and NOR group (all P<0.05). The results of binary multivariate analysis showed that AFC and AMH were protective factors of LOR (all P<0.05), while AFC and AMH were risk factors of HOR ( P<0.05). The sensitivity and specificity of AMH and AFC in predicting LOR were 83.8% and 75.7%, 65.7% and 84.2%, respectively. The sensitivity of AMH or AFC positive as the standard for predicting LOR was 94.6%, and the specificity of AMH and AFC was 91.6%. The sensitivity and specificity of positive AMH and AFC in predicting HOR were 69.8% and 74.4%, 69.6% and 83.6%, respectively. The sensitivity of AMH or AFC positive as the standard for predicting HOR was 93.0%, and the specificity of AMH and AFC positive as the standard for predicting HOR was 93.0%. Conclusions:AMH and AFC are significantly correlated with oocyte number in patients with primary infertility. Flexible application of AMH and AFC is beneficial to better predict the number of oocytes obtained, which provides a reference for clinical development of individualized ovarian stimulation program.

Effect of different ovulation induction regimens for polycystic ovary syndrome / 中国医师杂志

Objective:To explore effects of controlled ovarian stimulation (COS) protocols on pregnancy outcomes for patients with polycystic ovarian syndrome (PCOS) undergoing in vitro fertilization-embryo transfer (IVF-ET). Methods:A total of 1 032 patients with PCOS who underwent IVF-ET from September 1, 2016 to July 31, 2020 in the Reproductive Center of Hunan Provincial Maternal and Child Health Care Hospital were retrospectively analyzed. The patients were divided into modified long regimen group (group A, 126 cases), luteal phase long regimen group (group B, 185 cases), antagonist regimen group (group C, 344 cases), and progestin primed ovarian stimulation (PPOS) group(group D, 377 cases) according to different ovulation stimulation regimens. The ovulation promotion status [days of gonadotropin (Gn), total amount of Gn, estradiol (E 2) level on the day of human chorionic gonadotropin (HCG) injection, number of retrieved eggs, number of mature eggs (MII eggs), number of normal fertilized embryos (2PN), number of high-quality embryos] and the first frozen embryo transfer pregnancy status (clinical pregnancy rate, implantation rate, early abortion rate) were compared among the patients in each group. Results:(1) There was no significant difference in general clinical data between the four groups (all P>0.05). (2) The number of Gn days in group D was significantly less than that in groups A, B and C, and the total number of Gn was significantly less than that in groups A, B and C (all P<0.05); The E 2 level of patients in group C and group D on the day of hCG injection was significantly lower than that of group A and group B (all P<0.05); The number of eggs obtained and MII eggs in group C and group D were significantly lower than those in group A and group B (all P<0.05); The number of high-quality embryos and 2PN in group D were significantly different from those in group A, group B and group C (all P<0.05). (3) The clinical pregnancy rates of the first frozen embryo transfer after whole embryo cryopreservation in group A, group B, group C and group D were 54.72%(29/53), 56.79%(46/81), 52.56%(82/156) and 54.32%(195/359), respectively, with no significant difference among the four groups (all P>0.05). There was no significant difference in embryo implantation rate and early abortion rate among the four groups (all P>0.05). Conclusions:The modified long regimen, luteal phase long regimen, antagonist regimen and PPOS regimen can achieve better pregnancy outcomes in patients with PCOS. Among them, PPOS regimen can reduce the amount and time of Gn, and frozen embryo transfer does not affect the pregnancy outcome of patients. It can be used as one of the priority recommended strategies for PCOS patients who plan to undergo frozen embryo transfer.

Impact of blood levels of progesterone on the day of ovulation onset on clinical, laboratory and reproductive parameters of young patients undergoing assisted reproduction: a cross-sectional study

ABSTRACT Objective: To assess whether there is an association between the level of progesterone on the day of administration of human chorionic gonadotropin and clinical and laboratory characteristics, in addition to the results of in vitro fertilization of patients with a good prognosis. Methods: A cross-sectional study comprising 103 women who underwent intracytoplasmic sperm injection treatment, between November 2009 and May 2015, aged ≤35 years, with no comorbidities, with fresh embryo transfer. Data were collected from patient medical records. Results: There was a weak positive correlation between the level of progesterone on the day of human chorionic gonadotropin and the number of follicles larger than 14mm (ß=0.02, p=0.001), retrieved oocytes (ß=0.01, p=0.01) and oocytes in metaphase II (MII) (ß=0.02, p=0.02); that is, the increase in progesterone level has a slight association with increased values of these variables. Body mass index was inversely correlated with progesterone level on the day of human chorionic gonadotropin (ß=-0.01, p=0.02). No association was found between the level of progesterone on the day of human chorionic gonadotropin and the protocols used for controlled ovarian stimulation, quality of transferred embryos and the pregnancy rate. Conclusion: There is an association between the value of progesterone on the day of human chorionic gonadotropin administration with body mass index, number of follicles larger than 14mm, number of retrieved oocytes and oocytes in metaphase II. Unlike embryo quality and pregnancy rate, which do not have a statistically significant relation with this value in the population studied.