Fragmentación de ADN espermático en pacientes infértiles y su correlación con técnicas de reproducción con técnicas de reproducción asistida de alta complejidad (ICSI) / Sperm DNA fragmentation in infertile patients and its correlation with reproduction techniques with assisted reproduction of high complexity (ICSI)

La integridad del ADN es crucial para el normal desarrollo embrionario. La evaluación de la fragmentación de ADN espermático se ha propuesto como un método para predecir probabilidades de lograr un embarazo, tanto por concepción natural como por técnicas de reproducción asistida (TRA). La inyección intracitoplasmática del espermatozoide (ICSI) es la TRA de alta complejidad más utilizada en los últimos años. Sin embargo, ésta técnica es mucho más invasiva y no tiene en cuenta las características moleculares o genéticas del espermatozoide seleccionado. Lo cual podría llevar a introducir dentro del óvulo a espermatozoides con ADN dañado. Mediante la técnica de TUNEL se evaluó la fragmentación de ADN en espermatozoides de hombres infértiles que realizaban TRA por ICSI. Los valores fueron cotejados con los resultados del procedimiento. No se observaron correlaciones ni diferencias significativas entre el porcentaje de espermatozoides con fragmentación de ADN y las tasas de fertilización, calidad embrionaria o tasa de embarazo. Utilizando la evaluación simultanea de morfología espermática y fragmentación de ADN, se determinó que la mayor proporción de espermatozoides con ADN dañado eran células con morfología espermática anómala. Solo el 1,9 % de los espermatozoides con ADN fragmentado presentaban morfología normal.

Abstract: DNA integrity is crucial to normal embryonic development. Sperm DNA fragmentation evaluation has been proposed as a method to predict pregnancy, both natural conception and assisted reproductive technique (ART). Intracytoplasmatic sperm injection (ICSI) is the ART most used in the last years. However, this technique is most invasive and ignore molecular and genetics condition of selected sperm. This could lead to inject DNA damaged sperm into the egg. Sperm DNA fragmentation was evaluated by TUNEL in a fraction of the same separated sample used for ICSI. Percentage of sperm DNA damage was compared with the ICSI outcomes. There was not a statistically significant association between percentage of sperm DNA integrity and fertilization, embryo quality or pregnancy outcome. Simultaneous evaluation of sperm DNA fragmentation and morphology in the same sperm cell was used. Our data indicate that the majority of the cells showing DNA fragmentation have abnormal forms. Only 1.9% of sperm with fragmented DNA showed normal morphology. It is well known that in ICSI procedure only motile and normal sperm will be selected to injection. According this knowledge and our previous results, sperm DNA fragmentation evaluation was performed in normal spermatozoa from samples used for ICSI. Results demonstrate an association between the incidence of morphologically normal spermatozoa with fragmented DNA and poor embryo quality. In addition, a threshold was found to predict likelihood to pregnancy.

Gamete and embryo donation and surrogacy in Australia: the social context and regulatory framework

The social and legal acceptability of third-party reproduction varies around the world. In Australia, gamete and embryo donation and surrogacy are permitted within the regulatory framework set out by federal and state governments. The aim of this paper is to describe the social context and regulatory framework for third-party reproduction in Australia. This is a review of current laws and regulations related to third-party reproduction in Australia. Although subtle between-state differences exist, third-party reproduction is by and large a socially acceptable and legally permissible way to form a family throughout Australia. The overarching principles that govern the practice of third-party reproduction are altruism; the right of donorconceived people to be informed of their biological origins; and the provision of comprehensive counselling about the social, psychological, physical, ethical, financial and legal implications of third-party reproduction to those considering donating or receiving gametes or embryos and entering surrogacy arrangements. These principles ensure that donors are not motivated by financial gain, donor offspring can identify and meet with the person or persons who donated gametes or embryos, and prospective donors and recipients are aware of and have carefully considered the potential consequences of third-party reproduction. Australian state laws and federal guidelines prohibit commercial and anonymous third-party reproduction; mandate counselling of all parties involved in gamete and embryo donation and surrogacy arrangements; and require clinics to keep records with identifying and nonidentifying information about the donor/s to allow donor-conceived offspring to trace their biological origins

Gamete Intrafallopian Transfer Versus Super-Ovulation with Intrauterine Insemination for the Treatment of Infertility : a Prospective Randomised Study on Pregnancy Outcome

Background. A prospective randomised controlled trial comparing gamete intrafallopian transfer (GIFT) with intrauterine insemination (IUI) was undertaken at the Fertility and Reproductive Biology Unit of the Department of Obstetrics and Gynaecology; Tygerberg Hospital; between July 1999 and June 2000. Method. Eighty-five women were included the study and were randomly allocated between the two groups after routine infertility investigations; 41 women to IUI and 44 women to GIFT. A combination of clomiphene incitrate and human menopausal gonadotropin was administered to both groups to achieve ovulation. Results. Six (13.6) of the 44 cycles in the IUI group and 24 (53.3) of the 45 cycles in the GIFT group achieved conception. The mean number of cycles needed to achieve pregnancy in IUI was 7.3 (44/6) and in GIFT was 2.05 (45/24). The ongoing pregnancy rate of GIFT was 39.7 more effective than that of IUI (p=0.0001.The total ongoing pregnancy rate of GIFT was 30.8 superior to that of IUI (p=0.0021). When 2 folli-cles were obtained in an IUI cycle; GIFT was 41.6 more effective (p=0.0024); and when more than 2 follicles were obtained; GIFT was 28.3 more effective (p=0.0265). Conclu- sions. The number of mature follicles significantly increased the chance of pregnancy with IUI. In comparing the number of cycles needed to achieve a pregnancy; 1 GIFT cycle is equivalent to more than 3 IUI cycles. It is important to note that 4 IUI cycles will give equivalent or even better results if 2 - 3 follicles are recruited per cycle. In spite of the greater efficacy of GIFT; the authors conclude that at least 3 to 4 IUI cycles should be attempted before GIFT; on the basis that it is more cost effective and less invasive

La procreación asisistida / The assisted procreation

Menciona las diferentes técnicas de procreación asistida y presenta unas consideraciones generales y específicas y valoraciones que de las técnicas hacen en algunos países. Hace un resumen de los pronunciamientos de la Iglesia sobre el tema y una reflexión ética sobre el mismo

Gestaçäo ectópica cornual após GIFT: resoluçäo com uso de metotrexate / Cornual ectopic pregnancy after GIFT: resolution with methotrexate

A incidência de gravidez ectópica (GE) está aumentada em pacientes inférteis submetidas à fertilizaçäo in vitro (FIV). A elevada frequência de alteraçöes tubárias observadas nestas mulheres é determinante principal da nidaçäo anormal. A grande maioria das GE localiza-se na porçäo ampolar da tuba, entretanto, gestaçöes cornuais têm sido descritas após FIV. Atualmente, o tratamento clínico da GE substitui a cirurgia em grande parte dos casos. Apresentamos a seguir, um caso de gestaçäo cornual resultante da transferência intra-tubária de gametas(GIFT), com ótima evoluçäo após uso de metotrexate.

Gift por histerectomia modificado (MH/GIFT): os dois primeiros nascimentos do Brasil / Gamete intrafallopian transfer by hysterectomy: first report cases in Brazil

OBJETIVO: Avaliar a eficiência de modificaçöes técnicas (gás, Cateter, técnica de transferências, tipo de histeroscópio) no Gift por Histeroscopia (H/GIFT) e sua praticabilidade comparadas aos resultados da literatura do H/GIFT tradicional e do GIFT por Laparoscopia (LSC/GIFT). MATERIAL E MÉTODO: Relatamos um programa piloto no Brasil com o Gift por Histeroscopia Modificado (MH-GIFT), iniciado em novembro de 1995 e concluído em Fevereiro de 1996, onde utilizamos o protocolo proposto pelo South Florida Institute for Reproductive Medicine (Miami - Florida - USA) apresentados em abril de 1995 em Viena (Ýustria) durante o IX Congresso de IVF. Seis pacientes entre 30 e 43 anos, foram submetidas a oito ciclos de hiperestímulo ovariano controlado. A etiologia da infertilidade foi: fator masculino (n=1 - 16,6 por cento), endometriose (n=3 - 50 por cento), fator tubário (n=1 - 16,6 por cento) e anovulaçäo (n=1 - 16,6 por cento). As modificaçöes básicas utilizadas foram: o histeroscópio Flexível flex. 7; o g s Nitrogênio para distensäo da cavidade uterina; apropriada introduçäo do Cateter para transferência dos gametas. Diferente do SFIRM, em nenhum caso utilizamos câmara de fluxo laminar. RESULTADOS: Desconsiderando o ciclo de uma paciente (40a) que, por seu próprio engano, interrompeu a progesterona devido a sangramento e abortou mais tarde após teste de gravidez positivo, dos 7 ciclos obtivemos 3 gestaçöes (42,8 por cento de TG) e 2 nascimentos (28,6 por cento de TBC) de fetos únicos (feminino e masculino). CONCLUSÖES: O H/GIFT Modificado apresentou resultados de gestaçöes e nascimentos comparáveis aos relatados pelo GIFT por Histeroscopia convencional e pelo GIFT por Laparoscopia (LSC/GIFT). Por näo necessitar de um complexo laboratório sua aplicaçäo poder contribuir para uma maior expansäo da Reproduçäo Assistida, principalmente em centros menores, beneficiando um maior número de pacientes. A utilizaçäo do g s Nitrogênio (WHITE MARTINS) pareceu fundamental para obtençäo dos resultados.O Histeroscópio flexível (LEISEGANG) e o Cateter (Katayama - COOK/OB-GYN) com a ponta pré-marcada contribuem para uma transferência atraumática. Nossos resultados säo semelhantes aos relatados pelo SFIRM (40,7 por cento de TG e 25,9 por cento de TBC).

Vigencia de la transferencia intratubaria de gametos (G.I.F.T.) en el momento actual / Standing of G.I.F.T. in the present moment

Hemos analizado los resultados obtenidos en 180 ciclos consecutivos de 131 pacientes en las que se realizó una transferencia intratubaria de gametos entre los años 1993-1996 en el Instituto de Ginecología y Fertilidad (IFER). La edad promedio de las mismas era de 33,8ñ4,1 años, siendo de 28,7ñ5,4 en las menores de 37 años y de 39,2ñ2,1 en las mayores de 37 años. El promedio de años de esterilidad era de 4,1ñ2,8 años, siendo el tiempo de esterilidad de 3,8ñ2,5 en las menores de 37 años y de 4,6ñ3,2 en las de edad mayor o igual a 37 años. Las causas por las que se realizó el procedimiento fueron: 45 ciclos de endometriosis, 40 de esterilidad sin causa aparente, 30 de factor masculino, 24 de factor tubo peritoneal y 26 de síndrome de ovario poliquístico. El porcentaje de embarazos global fue de 35,7 por ciento por ciclo de captación con un 16,9 por ciento de abortos y un porcentaje de nacidos vivos de 29,7 por ciento, con un 23,7 de embarazos múltiples y un 1,6 de embarazos ectópicos. El índice de implantación fue del 12 por ciento. Los resultados obtenidos más los datos aportados por la bibliografía nos permiten sostener que este procedimiento mantiene su vigencia al momento actual, en todas las indicaciones de infertilidad a excepción del factor masculino severo, siendo la edad de las pacientes un factor importante en el logro de embarazos

Gamete intrafallopian transfer [GIFT] compared with intrauterine insemination in the treatment of unexplained infertility

This study included 60 couples with unexplained infertility, they were divided into two groups: The first [GI] included 30 couples treated by GIFT and the second [GH] included 30 couples treated by intrauterine insemination [IUI], three cycles of each therapy were offered. The results indicated a statistically significant increase in group I than group II. There was a statistically significant increase in number of ampoules, stimulation days as well as number of follicles. There was no statistically significant increase in types of infertility between group II and I. The clinical pregnancy was significantly higher in group I than group II. There was no significant difference between the two groups as regards number of abortion and ectopic pregnancy. It was concluded that pregnancy outcome was statistically higher in GIFT than IUI in management of unexplained infertility. The number of ectopic and abortion was higher in GIFT than IUI without a significant difference. The multiple gestation was higher in GIFT compared with IUI with a statistical difference

Embarazo heterotópico asociado a inducción de ovulación: su dificultad diagnóstica / Heterotopic pregnancy associated to ovulation induction: diagnostical difficulty

El embarazo heterotópico (embarazo intrauterino y extrauterino simultáneo), debe ser siempre investigado en todas las pacientes sometidas a inducción de ovulación con o sin técnicas de fertilización asistida. El embarazo heterotópico debe ser sospechado clínicamente y no descartado pese a la presencia de un embarazo intrauterino, a un ascenso normal de la subunidad beta de gonadotrofinas o a una ecografía con imágenes de apariencia normal a nivel anexial. Esto nos permitirá evitar un diagnóstico tardío con la morbilidad asociada que ello implica (salpingectomía) así como la mortalidad en casos excepcionales

Consideraciones éticas y legales sobre la reproducción asistida en México / Legal and ethical considerations on Assisted Human Reproduction in Mexico

La Reproducción Asistida (RA) ha consitituido sin duda, uno de los más formidables avances de la tecnología en ginecoobstetricia y ha contribuido de manera importante en el conocimiento cada vez más profundo de los mecanismos finos de la biología de la reproducción humana. Desde el nacimiento de Louise Brown en 1978, la fertilización in vitro y Transferencia de Embriones (FIVTE) desarrollada por Steptoe y Edwards, vino a ser la base fundamental para el desarrrollo de las nuevas tecnologías en RA. Después de esta fecha, se ha enriquecido cada vez más la bilbiografía al respecto, de manera tal que se puede encontar una enorme cantidad de artículos científicos en las revistas internacionales y nacionales más calificadas en la especialidad. En estos artículos se pueden encontrar no sólo los avances tencológicos sino también una gran cantidad de reflexiones desde el punto de vista ético y que han llevado a la necesidad de establecer tanto los aspectos éticos como la legislación correpondiente, en diversos países del mundo

Estudo prospectivo e randomizado comparando gonadotrofina coriônica humana e progesterona intramuscular para suporte da fase lútea em reproduçäo assistida / Prospective and randomized trial comparing human chorionic gonadotropin and intramuscular progesterone for lutual phase support in assisted fertilization

Os autores fazem uma análise prospectiva de 77 casos de fertilizaçao assistida (GIFT, ZIFT e IVF) distribuídos de forma randomizada para suporte da fase lútea com HCG (2000 UI nos dias 3, 6, 9 e 12 após a aspiraçao folicular) ou progesterona natural (5Omg, injeçao diária durante 14 dias). Nessa análise observaram taxas de gravidez, de implantaçao, de abortamento, níveis hormonais e complicaçoes com ênfase à hiperestimulaçao ovariana. A comparaçao entre os dois grupos nao mostrou diferença com relaçao às taxas de gravidez, implantaçao e abortamento. A incidência de prenhez ectópica e múltipla também nao foi diferente. No entanto, os níveis de estrogênio e progesterona nos dias 8 e 12, após a aspiraçao folicular, foi estatisticamente superior no grupo do HCG. Observamos uma incidência aumentada de hiperestimulaçao ovariana no grupo do HCG, demonstrando que o uso dessa medicaçao para suporte da fase lútea deve obedecer a critérios rigorosos a serem ainda melhor definidos.

Técnicas de fertilizaçäo assistida: uma revisäo simplificada / Assisted fertilization techniques: a simple revision

As probabilidades de tratamento de um casal infértil mudaram dramaticamente em 1978, após o nascimento do primeiro indivíduo por procedimentos de fertilizaçäo "in vitro" e transferência de embriöes. Desde entäo, continuamente säo melhoradas as técnicas já conhecidas de fertilizaçäo assistida, assim como säo incorporadas grandes variedades de novas técnicas, visando melhorar as taxas de sucesso da concepçäo assistida.

Endometriosis-current management

This article extensively reviews different aspects of the current management of endometriosis. Various drug therapies are discussed in detail with reference to their use alone and/or in combination with surgery. The effectiveness in terms of symptomatic relief is 75-100% with pseudopregnancy, 66-100% with danazol and 85-95% with GnRH analogues. The pregnancy rates are 28 - 76% with danazol and 10-58% with pseudo-pregnancy. The pattern of side effects favours the use of GnRH analogues but their cost prevents them being used as a drug of first choice in our community

The value of serum beta-hCG in the prediction of pregnancy following gamete intrafallopian transfer.

Serum beta-hCG values in 149 GIFT pregnancies obtained on day 14 after oocytes retrieval and gamete intrafallopian transfer were evaluated. Mean beta-hCG value in multiple livebirths was higher than in the singleton and non-viable pregnancy groups and mean beta-hCG value in the latter two groups did not differ from each other. Serum beta-hCG level > or = 70 mIU/ml could be a suitable level to predict viable pregnancy with 72.8 per cent sensitivity and 92.85 per cent positive predictive values.