Ovarian hyperstimulation syndrome and thrombotic events.

Ovarian hyperstimulation syndrome (OHSS) is one of the most important complications of ovarian stimulation with severe morbidity and is still a threat to every patient undergoing ovulation induction. This manuscript reviews the current evidence regarding the relationship between OHSS and thromboembolism in infertile patients undergoing ovarian stimulation published in the world literature. The PubMed Database was searched for publications on reported cases of OHSS and thromboembolic phenomenon published between 1965 and 2013. One hundred and forty cases of OHSS and thromboembolic phenomena were retrieved. The vascular accident had already occurred in the first cycle of treatment among 119 women (85%), at early stage of OHSS in 43% and late stage in 57% of cases. Venous thrombotic events were recorded mostly in unusual sites, jugular, and subclavian veins, with 69 and 38 thrombotic events, respectively. Coagulation status was found at 86 of the 140 cases (61%). Fifty-three of the pregnant patients (68%) delivered singleton births and 47% had preterm deliveries, and termination of pregnancy was indicated in 11 cases (14%). The most serious complication associated with OHSS is thrombotic phenomena as shown in the present review of 140 cases, world data, on both arterial and venous side. Thromboprophylaxis should be initiated in patients with thrombophilia and who develop moderate-to-severe OHSS.

The risks and outcome of pregnancy in an advanced maternal age in oocyte donation cycles.

The maternal age at the first and repeated deliveries constantly rises in developed countries due to current social trends that favor values of personal achievements upon procreation. Assisted reproduction technologies and especially the availability of oocyte donation programs extend the age of fecundity to the fifth and sixth decades of life. The ability to conceive and deliver at such age raises serious medical, moral, social and legal concerns regarding the health and welfare of the mother and child will be presented and discussed here.

Human reproduction: Jewish perspectives.

Developments in science and technology and corresponding clinical applications raise new religious questions, often without clear answers. The role of theology in bioethics is integral to clarify perceived attitudes toward these developments for different religious communities. The Jewish attitude towards procreation is derived from the first commandment of God to Adam to 'Be fruitful and multiply'. Judaism allows the practice of all techniques of assisted reproduction when the oocyte and spermatozoon originate from the wife and husband respectively. This paper presents the attitude of Jewish Law -- Halacha to therapeutic procedures, such as IVF-embryo transfer, spermatozoa, oocytes, embryo donation, cryopreservation of genetic material, surrogacy, posthumous reproduction, gender preselection, reproductive and therapeutic cloning.

Parathyroid and calcium metabolism disorders during pregnancy.

Parathyroid disorders are not common among pregnant women, but harbor a significant morbidity and mortality potential if they remain unrecognized and untreated. The symptoms caused by abnormally low or high blood free calcium level are mostly non-specific in the initial stages, thus when recognized might pose a real danger. Here we will survey the alterations in calcium metabolism induced by pregnancy, and describe the clinical manifestations, diagnosis and treatment of parathyroid and other calcium metabolism disorders during pregnancy. The current literature on the impact of calcium and vitamin D deficiency during pregnancy will also be reviewed.

Thyroid disorders during pregnancy.

Thyroid physiology is altered during pregnancy as a result of an increase in thyroid-binding globulin, the stimulatory effect of hCG on TSH receptors, and increased peripheral thyroid hormone requirements. In addition, hyper and hypothyroid disorders are prevalent among women of reproductive age, and most of them have a significant impact on the gravida, fetus and neonate. Aberrant thyroid function can be readily recognized and treated during pregnancy, avoiding such complications. Here, we will review the thyroid function changes occurring during pregnancy, the different disorders, their maternal and fetal implications, and the ways to screen, prevent and treat these conditions.

Pregnancies beyond the human biological fecundity.

The maternal age at first delivery constantly rises in developed countries due to a social trend to postpone the age of parenting. Assisted reproduction technologies do extend the age of fecundity to some limit, but their success rate is inversely related to the patients' age. The major factor limiting human fecundity in the fifth decade of life is the quality of the human oocyte. This problem can be readily bypassed using oocytes from young donors thus significantly extending the age limit in which conception and delivery are possible well into menopause. The ability to become pregnant and deliver at such an age raises serious medical, moral, social and legal concerns regarding the health and welfare of the mother, child and oocyte donor, which will be presented and discussed here.

Cryopreservation of human genetic material.

Up-to-date cryopreservation is a central component of contemporary human-assisted reproduction and fertility preservation technologies. Presently, the preservation of seminal and testicular spermatozoa, embryos, and oocytes can be readily achieved with a high functional survival rate. Preservation of the ovarian cortex containing a greater number of female germ cells is an experimental procedure under extensive investigation in many centers. All these techniques are used for various purposes like optimization of assisted reproduction, provision of donor gametes, fertility preservation for cancer patients and aging women, and posthumous reproduction. Here, we present a comprehensive review of the various applications of gamete, embryo, and ovarian tissue cryopreservation and discuss their basic biological principles, practical applicability, and limitations.

Assisted reproductive technology: perspectives in Halakha (Jewish religious law).

The Jewish religion is characterized by a strict association between faith and practical precepts. In principle, Jewish law has two divisions, the Written and the Oral traditions. The foundation of the Written Law and the origin of authority is the Torah, the first five books of the Scripture. This paper presents the attitude of Jewish religion to assisted reproductive therapeutic procedures such as IVF-embryo transfer, spermatozoa, oocytes, embryo donation, cryopreservation of genetic material, surrogacy, posthumous reproduction, gender preselection and reproductive and therapeutic cloning.

The beginning of human life : status of embryo. Perspectives in Halakha (Jewish Religious Law).

INTRODUCTION: The Jewish religion is characterized by a strict association between faith and practical precept. Jewish law has two sections, the written and the oral tradition. The foundation of the written law and the origin of authority is the Torah, the first five books of the Scripture. It is an expression of God's revelation, teaching and guiding humanity. The oral laws interpret, expand, and elucidate the written Torah and behavior patterns regulate new rules and customs. The main parts of the oral law are as follows: the Mishnah, the Talmud, Post-Talmudic Codes and. Responsa Literature. DISCUSSION: Life is a process that has a beginning and an end. The consensus about the time when human life really begins is still not reached among scientists, philosophers, ethicists, sociologists and theologizes. The scientific data suggested that a single developmental moment marking the beginning of human life does not exist. Current biological perspectives on when human life begins range through fertilization, gastrulation, to birth and even after. The development of a newborn is a smoothly continuous process. RESULTS: Procreation is acknowledged in the Bible to be the gift of God. The (Halachic) Jewish interpretation of when human life begins is extracted predominantly from procreation is acknowledged in the Bible to be the gift of God. The Jewish interpretation of when human life begins is extracted predominantly from The Halachic sources. The Bible does not make any other direct references regarding the beginning of human life. CONCLUSION: While the Talmud gives the full status of humanness to a child at birth, the rabbinical writings have partially extended the acquisition of humanness to the 13th postnatal day of life for full-term infants. The Babylonian Talmud Yevamot 69b states that: "the embryo is considered to be mere water until the fortieth day." Afterwards, it is considered subhuman until it is born. The issues of abortion, embryo research, multifetal reduction and cloning will be discussed according to Jewish Law perspectives. Life is a process that has a beginning and an end. The consensus about the time when human life really begins is still not reached among scientists, philosophers, ethicists, sociologists and theologizes. The scientific data suggested that a single developmental moment marking the beginning of human life does not exist. Current biological perspectives on when human life begins range through fertilization, gastrulation, to birth and even after. The development of a newborn is a smoothly continuous process.

Cesarean section upon request: is it appropriate for everybody?

The request for cesarean section without medical indication has become one of the dilemmas faced by the obstetrician. Most recent studies that compare vaginal delivery with elective cesarean section find them equally safe. This comparison is lacking in the option of trial of labor, which may result in an assisted vaginal delivery or intrapartum cesarean section, both with increased morbidity and mortality for the mother and newborn. When considering elective cesarean section, the obstetrician has to take into account improved anesthetic techniques and the decrease in morbidity and mortality after cesarean section with the trend toward patient autonomy to decide on her own treatment. On the other hand, the obstetrician has to advise his patient of the best treatment with respect to possible complications in future pregnancies, such as placental complications and increased morbidity and mortality resulting from repeated cesarean sections. The advantage of cesarean section for pelvic floor protection does not exist after three consecutive cesarean sections and equals the rate of urinary incontinence after consecutive three vaginal deliveries. In countries such as ours, where most women wish for several children, the risk-benefit balance is toward repeated spontaneous vaginal deliveries.

Ethical consideration of intentioned preimplantation genetic diagnosis to enable future tissue transplantation.

Recently, a case was presented where a couple with one normal child requested preimplantation genetic diagnosis (PGD) with human leukocyte antigen (HLA) typing in order to conceive children who could serve as mutual donors for future transplantations if needed. While PGD for medical reasons is well defined and accepted, application for non-medical conditions is less obvious and still in debate. The present case calls to further extend the indications for PGD and raises a moral question as to whether to allow such intentioned treatment. Although it seems that all siblings might benefit from the procedure, when weighing the risks benefits and the ethical issues included in performing intentioned PGD, it seems that the procedure harbours risks and ethical issues that outweigh the benefit it offers. Therefore, it is time to constrain the slippery slope and state that intentioned PGD for conceiving children who might serve as siblings for mutual tissue donations should be declined.

Maternal mortality following diagnostic 2nd-trimester amniocentesis.

We present 2 cases of maternal mortality after transabdominal amniocentesis performed during the 2nd trimester of pregnancy. In both these cases, blood cultures revealed Escherichia coli. Broad-spectrum intravenous antibiotic treatment started immediately after admission to the hospital did not change the rapid progression of the disease. Despite evacuation of the uterus within <10 h from the diagnosis of septic abortion and transfer to the intensive care units to treat multiorgan failure, these patients died. Septic abortion and septic shock following transabdominal amniocentesis are very rare; however, they carry a serious risk to the patients' life. The combination of fever and leukopenia several days after amniocentesis should alert the physician to the evolution of sepsis. Because of the risk involved, information given to the patient prior to amniocentesis should refer to possible fetal complications and to the remote possibility of maternal risks as well.

Ethical aspects of advanced reproductive technologies.

The progress achieved during the last 25 years in the assisted reproductive technology field has been phenomenal. Many countries currently practice genetic material donation, human embryo cryopreservation, selective embryo reduction, preimplantation genetic diagnosis, and surrogacy. While embryo research and therapeutic cloning are carried out only in a few centers, thus far human cloning has been universally condemned. Nonetheless, the rapid evolution and progress of these various techniques of assisted reproduction has opened a Pandora's box of ethical issues that must be urgently addressed.

Codes of perinatal ethics: an international perspective.

The research on different aspects of perinatal medicine offers valuable avenues into developmental biology and medicine that could markedly improve therapy of the pregnant patient and premature and newborn babies. Research with all sources of human cell stems should be supported to provide new therapeutic modalities. This research should be regulated, peer reviewed, and ethically controlled. The range of ethical questions raised by new scientific achievements in the life science, and methods of taking care of women's health especially, have been debated by international political and professional bodies. Biomedical ethical issues, guidelines, principles, and regulations cut across national boundaries and often have universal implications. Although cultures differ, certain values are common to all. In this context, the most important value is respect for human dignity, and this should not be negotiable. The establishment of international and interdisciplinary forums in which scientists and lay people can exchange views on topics of immediate concern, unhampered by administrative, political, or other considerations, was needed. They are intended especially for the discussion of the scientific and technical bases of advances in biology and medicine and other related areas and their social, economic, ethical, administrative, and legal implications. Commissions appointed by institutions, governments, and international bodies serve to alleviate the medical profession from making ethical decisions and to protect human subjects from any harm. The deliberations of these committees are usually followed by guidelines of operation, which in many cases have become abiding law. For these committees to be of full advantage, they must convene promptly as issues arise so as not to delay medical advances from being implemented.

Gender selection: cultural and religious perspectives.

OBJECTIVE: To review the current developments in the field of preconceptual sex selection and to discuss the cultural and religious perspectives as that accompany the scientific progress. DESIGN: A survey of the major publications in Judaism, Christianity and Islam regarding the issue of gender selection. Examination of current methods of preconceptual gender selection revealed that in vivo methods such as timing of intercourse, the use of ovulation induction medications, and artificial insemination do not appear to affect the sex ratio to a clinically significant degree. In vitro separation of X- and Y-bearing spermatozoa by gradient techniques have been reported to alter significantly the sex ratio at birth. However, these trials were not controlled, and molecular biological techniques could not validate that these methods indeed change the Y- to X bearing spermatozoa ratio sufficiently for clinical use. Nevertheless recent scientific advances have made highly reliable preconceptual sex selection possible by using preimplantation diagnosis (PGD) or sperm separation by flow cytometry combined with AIH or IVF. At present, these methods have been used to avoid sex-linked disorders. Both involve the invasive procedure of IVF and thus are held by most as inappropriate for nonmedical indications. However, improvement in flow cytometry output of sexed spermatozoa might provide in the near future sufficient sorted gametes for artificial insemination. It may be that in the near future, an improvement in flow cytometry output of sexed spermatozoa will provide sufficient sorted gametes for artificial insemination. In such a case, the medical community will be forced to take a stand, whether this reliable noninvasive method of sexing will be allowed for social purposes and even if the practice of PGD should be allowed for nonmedical indications. CONCLUSION: The requirement for a man to procreate by having a minimum of two children-a boy and a girl-is obligatory according to Jewish law. According to both schools, Beit Shamai and Beit Hillel, in order to fulfill the obligation of procreation at least one son is required. Therefore the application of sex preselection for nonmedical indications may by of practical importance using the method of sperm separation or sex selection of pre-embryo by PGD. According to Christian view, especially the one of the Catholic Church, gender preselection even for medical indications is forbidden. Islamic legal viewpoint is that fetal sex selection is lawful when it is practiced on an individual basis, to fulfill the wish of a married couple to have a boy or a girl through available medical means.

The gynecologist and the early diagnosis of breast cancer

The breast is a organ of reproduction and the diagnosis and treatment of certain breast conditions is the responsability of the obstetrician/gynecologist. We fully support the FIGO Committee for the Study of Female Breast who recently recommended that obstetricians and gynecologist world-wide include mastology as routine part of gynecologic education and practice. The teaching program should include all aspects of physiology and pathophysiology of breast disease, epidemiology, screening procedures, and follow-up of breast diseases. Every gynecologist should follow the guidelines for screening and early detection of breast cancer, and should be able to perform simple diagnostic procedures as summarized...