Implantation of embryos. The way for the improvement of the cumulative life birth rate (CLBR) in the assisted reproductive technology (ART).

Despite the willingness, humans belong to the species with the limited procreation possibilities. Infertility affects about 15% of population is the very important subject for the reproductive medicine. An assisted reproductive technology (ART) offers the significant chance for the infertile couples, but it does not give the guarantee for the pregnancy and for the birth of a healthy child. The implantation of embryo, despite numerous trials and attempts, remain the last barrier in the assisted reproduction technologies; thus, the endometrial receptivity becomes the subject of permanent interest. In this review we have tried to present various methods of improvement of an endometrial receptivity with the conclusion that we still wait for the valuable prognostic factor in the treatment of infertility by ART which could predict the chance for the birth of a healthy child.

Recent advances in prophylactics and treatment of osteoporosis.

Recently, a dramatic increase in the average life expectancy has been noted, regarded as the one of the greatest achievements of the last decades, but in consequence osteoporosis affects millions of people all over the world. Currently osteoporosis is defined as a skeletal disorder characterized by compromised bone strength which leads to an increased risk of fractures. The most commonly used tool to evaluate the 10-year risk of fractures is the fracture risk assessment tool validated in many independent cohorts. Osteoporosis itself has no symptoms, but fractures are common symptoms of osteoporosis which can result in disability and mortality. Hence, osteoporosis is called a silent epidemic as well as a silent killer. The best way to assess patients with osteoporosis is by using the most widely employed techniques - dual-energy X-ray absorptiometry or quantitative computed tomography. There are a lot of precisely documented risk factors of osteoporosis - e.g. cigarette smoking, alcohol use, getting little or no exercise, being small-framed or thin, a diet low in foods containing calcium and vitamin D - and their limitation or elimination is the best way for prophylactics of this dangerous disease. Some other risk factors such as age and sex of patients should not be omitted in the decision making process. In the literature there are numerous therapeutic proposals and different guidelines. In this review we present the recent advances in the prophylactics and treatment of osteoporosis.

Proven and unproven methods for diagnosis and treatment of infertility.

Infertility and subfertility affect a significant part of the population. Among various definitions of this pathology, the most common one is provided by the World Health Organisation; it says that infertility is 'a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourses'. The global prevalence of infertility is about 50-70 million couples. Since the process of human reproduction involves a large number of factors, a broad spectrum of infertility tests might be applied. Some of the tests focus directly on the pregnancy, some are only partially effective, whereas others should not be recommended for infertile couples. The aim of this review is to present a critical evaluation of the infertility diagnostic process and to discuss the recommendations for its most effective treatment.

Assisted reproductive technology in reproductive medicine - possibilities and limitations.

Infertility has become an increasingly common health problem and has been estimated to affect approximately 10% of women in the reproductive age. Due to its high prevalence, it has been deemed a social disease by the World Health Organization (WHO). The causes of infertility are numerous and vary from person to person. As for treatment, the three main therapeutic strategies include pharmacological therapy, surgical therapy - mostly endoscopy, and assisted reproductive technology (ART). Recent decades have witnessed great progress in ART, resulting in successful treatment of the previously untreatable cases, particularly in the field of fertility preservation, preimplantation screening for aneuploidy, uterine transplantations and mitochondrial replacement techniques as prevention against a number of severe diseases. Regardless, ART treatment does not guarantee pregnancy and live birth. The success rate is much smaller as compared to the failure rate, it being among its most important limitations. Embryo implantation is an extremely complex process and represents the most critical step of the reproduction process in humans. Attempts to evaluate endometrial receptivity and strategies for its correction have been discussed. The search for new effective predictors of an individual prognosis remains a crucial challenge for the contemporary reproductive medicine.

How can gynaecologists cope with the silent killer - osteoporosis?

Osteoporosis is a very common disease among women. It is frequently called a silent epidemic and, due to its impact on osteoporotic fractures with high morbidity and mortality, also a silent killer. There are a number of significant risk factors for osteoporosis, some of them very strongly related to the functioning of the reproductive system. These include menstrual irregularities, premature ovarian failure, early natural or surgical menopause, a high number of pregnancies, and long-term breast-feeding. Hence, there is every reason to include gynaecologists in the multidisciplinary team striving to cope with this dreadful disease. Calculation of the 10-year fracture risk, done by means of the FRAX calculator, and classification of women according to the level of risk could prove to be an effective method of limiting the negative effects of osteoporosis.

[Selective progesterone receptor modulator (ulipristal acetate--a new option in the pharmacological treatment of uterine fibroids in women]. / Selektywny modulator receptora progesteronowego (octan ulipristalu) nowa opcja farmakologicznego leczenia miesniaków macicy u kobiet.

Uterine leiomyomata (fibroids) are very common, mostly benign tumors in women of reproductive age. Symptomatic fibroids cause significant morbidity and are characterized by heavy prolonged menstrual bleeding, by pain and pelvic pressure and, in some cases, they may lead to reproductive dysfunctions. Up to date, surgical procedures (hysterectomy or myomectomy) have been the dominant managements but recently uterine artery embolization and focused ultrasound surgery have also been taken into consideration. Hysterectomy is curative but for women of reproductive age the need for uterus-sparing medical therapy is evident. There are convincing data that progesterone and its receptors increase the proliferation activity of the cells in uterine leiomyomata, hence treatment with antiprogestins and progesterone receptor modulators seems to be reasonable. Results of a successfully completed phase III clinical trials with the application of ulipristal acetate (UPA) (first-in-class selective progesterone receptor modulator--SPRM) have been published at the beginning of this year Administration of 5 mg or 10 mg UPA daily has been shown to rapidly stop (within a week) excessive uterine bleeding, reduce the volume of the three largest fibroids by -44.8% and -54.8% for UPA 5 mg and 10 mg, respectively The effect on fibroid volume has been observed for up to 6 months after treatment cessation. It is also important that UPA restores patient Quality of Life scores to the level of healthy women and in the majority of patients resumes menstruation and ovulation within one month after treatment cessation. When compared with the Gn-RH agonist (leuprolide acetate), UPA has controlled uterine bleeding faster and more consistently (7 days vs. 30 days), fibroid reduction for up to 6 months has been smaller for Gn-RH a (-16.5%) and UPA has shown a superior safety profile as estradiol levels are maintained in the mid-follicular range. The UPA has caused temporary changes in endometrial morphology but 6 month after the treatment the endometrium returned to normal histology in the majority of cases. The presented results on the application UPA in the medical treatment of symptomatic uterine fibroids are very promising and gynecologists are given a new treatment option.

[The role and place of the assisted reproductive technology (ART) in treatment of infertility]. / Rola i miejsce technik rozrodu wspomaganego medycznie (ART) w leczeniu nieplodnosci.

The assisted reproductive technics (ART) compose the very valuable tool in the infertility treatment additionally to pharmacological and surgical methods. ART comparises the classical in vitro fertilization and embryotransfer (IVF/ET) intracytoplasmic sperm injection (ICSI) intrauterine insemination (IUI), microepididymal sperm spiration (MESA), and testicular sperm aspiration (TESA). Male infertility, tubal factor, ovarian factor, endometriosis or an unexplained infertility constitute pathologies where ART can be applied as the methods of choice or as the methods of the last chance. The efficacy of ART is closely related to the age of the female partner. Hence, taking a decision of the inappropriate treatment of the infertility and prolongation of such treatment for years is the "Theft" of the reproductive time of women and a diminution or even deprivation of the chance for pregnancy. The role and the appropriate time of the ART application in different infertility causes are described.

[Effectiveness and tolerance of pulsed estrogen therapy in the treatment of menopausal symptoms. Results of a Polish multicenter study]. / Skutecznosc i tolerancja pulsacyjnej terapii estrogenowej u kobiet z objawami menopauzy. Wyniki Polskiego Badania Wieloosrodkowego.

OBJECTIVE: The main objective of the trial was to evaluate the efficacy and tolerance of a three-month pulsed estrogen therapy with intranasal 17 beta-estradiol in patients with menopausal symptoms. MATERIAL AND METHODS: Four-month, open, multicenter study (16 study centers in Poland). 309 patients with normal results of mammography and cytological examination who previously expressed informed consent for the participation in the trial were qualified to the study. Inclusion criterion was the diagnosis of at least moderate menopausal symptoms, defined as presence of night sweats disturbing sleep and hot flushes disturbing daily activity, and more than 30 points in the Green index. Exclusion criteria were: general estrogen-intake contraindications and contraindications for participation in the clinical trials. Patients included into the study were given intranasal 17 beta-estradiol 300 microg daily in continuous therapy and (patients with uterus) progestagen, according to the prescription. Main efficacy criterion was change of frequency and intensity of menopausal symptoms: night sweats and hot flushes. Additionally, Green index score was observed. Tolerance was assessed based on the adverse effects. Statistical analysis was performed using nonparametric Wilcoxon test and descriptive statistics. RESULTS: 273 patients completed the study. The night sweats were observed before the treatment in 90.5% patients with frequency of 8.8 per week. After 3 and 4 months of treatment the proportion of patients with night sweats decreased to 28.2% and 11.8% respectively, and the number of episodes to 2.7 and 2.2 per week (p < 0.0005). The hot flushes occurred before the treatment in average 12.1 times daily, after 3 months of treatment 1.3 times daily (p < 0.0005) and after 4 months of treatment 0.4 times daily (p < 0.0005). The Green index decreased from 35.6 points (before the treatment) to 11.6 points (after 3 months of treatment) (p < 0.0005) and 7.4 points (after 4 months of treatment) (p < 0.0005). During the treatment the adverse events were monitored--they occurred in 5.4% patients. The tolerance of the treatment after the end of the study was assessed by the physician as excellent or good in 96% patients. CONCLUSIONS: The results of the study give evidence for a high efficacy and very good tolerance to the treatment of menopausal symptoms using pulsed estrogen therapy with intranasal 17 beta-estradiol.

Cystic fibrosis as a cause of infertility.

Cystic fibrosis (CF) is one of the autosomal recessive diseases, caused by mutations in a gene known as cystic fibrosis transmembrane regulator (CFTR). The majority of adult males with CF (99%) is characterized by congenital bilateral absence of vas deferens (CBAVD). CBAVD is encountered in 1-2% of infertile males without CF. Females with CF are found to be less fertile than normal healthy women. In females with CF, delayed puberty and amenorrhoea are common due to malnutrition. CFTR mutations are also associated with congenital absence of the uterus and vagina (CAUV). The National Institutes of Health recommend genetic counseling for any couple seeking assisted reproductive techniques with a CF male or obstructive azoospermia which is positive for a CF mutation.

[Two treatment methods of infertility associated with polycystic ovarian syndrome]. / Porównanie skutecznosci dwóch metod leczenia nieplodnosci zwiazanej z zespolem policystycznych jajników.

OBJECTIVES: 30 patients treated for infertility associated with PCO were analyzed. Anovulatory cycles and US scans of ovaries were taken as criteria for PCO. MATERIALS AND METHODS: Patients were treated either by the laparoscopic electrocauterization (n = 16) of ovaries or by the ultrasonographic punction of follicles (n = 14). Number of ovulatory cycles, cumulative pregnancy rate and hormonal changes were analyzed. RESULTS: We observed the same efficacy of both methods in terms of ovulatory cycles and pregnancy rates. The cumulative pregnancy rate was 37.5% in laparoscopic and 35.7% in ultrasonographic groups during the 3 months' observation. CONCLUSIONS: Ultrasonographic punction has appeared to be easier to do and safer for the patient and have the same pregnancy rate. It also gives opportunity for in vitro culture and maturation of obtained oocytes.