Genetic counseling for the orthodox jewish couple undergoing preimplantation genetic diagnosis.

Orthodox Jewish patients who seek genetic counseling are often placed in a difficult position of having to choose between their desire to follow Jewish religious instruction (halacha) and following the advice of the genetic counselor. In this article we will present the work of the Puah Institute based in Jerusalem that is dedicated to assisting and guiding such couples to navigate through the medical system and medical recommendations and create a harmony between modern genetic counseling and the Orthodox Jewish tradition. In light of the expanding use of preimplantation genetic diagnosis (PGD) for a variety of medical and non-medical conditions, this dilemma is even more poignant. There is an ethical debate regarding PGD and the correct parameters for its use. Here we present the Orthodox Jewish view of the use and abuse of PGD. We present three case studies that sought the assistance and guidance of the Puah Institute. Each of these cases raises ethical dilemmas for the genetic counselor and for the rabbinic counselor. We discuss; the status of the embryo, the status of a carrier of a genetic abnormality and whether PGD is an obligation or good practice. In addition we deal with whether PGD and the search for the desired traits can be defined as eugenics or not.

Male partner screening before in vitro fertilization: preselecting patients who require intracytoplasmic sperm injection with the sperm penetration assay.

OBJECTIVES: To determine the diagnostic accuracy of the sperm penetration assay (SPA) and standard semen parameters for subsequent fertilization in in vitro fertilization-embryo transfer (IVF-ET). DESIGN: Prospective study. SETTING: Andrology Laboratory, and university research laboratory. PATIENTS: Two hundred sixteen couples undergoing male-partner screening before IVF-ET (265 cycles). INTERVENTION(S): Male-partner screening (semen analyses [SA] and SPA), standard IVF-ET procedures, follow-up of fertilization in IVF-ET. MAIN OUTCOME MEASURE(S): Diagnostic accuracy of SA and SPA for prediction of fertilization in IVF-ET. RESULT(S): The SPA predicted IVF fertilization with high negative (84%) and positive (98%) predictive rates, and correct prediction in 88% of cycles. In contrast, sperm concentration, motility, morphology, and complete SA showed poor diagnostic accuracy, with correct prediction of IVF fertilization in 64%, 65%, 45%, and 68% of cycles, respectively. CONCLUSION(S): Very low sperm concentration and/or motility were good predictors of poor IVF fertilization, however, low to normal semen parameters were not predictive of successful IVF fertilization. The SPA is a useful screening tool that predicts IVF fertilization with high diagnostic accuracy. The SPA may be useful to discriminate between those couples with a high probability of normal fertilization in IVF and those with a low probability of normal fertilization that may benefit from assisted fertilization by intracytoplasmic sperm injection (ICSI).

Methylene blue but not indigo carmine is toxic to human luteal cells in vitro.

Methylene blue (MB) is reported to be teratogenic when injected intra-amniotically. Indigo carmine (IC) appears to be a safe alternative. To determine if MB has potential detrimental effects on ovarian tissue, we compared the effect of MB and IC on human granulosa luteal cell (GC) function in vitro. Human oocyte-cumulus complexes were obtained during in vitro fertilization cycles and one to three were placed in an organ culture dish. After insemination with sperm, oocytes were removed the day after retrieval and the attached GC were washed daily for 3 more days by changing 2 mL of culture medium. All the dishes were treated with human chorionic gonadotropin (hCG) for the next 24 h and progesterone (P) production during this interval was taken as baseline. Test chemicals were added with hCG for the next 48 h with daily media changes. The P production during the last 24 h of chemical treatment was expressed as a percentage of the baseline. MB significantly reduced P production whereas IC did not appear to have any effect. Moreover, under inverted microscopy more than 90% of the GC cells contained several small bluish intracellular granules when exposed to 0.01% MB but not 0.01% IC. These results indicate that MB may be taken up and processed by GC cells and inhibits P production. This finding adds to previous reports on the use of in vitro GC assay to identify potential reproductive toxicants. The clinical significance of this preliminary study needs further investigation.

Serial transvaginal ultrasound scans and beta-human chorionic gonadotropin levels in early singleton and multiple pregnancies.

OBJECTIVE: To determine if serum beta-hCG levels are higher in multiple gestation than in singleton pregnancy at the time of intrauterine sac visualization and the first appearance of fetal heart activity as documented by serial transvaginal ultrasound (US). DESIGN: Prospective analysis of serial transvaginal US findings in 19 pregnancies correlated with serum hCG levels during early gestation. SETTING: Reproductive endocrinology division of the University of Arkansas for Medical Sciences, Little Rock, Arkansas. PATIENTS: Nineteen infertility patients were studied after conceiving. Thirteen underwent IVF or GIFT, 4 received hMG therapy, 1 was treated with clomiphene citrate, and 1 pregnancy followed spontaneous ovulation. INTERVENTIONS: Transvaginal US and hCG levels were obtained every Monday, Wednesday, and Friday from 20 to 22 days after ovulation until the appearance of fetal heart activity. RESULTS: Initial sac visualization occurred at lower serum hCG levels in singleton versus multiple pregnancies (2,180 +/- 1,170 versus 7,028 +/- 4,280 mIU/mL, mean +/- SD). Sacs were always seen when the serum hCG level (mIU/mL) was > or = 1,161 in singleton, 1,556 in twin, 3,372 in triplet, and 9,399 in quadruplet pregnancies. CONCLUSION: Failure to observe an intrauterine sac by transvaginal US in the presence of serum hCG levels in the 1,000 to 2,000 mIU/mL range is not pathognomonic for an ectopic gestation. Clinical symptomatology, risk of multiple pregnancies, and gestational age must also be considered.

The effect of benzo(a)pyrene on murine ovarian and corpora lutea volumes.

OBJECTIVE: Women who smoke have impaired fertility and experience menopause at an earlier age. This experiment determined the effect of benzo(a)pyrene, a polycyclic aromatic hydrocarbon contained in cigarette smoke, on murine ovarian volume, total corpora lutea volume, individual corpora lutea volumes, and corpora lutea numbers. STUDY DESIGN: C57BL/6N mice were treated with intraperitoneal injections of 0 to 500 mg/kg benzo(a)pyrene in corn oil. The 20 mice at each dose were divided into four groups of five each and were killed at 1, 2, 3, or 4 weeks after treatment. Ovaries were serially sectioned and analyzed morphometrically. RESULTS: Benzo(a)pyrene produced a dose- and time-dependent decrease in ovarian volume, total corpora lutea volume, and number of corpora lutea per ovary. This effect was transitory at low doses with complete recovery of corpora lutea by 4 weeks. Compensatory hypertrophy of the individual corpora lutea occurred during the recovery phase. Ovarian function did not return in animals treated with the two highest doses. CONCLUSION: Benzo(a)pyrene is a murine ovarian toxicant that inhibits corpus luteum formation in a dose- and time-dependent fashion.

Morphometric assessment of the murine ovarian toxicity of 7,12-dimethylbenz(a)anthracene.

7,12-Dimethylbenz(a)anthracene (DMBA) is a polycyclic aromatic hydrocarbon and a component of cigarette smoke that has been identified as a murine reproductive toxicant. The morphometric parameters of total ovarian volume, individual corpus luteum volumes, and total corpora lutea volume were measured in C57BL/6N mice treated with DMBA. Each group received single intraperitoneal injections of 0, 0.1, 1.0, or 10 mg/kg and were sacrificed at 1, 2, 3, or 4 weeks after treatment. DMBA produced a dose-dependent decrease in ovarian volume and number of corpora lutea in each ovary. The observed reduction in total corpora lutea volume did not fully account for the loss in total ovarian volume. This is consistent with previous descriptions of a toxic effect on all ovarian components including growing and resting follicles. Growing follicles that escaped the toxic effects of DMBA and achieved ovulation resulted in a corpus luteum that appeared histologically normal. Morphometric analysis of this animal model further defines the dynamic changes in the mouse ovary in response to DMBA.

In vitro fertilization: an overview.

The advanced reproductive technologies are an acceptably safe but invasive method to treat infertility. The decision to proceed with IVF/ET should be based on 1) a complete infertility investigation, 2) an understanding by the couple of the emotional, physical and financial aspects of the process and 3) an understanding by physicians of the real advantages and disadvantages of the procedures.

Classification of endometriosis.

The classification of endometriosis has evolved during this century under the influence of many factors. Although classifications initially paralleled the staging of pelvic malignancies, more modern systems follow the natural progression of this pathologic process. The diagnosis of endometriosis at earlier stages has been limited by the technology of the era. Previously, only patients with more severe disease or symptoms were evaluated and treated. Earlier therapies were more radical and centered on pain relief achieved with removal of the internal genitalia. The objectives of classification were to provide standardized documentation of the disease and--it was hoped--define those patients amenable to less radical therapy. As our diagnostic and therapeutic capabilities grew, so did our interest in infertile women with endometriosis and the treatment of such patients. The diagnosis of endometriosis was often made at an earlier stage of involvement, and therapy stressed repair rather than removal. Description of pelvic involvement, has become more detailed and accurate, and the stage of disease has become prognostic of future fertility. The basic tenet of the R-AFS classification system is to provide an objective and universal method for describing the severity of disease visualized at laparotomy or laparoscopy. Stage of disease will aid the physician in choosing the therapy most suited for the individual patient. If reparative surgery is undertaken, the stage of disease will reflect the extent of pelvic reconstruction required. Quantifying disease severity will, it is hoped, make it predictive of success in conception and prognostic of the need for future medical or surgical treatment. It will also serve to stratify patients with a similar degree and distribution of disease into somewhat homogeneous groups. This will permit reasonable comparisons of effectiveness of different therapies and investigators' methods. Refinement of this type of classification scheme will depend on critical analysis of the system's prognostic capabilities. Further studies will help elucidate the relative importance of individual variables on the potential for success in achieving pregnancy.

Temporal relation of ovulation to salivary and vaginal electrical resistance patterns: implications for natural family planning.

An independent assessment of the CUE Monitor (Zetek, Aurora, Colorado) as an ovulation predictor was made with emphasis on its potential role in "natural family planning". The device provides a digital measurement of the electrical resistance of saliva and vaginal secretions. Twenty-nine menstrual cycles from 11 regularly cycling women were monitored with basal temperatures, urinary LH, pelvic ultrasound and the CUE monitor. Patterns of peak salivary electrical resistance were able to predict ovulation on average 5.3 (+/- 1.9 SD) days in advance. Despite variations in total length of the follicular phase from cycle to cycle, the within-subject variation of this predictive interval was quite small. Nadirs in the electrical resistance of vaginal secretions occurred within 2 days of ovulation in all but one patient. Variation in this interval from cycle-to-cycle was small as well. We propose an algorithm for the use of these intervals in "natural family planning" that could safely reduce the monthly abstinence period of present methods. The simplicity, objectivity and consistency of this device could result in their greater general acceptance.

PIP: The use of the CUE monitor of resistance of saliva and vaginal secretions for predicting ovulation was assessed in 29 cycles from 11 women. The CUE probe is battery-operated, and gives a reading in units proportional to ohms, in 10 seconds. It is used twice daily, at the same time, at least 10 hours after coitus. Salivary resistance is a reflection of ACTH and aldosterone secretion, and rises a mean of 7.2 (range 5-8) days before ovulation. The oral "signal" is defined as the 2nd day after the peak in resistance. The vaginal "signal" is defined as the 4th day after the nadir in resistance. Actual days of the LH surge in experimental subjects were determined, in 3 consecutive cycles in 7 women, by urinary LH by kit, by ultrasound and by basal body temperature. Within-subject variations in length of follicular phase were quite small. An algorithm for use of the CUE device for "natural family planning", using abstinence for 9 days, not including menses and alternate days avoiding coitus to measure vaginal mucus more accurately, is suggested.

Endocervical brush cytology. An alternative to endocervical curettage?

The usefulness of an endocervical brush for cytologic sampling was studied in 288 consecutive women attending a colposcopy clinic. One hundred sixty had initial colposcopic examinations with directed biopsies and endocervical curettage (ECC). One hundred twenty-eight had follow-up examinations that included Papanicolaou smears and ECC some time after evaluation and/or treatment for cervical dysplasia. Within an established protocol for the evaluation and management of abnormal Papanicolaou smears, the endocervical brush was compared to ECC. When the combination of colposcopy and cervical conization showed that dysplasia was confined to the endocervix, the endocervical brush was significantly more sensitive than ECC in detecting this endocervical disease (P less than .05). In follow-up evaluations and in patients with unsatisfactory colposcopic examinations, endocervical brush cytology could replace ECC without affecting clinical management. In patients with a satisfactory colposcopic examination, ECC may be required only when endocervical brush cytology is abnormal. Endocervical brush cytology is less costly and painful and could prove to be a reasonable alternative to ECC for the initial evaluation of the endocervix. Endocervical brush cytology shows promise as a safe adjunct to the colposcopic evaluation of pregnant women, whereas ECC is contraindicated in such women.

Metal-dependent neutral proteoglycanase activity from monolayer-cultured lapine articular chondrocytes.

Neutral proteoglycanase and other protease activity from cellular and CM fractions of monolayer-cultured rabbit articular chondrocytes were studied. The cellular fraction comprising soluble cytoplasmic enzymes possessed concentration-dependent elastase-like esterase activity and activity against trypsin and chymotrypsin synthetic substrates but had little caseinase activity. The 20% ammonium sulfate precipitate of CM possessed more neutral caseinase activity than the 60% ammonium sulfate precipitate and the bulk of activity against the synthetic substrates. Activity against bovine nasal septum PG was present in these fractions. Both the 20% and 60% ammonium sulfate fractions reduced the viscosity and the S of the PG substrate. This activity was incompletely inhibited by preincubation with either 5 mM o-phenanthroline or 10 mM EDTA, indicating that it was paritally metal-dependent. The activity in the cellular fraction was also partially inhibited by o-phenanthroline but more so by EDTA. These data indicate that chondrocytes synthesize and secrete into the culture medium neutral proteoglycanase(s) capable of initiating degradation of PG derived from the neutral pH cartilage matrix. The inhibitory profiles, together with recent evidence of enzymes with similar activity extracted from cartilage suggested that the proteoglycanase enzyme(s) may occur in multiple forms.