The issue of infertility in times of COVID-19: what do we know about it?

ABSTRACT: Couple infertility constitutes a major source of concern and even distress for those involved, affecting roughly 50-80 million people in the world, according to World Health Organization data. There is no denying that medical and technological advancements in the field of as-sisted reproductive technology (ART) are among the greatest and most beneficial achievements of modern medicine. Countless couples have been able to achieve parenthood who in the past could not have, thanks to ART. Infertility itself used to be deemed insurmountable, especially when arising from uterine conditions (referred to as absolute uterine factor infertility, AUFI), neoplastic conditions or major complications affecting reproductive organs during previous pregnancies. The inability to have children is often considered by couples as a failure severely impacting their relationships, due to the unfulfilled biological potential in regard to parenting. However, in addition to its significance as a social problem, infertility is a medical issue which requires a strict and clearly defined path of diagnosis and treatment, particularly in times of COVID-19, when access to essential care has often been delayed with potentially harmful repercussions for patients seeking to achieve parenthood or to keep their fertility.

Emergency Contraception: are the rights to conscience and to reproductive freedom irreconcilable?

Emergency Contraception (EC) has been gaining attention for its controversial nature, from the ethical, moral and religious perspectives. Objecting health professionals feel that the implementation of certain procedures or the prescription of some drugs would engender a conflict of conscience. That is also true in the context of reproductive medicine and not only limited to EC, but including abortion and some medically-assisted procreation procedures; all such procedures have created a rift between sexuality and procreation that has substantial ethical complexities. Provided that respect for conscience is essential, and codified in many national and international statutes, any refusal to provide services or medication should be limited if it might negatively affect a patient's health, is based on scientific misinformation, or could bring about inequalities of any kind. First and foremost, any imposition of religious or moral beliefs on patients should not be countenanced. In fact, any form of conscientious objection that could harm patient well-being should be allowed only if the fundamental duty towards patients can be effectively discharged. The right to thorough and unbiased information is crucial so as to enable patients to make well-informed decisions. Moreover, as the WHO has remarked, access to safe and legal reproductive services should be fostered particularly in at-risk, resource-poor areas.

Minimally invasive fetal autopsy using ultrasound: a feasibility study.

OBJECTIVES: To evaluate postmortem ultrasound (PM-US) for minimally invasive autopsy, and to demonstrate its feasibility, sensitivity and specificity, as compared with conventional autopsy, in detecting major congenital abnormalities. METHODS: Over a 19-month study period from 1 March 2012 to 30 September 2013, we recruited from a referral hospital 88 consecutive fetuses, at 11-40 weeks' gestation, which had undergone termination, miscarriage or intrauterine fetal death. We performed PM-US using different transducers and compared the data with those from conventional autopsy. The latter was performed, according to the Societé Francaise de Foetopathologie (France) guidelines, by experienced perinatal pathologists who were blinded to the ultrasound data. RESULTS: Complete virtual autopsy by ultrasound was possible in 95.5% of the cases. The sensitivity of PM-US for detecting brain abnormalities was 90.9% (95% CI, 58.7-99.8%) and the specificity was 87.3% (95% CI, 75.5-94.7%). In 20% of cases, a neuropathological examination was not possible due to severe maceration. The sensitivity for detection of thoracic abnormalities was 88.9% (95% CI, 65.3-98.6%) and the specificity was 92.8% (95% CI, 84.1-97.6%), and the sensitivity for detection of abdominal anomalies was 85.7% (95% CI, 57.2-98.2%) and the specificity was 94.6% (95% CI, 86.7-98.5%). CONCLUSION: This pilot study confirms the feasibility of PM-US for virtual autopsy as early as 11 weeks' gestation. This new technique shows high sensitivity and specificity in detecting congenital structural abnormalities as compared with conventional autopsy. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.

Efficacy of ovarian tissue cryopreservation for fertility preservation: lessons learned from 545 cases.

STUDY QUESTION: How effective is ovarian tissue cryopreservation (OTC)? SUMMARY ANSWER: In our cohort of patients who underwent OTC, premature ovarian failure (POF) rates, return rates and pregnancy rates after autotransplantation were 31.5, 4.4 and 33%, respectively. WHAT IS KNOWN ALREADY: OTC for fertility purposes has been performed for >20 years now. With over 86 live births reported worldwide and success rates of ~30% after autotransplantation of frozen-thawed ovarian cortex, the procedure should no longer be considered experimental. However, very few publications report the efficacy of this procedure. STUDY DESIGN, SIZE, DURATION: Cases of ovarian tissue cryobanking for fertility preservation performed between 1997 and 2013 in a single institution were reviewed by analysis of the cryobank database and a prospective questionnaire sent out in March 2015. PARTICIPANTS/MATERIALS, SETTING, METHODS: There were 545 patients who underwent OTC during this period. The analysis included indications for OTC, survival rates, ovarian function and spontaneous pregnancies after OTC, come-back rates for ovarian tissue transplantation, pregnancy rates after transplantation, and complication and satisfaction rates. MAIN RESULTS AND THE ROLE OF CHANCE: OTC was performed in this cohort at a mean age of 22.3 ± 8.8 years for oncological indications (79%), benign gynecological pathologies (17.5%) and genetic risks of POF (3.5%). Of the 545 patients, 29% were under 18 years of age at the time of OTC and 15% were prepubertal. While 10% of patients died from their disease, 21 patients (3.9%) underwent autotransplantation, 7 of whom delivered a healthy baby, yielding a post-transplantation live birth rate of 33%. Of 451 patients who were sent the questionnaire, 143 agreed to respond (32%). Nevertheless, ovarian function could not be evaluated in 36% of those who answered. Of 92 evaluable patients, 31.5% were menopausal and 68.5% showed persistent ovarian function. Of 52 women who attempted to conceive naturally, 37 were successful (71%). Among 140 patients who answered the questionnaire, 96% were satisfied with the procedure and only 1 major complication (intra-abdominal hemorrhage) was encountered. Among all the patients, 12% have donated their ovarian cortex for research purposes or have had it destroyed. LIMITATIONS, REASONS FOR CAUTION: The questionnaire participation rate (32%), limited follow-up (mean 7.6 ± 3.5 years) and use of only clinical criteria for evaluation of ovarian function made it difficult to accurately assess the risk of POF and efficiency of OTC. WIDER IMPLICATIONS OF THE FINDINGS: Our findings confirm a 30% pregnancy rate after ovarian cortex autotransplantation but also stress the difficulties of evaluating the real efficacy of OTC. STUDY FUNDING/COMPETING INTEREST(S): No funding was sought for this study and none of the authors have any conflict of interest. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registration ID: CRYOFONOV01.