Future Fertility Potential Research Articles

Low total motile sperm in transgender women seeking hormone therapy.

This study was undertaken to compare semen quality, hormonal status, and social factors in transgender women seeking fertility preservation with those of fertile cisgender men. Long-range goals are to establish standard practice measures ensuring optimum semen quality for cryopreservation and fertility preservation in transgender women. This is a case-control study carried out at an academic medical center. Cases are transgender women seeking fertility preservation prior to initiation of hormone therapy. Controls are cisgender men recently fathering a child. All participants completed the Depression Anxiety Stress Scales 21 survey and additional survey questions related to personal behaviors. Complete semen analysis was carried out in a clinical andrology laboratory according to WHO guidelines, 5th edition. Serum follicle stimulating hormone, estradiol, and testosterone were measured at the time of semen analysis. Sperm concentration, total sperm per ejaculate, total motile sperm, volume, and normal sperm morphology were significantly lower in transgender females compared with fertile cisgender men. Other measures of semen parameters and hormone concentrations were not different between groups. Survey results indicated transgender women were more likely to have symptoms of depression, anxiety, and stress and utilize tucking and tight undergarments, compared with controls; however, both groups reported similar numbers of ejaculations per week. Although semen parameters were low, cryopreservation of sperm prior to hormone therapy is a viable fertility preservation option for most transgender women. The etiology of the differences in semen parameters is not known. Enhanced education related to personal behaviors or treatment to reduce effects of stressors prior to cryopreservation may improve future fertility potential.

SUN-266 Anti-Mullerian Hormone as a Marker of Ovarian Reserve in Female Pediatric Patients Undergoing Hematopoietic Stem Cell Transplantation

Background/Methods: Gonadal dysfunction leading to infertility is a common complication after hematopoietic stem cell transplant (HSCT). Previous work by our group has shown that there is a significantly higher risk of delayed puberty and premature ovarian insufficiency among girls who receive high intensity, myeloablative conditioning (MAC) regimens compared to reduced intensity conditioning (RIC) regimens. Anti-Müllerian Hormone (AMH) is not regulated by gonadotropins and has minimal inter-cycle variations; therefore, it can be used as a marker of follicular ovarian reserve and aid in fertility counseling. We sought to assess ovarian reserve utilizing AMH levels in a retrospective study of female pediatric patients undergoing HSCT from 2013-2017 who received either MAC or RIC regimens. Results: In total, 100 female patients with a median age of 7 years had AMH levels pre-HSCT, of whom 33 (33%) also had post-HSCT levels. A wide variety of diagnoses were included: 32% had malignancy; 19% had immunodeficiency; 17% had Fanconi anemia (FA), 17% had hemoglobinopathy; 12% had non-FA marrow failure, and 3% had a metabolic disorder. Among those with pre-HSCT AMH levels, 71 (71%) had normal AMH for age, and 29 (29%) had low AMH for age. Of the 33 patients who also had post-HSCT AMH, 24 (72%) had low levels following transplantation. Twenty-five patients had both a normal pre-HSCT AMH and subsequent post-HSCT levels performed, 13 of whom (52%) received a MAC regimen and 12 of whom (48%) received RIC regimen. All (13/13) of the patients who received a MAC regimen had low AMH post-HSCT, while only 25% (3/12) of the patients who received a RIC regimen had low AMH post-HSCT (p=0.0002). Eight patients had both a low pre-HSCT AMH and subsequent post-HSCT AMH levels performed, 5 of whom received a MAC regimen and 3 of whom received a RIC regimen. All subject with low pre-HSCT AMH levels additionally had low post-HSCT AMH regardless of conditioning regimen used. Conclusions: AMH levels can be a useful marker for detection of low ovarian reserve and fertility counseling, especially if trends are followed before and after exposure to alkylating agents used for HSCT preparation. Our data show a significantly higher risk of low, downtrending AMH after exposure to high intensity MAC regimens compared to RIC regimens during childhood HSCT, which likely indicates a greater potential for infertility in patients receiving MAC regimens. These data correlate with a previous analysis demonstrating a significantly higher incidence of premature ovarian insufficiency and delayed puberty among girls receiving MAC regimens vs RIC regimens. Long-term follow up of this cohort will provide more information to understand the effects of HSCT on ovarian function and the utility of AMH as a predictor of future fertility potential.

Association between semen parameters and chance of fatherhood - a long-term follow-up study.

Evaluation of male fertility includes standard semen analysis; however, there is uncertainty about the value of sperm parameters in predicting fertility. To evaluate the association between semen parameters and fatherhood during a long-time period. Semen parameters (total sperm count, concentration, motility, and morphology) and sperm DNA fragmentation Index (DFI) assessed on samples collected from 195 Norwegian men from the general population in 2001/2002 were matched with information about fatherhood until 2015, obtained from the Medical Birth Register. The parameters were dichotomized as normal vs. abnormal according to the WHO reference values from 1999 and 2010. Cut-offs at 20% and 30% were used for DFI. Among men who had no children before 2003, those with normal progressive sperm motility had more often become fathers (WHO 1999, cut-off ≥50%, adjusted OR 2.8, 95% CI 1.3-6.1 and WHO 2010, cut-off ≥32%; aOR 4.2, 95% CI 1.1-15). Based on the WHO 1999 reference value, men with normal sperm concentration (≥20 × 106 /mL) had more often become fathers (aOR 3.1, 95% CI 1.1-8.6). Men with progressive sperm motility ≥50% and concentration ≥20 × 106 /mL did more often achieve fatherhood (aOR 8.4, 95% CI 2.1-34). For DFI, there was a borderline significance at cut-off 20% in the group of men who had ever been fathers (OR 2.7, 95% CI 1.0-7.0 p<0.05). The results indicate that sperm progressive motility, sperm concentration, and DFI are associated with fatherhood during a longer time period, with sperm motility being most consistent. Although the sample size is relatively small and our results should be replicated in larger studies, they may be of clinical relevance. Semen parameters may have a diagnostic value not only in a short time frame but also for predicting future fertility potential.

Partial tubal devascularisation: a novel procedure for tubal conservation in ectopic pregnancy

Ectopic pregnancy is a serious condition that complicates 1–2% of pregnancies. Using surgical management is efficient, but may have an impact on future fertility. Although conservative tubal surgery has not been shown to have a significant advantage over a salpingectomy in terms of the future fertility potential, the conservative surgical techniques remain widely-utilised, particularly in the context of a contralateral diseased or absent tube. We hereby report a case series of a novel procedure to conserve the fallopian tube with the minimal risk of an incisional site bleeding through a partial segmental devascularisation. This technique seems to be an efficient method to minimise the intraoperative bleeding, limit the need for a blood transfusion, and yields a higher success rate of the procedure without jeopardising the blood supply and vitality of the tubes.Impact StatementWhat is already known on this subject? Conservative surgery has a significant value in women with a contralateral absent or diseased tube. However, a conservative management could be challenging due to the significant bleeding which can be encountered during the surgery.What the results of this study add? The partial devascularisation technique could achieve an adequate haemostasis by blocking the ascending blood supply only to the affected segment of the fallopian tube.What the implications are of these findings for clinical practice and/or further research? A partial devascularisation is a successful conservative surgical treatment option in most patients when the procedure is indicated.

011-Disclosures of Disorders of Sex Development to Children: When and How Do We Tell Kids About Their Diagnosis?

Background: Children can be diagnosed with a disorder of sex development (DSD) at birth with ambiguous genitalia, or later in childhood after investigations of other symptoms. In all cases, the diagnosis comes as a surprise, and there is initial parental distress and uncertainty about their child's future. The diagnosis of DSD can have a significant impact on the psychosocial development and wellbeing of the child, with challenges around diagnosis complexity, sex of rearing, uncertain outcomes, treatment options and psychological stressors. Purpose: Whilst disclosure in practice often occurs in a gradual manner when working within a multidisciplinary team, we propose to formalise a guidance system describing a developmentally staged approach. The process involves sequential information about body parts, differences between male and female, the wide potential for gender roles and later the potential for different individual development of sex, gender, sexuality and fertility. Description of Topic: The development of gender identity begins after the first year of life, with children generally identifying with one sex by age three. Self-awareness regarding identity and gender role evolves during childhood, with sexuality developing through adolescents, along with physical secondary sex characteristics. Critical psychological development also starts to occur, including the capacity to understand concepts such as future fertility potential. Therapeutic events such as genital surgery or requirement for sex hormone therapy can affect this process. Information provided to a child about their diagnosis therefore needs to be age appropriate, and tailored to the individual's developmental needs. Criticism of past DSD management has been poor or late disclosure of diagnosis to the young person, and although advice now supports earlier disclosure, there is limited literature guiding a method for this. Clinical Implications: The goal of treatment is to ensure that the child's psychological, physical and sexual well-being are supported in a respectful and appropriate manner. This can be achieved via a multidisciplinary team working with the parents to support the child, communicating honestly and respectfully to maintain trust, and providing guided appropriate information through defined developmental stages from infancy to adolescence and adulthood. The paediatric endocrine nurse plays a critical role in this process as both child's advocate and family educator.

Endovascular uterine artery interventions.

Percutaneous vascular embolization plays an important role in the management of various gynecologic and obstetric abnormalities. Transcatheter embolization is a minimally invasive alternative procedure to surgery with reduced morbidity and mortality, and preserves the patient's future fertility potential. The clinical indications for transcatheter embolization are much broader and include many benign gynecologic conditions, such as fibroid, adenomyosis, and arteriovenous malformations (AVMs), as well as intractable bleeding due to inoperable advanced-stage malignancies. The most well-known and well-studied indication is uterine fibroid embolization. Uterine artery embolization (UAE) may be performed to prevent or treat bleeding associated with various obstetric conditions, including postpartum hemorrhage (PPH), placental implantation abnormality, and ectopic pregnancy. Embolization of the uterine artery or the internal iliac artery also may be performed to control pelvic bleeding due to coagulopathy or iatrogenic injury. This article discusses these gynecologic and obstetric indications for transcatheter embolization and reviews procedural techniques and outcomes.

Developing a post-treatment survivorship care plan to help breast cancer survivors understand their fertility.

Reproductive-aged breast cancer survivors (BCS) who have completed initial cancer treatment frequently want to know about their future fertility potential. The purpose of this qualitative study was to assess if the fertility-related content presented in the survivorship care plan prototype met the informational needs of post-treatment BCS and to provide an opportunity for the target audience to review and react to the proposed content and design. We conducted and analyzed transcripts from seven focus groups with BCS to evaluate their reactions to the survivorship care plan prototype. We independently coded transcripts for consistent themes and sub-themes and used a consensus-building approach to agree on interpretation of results. We identified five themes that describe the post-treatment BCS' responses to the prototype survivorship care plan in the context of their informational needs and experiences: (1) the prototype's fertility-related information is relevant; (2) desire for clinical parameters to help survivors understand their infertility risk; (3) fertility-related information is important throughout survivorship; (4) evidence-based content from a neutral source is trustworthy; and (5) the recommendation to see a fertility specialist is helpful, but cost is a barrier. BCS have concerns and needs related to their fertility potential after initial breast cancer treatment. The evidence-based information offered in our prototype survivorship care plan was acceptable to BCS and has significant potential to address these needs. Additional primary data that identify post-cancer treatment indicators of fertility would advance this effort.

Selective progesterone receptor modulators for fertility preservation in women with symptomatic uterine fibroids.

Uterine fibroids (UFs, AKA leiomyoma) are the most important benign neoplastic threat to women's health, with costs up to hundreds of billions of health care dollars worldwide. Uterine fibroids caused morbidities exert a tremendous health toll, impacting the quality of life of women of all ethnicities, especially women of color. Clinical presentations include heavy vaginal bleeding, pelvic pain, bulk symptoms, subfertility, and obstetric complications. Current management strategies heavily lean toward surgical procedures; nonetheless, the choice of treatment is generally subject to patient's age and her desire to preserve future fertility. Women with UF who desire to maintain future fertility potential face a dilemma because of the limited treatment choices that are currently available to help them achieve that goal. Recently, ulipristal acetate the first of the promising family of oral selective progesterone receptor modulators has been approved for UF treatment in Europe, Canada, and several other countries and is under review for possible approval in the USA. In this review article, we discuss recent advances in the management options against UF with a bend toward oral effective long-term treatment alternatives who are particularly suited for those seeking to preserve their future fertility potential. We also explore the transformative concept of primary and secondary UF prevention using these new anti-UF agents. We envision a remarkable shift in the management of UF in future years from surgical/invasive treatment to orally administrated options; clearly, this potential shift will require additional intense clinical research.

Presence of Germ Cells in Disorders of Sex Development: Implications for Fertility Potential and Preservation

We sought to determine the presence of germ cells in the gonads of patients with disorders of sex development to establish whether preservation of germ cells for future fertility potential is possible. We hypothesized that germ cells are present but vary by age and diagnosis. We reviewed histology from patients with disorders of sex development who underwent gonadectomy/biopsy from 2002 to 2014 at a single institution for pathological classification of the gonad, composition of gonadal stroma and germ cell presence. A total of 44 patients were identified and germ cells were present in 68%. The presence and average number of germ cells per mm2 were analyzed by gonad type and diagnosis. By gonad type all ovotestes, most testes, ovaries and dysgenetic testes, and 15% of streak gonads had germ cells present. By diagnosis germ cells were present in all patients with complete androgen insensitivity syndrome, Denys-Drash syndrome, SRY mutation, mixed gonadal dysgenesis, ovotesticular conditions and StAR (steroid acute regulatory protein) deficiency, in some patients with persistent müllerian duct syndrome, XO/XY Turner syndrome and disorders of sex development not otherwise specified, and in none with complete or partial gonadal dysgenesis. Germ cells were present in the gonads of 88% of patients 0 to 3 years old, 50% of those 4 to 11 years old and 43%of those older than 12 years. Germ cells were present in the majority of our cohort and the presence decreased with age. This novel, fertility driven evaluation of germ cell quantity in a variety of disorders of sex development suggests that fertility potential may be greater than previously thought. Further studies must be done to evaluate a larger population and examine germ cell quality to determine the viability of these germ cells.

MP91-11 REPRODUCTIVE KNOWLEDGE AND ATTITUDES OF PATIENTS UNDERGOING RADICAL PROSTATECTOMY

You have accessJournal of UrologyInfertility: Epidemiology & Evaluation1 Apr 2016MP91-11 REPRODUCTIVE KNOWLEDGE AND ATTITUDES OF PATIENTS UNDERGOING RADICAL PROSTATECTOMY Nelson Bennett, Alexander Muller, Patricia Guhring, and John Mulhall Nelson BennettNelson Bennett More articles by this author , Alexander MullerAlexander Muller More articles by this author , Patricia GuhringPatricia Guhring More articles by this author , and John MulhallJohn Mulhall More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2598AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES While sexual sequelae of radical prostatectomy (RP) are well appreciated and often discussed, infertility in this population is rarely written about in the literature. This analysis was undertaken to better understand the fertility discussion experience and attitudes of men undergoing RP. METHODS The population chosen for this analysis was men who had had a RP within the prior 6 months who were ≤50 years of age with a partner of reproductive age (≤45 years). Men were asked about their understanding of the impact of RP on their future fertility potential, whether they were advised to bank sperm, whether they actually banked sperm, and if they had not, their level of interest in sperm extraction post-RP. Patient and partner demographic data was recorded. Interest (pre or postop) was listed as no, maybe and yes. Multivariable model was constructed to look for predictors of interest in fertility in men undergoing RP. RESULTS 364 men were interviewed. Mean patient and partners age were 44±3 (38-50) years and 34±4 (32-42) years respectively. 58% of men could not recall ever being told about failure to ejaculate. With regard to interest in fertility; 11% said yes, 17% maybe, 72% no. 84% never appreciated banking preoperatively was an option, however, 20% of those definitely interested in fertility and 6% of those who might be interested actually banked semen. Only 8 men (2%) were aware that testis sperm extraction was a possibility post-RP. Predictors of yes/maybe interest in fertility were: young partner age, men without children, partner without children (see Table). CONCLUSIONS While the majority of younger men undergoing RP are not interested in fertility, a distinct minority are and appear to be poorly educated and prepared for fertility decisions before or after RP. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1157 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Nelson Bennett More articles by this author Alexander Muller More articles by this author Patricia Guhring More articles by this author John Mulhall More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Clinical and pathological investigation of adnexal masses in adolescents who underwent surgery in a tertiary center

Objective: Adnexal masses are the most common reason for gynecologic surgery in adolescent patients. Early detection and adequate management of adnexal lesions are very important for saving lives and preserving fertility. In this study, we analyzed the clinical characteristics of 106 Turkish adolescent women who underwent surgery for adnexal masses. Methods: The study included 106 patients aged ≤20 years that underwent surgery for adnexal masses at our hospital between January 2008 and December 2013. Clinical profiles were retrospectively collected from the hospital medical records. The records were analyzed for demographic profiles, initial symptoms, preoperative radiologic findings, operative approach, surgical procedure, pathology findings, and the maximum diameter of the adnexal mass. Results: The age of the patients ranged from 12 to 20 years (median, 18.8 years). The most common initial symptom in these patients was abdominal pain (56.6%). Non-neoplastic ovarian lesions in the patients included 7 (6.6%) corpora hemorrhagica, 10 (9.4%) corpus luteal cysts, 4 (3.8%) paratubal cysts, and 7 (6.6%) simple cysts. Benign neoplastic tumors included 20 (18.9%) mature cystic teratomas (i.e., dermoid tumors), 10 (9.4%) serous cystadenomas, 1 (0.9%) mucinous cystadenomas, and 7 (6.6%) endometriomas. The most common surgical approach and procedure were laparoscopy (67.0%) and cystectomy (60.4%), respectively. Conclusion: Laparoscopy can be performed in many adolescent patients and conservative, adnexal-sparing surgery should be encouraged for all patients. Ovarian-preserving techniques should be a priority when surgery is performed for benign masses in order to optimize future fertility potential. J Clin Exp Invest 2015; 6 (2): 96-101 Key words: Adolescent, adnexal, laparoscopy

The influence of hormonal treatment with beta-human chorionic gonadotropin for cryptorchidism on future fertility in rats

There have been two treatment modalities for cryptorchidism such that surgical and hormonal; the latter being highly controversial. While some authors suggest that hormonal treatment increases the number and maturation of germ cells in cryptorchid testes, others believe just the opposite. We aimed to find out the sperm counts and testicular index; briefly fertility potential of the normally descended contralateral testes in adulthood period in rats treated with Beta-HCG in early period of their lives. Three groups, each including 10 rats aged 22 days old, in which delactation and normal feeding can be started, were formed to be Group 1: Sham operated, Group 2: Experimental cryptorchidism (EC) and Group 3: Hormone-treated after experimental cryptorchidism was performed (HT-EC). Left testis was placed in the abdomen in group 2 and 3. In group 1, a sham operation was performed. The rats in EC-HT group received subcutaneous injections of 50 IU/kg Beta-HCG daily for 7 days. Right orchidectomy was performed when they reached reproductive period to evaluate fertility potential with sperm counts and testicular index. Testicular index was calculated according to the formula "testicular length × width/weight of rat". Epididymal sperm count was made with hemocytometer. We evaluated the physical characteristics and fertility potential (sperm counts) of contralateral normal testes during adulthood in rats that underwent experimental unilateral cryptorchidism during infancy. A relationship between testis weight and sperm counts were also investigated. We could not find any direct correlation of sperm count with either testicular weight or testicular index in our study. Although the rats had normal testes at birth, we found decreased sperm counts in contralateral normal testes in EC group. This suggests that unilateral cryptorchidism may cause some systemic effects that reach the other testis. Hormone treatment was not beneficial. This is comparable to Nambirajan et al. who reported histological changes and decreased spermatogenic cell count in contralateral scrotal testes in experimentally induced unilateral cryptorchidism in early period of life in rats. Heiskanen et al. reported that treatment with Beta-HCG leads to decreased total sperm counts in the future due to increased germ cell apoptosis caused by hormonal withdrawal after treatment. Cortes et al. also reported decreased number of germ cells in 1-3 year-old boys who underwent surgery after unsuccessful Beta-HCG treatment. The reasons could be delayed testicular descent or adverse effect of hormone treatment though. Our results concurred with them. Apparently, our model has failed to mimic the pathophysiologic mechanisms of congenital cryptorchidism in humans. Furthermore, we applied hormone treatment in normal rats with normally descended testes. Therefore, the "by-product" information of our study is that, unnecessary use of Beta-HCG during infancy may impair future fertility. Our study suggests that Beta-HCG treatment may decrease sperm counts and decrease the future fertility potential. We could not find any direct correlation of sperm count with either testicular weight or testicular index.

Transition in endocrinology: induction of puberty.

Puberty is the period during which we attain adult secondary sexual characteristics and reproductive capability. Its onset depends upon reactivation of pulsative GNRH, secretion from its relative quiescence during childhood, on the background of intact potential for pituitary-gonadal function. This review is intended: to highlight those current practices in diagnosis and management that are evidence based and those that are not; to help clinicians deal with areas of uncertainty with reference to physiologic first principles; by sign-posting relevant data arising from other patient groups with shared issues; to illustrate how recent scientific advances are (or should be) altering clinician perceptions of pubertal delay; and finally, to emphasise that the management of men and women presenting in advanced adult life with absent puberty cannot simply be extrapolated from paediatric practice. There is a broad spectrum of pubertal timing that varies among different populations, separated in time and space. Delayed puberty usually represents an extreme of the normal, a developmental pattern referred to as constitutional delay of growth and puberty (CDGP), but organic defects of the hypothalamo-pituitary-gonadal axis predisposing to hypogonadism may not always be initially distinguishable from it. CDGP and organic, or congenital hypogonadotrophic hypogonadism are both significantly more common in boys than girls. Moreover, around 1/3 of adults with organic hypogonadotrophic hypogonadism had evidence of partial puberty at presentation and, confusingly, some 5-10% of these subsequently may exhibit recovery of endogenous gonadotrophin secretion, including men with Kallmann syndrome. However, the distinction is crucial as expectative ('watch-and-wait') management is inappropriate in the context of hypogonadism. The probability of pubertal delay being caused by organic hypogonadism rises exponentially both with increasing age at presentation and the presence of associated 'red flag' clinical features. These 'red flags' comprise findings indicating lack of prior 'mini-puberty' (such as cryptorchidism or micropenis), or the presence of non-reproductive congenital defects known to be associated with specific hypogonadal syndromes, e.g. anosmia, deafness, mirror movements, renal agenesis, dental/digital anomalies, clefting or coloboma would be compatible with Kallmann (or perhaps CHARGE) syndrome. In children, interventions (whether in the form or treatment or simple reassurance) have been historically directed at maximising height potential and minimising psychosocial morbidity, though issues of future fertility and bone density potential are now increasingly 'in the mix'. Apubertal adults almost invariably harbour organic hypogonadism, requiring sensitive acknowledgement of underlying personal issues and the timely introduction of sex hormone replacement therapy at more physiological doses.

Spermatogenesis and cryptorchidism.

Cryptorchidism represents the most common endocrine disease in boys, with infertility more frequently observed in bilateral forms. It is also known that undescended testes, if untreated, lead to an increased risk of testicular tumors, usually seminomas, arising from mutant germ cells. In normal testes, germ cell development is an active process starting in the first months of life when the neonatal gonocytes transform into adult dark (AD) spermatogonia. These cells are now thought to be the stem cells useful to support spermatogenesis. Several researches suggest that AD spermatogonia form between 3 and 9 months of age. Not all the neonatal gonocytes transform into AD spermatogonia; indeed, the residual gonocytes undergo involution by apoptosis. In the undescended testes, these transformations are inhibited leading to a deficient pool of stem cells for post pubertal spermatogenesis. Early surgical intervention in infancy may allow the normal development of stem cells for spermatogenesis. Moreover, it is very interesting to note that intra-tubular carcinoma in situ in the second and third decades have enzymatic markers similar to neonatal gonocytes suggesting that these cells fail transformation into AD spermatogonia and likely generate testicular cancer (TC) in cryptorchid men. Orchidopexy between 6 and 12 months of age is recommended to maximize the future fertility potential and decrease the TC risk in adulthood.

Salpingotomy versus salpingectomy in women with tubal pregnancy.

Evaluation of: Mol F, van Mello NM, Strandell A et al. Salpingotomy versus salpingectomy in women with tubal pregnancy (ESEP study): an open-label, multicentre, randomised controlled trial. Lancet 383(9927), 1483-1439 (2014). Ectopic pregnancy can still manifest itself as a life-threatening condition and, hence, the establishment of accurate evidence-based treatment modalities remain paramount. Surgical treatment has long been a mainstay of ectopic pregnancy treatment. To date, there is a wealth of data establishing laparoscopic treatment as the 'gold standard'; however, paradoxically, the evidence behind choosing the two main treatment methods of salpingotomy and salpingectomy, especially with regards to future fertility potential, remain unclear. This article is a summary of a randomized controlled trial of salpingotomy versus salpingectomy in patients with an apparent contralateral healthy tube and the impact on future fertility. It attempts to answer the clinical question whether preservation of tube by salpingotomy increases the futures chances of natural conception as opposed to salpingectomy.

Preservation of sperm of cancer patients: extent of use and pregnancy outcome in a tertiary infertility center

Sperm cryopreservation is the best modality to ensure future fertility for males diagnosed with cancer. The extent to which cryopreserved sperm is actually used for impregnation, the fertility treatment options that are available and the success rates of these treatments have not been investigated in depth. The medical records of 682 patients who cryopreserved sperm cells due to cancer treatment were analyzed. Seventy of these patients withdrew their frozen sperm for fertility treatments over a 20-year period (most within the first 4 years after cryopreservation). Sperm quality of different malignancies and outcomes of assisted reproduction treatment (ART) for pregnancy achievement in relation to the type of treatment and the type of malignancy were evaluated. The results showed that the rate of using cryo-thawed sperm from cancer patients for fertility treatments in our unit was 10.3%. Sperm quality indices differed between different types of malignancies, with the poorest quality measured in testicular cancer. Conception was achieved in 46 of the 184 ART cycles (25%), and resulted in 36 deliveries. The use of intracytoplasmic sperm injection (ICSI) methodology yielded a significantly higher pregnancy rate (37.4%) than intrauterine insemination (IUI; 11.5%) and was similar to other groups of infertile couples using these modalities. In vitro fertilization (IVF) failed to produce pregnancies. In conclusion, the rate of use of cryopresseved sperm in cancer patients is relatively low (10.3%). Achievement of pregnancies by ICSI presents the best option but when there are enough stored sperm samples and adequate quality, IUI can be employed. Cryopreservation is nevertheless the best option to preserve future fertility potential and hope for cancer patients.

The Relation between Adult Dark Spermatogonia and Other Parameters of Fertility Potential in Cryptorchid Testes

The fertility potential of boys with cryptorchidism may be related to the number of adult dark spermatogonia per tubular transverse section in testicular biopsies taken at orchiopexy. Placental-like alkaline phosphatase positive gonocytes in testes within year 1 of life indicate preserved ability for germ cell transformation. We related these parameters to the total number of tubular germ cells and other factors associated with fertility potential. The study comprised 89 boys 0.7 to 3 years old (median age 1.8) who underwent bilateral testicular biopsy at bilateral orchiopexy and provided blood samples for gonadotropins and inhibin B. Of 76 boys with adult dark spermatogonia 44 (58%) had a normal mean number of spermatogonia per tubular transverse section compared to 2 of 13 (15%) without adult dark spermatogonia (p <0.05). In the 30 boys with good fertility potential, including a normal mean number of tubular germ cells, and normal gonadotropins and inhibin B, the mean number of adult dark tubular germ cells was 0.081 vs 0.031 in the 38 with low fertility potential, including impaired tubular germ cells and/or low inhibin B but no reactive increase in gonadotropins (p <0.05). In the 21 patients with increased gonadotropins the mean number of adult dark spermatogonia per tubular transverse section was 0.063. Of the 20 boys with normal mean adult dark spermatogonia per tubular transverse section 12 (60%) had good fertility potential, including a normal mean number of tubular germ cells, normal gonadotropins and normal inhibin B, compared to only 18 of 69 (26%) with an impaired mean number of adult dark spermatogonia per tubular transverse section (p <0.05). Of 46 boys with a normal mean number of tubular germ cells 26 (57%) had placental-like alkaline phosphatase positive cells compared to 14 of 43 (33%) with a decreased mean number of tubular germ cells (p <0.05). The number of placental-like alkaline phosphatase positive gonocytes and adult dark spermatogonia per tubular transverse section are important parameters related to the fertility potential of boys with cryptorchid testes.

Fertility potential in men with a history of congenital undescended testes: a long‐term follow‐up study

Men with a history of congenital undescended testes (UDT) have an increased risk of fertility problems. Despite no definitive proof, current guidelines recommend early surgical intervention because this may have a positive effect on future fertility potential by preventing degenerative changes of the testes in early life. Also surgical intervention facilitates observability of the testes in view of possible malignancy. We evaluated testicular function in adult men with previous UDT treated at different ages before puberty. A long-term follow-up study of men with previous UDT was performed. Andrological evaluation included medical history taking, physical examination, scrotal ultrasound, determination of reproductive hormones, and semen analysis. Findings were compared with those of a control group of men with normal testicular descent. The influence of age at orchiopexy on future fertility parameters was evaluated in a multivariate regression analysis. 62 men were included of whom seven had had bilateral UDT. Twenty-four patients had had their orchiopexy before the age of 24months of whom eight men had it before 12months of age. Forty-eight men had had unsuccessful luteinizing-hormone-releasing-hormone (LHRH) nasal spray treatment during childhood, whereas 14 of 24 men operated before 24months of age had not received LHRH treatment before orchiopexy. Fertility potential in men with a history of UDT is compromised in comparison with controls. We could not detect any influence of age at orchiopexy on fertility parameters. However, the number of patients operated before the age of 12months is limited. This study does not support the assumption that early orchiopexy results in better fertility potential.

Beyond Hemostasis: Spectrum of Gynecologic and Obstetric Indications for Transcatheter Embolization

Percutaneous vascular embolization is a useful therapeutic option for a wide range of gynecologic and obstetric abnormalities. Transcatheter embolization procedures performed with the use of radiologic imaging for guidance are minimally invasive and may obviate surgery, thereby decreasing morbidity and mortality and safeguarding the patient's future fertility potential. To integrate this treatment method optimally into patient care, knowledge is needed about the clinical indications for therapeutic embolization, the relevant vascular anatomy, technical considerations of the procedure, and the potential risks and benefits of embolization. The most well-known and well-studied transcatheter embolization technique for treating a gynecologic-obstetric condition is uterine fibroid embolization. However, the clinical indications for transcatheter embolization are much broader and include many benign gynecologic conditions, such as adenomyosis and arteriovenous malformations, as well as intractable bleeding due to inoperable advanced-stage malignancies. Uterine artery embolization may be performed to prevent or treat bleeding associated with various obstetric conditions, including postpartum hemorrhage, placental implantation abnormality, and ectopic pregnancy. Embolization of the uterine artery or the internal iliac artery also may be performed to control pelvic bleeding due to coagulopathy or iatrogenic injury, and ovarian vein embolization has been shown to be effective for the management of pelvic congestion syndrome. The article discusses these and other gynecologic and obstetric indications for transcatheter embolization, provides detailed descriptions of imaging findings before and after embolization, and reviews procedural techniques and outcomes.

Undescended Testis Histology Correlation with Adult Hormone Levels and Semen Analysis

Cryptorchidism has been associated with infertility. We hypothesize that a positive correlation exists between testicular histopathology at orchiopexy and future fertility potential in patients with cryptorchidism. Patients with cryptorchidism who underwent orchiopexy with bilateral testis biopsies were followed into adulthood. Testis histology was stratified into groups based on total germ cells per tubule and adult dark spermatogonia per tubule. After age 18 years, patients underwent hormonal testing and semen analysis. Mean semen analysis parameters and hormone levels were compared among histopathology groups. A total of 91 patients with unilateral undescended testes and 19 with bilateral undescended testes had data for review. No significant differences in semen analysis parameters were seen among the germ cells per tubule groups. In unilateral undescended testis, sperm density and sperm count in the abnormal adult dark spermatogonia per tubule group remained within normal range but were significantly decreased (p = 0.005 and p = 0.028). Follicle-stimulating hormone levels were significantly higher in patients with unilateral undescended testis with abnormal adult dark spermatogonia per tubule but remained within normal range (p = 0.009). Sperm density was below normal range and was significantly decreased in the abnormal adult dark spermatogonia per tubule group in the bilateral undescended testes cohort (p = 0.0496). In bilateral undescended testes follicle-stimulating hormone level, sperm count and percent motility in the abnormal adult dark spermatogonia per tubule group were outside normal clinical range but these results were not statistically significant (p = 0.07-0.2). Total germ cell histopathology at the time of orchiopexy was not associated with significant changes in hormone levels or semen analysis results in adulthood. Testis biopsy at orchiopexy may be limited in predicting future fertility in unilateral undescended testis but more clinically useful in predicting fertility potential for those with bilateral undescended testes.