25 historic papers: an ASRM 75th birthday gift from Fertility and Sterility

Happy Birthday, ASRM!
25 historic papers: an ASRM 75th birthday gift from Fertility and Sterility

Volume 112, Issue 4, Supplement 1, Pages e2–e27


Craig Niederberger, M.D., Antonio Pellicer, M.D., Carlos Simon, M.D., Ph.D., Martin Kathrins, M.D., Marc Goldstein, M.D., Mark Sigman, M.D., Peter N. Schlegel, M.D., Santiago Munné, Ph.D., David K. Gardner, D.Phil., Ana Cobo, Ph.D., Christos Coutifaris, M.D., Ph.D., Jacques Donnez, M.D., Ph.D., Hugh S. Taylor, M.D., Linda C. Giudice, M.D., Ph.D., Bart C.J.M. Fauser, M.D., Ph.D., Steven R. Lindheim, M.D., M.M.M., Zev Rosenwaks, M.D., Robert F. Casper, M.D., Dominique de Ziegler, M.D., William E. Gibbons, M.D., Richard J. Paulson, M.D., M.S.5, Neri Laufer, M.D., Susan C. Klock, Ph.D., Pauline Mendola, Ph.D., Mark V. Sauer, M.D., M.S.


  1. Semen quality in one thousand men of known fertility and in eight hundred cases of infertile marriage
  2. Effect of clomiphene citrate on spermatogenesis in the human: a preliminary report
  3. Varicocele size and results of varicocelectomy in selected subfertile men with varicocele
  4. Predictive value of abnormal sperm morphology in in vitro fertilization
  5. High serum FSH levels in men with nonobstructive azoospermia does not affect success of microdissection testicular sperm extraction
  6. Embryo morphology, developmental rates and maternal age are correlated with chromosome abnormalities
  7. Blastocyst score affects implantation and pregnancy outcome: towards a single blastocyst transfer
  8. Comparison of concomitant outcome achieved with fresh and cryopreserved donor oocytes vitrified by the Cryotop method
  9. Dating the Endometrial Biopsy
  10. Histological dating of timed endometrial biopsy tissue is not related to fertility status
  11. Peritoneal endometriosis, ovarian endometriosis, and adenomyotic nodules of the rectovaginal septum are three different entities
  12. Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries
  13. Pathogenesis and pathophysiology of endometriosis
  14. Women with polycystic ovary syndrome wedge resected in 1956 to 1965: a long-term follow-up focusing on natural history and circulating hormones
  15. The medical treatment of unruptured ectopic pregnancy with methotrexate and citrovorum rescue: preliminary experience
  16. Follicle-stimulating hormone levels on cycle day 3 are predictive of in vitro fertilization outcome
  17. Use of an aromatase inhibitor for induction of ovulation in patients with an inadequate response to clomiphene citrate
  18. Antimüllerian hormone serum levels: a putative marker for ovarian aging
  19. Transvaginal ultrasound scanning of ovarian follicles
  20. Donor eggs: their application in modern reproductive technologies
  21. IVF in unstimulated cycles: a new application
  22. Ovarian hyperstimulation syndrome in novel reproductive technologies: prevention and treatment
  23. The emotional needs of infertile couples
  24. Estimates of human fertility and pregnancy loss
  25. Assessing the clinical utility of in vitro fertilization with intracytoplasmic sperm injection in human immunodeficiency virus type 1 serodiscordant couples: report of 113 consecutive cycles

1. Semen quality in one thousand men of known fertility and in eight hundred cases of infertile marriage

Craig Niederberger, M.D.

Department of Urology and Department of Bioengineering, University of Illinois at Chicago College of Medicine, Chicago, Illinois

This is the article that began the medical field of male reproductive medicine. It's also an unsolved puzzle.

I would ask the reader to read the entire paper, including the comments at the end. It is a beautiful and elegant analysis of the most fundamental physical contribution of the male to the making of a baby, his semen. At the time the male was nearly hidden in the evaluation of fertility and would remain at least partially so for many decades to come. But this paper provided a quantitative method of evaluating a man's fertility potential for the very first time.

Dr. MacLeod measured parameters observable by light microscopy of semen from “1000 married men whose wives were pregnant at the time the semen examination was made” and from “800 semen specimens from individuals who had presented themselves for examination because of infertile marriage,” and performed a stringent descriptive statistical analysis on the results. His description was so exacting that it is possible to perform receiver operating characteristic (ROC) curve analysis on his data. A hot topic in publishing today is whether and how to make available the raw data for the reader of a scientific communication. Here, Dr. MacLeod was far ahead of his time.

Volume and sperm concentration are direct, unequivocal physical measurements. Motility is a different matter, and as anyone who has looked under the microscope at sperm can attest, it's difficult to say whether the tiny sperm is wiggling towards an egg or is bobbing around solely in accordance with Brownian motion. Dr. MacLeod “arbitrarily” graded progressive movement of sperm on a ordinal scale of 1 to 4, a system still in use today. Interestingly, he refrained from a statistical analysis of morphology, mainly due to the extraordinary amount of work involved in classifying and calculating the variant shapes of sperm. This work would wait to be performed for nearly 4 decades and is described in Thinus Kruger's paper in this compendium.

So how did John MacLeod do in separating men in fertile from infertile couples? Keeping in mind that an area under the curve (AUC) of 0.5 in ROC analysis is that due to pure chance, the AUC for sperm concentration calculated from the raw data in this paper is 0.59 and that of motility is 0.50. In other words, fertile and infertile couples don't separate at all by guessing if a sperm is moving forward, but a bit by counting the number of swimmers. Fifty years later David Guzick and co-investigators in the National Cooperative Reproductive Medicine Network reported similar findings from a study of men in 765 infertile couples and 696 fertile couples, with a ROC AUC for sperm concentration at 0.60 and that of motility at 0.59 (1). Motility had inched up a tad, but concentration was the same. And both weren't great.

What do you do with a test that reveals such overlap between fertile and infertile men? The first step is to show the numbers, which is what the WHO does in the 5th edition of its laboratory manual for the examination and processing of human sperm (2). The second is to pick a low number from which to say below it there's a good chance that a man is infertile. What not to do is to then say everyone above that number is in the clear, a mistake I've seen made countless times in scientific talks and papers. Guzick and co-authors use classification-and-regression-tree (CART) analysis to generate 2 thresholds for each parameter, below which is likely infertile, above which is probably fertile, and between is unknowable (1). It's a great idea but one sadly not in common clinical use.

So back to those fascinating comments at the end of this paper. Dr. Ernest Page noted that on removing the lowest results, the remaining would appear identical, exactly the problem identified by ROC analysis and prompting Guzick and co-investigators to consider CART as a reasoned approach. Dr. Page even goes as far as writing, “I can't believe that there will ever be a dividing line except in one category, namely, “sperm present” or “sperm absent.””

And therein lies our unsolved puzzle. This paper ushered in the field of male reproductive medicine as a science with quantitative metrics. The semen analysis remains the most obvious and obtainable assay, but unless it results in no or precious few sperm, it's unhelpful. How can we do better? John MacLeod opened the first door. Let's find the next.

Disclosure(s): C.N. has nothing to disclose.

Original article available at: https://www.fertstert.org/article/S0015-0282(16)30482-4/fulltext

2. Effect of clomiphene citrate on spermatogenesis in the human: a preliminary report

Martin Kathrins, M.D.

Division of Urology, Brigham and Women’s Hospital, Boston, Massacusetts

Clomiphene citrate remains one of the most commonly prescribed empiric therapies for male factor infertility (3). This groundbreaking study from the Department of Endocrinology at the Medical College of Georgia in the early 1960s was the first to examine the effects of clomiphene citrate on oligospermic men. Prior to this paper, trials had examined the ability of clomiphene to augment urinary gonadotropin levels in fertile controls but not yet in infertile men (4). Whether or not clomiphene was previously proposed to treat male infertility, it was nevertheless this small cohort of 29 men with oligospermia—compared with fertile controls—which was first treated with this goal in mind.

The authors noted a now all-too familiar pattern of inconsistent results regarding bulk semen parameters. Just under two-thirds of the treated patients experienced improved sperm counts. They also discovered what would prove to be one of the more vexing and mysterious complications of clomiphene therapy—the paradoxical effect. The authors observed that one-fifth of the men ended up with worsening sperm counts after treatment. While we have our own unproven theories as to the physiology of the paradoxical effect, the authors did not advance any hypotheses. No hidden truths to be found here.

When compared with our current standard treatment, there are some obvious differences here. The authors treated their patients without regard to baseline hormonal parameters. Presently, andrologists continue to debate the merits of empiric versus directed hormonal therapy for infertile men, the latter seeking to correct a specific underlying endocrinopathy. While our contemporary approach relies on verification of treatment effects on testosterone and estradiol, this early manuscript provided no such follow-up information. To the frustration of our eager patients, most andrologists will wait several months after initiating clomiphene prior to checking an initial semen analysis—allowing for a few cycles of spermatogenesis. The authors obtained semen analyses at the 4, 5, and 8-week points. Unfortunately, there is only aggregate follow-up data provided in the manuscript. The change in sperm counts over time would have been interesting to see as our present literature often relies on fewer data points when assessing the efficacy of hormonal therapy.

The presence of multiple different dosing regimens in this study is prophetic of the current controversies related to clomiphene use. While under-powered, the authors did observe a greater proportion of men with improved semen parameters after 50 mg daily versus 25 mg daily. Other than the paradoxical effects, the authors make no mention of any adverse effects. It would be an understatement to observe that there is still no consensus on optimal clomiphene dosing for men—whether used for infertility or to treat testosterone deficiency.

This paper also suffered from one of the more common lapses of male reproductive medicine research—no pregnancy rates were reported. The absence of this important outcome remains so commonplace in our contemporary literature that any criticism would be hypocritical. Unfortunately, we still have precious little high quality, controlled evidence that can confidently point to a true fertility benefit from clomiphene use. In fact, in their concluding sentence, the authors made no mention of a need for pregnancy and birth rates, but instead called for future studies to examine the hormonal effects of clomiphene.

The work of Jungck et al. highlights how little has changed in our understanding of clomiphene. It remains the quintessential pharmacotherapy for male factor infertility but is still used as a blunt instrument. In the age of personalized medicine, all we have is the semen analysis to guide our therapy (we still cannot even agree on the use of serum testosterone as a criterion for fertility therapy). While marveling that at one time clomiphene was a novel therapy for low sperm counts, any nostalgia should be replaced with a clear call to action. We should finally study this medication in a large, controlled, multi-institutional fashion. We must seek more accurate biomarkers to guide therapy. Regardless of where we still must go, this concise study’s importance and originality ultimately stands beside the earliest descriptions of the quantitative semen analysis and varicocelectomy.

Disclosure(s): M.K. has nothing to disclose.

Original article available at: https://www.fertstert.org/article/S0015-0282(16)35106-8/fulltext

3.Varicocele size and results of varicocelectomy in selected subfertile men with varicocele

Marc Goldstein, M.D.

Center for Reproductive Medicine and Department of Urology, Weill Cornell Medicine, New York, New York

Laurence Dubin and Richard Amelar were pioneers in recognizing the contribution of varicocele to male factor infertility and showing that varicocelectomy can be an effective treatment for improving semen parameters and achieving pregnancies in men with infertility. This seminal 1970 paper by Dubin and Amelar was the first to describe a varicocele grading system based on palpable reflux in all cases, and then categorized according to venous bundle size in the upright position. This is essentially the same grading system employed by urologists today. Currently what Dubin and Amelar called “small” is a grade I varicocele, characterized by easily palpable reflux on Valsalva, “moderate” is grade II, characterized by palpable reflux on Valsalva and a mass of veins in the spermatic cord measuring 1 to 2 cm in diameter, and “large,” characterized by palpable reflux on Valsalva, and easily visible veins when upright, even without Valsalva, is grade III.

The authors reported the outcomes of 111 varicocelectomies in men with primary infertility and no other confounding male factors, utilizing non-magnified ligation of the veins at the level of the internal inguinal ring, unilateral in 105 cases and bilateral in 6. There was no control group. The authors reported similar percentages of improvement following varicocele ligation, regardless of varicocele size. Two hydroceles were reported. Semen analysis outcomes were reported in 90% of the cases and were reported as simply improved or not improved compared to pre-operative levels. During the 18-month post-operative period, 53 pregnancies occurred, resulting in 49 births.

The authors report a similar number of improved and a similar pregnancy rate regardless of varicocele size. Since semen analysis improvements were not broken down by varicocele size, what the authors did not realize was that men with large varicoceles started out with much poorer semen parameters than men with smaller varicoceles but had much greater improvement post-operatively than men with smaller varicoceles. We reported this in 1993 (Fig. 1) (5). Recent studies have confirmed the relationship between varicocele size and pre- and post-operative semen analysis (6). Currently, in general, male reproductive urologists are more enthusiastic about repairing large varicoceles than they are about repairing small or subclinical varicoceles.

Figure 1: Improvement in semen parameters following left microsurgical varicocelectomy based on varicocele grade.

Use with permission from Steckel, J., Dicker, A., & Goldstein, M. (1993) Relationship between varicocele size and response to varicocelectomy. J Urol, 149: 769 – 771.

Finally, microsurgical, artery and lymphatic sparing techniques are now considered the gold standard for repair, virtually eliminating post-operative hydrocele formation and ligation of the testicular artery (7). It is inarguable that the ligation of the main testicular artery is unlikely to enhance testicular function. In their later writings, Amelar and Dubin did recognize the importance of preserving lymphatics to prevent hydrocele formation. This is much more easily accomplished with microsurgical technique. Additionally, it is now recognized that varicocele is associated with androgen deficiency, and its repair results in significantly increased serum testosterone levels, providing an additional indication for repair. In many men in whom fertility is not an issue but who have palpable varicoceles, microsurgical varicocelectomy may be a viable option to treat androgen deficiency, or at the least, obviate the need for future hormone replacement therapy.

In summary, this paper by Dubin and Amelar, at the time of its publication, was the largest series to describe the benefits of varicocelectomy in improving semen analysis and reported impressive pregnancy rates. This paper also described, for the first time, a system of categorization of varicocele size that is still used today by all urologists.

Disclosure(s): M.G. has nothing to disclose.

Original article available at: https://www.fertstert.org/article/S0015-0282(16)37684-1/fulltext

4. Predictive value of abnormal sperm morphology in in vitro fertilization

Mark Sigman, M.D.

Division of Urology, Department of Surgery, Warren Alpert Medical School of Brown University and Lifespan Healthcare System, Providence, Rhode Island

Assessment of sperm morphology has remained the most difficult and controversial semen analysis parameter. The use of spermatozoal shape to assess fertility began with Dr. MacLeod’s landmark publications in the 1940s (presented elsewhere in this compendium). At that time and for the next 40 years, pictures of abnormal sperm were used as references for categorizing sperm. Most importantly, sperm were grouped into a variety of categories of abnormalities such as large, small, and tapering forms. Sperm with mild abnormalities that did not fit those categories were considered normal. The difficulty of trying to find a specific category for every abnormality was understood by Macleod who stated that they set up their own rather arbitrary standards of classification. This difficulty with sperm shape classification and its unknown relevance to the new field of IVF led to the publication of this paper by Thinus Kruger’s team where sperm morphology assessment was turned upside down. They decided to determine what morphology could tell them about fertilization of oocytes. The system they developed changed the paradigm of sperm morphology assessment. Previously, sperm that did not fit into specific categories of abnormalities were classified as normal. In this new system sperm were abnormal unless they fit the precise parameters of “normal.” Most importantly, borderline forms were considered abnormal. The presented data were impressive but has generated significant controversy that persists to this day.

The approach involved examining and determining dimensions and characteristics of sperm from the upper endocervical canal mucus to develop strict criteria for normal sperm morphology. The authors felt that these sperm were likely the most fertile. The authors selected a group of couples undergoing IVF in which the males had primarily isolated low morphology scores. It is important to note that this is not representative of most infertile males, who often have multiple impaired parameters. This group was chosen to try to isolate the effect of morphology on IVF outcomes. Extrapolation of these thresholds for counselling couples with defects in other semen parameters or for couples not undergoing IVF may not have been appropriate. However, this is exactly what the clinical community began to do. Even though the authors realized the potential limitations by commenting that the criteria were useful only for IVF with the techniques used in their laboratory and that it would need modification by experts in the field.

The authors had previously found lower fertilization and pregnancy rates in couples with morphology scores of 0% to 14% but fertilization and pregnancy were still possible in this range (8). The purpose of the current paper was to try to establish a morphology score which would differentiate those that fertilized ova from those that would not by studying couples with female tubal infertility and males with isolated strict morphology scores of ≤ 14%. Analysis of IVF results determined that only sperm morphology was significantly different between those that fertilized ova and those that did not. They determined that a threshold to indicate impaired fertilization was 4%. Fertilization rates were 7.6 % in the < 4% morphology group compared to 63.9% in the > 4% group. While readers will find much of interest in this paper, the threshold of 4% has persisted and is the same number used in the current WHO semen reference range of men proven fertile by intercourse, not IVF (9). Despite cautions that the data were from IVF and scoring was in their lab with their technicians, the approach became widely utilized. While the authors maintained excellent consistency, most have found technicians tended to become stricter over time leading to a reduction in prognostic value of the scoring system. This has also become one of the biggest problems with the system – tremendous inter-lab variability making it difficult to compare results and therefor prognostic value between labs. Articles confirming the thresholds have been reported but many have found no clinical significance to morphology scoring.

Although some have argued that there is no value to morphology assessment, this is certainly not true. There are certain specific morphology patterns that always have prognostic significance such as globoozospermia (absent acrosomes). While these are uncommon, they greatly affect pregnancy rates by any approach and should not be missed. Assessment of morphology by strict criteria is clearly an improvement over the rather arbitrary morphology scoring which predated it but is certainly not the end of the road. As the authors noted in 1980’s, other experts will need to study and weigh in to keep the field moving forward.

Disclosure(s): M.S. has nothing to disclose.

Original article available at: https://www.fertstert.org/article/S0015-0282(16)59660-5/fulltext

5. High serum FSH levels in men with nonobstructive azoospermia does not affect success of microdissection testicular sperm extraction

Peter N. Schlegel, M.D.

Department of Urology, Weill Cornell Medical Center, New York, New York

The evaluation and treatment of men with non-obstructive azoospermia can be challenging. These men have such severely impaired sperm production that no sperm are present in the ejaculate. However, many of these men are treatable using sperm retrieval and ICSI. The highest success rates for sperm retrieval have been achieved, to-date, with the procedure of microTESE (10). Successful sperm retrieval is based on having at least one area of the testis with a heterogeneous or “different” area of sperm production than other regions of testicular tissue; and application of a surgical technique that can identify these very limited areas of the testicle with sperm. Since success of treatment is dependent on identifying a limited area of the testis, perhaps less than 1% of the entire testicular tissue, it may be difficult to identify the “better” testes based on evaluation of overall testicular function, commonly reflected by measures such as testicular volume or, as discussed in this article, serum FSH levels.

Men with non-obstructive azoospermia have either predominant Sertoli cell-only pattern or maturation arrest. If large areas of the testis had complete spermatogenesis, then sperm would be present in the ejaculate. If most of the testis has a Sertoli cell-only pattern, then there is usually less pituitary feedback from Sertoli cells and therefore higher FSH levels. In men with diffuse maturation arrest, the large volume of germ cells interacting with Sertoli cells results in substantial production of inhibin and other factors that suppress FSH production. Given the lower chances of sperm retrieval in men with maturation arrest (11), it is not surprising that men with the lowest FSH level tended to have lower sperm retrieval rates. However, for men with elevated or markedly elevated FSH levels, sperm retrieval rates were maintained at 60% to 67%. Why is that? Shouldn’t men with elevated FSH have worse testes?

All men with non-obstructive azoospermia have abnormal testes. It turns out that the men with the greatest elevation of serum FSH typically have a background pattern of Sertoli cell-only but often still have focal areas of spermatogenesis. The pattern of high FSH in non-obstructive azoospermia often predicts the presence of heterogeneity that is critical (with effective surgical technique) for sperm retrieval. Indeed, men with Klinefelter syndrome, who typically have very small volume testes, extensive sclerosis within the testis and Leydig cell hyperplasia with only focal areas of spermatogenesis, classically have high mean FSH levels and high sperm retrieval rates (65-70%, in our experience) (12).

In distinction to the results we and others have reported with microTESE, some investigators have reported that men with lower FSH levels are more likely to have sperm found with simple TESE procedures than the men with higher FSH levels. We believe that this observation reflects the limited sampling of the testis that occurs with standard TESE that makes it difficult to find limited, focal areas of sperm production. The higher sperm retrieval rates with microTESE probably reflect the ability of this procedure to identify and retrieve sperm from these isolated foci of seminiferous tubules with active spermatogenesis, so men with high FSH levels and limited heterogeneity of testicular function may disproportionately benefit from the microTESE procedure.

In summary, this article documents the power of microTESE to isolate even isolated areas of spermatogenesis in highly dysfunctional testes of men with elevated FSH. Even men with FSH levels above 120 IU/L have had sperm retrieved and successfully used with ICSI to initiate normal pregnancies. So, the presence of high FSH does not preclude successful treatment of men with non-obstructive azoospermia. Although the higher FSH levels reflect less overall spermatogenic activity, a high FSH is often a favorable prognostic factor in the management of men with non-obstructive azoospermia.

Disclosure(s): P.N.S. has nothing to disclose.

Original article available at: https://www.fertstert.org/article/S0015-0282(08)01478-7/fulltext

6. Embryo morphology, developmental rates and maternal age are correlated with chromosome abnormalities

Santiago Munné, Ph.D.

Department of Obstetrics Gynecology and Reproductive Science, Yale University, New Haven, Connecticut; and Overture Life, Barcelona, Spain

Prior to the use of FISH, chromosome abnormalities could only be detected by karyotype analysis and since few cells are at any time in metaphase stage, especially in the arrested embryos usually used for research, we had a very poor understanding of meiotic abnormalities (aneuploidy) and post-meiotic abnormalities (mosaicism, polyploidy) in early embryos.

We used FISH with multiple probes for the first time in 1993 (13) and after analysing a sizable amount of embryos, we were able in the 1995 paper to report two important features of early embryo development, one, that post-meiotic chromosome abnormalities increase with increasing dysmorphism, and two, that aneuploidy increases with advancing maternal age. Obviously, we knew from spontaneous abortions that aneuploidy should increase with maternal age, but at the time there was no karyotype evidence in early embryos. More surprising was the extent of abnormalities found. A plurality of arrested embryos was abnormal just for 5 chromosomes, and in older patients a majority of embryos were aneuploid. That led us to hypothesize that the loss of implantation potential with advancing maternal age was mostly due to maternal age and not to endometrial factors. Screening for chromosome abnormalities could therefore improve ongoing implantation rates which led to the use of Preimplantation Genetic Testing for aneuploidy (PGT-A).

The hypothesis that embryo loss with advancing maternal age is mostly due to aneuploidy was proven later on two fronts, one with data from oocyte donation, which showed that young eggs implanted equally well in recipient women irrespective of their maternal age, thus showing that uterine factors were not the cause of embryo loss with advancing maternal age. We had to wait many years and many procedures of PGT for us to find the other proof, which is that after PGT, euploid embryos (chromosomally normal) implant equally well at any age (14). Currently, there is still some controversy regarding the use of PGT. My opinion is that the science is sound, but the biopsy methods are not standardized or automated to produce consistent results across all fertility centers. This is not a surprise since techniques and skills vary tremendously between centers. For instance, livebirth rates after SET in egg donors and chromosome abnormality rates in embryos of egg donors can double from one center to another.

This bring us to the relevance of post-meiotic abnormalities. Spindle abnormalities both disturb mitosis as well as cell division resulting in post-meiotic chromosome abnormalities, and dysmorphisms such as multinucleation, fragmentation, uneven cells, slow development and embryo arrest. Disturbances caused by unsuitable conditions in the lab can therefore increase embryonic arrest, dysmorphism, mosaicism and polyploidy (through nuclear division without cytokinesis). These chromosome abnormalities could be an indicator of the quality of the embryology in a laboratory or used to assess new techniques, conditions or media. It is no wonder that morphological assessment of embryos by dynamic time-lapse observation is able to screen for some chromosome abnormalities by looking at features of morphology that were previously analyzed manually. However, gross dysmorphism is not linked to aneuploidy, only to post-meiotic abnormalities. It is possible that artificial intelligence (AI) and more sophisticated image analysis might result in a more complete non-invasive diagnosis of aneuploidy, and some evidence of that is already being reported. Similarly, non-invasive PGT might soon be as reliable as biopsy-based PGT by assessing spent media.

Disclosure(s): S.M. is a consultant for CooperGenomics.

Original article available at: https://www.fertstert.org/article/S0015-0282(16)57739-5/fulltext

7. Blastocyst score affects implantation and pregnancy outcome: towards a single blastocyst transfer

David K. Gardner, D.Phil.

School of BioSciences, University of Melbourne, and Melbourne IVF, Melbourne, Victoria, Australia

Since the first prospective randomised trial of blastocyst culture and transfer which demonstrated higher implantation rates when embryos were transferred on day 5 rather than day 3, clinical use has increased to the point that blastocyst transfer has been adopted as the standard of care in many countries. Over the past two decades the use of the elegant alpha numeric system for quantifying blastocyst potential has been applied increasingly, and consequently we can now reflect on which of the parameters initially identified have the greatest importance in predicting transfer outcome.

The premise when developing this grading system was to incorporate as much visual information as possible. Initially it was considered that the size of each blastocyst was an important time-sensitive parameter, as it required both appropriate developmental programming and considerable metabolic activity to form the blastocoel. As metabolic rate had been shown to be an effective biomarker of viability in the cow and mouse blastocyst, it was considered that rate of expansion would be an indirect measure of viability and normality. Secondly, the differentiation and quantification of the blastocyst into its two constituent cell types, the Inner Cell Mass (ICM) and Trophectoderm (TE), was considered. It was deemed that scoring ICM development would reflect fetal development capacity, while the quality of the TE would impact implantation potential, given the significance of this tissue in signalling with the endometrium. In the initial study by Gardner and colleagues, it was observed that blastocysts with expansion scores of 3 and higher, combined with an ICM and TE score of AA, possessed an implantation potential of 70%. Hence given the very high rate of twins resulting from the transfer of 2 high scoring blastocysts (∼50%), the grading of blastocysts could be used to identify a single embryo for transfer. Indeed, this approach was subsequently used successfully in a prospective randomized trial to show that single blastocyst transfer is a most effective approach for eliminating multiple gestations.

Twenty years on, the paper by Gardner and colleagues has been cited over 1,000 times, and the Gardner Grading system widely adopted and adapted. In this time, many studies have considered which parameter has the greatest weight with regards to blastocyst transfer outcome (15). It has been reported that degree of expansion (numeric score) is positively related to transfer outcome, and that TE score is highly predictive of pregnancy and live birth, while ICM score is consistent with both higher pregnancy and with lower pregnancy loss. Hence, all 3 parameters from the original scoring system remain of value in assessing developmental potential.

However, an evident drawback at the time that the grading system was developed, was that observations were typically performed only once a day. The advent of time-lapse microscopy facilitated evaluation of blastocyst expansion rate, which can now be factored into the information gleaned. Of note, aneuploidy in somatic cells results in a phenomenon known as aneuploid-stress, whereby altered karyotype leads to altered gene expression, proteome and metabolism. Consistent with this, data to date indicate that aneuploid embryos take a longer time from initiation of cavitation to full expansion, implying a compromised metabolic state. Furthermore, although a significant proportion of aneuploid embryos are able to form blastocysts with a high score, there does appear to be a higher prevalence of lower blastocyst scores associated with aneuploidy, especially with regards to the ICM. Although chromosomal imbalance has a greater negative impact on blastocyst morphology as opposed to the cleavage stages, these differences are evidently not absolute and hence there remains a need to assess blastocyst DNA either through TE biopsy or media analysis, to ensure that euploid embryos are identified.

A second issue associated with blastocyst scoring is that the assessment is subjective. So, when is a 4AA blastocyst not a 4AA blastocyst? The answer is possibly when it is scored by another embryologist. Hence, although blastocyst scoring by embryologists has been used for 20 years, this approach can now be augmented with rapid developments in AI, which rather than simply considering a single event during development, is capable of evaluating the entire history of an embryo’s development to the blastocyst (16). This approach has the advantage of not only alleviating the subjectivity associated with embryo grading but is fully automated.

Is there more we can learn about fetal/child health from the blastocyst before transfer? Although quantification of embryo morphology, through time-lapse and/or AI, is of immense benefit, morphology can only provide a partial insight into the embryo. Analysis of the medium around the embryo provides key insight into the metabolic state and consequent health of the embryo (17). Hence, the future of blastocyst selection could include both AI and media analysis to assess both metabolic state and ploidy of the embryo. Such a complete approach will ensure the appropriate ranking of healthy euploid embryos for transfer, thereby significantly decreasing the time it takes to pregnancy and maximising the opportunity for the birth of a healthy child.

Disclosure(s): D.K.G. has nothing to disclose.

Original article available at: https://www.fertstert.org/article/S0015-0282(00)00518-5/fulltext

8. Comparison of concomitant outcome achieved with fresh and cryopreserved donor oocytes vitrified by the Cryotop method

Ana Cobo, Ph.D.

IVI Valencia, IVI-RMA Global, Valencia, Spain

Successful oocyte cryopreservation is a milestone in the history of reproductive medicine. After nearly three decades of unsuccessful results, the notorious refinement of vitrification technology provides the way to store unfertilized oocytes at cryogenic temperatures with very high efficiency upon warming. In recent years, we have witnessed egg-banking being established in many clinical settings that count on successful vitrification programs worldwide. This technology has contributed to not only improve the results of the old embryo cryopreservation programs using slow freezing, but to also open up a wide range of new treatment indications in reproductive medicine based on the cryopreservation of the unfertilized MII oocyte.

The widespread utilization of this technique in routine clinical practice started just over 10 years ago. Indeed, the study entitled “Comparison of concomitant outcome achieved with fresh and cryopreserved donor oocytes vitrified by the Cryotop method” has greatly contributed to reach the turning point for the clinical validation of the technique. This study soon stood out, mainly because oocyte vitrification was assessed for the first time in a very interesting experimental design, which allowed the development of vitrified and fresh oocytes harvested from the same ovarian stimulation cycle and inseminated with the same semen sample for each patient, to be evaluated. For this purpose, we randomly allocated oocytes to two groups of vitrified fresh and oocytes. While the former were vitrified following the protocol developed by Kuwayama et al. (18) and were warmed after 1 hour, the latter remained in the incubator. The simultaneous insemination of oocytes from both groups provided the opportunity to evaluate the development of embryos generated concomitantly from vitrified and fresh oocytes under the same conditions. The most significant findings were that we did not observe statistical differences in fertilization rates (76.3% and 82.2%), development to day 2 (94.2% and 97.8%) or day 3 (77.6% and 84.6%), or blastocysts formation (48.7% and 47.5%) for vitrified and fresh oocytes, respectively. The morphological quality of blastocysts or embryos in early stages was also equivalent.

This study did not allow the assessment of the implantation potential of the vitrified oocytes, because single embryo transfers were not performed at that time, and there were no cases where the embryos replaced were developed exclusively from vitrified oocytes. Nonetheless, the encouraging data on the viability of oocytes after vitrification found in the study, led to further publications that allowed the clinical validation of the technique. Consequently, the efficiency of oocyte vitrification was demonstrated later in a large clinical trial with comparable results in ongoing pregnancy rate terms (19). Several different studies published afterward endorsed the validity of the approach, and egg-banking became a standard procedure in ovum donation programs which underwent marked improvements, especially in the logistics of the process to avoid former long waiting lists and to offer the possibility of saving the quarantine period.

Given the success rates achieved with donors, the use of vitrified oocytes in autologous cycles did not take long to appear. The benefits of this approach in infertile populations include several indications, as in cases of having to avoid the hyperstimulation risk, in poor responders or in fertility preservation (FP). In fact, successful FP has revolutionized the assisted reproduction practice and provides specialists with the opportunity to offer the future motherhood option to a large population, including women who are genetically predisposed to premature ovarian reserve depletion, woman about to receive treatment for cancer or immunological diseases, or women with endometriosis, which may compromise future fertility. Elective FP has well-broken into society and its impact has been compared with that caused by the arrival of the contraceptive pill. Emerging studies are showing that FP is an efficient alternative to ensure success in the future, but one with limiting factors, of which age and oocyte number are the most powerful (20). Elective freezers should be encouraged to do this at ages under 35 years. Although cancer patients have been found to benefit from FP, they seem to present lower reproductive outcomes, but the role of the disease in this remains to be confirmed (20).

Both success rates and the broad scope of the approach drove us to today’s scenario, where female gamete cryopreservation is an essential part of assisted reproduction.

Disclosure(s): A.C. has nothing to disclose.

Original article available at: https://www.fertstert.org/article/S0015-0282(07)01218-6/fulltext

9. Dating the Endometrial Biopsy

Carlos Simon, M.D., Ph.D.

Department of Obstetrics and Gynecology, Valencia University and INCLIVA, Valencia, Spain; Department of Obstetrics and Gynecology, Stanford University, Stanford, California; and Igenomix, Valencia, Spain

The journey of a thousand miles begins with one step.”
—Lao Tzu

The inaugural issue of Fertility and Sterility published a paper by Noyes, Hertig, and Rock that has since become the most-cited in obstetrics and gynecology (over 3,000 times). At that historical moment, anatomical medicine—specifically, histology—provided the first diagnostic tool to date the human endometrium after ovulation. This breakthrough contribution opened the eyes of our predecessors to understanding the secretory phase, thus paving the way for the later discovery of the endometrial factor as a key in reproductive medicine.

Given our contemporary vision of evidence-based medicine, one might think that such a breakthrough stemmed from extensive, solid data obtained prospectively after proper IRB approval and patient consent—but this was not the case. Instead, this discovery was based on a retrospective review of 13 representative biopsy slides photographed by Leo Goodman at the Boston City Hospital. These slides were obtained from 40 medical protocols that had corresponding basal body temperature graphs, from a total of 300 revised cases. Yes, that’s right: the graphical representation of the eight major histologic criteria defining the secretory phase of the human endometrium, which has been used to date endometrial biopsies worldwide for more than 50 years, was drawn based on thirteen endometrial biopsy slides (21).

Given the standard scientific peer review system, one might also expect that such an outstanding scientific contribution passed the regular filters of anonymous reviewers; alas, this was not the case either. Arthur Hertig, then Professor of Pathology at Harvard Medical School, gave Robert Noyes a letter he had received from Pendleton Tompkins, recently made editor of a new journal to be called Fertility and Sterility; the letter invited contributions for the first issue. Hertig offered co-authorship if Noyes could get some material together with John Rock, who, along with M. K. Bartlett, had conceptualized endometrial dating in 1937. The manuscript based on the photographs of 13 endometrial biopsies was sent to Tompkins in June 1949 (21).

The fundamental contribution by Noyes and colleagues was to create, for the first time, a practical quantitative bioassay that bridged the gap between clinicians and pathologists for the translational benefit of patients. This work provided something each professional could understand and use, shedding light on interpretations and personal beliefs, and disrupting the then-current state of the art. Today, endometrial histology is not included in the infertility work-up of couples seeking to conceive, but it was the gold standard serving gynecologists for more than 50 years. This anatomical medicine protocol was created in the 1950s with the aim to date the endometrium in natural cycles, a time when endocrinology was in its early days. The recent replacement of this histologic approach with modern tools of molecular medicine now enables diagnosis of complex functions such as endometrial receptivity or enigmatic diseases such as endometriosis, which were difficult or impossible to diagnose via histology. Histology of the endometrium remains relevant for diagnosis of malignancy, infection and inflammation especially when coupled with molecular medicine that can guide pharmacogenomics but is not informative for guiding embryo transfer in assisted reproduction. Similar diagnostic failure for endometrial receptivity has been demonstrated using vaginal ultrasound despite high resolution and widespread use, or hysteroscopy regardless of its visual improvement. The transition from anatomical to molecular medicine promises additional ability to evaluate the endometrium and the limited period in which the maternal endometrium is ready to accept the adhesion of the embryo, known as the window of implantation (2223).

Going back to the beginning, we know that the endometrium controls the initiation of conception, and the maternal decidua the course of pregnancy by surveilling trophoblast invasion. In this editorial, I am honoring the visionaries who, ahead of their time, appreciated the clinical relevance of the uterine mucosa, initiating the first step of the understanding of what now is considered an organ itself. Modern reproductive medicine owes a debt of gratitude to these pioneers, who, by creating knowledge, enabled decades of new and exciting science.

Disclosure(s): C.S. has nothing to disclose.

Original article available at: https://www.fertstert.org/article/S0015-0282(16)30062-0/fulltext

10. Histological dating of timed endometrial biopsy tissue is not related to fertility status

Christos Coutifaris, M.D., Ph.D.

Department of Obstetrics and Gynecology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

This article from 2004, which reports a multicenter study conducted by the NICHD Reproductive Medicine Network, along with another study from the University of North Carolina published the same year (24), changed practically overnight the standard of care for the evaluation of the infertile couple. Since 1950 and up to that point, based on an invited manuscript, (authored by Dr. Noyes, a fellow at the time of publication, and his mentors, Dr. Howard Hertig, a pathologist, and Dr. John Rock, a reproductive medicine specialist and obstetrician gynecologist), female partners of couples presenting with infertility all had to undergo a timed endometrial biopsy to evaluate endometrial cellular morphology (25). Specifically, Noyes had observed that there were specific morphological cellular changes observed on histologic tissue sections which were associated with specific days of the endometrial cycle. Therefore, it made perfect sense for clinicians to start using histological dating of the endometrium to evaluate couples who presented with infertility in search for a uterine factor contributing to their inability to conceive. This was implemented clinically without any clinical trial to evaluate the utility of the histologic findings as a diagnostic test, but without any studies defining neither the accuracy nor the cycle to cycle variability of the test. In fact, even the observer to observer variability was never conclusively determined. Nevertheless, the endometrial biopsy and histological dating of the endometrium continued to be used widely in the clinic.

Evaluation of the dys-synchronous development of the endometrium using histologic criteria became routine, standard of care clinical practice and linked conditions related to infertility and pregnancy loss to an inadequate response of the endometrium to the hormonal changes during the menstrual cycle. As a result, the pathologic condition termed luteal phase deficiency was described, criteria for its definition were developed and therapies prescribed. The biologic plausibility of the hypothesis underlying this practice clearly fueled continuation of the use of this non-validated diagnostic test. What added further support for the routine evaluation of the endometrium during an infertility evaluation was the introduction of the concept of endometrial receptivity and the potential existence of a window of implantation. This concept was introduced by Professor Psychoyos and his collaborators in the late sixties and early seventies (26). They showed, initially in rats, that there is a defined period during the cycle that an embryo could implant. In addition, studies utilizing the egg donation model demonstrated the existence of a window of implantation in the human as well. These observations provided further theoretical support for using the evaluation of the endometrium as part of the routine work-up of the infertile couple and, in fact, its use was further expanded in the evolving field of assisted reproductive technologies in an attempt to improve the timing of embryo transfer and/or to explain implantation failure. It is impossible to estimate the physical, financial, psychological and in-time costs involved in what appeared to be a logical and biologically sound medical evaluation. It is unfortunate that it took more than fifty years before this clinical practice was shown to be non-contributory to the evaluation of the infertile couple and, to put it bluntly, useless!

In the concluding paragraph of our 2004 manuscript we state that “…. continued research on the emerging molecular markers of endometrial development should be encouraged”. Clearly, the past fifteen years have witnessed an explosion of new molecular data contributing to our understanding of function in the human endometrium and how some of the transcriptomic analyses may provide hints towards identifying composite molecular fingerprints defining the window of implantation. Such molecular findings may also point to directions to understand the functional significance of some of these molecular mediators vis a vis embryo implantation. Even though studies exist to suggest that such endometrial evaluation may be appropriate for cases of recurrent implantation failure, application of this molecular testing technology should not be applied across the board to all infertility patients at this time. Our concluding sentence in our 2004 manuscript stated “…. as proven in this study, rigorous evaluation of any tests based on new parameters needs to be undertaken before their routine application to clinical practice and their proclamation as “gold standards” for the evaluation of the luteal phase”. As stated earlier about the rationale of using endometrial histologic criteria in the clinical evaluation of the infertile couple, similarly, the evaluation of molecular markers makes sense. Nevertheless, their universal clinical use should be considered premature. We should not allow history to repeat itself. A randomized controlled clinical trial evaluating the use of the molecular evaluation of the window of implantation in the human should be performed before we apply this technology in the clinic and at significant costs to patients.

It is my hope that the horse has not left the barn yet AGAIN!

Disclosure(s): C.C. has received grants from the National Institutes of Health; and is a board member of the American Society for Reproductive Medicine.

Original article available at: https://www.fertstert.org/article/S0015-0282(04)02276-9/fulltext

11. Peritoneal endometriosis, ovarian endometriosis, and adenomyotic nodules of the rectovaginal septum are three different entities

Jacques Donnez, M.D., Ph.D.

Université Catholique de Louvain, Brussels, Belgium and Société de Recherche pour l'Infertilité (SRI), Brussels, Belgium

Since it was first published in 1997 that peritoneal, ovarian and deep endometriosis are three distinct entities, each likely with a different etiopathogenesis, most experts in the field have adopted this classification, while reporting their diverse therapeutic results in terms of pain relief or restoration of fertility. Unfortunately, as stated by Koninckx et al. (27), although the number of articles on endometriosis has increased exponentially over recent decades, their quality has not.

Evidence-based medicine, which aims to apply the best available treatment, has the tendency to consider everything unproven as untrue, contributing to the controversy, especially when it comes to surgery. Even if new drugs like gonadotropin-releasing hormone antagonist are being increasingly used to manage endometriosis-associated pain, they only treat the symptoms, while the pathology and evolution of the disease remain largely unknown.

It is now generally accepted that peritoneal endometriosis is caused by implantation of retrograde menstrual debris, associated or not with metaplasia, but the pathogenesis of ovarian endometriomas has not been elucidated. Is it coelomic metaplasia? Invagination? Secondary involvement of functional ovarian cysts? Whatever it is, therapy in case of endometrioma-related infertility is still a bone of contention, as demonstrated in a very recent paper where experts advocated either surgery or IVF as the primary approach (28). Surgery has a fundamental role to play in endometrioma management, but there are a number of concerns about its impact on the ovarian reserve. The skill and experience of the surgeon are the key drivers of high success and low complication rates (28). We should also bear in mind that the presence of ovarian endometriomas may itself inflict damage on the ovarian reserve, even before any surgical intervention (28). Indeed, focal inflammation and dysregulated folliculogenesis (the burnout hypothesis) could well be responsible for the low ovarian reserve in women with ovarian endometriomas (Kitajima et al., Fertil Steril 2014;101:1031-7). The debate is still ongoing and, as stressed by Somigliana (28), the decision between IVF and surgery should first be based on complete transparency with patients and freedom of choice.

As far as deep endometriosis is concerned, Donnez et al. (Donnez et al., Fertil Steril 1996;66:3262-8) consider the origin of the disease to be retrocervical or rectovaginal, manifesting as adenomyotic nodules. But we should remain modest in our nomenclature. Indeed, none of us were first to coin the term, as Sampson, Lockyer, and Cullen described these lesions as ‘interstitial adenomas of endometrial type’ as far back as the start of the 20th century. Low mitotic activity, low steroid receptor content and deficient endocrine dependency (progesterone resistance) account for the relatively slow evolution of deep adenomyotic nodules. It was also very recently proven that collective cell migration and nerves play a role in the establishment of lesions (29).

The prevalence of deep endometriosis has increased over the last two decades and a number of possible explanations, like the genetic-epigenetic theory (Koninckx et al., Fertil Steril 2019;111:327-40) or a cervical origin for the disease (Donnez et al., 2019;111:454-6), suggest the influence of various environmental factors, preexisting immunological defects, and/or oxidative stress.

However, it is not only the pathogenesis of deep endometriosis that is a source of debate, but also its treatment. Deep endometriosis remains the most difficult endometriotic entity to treat. Surgical removal is required when lesions impair bowel, urinary, sexual or reproductive functions, but there is clearly a trend towards a less aggressive surgical approach than bowel resection. A recent review reported that shaving or disc excision are feasible even for advanced disease, and the risk of complications is lower than after colorectal resection. The latter procedure should be reserved for very advanced lesions causing major stenosis (>60-70%) with signs of bowel occlusion (and not only dyschezia), and cases involving multiple nodules infiltrating the rectosigmoid junction and sigmoid colon (Donnez et al., Fertil Steril 2017;108:931-42).

In conclusion, our classification of three distinct endometriotic entities remains valid, but the pathogenesis and therapy continue to be contested. Despite the difficulties involved in treating this enigmatic disease, progress is being made.

Disclosure(s): J.D. has received grants and personal fees from the Gedeon Richter Group.

Original article available at: https://www.fertstert.org/article/S0015-0282(97)00191-X/fulltext

12. Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries

Hugh S. Taylor, M.D.

Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut

Endometriosis is defined by the presence of ectopic endometrium outside of the uterus. Most commonly lesions are in the pelvis surrounding the uterus and thought to arise by retrograde menstruation. Traditionally we have considered the lesions to be the source of pain and focused on the local pelvic symptoms. Due to studies such as this one, we have come to recognize the wider manifestations of the disease. Endometriosis is far more than a few painful lesions in the pelvis!

This paper describes the impact of the disease beyond simply the pelvic discomfort. Endometriosis results in a distressing loss of quality of life as well as a substantial loss of productivity. Work is missed and productivity is also decreased while at work. Here nearly 1500 women were evaluated, with just over half having endometriosis. Women affected by endometriosis lost approximately 25% of their work week on average due to the disease; this number includes both absenteeism and diminished efficiency while at work (termed presenteeism). In younger women the corresponding outcome should be considered school performance and academic achievement. The long-term consequences on education, careers and social relationships can be easily extrapolated. The importance of early disease recognition and treatment cannot be overemphasized. There is an enormous effect on the individual and society.

The study also confirmed the long delay in diagnosis of the disease and showed that this lag is seen universally throughout the world. Due to the diagnostic delay the life impact described is more severe than would be expected if treatment were prompt and effective. Identification and prompt treatment of endometriosis is essential and thankfully is becoming more likely due to efforts to move to clinical diagnosis rather than relying solely on surgical diagnosis (30). We can and should make a clinical diagnosis of endometriosis and initiate therapy far earlier than has been done in the past; currently there is still a significant delay and need for improvement.

Not only is diagnosis delayed, we now realize that the time to effective therapy is also prolonged. Many women with endometriosis are not satisfactorily treated with combination oral contraceptives and providers are often hesitant to advance therapy. The introduction of patient-friendly and highly effective medications such as GnRH antagonists has helped to prevent the consequences of this disease (31). First line therapies such as combined oral contraceptives frequently fail due to the progestin resistance that often develops in endometriosis. In the past second line treatment options were primarily surgery or GnRH agonist; both of those options were cumbersome and had significant negatives associated with them. The development of GnRH antagonists has provided drugs that are oral and have fewer side effects than prior second line therapies; this allows for rapid movement between treatment options to optimize and personalize endometriosis care.

We are now beginning to understand that endometriosis is a systemic disease rather than a disease predominantly affecting the pelvis. Endometriosis affects multiple organ systems, either directly or indirectly. In animal models of the disease we have previously shown that endometriosis affects metabolism in liver and adipose tissue, explaining the low body mass index seen in women with endometriosis. Endometriosis leads to systemic inflammation, likely contributing to the higher incidence of cardiovascular and autoimmune disease seen in these women. Endometriosis leads to alterations in the brain that cause the increased pain perception (central sensitization) and mood disorders found more commonly in patients.

The totality of endometriosis related disease and its consequences are likely even greater than shown in this classic paper. If studied today, we would include not only productivity but the myriad of clinical presentations of endometriosis. These would include pain sensitization, affective disorders, anxiety, metabolic derangements, inflammation, cardiovascular and cancer risk as well as numerous additional manifestations of the disease. The systemic manifestations compound the impairment of the disease. Pelvic pain is simply the most distinct and easily described symptom that happens to coincide with the observed location of the lesions. The real impact of the disease is still not fully recognized and goes far beyond the pelvis.

Disclosure(s): H.S.T. has received personal fees from Abbvie; and has a patent owned by Yale University pending to Dot Labs.

Original article available at: https://www.fertstert.org/article/S0015-0282(11)00876-4/fulltext

13. Pathogenesis and pathophysiology of endometriosis

Linda C. Giudice, M.D., Ph.D.

Center for Reproductive Sciences and Center for Reproductive Health University of California, San Francisco, California

Endometriosis is a common, estrogen-dependent, inflammatory disorder characterized by growth of endometrial-like tissue at extra-uterine locations. Insights into its pathogenesis and pathophysiology have burgeoned since this topic was reviewed by Burney and Giudice in Fertility and Sterility in 2012. Fueling new insights over the intervening 7 years have been advances in genomics, disease modeling, computational biology, and metadata. Herein, some of the major advances between 2012-2019 in endometriosis research are highlighted, with the caveat that the pace of scientific discovery rarely is characterized by quantum leaps.

The 2012 Fertility and Sterility review invoked origins of endometriosis in uterine endometrium or tissues other than the uterus with inciting factors and genetic susceptibilities whose roles were beginning to be delineated, although insufficient to confirm causality. Refluxed tissue, endocrine disrupting chemicals, coelomic metaplasia, induction of Müllerian rests, bone marrow-derived stem cells, and hematogenous and lymphatic spread of disease were and still are believed to be involved in the disease pathogenesis. However, one of the most significant advances in the past 7 years has been in genetics and genomics. Genetic studies reveal that ∼50% of endometriosis risk is due to genetic factors and ∼50% to environmental factors. As a complex disorder, single gene mutations have not been found in families with disease. However, genome wide association studies (GWAS) reveal 41 statistically significant loci in intergenic or intronic regions across the genome associated with endometriosis, with variants of low effect size (32). Some are in proximity to genes with biologic plausibility for abnormalities in this disorder (e.g., ESR1, FSHR) (32). In addition to genetic variants found in GWAS, somatic cancer driver mutations were recently reported in endometriosis lesions and eutopic endometrium - specifically in epithelial but not stromal cells (33). The data support clonality of the epithelium and that lesions derive from abnormal eutopic endometrium and/or acquire mutations in ectopic environments, including inflammation (3334). Stem cells may also be involved. Understanding germ-line variants and somatic mutations in the pathogenesis of endometriosis is anticipated to rapidly propel the field forward.

Since 2012, major advances have been made in elucidating mechanisms underlying estrogen and progesterone signaling and their roles in the inflammatory component of endometriosis and perhaps cancer mutations (34). While an inflamed pelvic cavity is indisputable in women with disease, bulk tissue analysis has revealed a pro-inflammatory environment in lesions and eutopic endometrium per se. Analyses at the cellular level have further refined molecular events underlying steroid hormone action and abnormalities in women with disease in the lesions and in the eutopic endometrium compared to controls (34). We now appreciate that steroid hormones alter chromatin structure and availability of hormone binding sites, engage transcription factors and nuclear receptor co-modulators, and components of epigenetic machinery, and contribute to aberrant gene regulation in lesions and in eutopic endometrium. Abnormal progesterone signaling, due largely to silencing PR gene expression, contributes to progesterone “resistance” associated with the disease and estradiol-induced inflammatory response and pain generation in lesions and unreceptive endometrium for fertility (3233).

These advances have given rise to searches for biomarkers of endometriosis. Circulating micro-RNAs and upregulation of BCL6 in eutopic endometrium of women with endometriosis have promise for clinical utility (32). Biomarker development is poised for further mining and validation in prospective, multi-site clinical trials with clearly defined outcomes. Moreover, these discovery approaches, enabled by sophisticated bioinformatic analyses, offer opportunities to develop novel medical therapies aimed at specific lesion and eutopic endometrium abnormalities and individualized symptom management. They are anticipated to further define sub-classes of disease - getting away from a “one size fits all” approach. Essential to leveraging “big data” is well annotated clinical phenotyping using standardized approaches developed in 2014 (http://endometriosisfoundation.org/ephect/). Furthermore, mining patient medical records and other e-data to pursue phenome-wide associated studies (PheWAS) coupling endometriosis with other disorders holds promise for the future.

While endometriosis is not malignant, it is hardly “benign”, given the enormous impact on affected individuals. Endometriosis research has come a long way in the past 7 years, despite limited investments incongruent with other common, chronic diseases. Major funding for research is required to realize goals of personalized interventions for symptom management, disease prevention, and ultimately cure. Increased awareness about endometriosis is gaining momentum among health care professionals, government agencies, and the lay public around the world. However, research and awareness campaigns go together, and both need to be resourced for this public health issue on the global stage. Hopefully, in the next celebratory period of the ASRM, these goals will have been realized.

Disclosure(s): L.C.G. has a U.S. patent (9175349) for methods of diagnosing endometriosis.

Original article available at: https://www.fertstert.org/article/S0015-0282(12)00682-6/fulltext

14. Women with polycystic ovary syndrome wedge resected in 1956 to 1965: a long-term follow-up focusing on natural history and circulating hormones

Bart C.J.M. Fauser, M.D., Ph.D.

Department of Reproductive Medicine, University of Utrecht, Utrecht, the Netherlands

A visionary study by Eva Dahlgren and colleagues was set out to address a clinically highly relevant question, still heavily debated today. This publication essentially represents a cross sectional, small sample size, retrospective, controlled study, comparing 33 women 40 to 59 years of age from the Goteborg region in Sweden and diagnosed with PCOS around 20 years earlier (based on classical ovarian morphology investigation following ovariectomy) with 132 age-matched population controls. The investigators observed a normalization of cycle irregularity over time, a delayed age of menopause, and an increased prevalence of obesity, diabetes and hypertension in women with PCOS.

This study represents the first clear indication of potential later life health implications of PCOS beyond reproductive dysfunction earlier in life. These important observations have subsequently been confirmed by several other research groups, but its true implications for later life health remain unclear, in terms of actual disease prevalence, quality of life or longevity (35). PCOS used to be a gynaecologic condition, where the focus of attention was solely geared towards irregular bleeding control, hirsutism and infertility. At present, many other specialists gained interest in this complex condition in relation to potential later life health implications, including medical endocrinologists, diabetologists, cardiologists, vascular medicine specialists and even geriatrists.

It is interesting to note, that a more recent study involving the same women included in the initial Dahlgren study, but now 20 years older (between 61 and 79 years), failed to demonstrate an increase in cardiovascular events despite multiple abnormal intermediate outcomes (36).

Beyond doubt, a definitive answer concerning later life health implications of PCOS should come from sufficiently powered, prospective cohort follow-up studies of adequately phenotyped and untreated patients. In conducting such a study, there are some major problems to be faced; PCOS is often diagnosed in women between 20 and 30 years of age, and cardiovascular disease in women rarely occurs before age 60 years. Will it be possible to perform a study with interval between inclusion and the actual assessment of endpoints 40 years later? Moreover, what sample size will be required to demonstrate convincingly for instance a 4-fold increased prevalence of true cardiovascular events in later life such as myocardial infarction, stroke or death? Will funding be available for such studies, where RCTs with inclusion periods of 1-2 years are often preferred?

Another approach would be to perform large sample size, cross-sectional studies in postmenopausal women, to investigate whether surrogate markers for PCOS (like elevated androgens levels, known to persist after menopause) are linked to cardiovascular disease. Such studies have indeed been undertaken, and our own recent investigation (37) involving a total of 2,578 women and a follow-up of 11 years showed no association between elevated free androgen index and increased cardiovascular risk.

We just have to better understand the natural cause of disease in (preferably untreated) women with PCOS, and if possible, identify specific risk factors associated with increased later life disease events, before rushing into all sorts of interventions. Many questions remain regarding the true risk of distinct cardiovascular disease events in later life of women with PCOS. This is a surprising conclusion, since so many of the known (well documented in the general population) risk factors for cardiovascular disease are present in women with PCOS, such as obesity, insulin resistance, hypertension and other forms of metabolic dysfunction. What are we missing; the long-term roles of changes in estrogens, androgens, progesterone, improved cycle regularity with increasing age, later age of menopause, or are we failing to comprehend the role of (yet unidentified) other overriding factor?

Currently PCOS, using much wider inclusion criteria, is diagnosed in up to 20% of all women of reproductive age. Hence, possible future general health implications of this condition may represent a major female health issue. In addition, long-term health implications of PCOS may vary in relation to heterogeneity in diagnosis, ethnicity, and distinct differences in obesity prevalence at a young age.

How can we manage patients diagnosed with PCOS, without clear proof of its long-term health implications? How to balance the risks of undertreatment (restrict attention to reproductive dysfunction only) versus overdiagnosis and treatment, with frequent follow up screening visits over many decades and medical interventions in case of abnormal biochemical findings? In addition, will we be able to reach a consensus between all the different specialists involved, and develop uniform criteria for follow-up and medical intervention if required. Such a multi-disciplinary but uniform approach seems far away at present.

We have to be thankful to Dr Dahlgren for her insightful study, opening our eyes for the potentially much wider implications of the diagnosis of PCOS beyond reproductive life. However, much remains to be understood, even almost 30 years after her original publication.

Disclosure(s): B.C.J.M.F. has received grants and personal fees from: Abbott, Controversies in Obstetrics & Gynecology (COGI), Dutch Heart Foundation (Hartstichting), Dutch Medical Research Counsel (ZonMW), Ferring, London Womens Clinic (LWC), Menogenix, Myovant, OvaScience, Pantharei Bioscience, PregLem/Gedeon Richter, Reproductive Biomedicine Online (RBMO), Teva/Theramex, and World Health Organisation (WHO).

Original article available at: https://www.fertstert.org/article/S0015-0282(16)54892-4/fulltext

15. The medical treatment of unruptured ectopic pregnancy with methotrexate and citrovorum rescue: preliminary experience

Steven R. Lindheim, M.D., M.M.M.

Department of Obstetrics and Gynecology, Wright State University Boonshoft School of Medicine, Dayton, Ohio; and Department of Reproductive Medicine, Shanghai Jiaotong University School of Medicine, Shanghai, People’s Republic of China

To think where we are today and where we were yesterday. It seemed like yesterday when methotrexate was considered avant-garde for the treatment of unruptured ectopic pregnancies. Prior to the 19th century, ectopic pregnancy, was considered a “universally fatal accident”. Despite attempts such as “vaginal section,” maternal starvation, purging, bleeding, strychnine administration, fetal morphine injection, it wasn’t until the first reported salpingectomy via laparotomy, in 1849 by W.W. Harbert, that “improved” the survival prognosis (38). By 1913, it was stated in Hartmann’s textbook that ‘‘every ectopic when diagnosed should be operated upon” where expectant management at that time led to death in 86% of women, but surgery saved 85% of women. By the late 20th century, with the advent of modern surgical techniques including laparoscopy, ultrasound and medical treatment, the mortality of ectopic pregnancy has fallen to 0.5 deaths per 100,000 live births in the U.S. (39).

The question about sacrificing the fallopian tube in favor of conservative surgery for the preservation of the childbearing function on all occasions had also been raised. As early as 1920, Beckwith Whitehouse successfully introduced salpingostomy. Despite confirmation by subsequent successful pregnancies, the argument against this conservative surgical approach was the possibility of a persistent ectopic pregnancy and then the need for additional surgical treatment.

With serum hCG monitoring, the fundamental contribution of medical therapy has markedly changed the course and prognosis of ectopic pregnancy with the ability to preserve subsequent fertility. Methotrexate (MTX) was first used in diagnosed ectopic pregnancies in the 1960s to aide safe surgical removal of the placenta from its abdominal implantation sites in second- and third-trimester cases. In the 1980s, the use of methotrexate for treatment of ectopic pregnancies was based on its use in gestational trophoblastic neoplasia where full chemotherapeutic doses, although achieving cure, produced significant side effects in women.

The work of Rodi et al. in their sentinel article, “The medical treatment of unruptured ectopic pregnancy with methotrexate and citrovorum rescue: preliminary experience” was landmark research as it laid the groundwork for others to explore the applicability of methotrexate for ectopic pregnancy that at the time was considered a medical emergency. The potential of methotrexate/folinic acid therapy as an outpatient treatment for ectopic pregnancy was considered “ludicrous” in terms of cost effectiveness and acceptability to patients. At that time, the gold standard of diagnosis of ectopic pregnancy was by direct visualization at surgery and part of the diagnostic alogarithm, as ultrasound at that time was still too crude an instrument to rely upon for a diagnosis. Furthermore, it required an IRB approved protocol with informed consent to consider such therapy.

In interviewing Dr Rodi, she reflected on the following:

  • [SRL] What were you thinking at the time?

  • [IR] A lot was happening in the area of ectopic pregnancy in the 1980s. a) HCG levels made it easier to diagnose an early pregnancy, which was a game changer for making an early diagnosis of ectopic pregnancy; b) Ultrasound, and especially transvaginal ultrasound made talking about a “discriminatory zone” possible. Add to that an increase in the number of ectopics, and you had people trying to figure out other approaches. Up to that time, most recognized ectopic pregnancies presented as a surgical emergency. The patient underwent a laparotomy and a salpingectomy. A significant number of patients went on to have another ectopic and another salpingectomy. Faced with that scenario, we wanted to explore alernatives. At about that time we started doing salpingostomies via laparotomy. I only started doing them laparoscopicaly in 1987-88. We knew from the literature and personal communications that Tanaka, Miyazaki, Chotiner, and Ory had experience with treating ectopic pregnancy with methotrexate. Initially, we were interested in using RU486, because we figured it would be less toxic. Fortunately, we were not able to get our hands on it, because it turned out to be way less effective than MTX.

  • [SRL] Was/were there any reservations on doing something so innovative?”

  • [IR] We were fortunate that we were at Harbor-UCLA where the IRB was familiar with all kinds of research. We were able to convince them that a) the doses of MTX had an excellent safety profile; b) on average the patients would not have to stay in the hospital much longer than they would otherwise; c) if it was successful, the patient would have avoided major surgery. Later, of course, they avoided even diagnostic laparoscopy; and d) there was the hope that the damage to the fallopian tube would be less than a salpingostomy.

  • [SRL] Did you feel any pressure going against the norm? What did the IRB say?

  • [IR] At Harbor-UCLA there was an environment that promoted research. Once I moved and was continuing to enroll patients in a community hospital the situation was very different. I talked to the gynecologists who were the senior partners in the group that I joined about their recollections of the early cases. Both responded that it was “terrifying”!

  • [SRL] What would you say today as you reflect over time?

  • [IR] What I have attempted to pass on to trainees, is to foster an attitude of questioning if there is a better solution for a particular problem, to think critically. We, and those who followed us, took a surgical condition and made it into one that is now treated medically in the vast majority of cases.”

I looked at the conclusions of this sentinel research paper, “The role of medical therapy for ectopic pregnancy is still uncertain, and any conclusions about its safety and efficacy are preliminary. We do not recommend medical therapy for clinical practice at this time. Further research will be required to determine (38) the optimal treatment dose that will maximize effectiveness and minimize toxicity (39) reproductive outcome following medical versus surgical therapy” and reflect that MTX was a game-changer. The clinical picture of an ectopic pregnancy, formally a life-threatening disease, has morphed into a more benign condition with MTX as a first line-medical approach.

Thank you, Dr Rodi and your colleagues, for fostering an attitude of questioning and finding a better solution for ectopic pregnancies.

Disclosure(s): S.R.L. has nothing to disclose.

Original article available at: https://www.fertstert.org/article/S0015-0282(16)49816-X/fulltext

16. Follicle-stimulating hormone levels on cycle day 3 are predictive of in vitro fertilization outcome

Zev Rosenwaks, M.D.

Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medicine and New York -Presbyterian Hospital, New York, New York

The search for a reliable prognostic marker of female fecundity has long been recognized as one of the great challenges for reproductive medicine specialists. A biomarker of female pregnancy potential would not only serve as a prognostic marker, but could also inform clinicians when to initiate medical intervention, assist them in selecting treatment strategies, and serve as a guide when efforts to treat should be abandoned.

The paper, “Follicle-stimulating hormone levels on cycle day 3 are predictive of in vitro fertilization outcome,” is one example of early efforts to identify biomarkers of fertility treatment success. Scott et al.’s paper represents the second manuscript to describe the value of early menstrual cycle follicle stimulating hormone (FSH) levels as an ovarian reserve test. As a senior author of the above paper, I believe it will be of interest for our readers to appreciate how the concept of FSH as a biomarker evolved. One can trace the development of FSH as a biomarker to Navot et al.’s 1987 Lancet paper entitled “Prognostic assessment of female fecundity” (40), wherein the clomiphene citrate challenge test (CCCT) was used as an indirect assessment of female fertility potential. The CCCT relied on measurements of baseline menstrual day 2–3 FSH, luteinizing hormone (LH), and 17-β estradiol (E2) levels before and after administration of 100 mg CC on days 5–9 of the menstrual cycle. Women with normal baseline FSH, who had exaggerated FSH responses after CC (>26 mIU/ml or higher), were reported to have diminished ovarian reserve. Only 1 out of 18 women exhibiting abnormal responses became pregnant, while in women with normal responses (no FSH elevation after CC), 14 out of 31 achieved pregnancies. In his paper, Navot acknowledged that the idea for the CCCT had its origin, in part, from a paper by Jones et al. entitled “Dynamic testing of hypothalamic-pituitary function in abnormalities of ovulation” (41).

The descriptions of Jones et al. and Navot and his coworkers led to the idea of investigating the impact of both baseline FSH and the gonadotropin response to GnRH agonists on ovarian E2 response and IVF pregnancy outcome. Indeed, the 1988 paper in this journal by Muasher et al. (42) suggested for the first time that basal FSH levels can distinguish different populations of IVF patients in terms of their E2 response, number of oocytes retrieved, and pregnancy outcome. These preliminary studies subsequently led to the paper by Scott et al., wherein 441 consecutive patients’ (in 758 cycles) baseline FSH, LH, and E2 levels were measured to assess their predictive value on stimulation response and pregnancy outcome. For the first time three distinct groups of patients, with low, adequate, and high FSH levels, were shown to have pregnancy rates of 17, 9.3, and 3.6%, respectively. Not only did the pregnancy rates vary by group, so did the number of oocytes retrieved and E2responses.

It should be noted that there have been several indirect or direct hormonal biomarkers of ovarian response and pregnancy outcomes described, including the basal FSH level, FSH/LH ratio, and antimüllerian hormone (AMH) levels. While all these tests shed light on female fertility potential, none to date have been definitive. While it is evident that AMH concentrations (which are often highly correlated with antral follicle counts [AFC]) have proven to be excellent markers of ovarian response and the number of oocytes retrieved, AMH alone does not prognosticate the attainment of pregnancy. A case can be made that baseline FSH levels, at any age, taken together with AMH levels might serve as a more accurate prognosticator than AMH alone.

Disclosure(s): Z.R. has nothing to disclose.

Original article available at: https://www.fertstert.org/article/S0015-0282(16)60615-5/fulltext

17. Use of an aromatase inhibitor for induction of ovulation in patients with an inadequate response to clomiphene citrate

Robert F. Casper, M.D.

Division of Reproductive Sciences, Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada

Clomiphene citrate (CC) has been used for ovulation induction in PCOS patients for more than 5 decades. It was the most frequently prescribed medication for infertility in the world. Because of its long, unchallenged history of use, gynaecologists and even family doctors were comfortable prescribing it for infertility patients. Around 1990, while exploring the correlation of ultrasound measurement of endometrial thickness with pregnancy rates we would often see women with unexplained infertility referred to us after 6 to 12 months of empirical CC treatment. Sonographically, many of these women had endometrial thickness ≤ 5 mm that we attributed to the estrogen receptor (ER) depletion caused by long-term CC. We published the first paper on an adverse endometrial effect of CC in 1990 (43) and knew it was necessary to find an alternative to avoid the ER side effects. I thought of the possibility of inhibiting aromatase to remove estrogen-negative feedback on the hypothalamic/pituitary axis, similar to the effect of CC but without ER depletion. At the time, the most effective aromatase inhibitor, 4-hydroxyandrostenedione, was administered systemically so we abandoned the idea.

Around 10 years later, a menopausal patient of mine diagnosed with breast cancer asked my advice about a new treatment she had been given called letrozole. On assessing its mode of action, I learned it was a potent oral aromatase inhibitor. With my fellow, Dr Mohamed Mitwally, we quickly obtained IRB approval to try letrozole for ovulation induction in polycystic ovary syndrome (PCOS) and unexplained infertility and started to recruit patients who were either unresponsive to CC or who ovulated but had a thin endometrial lining on CC. We published our first manuscript on the use of letrozole for ovulation induction based on this pilot feasibility study. It was pure serendipity that my menopausal patient was started on letrozole and not anastrozole, since the two drugs were concurrently approved for breast cancer. If she had been given anastrozole, this research may not have progressed since subsequent studies have shown that letrozole seems to be more effective for ovulation induction in PCOS than anastrozole.

There was much international interest in the concept of using aromatase inhibition for ovulation induction and several clinics began investigating the use of letrozole for infertility treatment, including a small clinic in Montreal run by Marinko Biljan. In 2005, Dr Biljan presented an abstract at the joint ASRM/CFAS conference in Montreal suggesting a possible teratogenic effect of letrozole when used for ovulation induction. Because of this abstract, Novartis sent a warning letter to physicians indicating that letrozole use in premenopausal women was contraindicated because of both fetal and maternal risk. This letter would likely have signalled the death knell of letrozole for infertility treatment had it not been for my colleague, Professor Togas Tulandi, who suggested that we do a multicenter Canadian study to follow-up babies born after the use of CC or letrozole. We recruited 5 clinics experienced with letrozole for ovulation induction and were able to publish birth outcomes on 911 babies, 397 born after the use of CC and 514 born after the use of letrozole (44). We found no evidence of any teratogenic effect of letrozole, and in fact, found a significant increase in cardiac anomalies in the babies born after CC use. Several publications since then have further validated the safety of letrozole for ovlation induction when pregnancy is ruled out before its use.

In 2014, Legro et al. published the results of a multicenter randomized trial comparing letrozole to CC in 750 women with PCOS followed for up to 5 cycles (45). The cumulative live birth rate in the letrozole group (25.5%) was significantly higher than in the CC group (19.1%; 95% CI 1.1 - 1.87). The ovulation rates were also higher in the letrozole group (61.7% vs. 48.3%). This study and a subsequent large meta-analysis were instrumental in establishing letrozole worldwide as a primary treatment for ovulation induction in PCOS patients. Letrozole is gradually replacing CC for ovulation induction in PCOS in many clinics and, as of last year, CC was no longer available in Canada.

As a footnote, shortly after our publication, I happened to meet Alan Decherney, the editor of Fertility and Sterilityat the time. He thought the idea was intriguing and just for his own interest planned to track how many papers included letrozole and reproduction or ovulation over the next few years. As of today, Alan, that number on PubMed is 600 contributions and climbing.

Disclosure(s): R.F.C. has a patent for multiple-dose and single-dose aromatase inhibitors for IVF and ovulation induction licensed to EMD Serono. No product have been developed or placed in practice and no payments have been received.

Original article available at: https://www.fertstert.org/article/S0015-0282(00)01705-2/fulltext

18. Antimüllerian hormone serum levels: a putative marker for ovarian aging

Antonio Pellicer, M.D.

Instituto Valenciano de Infertilidad (IVI), Rome, Italy; and Instituto de Investigación Sanitaria La Fe, Valencia, Spain

Antimüllerian hormone (AMH) is a dimeric glycoprotein member of the transforming growth factor-beta superfamily identified in Sertoli cells of fetal testis inducing the regression of the Müllerian ducts. It is also produced by granulosa cells of pre-antral and smaller antral follicles in adult women. The main physiological role of AMH in the ovary seems to be the inhibition of the early stages of follicular development by inhibition of primordial follicle recruitment, but its clinical relevance became apparent when it was shown that it can be detected in peripheral blood and can be a good marker of different physiological and pathological female conditions.

In this context, the manuscript by deVet et al in 2002 was one of the very first attempts to employ serum AMH as a marker of female fertility and perhaps an early marker in women who are destined to undergo menopause at a relatively young age for counseling them about their chances for pregnancy, either spontaneously or during fertility treatment. Since this study was published, AMH has gained relevance to the point that it is the most relevant marker of ovarian function with many current clinical applications and future expectations.

Although it was initially believed that there was no variation in women along the cycle, current practice prefers measuring serum AMH in the first days of the cycle. Also, a variety of factors vary the results including medications, such as oral contraceptives and GnRH agonists, smoking, obesity, ethnicity, vitamin D status or polymorphisms of AMH and its receptor. There are currently two automated assays with a high correlation (>0.9), but one provides levels 20% higher than the other and employs different units. Further standardization is of critical importance in clinical practice.

The role of serum AMH as a qualitative and quantitative marker of assisted reproduction technologies (ART) has been a matter of extensive research. It has been employed as a predictor of ovarian response to gonadotropin stimulation. AMH has been proven to be a good marker of both poor and excessive ovarian response (46). This led to the concept of individualization of gonadotropin dosage employing serum AMH and showing that not only is AMH a good marker, but it also helps to reduce complications such as ovarian hyperstimulation (47).

It has also been employed to predict pregnancy outcome in ART treatments, but the correlation seems to be less strong. Women with higher serum AMH have more ongoing and term pregnancies, which might be related to the total number of oocytes retrieved and to the incidence of aneuploidy that has been associated with low serum AMH levels.

Prediction of individual age at menopause, addressed in this early study from 2002, is also a topic of debate, because it is estimated that the ability to conceive naturally is lost 10 years before the onset of menopause. Since women delay childbearing today, many women inadvertently lose their opportunity to have a natural pregnancy. Predicting an individualized age at menopause employing serum AMH still needs considerable improvement. Recent publications show that serum AMH can predict early ovarian insufficiency, but individual predictions of age at menopause demonstrate limited precision compared to simply considering age (48).

Testing ovarian reserve might become important in carriers of BRC1/2 mutations, women who were born small for gestational age, women with type 1 diabetes mellitus or lupus erythematosus, anorexia nervosa, premature ovarian insufficiency or women with endometriosis or other ovarian diseases that undergo surgery or uterine embolization for fibroids. All the above are clinical situations in which various degrees of reduced ovarian reserve can be inferred.

On the other side of the spectrum, women with polycystic ovarian syndrome (PCOS) have a 2- to 3-fold increase in serum AMH levels that might represent an important key in the pathophysiology of PCOS and is becoming the central sign in the diagnosis of PCOS, even more accurate than ultrasound. The magnitude of AMH elevations in PCOS is associated with the extent of the disease and weight loss.

AMH has also been introduced as a marker in gynecological oncology as a marker of granulosa-cell tumors and fertility preservation. It is useful to classify the ovarian toxicity of chemotherapeutic agents. It can predict future fertility in women surviving after cancer providing the rationale for evaluating treatment alternatives and the need for applying fertility preservation protocols. However, AMH is not a good marker for women undergoing ovarian cortex transplantation after cancer treatment (46).

In summary, the publication of deVet et al. in 2002 introduced a “star” in reproductive medicine as has been proven in subsequent years.

Disclosure(s): A.P. has nothing to disclose.

Original article available at: https://www.fertstert.org/article/S0015-0282(01)02993-4/fulltext

19. Transvaginal ultrasound scanning of ovarian follicles

Dominique de Ziegler, M.D.

Department of Obstetrics, Gynecology and Reproductive Medicine, Hopital Foch – Faculté de Médecine Paris Ouest (UVSQ), Suresnes France

The history of our journal dedicated to the science of fertility and infertility disorders, has witnessed a revolution—the advent of assisted reproductive technologies (ART)—that hatched right in our backyard 40 years ago. Not only did ART rapidly prove to be effective for treating tubal-factor infertility, the disorder for which it was conceived, but it also led to the development of other related procedures that now address practically all forms of infertility. This has logically sparked a tremendous number of innovations, at times overwhelming, which have dominated our field and our publication in the journal. These inventions improved ART efficacy in many different ways and led to enormous strides in our understanding of the pathophysiology of human reproduction.

One practical innovation however arguably stands out above all else, as it impacted not only the field of infertility, but truly upended the daily routine of general gynecology practice. Indeed, the quest to optimize the monitoring of ovarian response for ART led Meldrum et al. (49) to realize that ovarian ultrasounds could be performed trans-vaginally instead of abdominally through a full bladder. In a seminal paper published in our Journal in 1984, Meldrum et al. (49) proposed to solve the problems of poor ultrasound resolution encountered in case of obesity and/or deep positioning of the ovaries through transvaginal scanning of ovarian follicles. The article provided eloquent images of the improvements provided.

The betterments offered by transvaginal scanning of pelvic organs were so readily recognized that within a year it led to development of ultrasound probes especially designed for vaginal use. These new probes were also adapted for performing direct transvaginal oocyte retrievals, which is now the routine approach for ART worldwide. Not only were the new probes shaped for easy vaginal use but also featured higher frequency emission, which improved resolution. Indeed, the proximity to the scanned organs, uterus and ovaries, from the vaginal fornix precluded the need for the deep penetration required in trans-abdominal scanning employing low frequency probes. In their original paper Meldrum et al. already foresaw the possibility of increasing probe frequency for improved resolution of trans-vaginal scanning. Ultimately, vaginal ultrasound was adopted nearly overnight for monitoring ovarian responses to ovarian stimulation in ART, becoming one of the most rapid changes in clinical practice ever implemented in medicine.

Beyond the limits of infertility treatments, the practical advantage of vaginal ultrasound was rapidly incorporated into general gynecology for scanning ovaries and the uterus, including early pregnancies. Vaginal ultrasound provided two main advantages. First, the improved resolution allowed a more precise view of ovarian and uterine structures. This included the identification and assessment of the extent of deep pelvic endometriosis, commonly undetectable by an abdominal approach. Second, trans-vaginal ultrasound performed with an empty bladder also provided dynamic information on the relative mobility of the different pelvic structures not previously appreciated. For example, movement applied to the ovary by pressure exerted with the vaginal probe, possibly with the help of abdominal pressure, allows us to determine if a cyst seen is ovarian or para-ovarian in nature pending on whether it moves or not with the ovary. Beyond studying the relative movement of different pelvic structures, vaginal ultrasound also allows us to correlate possible exquisite tenderness when pressure is exerted on a given structure with imaging findings, for example an endometriotic implant.

From ART specialists where it was developed, vaginal ultrasound, as first described by Meldrum et al., took the whole world of gynecology by storm. Indeed, vaginal ultrasound rapidly imposed itself, providing a true game change by endowing a renewed way of performing pelvic examination, one which is done “with a view”. Vaginal ultrasound for analyzing pelvic structures belongs to this category of invention, which, like the wheel, once found allows no turning back. Meldrum et al. said it all in their article. The rest, vaginal ultrasounds in ART and gynecology as we know it today, evolved from this seminal invention. Vaginal ultrasound, which is now an inherent part of the gynecological examination, is a gift of ART to general gynecology, one that was initiated by the creative innovation of Meldrum et al.

Disclosure(s): D.d.Z. has nothing to disclose.

Original article available at: https://www.fertstert.org/article/S0015-0282(16)48212-9/fulltext

20. Donor eggs: their application in modern reproductive technologies

William E. Gibbons, M.D.

Division of Reproductive Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas

The article, “Donor eggs: their application in modern reproductive technologies,” by Zev Rosenwaks is seminal for multiple reasons. First, this treatise comprehensively introduced for the Fertility and Sterility readership the physiology of the menstrual cycle and reviewed methods to allow embryo replacement in natural and artificially prepared endometrium establishing the background for our current practice. It carefully laid out indications, natural physiology, estrogen and progestin protocols that were evaluated in light of the natural menstrual cycle. Second, it allows for us to understand the historical status of this revolutionary therapy and the importance to patients without oocytes [or were inaccessible by oocyte recovery techniques available at that time]. It allows us to understand some of the ethical concerns for assisted reproductive technology (ART) teams and their patients.

So, while others had reported earlier pregnancies from the donor egg process in women, this article delved into the background including the efforts in cattle and primates, the work of Croxatto et al. on tubal ovum transport (50), and primate data from Gary Hodgen, Ph.D., one of the greatest reproductive biologists of his time (51). Our readership was introduced to the issues relating to asynchrony between glands and stroma and issues regarding the route of progesterone administration that are still being debated.

However, as important as the use of this technology for couples needing donor oocyte therapy is the importance of this article in discussing the precepts of endometrial preparation for embryo transfer. In the SART results for 2016 and 2017, there were more than 26,000 cycles resulting from thawed donor gametes alone. Further, more than 60% of infertility couples undergoing ART under the age of 40 had embryos cryopreserved. This mirrors the trend for fewer fresh transfers and more frozen transfers. So, the Rosenwaks paper provides important background for ART as it has evolved.

We are reminded of the leadership of the Norfolk team at the Jones Institute. The thought processes of Dr. Rosenwaks and Drs. Howard and Georgeana Jones are reflected in the article and represented ‘current’ thinking then. Figures 2 and 3 indicate that because the fundus of an anteverted uterus points up, women with an anteverted uterus were transferred in the knee-chest position to prevent the embryo transfer fluid from being expelled due to gravity. In addition, the concern about glove toxicity meant that in the Norfolk method no gloves were worn [and a tenaculum was always placed on the cervix]. When I joined the Eastern Virginia Medical School Department of Obstetrics and Gynecology faculty in 1990, I found that as I was initiated to their embryo transfer process, I was tempted to blush during the procedure. This time and this group were important to the development of assisted reproduction in the United States and the thoughtful care that the leadership of the Jones Institute produced is delightfully demonstrated in this seminal paper.

Disclosure(s): W.E.G. has nothing to disclose.

Original article available at: https://www.fertstert.org/article/S0015-0282(16)59220-6/fulltext

21. IVF in unstimulated cycles: a new application

Richard J. Paulson, M.D., M.S.

Department of Obstetrics and Gynecology, University of Southern California, Keck School of Medicine, Los Angeles, California

This article marks the return of IVF in natural cycles in the “modern era,” that is to say, after the introduction of transvaginal ultrasound-guided follicle aspiration. To put this article into the correct perspective, it is helpful to recall what IVF was like in 1989. After the birth of Louise Brown, ovarian stimulation was used for virtually all subsequent IVF pregnancies. Oocyte retrieval had just changed from being accomplished via laparoscopy to the new, transvaginal ultrasound-guided method. Embryo cryopreservation was in common use, but unreliable, with some 20% of embryos lost during freezing and lower implantation rates for those embryos that survived the thaw. Therefore, ovarian stimulation followed by fresh embryo transfer was strongly preferred and was the norm.

At the same time, we were beginning to see that ovarian stimulation was not a panacea and were considering the real possibility that the eggs that were retrieved after ovarian stimulation were of a lower quality than the individual eggs produced in natural cycles. Additionally, we had recently observed that ovarian stimulation caused a marked impairment of endometrial receptivity (52) and were concerned that this was a major effect. Thus, we theorized that the pregnancy-enhancing benefit of transferring multiple embryos was being offset by diminishing endometrial receptivity associated with ovarian stimulation.

The logical conclusion was that a return to IVF in a natural cycle would have several advantages that might outweigh the disadvantage of only working with one dominant follicle: avoidance of the inconvenience and cost of ovarian stimulation; natural selection and maturation of the best single oocyte; and no decrease in endometrial receptivity caused by ovarian stimulation.

We tried to time ovulation with serial LH monitoring, but this proved inefficient and we decided to add the hCG trigger to allow for a predictable time of retrieval. Since the cycle was no longer purely “natural” we decided to call the cycles “unstimulated.”

This article is the first report of our efforts. The live birth reported was achieved in the fourth attempt at unstimulated IVF. We subsequently performed many other cycles and became reasonably adept at anticipating ovulation and triggering at the correct time. In spite of all our efforts, some 20% of unstimulated cycles were canceled due to premature ovulation. Several years later, the GnRH antagonists became available and were added to unstimulated cycles to prevent ovulations. However, small amounts of stimulation, typically with hMG were needed to keep the dominant follicle growing. The resulting process was now commonly referred to as the modified natural cycle IVF (mnIVF). The cost of the small doses of hMG is offset by the added control over the timing of ovulation. Furthermore, it now appears that hCG alone can be used to achieve final follicle maturity, at a substantially lower cost than that of FSH-containing products (53).

After 30 years, mnIVF is still used, albeit rarely. Why has the modified natural cycle not taken over as the first-line approach for all patients? The reality is that many of its “appealing qualities” have not panned out. Ovarian stimulation is still expensive, but the cost it adds is offset by the increased number of oocytes that are retrieved. The quality of the oocytes from a stimulated cycle is not lower than those produced in a natural cycle; apparently, the polyovulatory capacity of the ovary was maintained through evolution. Endometrial receptivity is not markedly diminished in stimulated cycles, unless the patient has PCOS, and any concern about diminished endometrial receptivity in a particular category of patients can be circumvented by the cryopreservation of the embryos, a process which in 2019 is quite efficient. Nevertheless, mnIVF occupies a niche in our specialty, for patients who do not want to undergo ovarian stimulation, for those who do not respond to ovarian stimulation, and perhaps in low resource settings, where embryo cryopreservation will not be a reality and where the least stimulation of the ovary will be a desirable quality (54).

Disclosure(s): R.J.P. has nothing to disclose.

Original article available at: https://www.fertstert.org/article/S0015-0282(16)60746-X/fulltext

22. Ovarian hyperstimulation syndrome in novel reproductive technologies: prevention and treatment

Neri Laufer, M.D.

Department of Obstetrics and Gynecology, Hadassah University Hospital, Ein Kerem, Jerusalem

Ovarian hyperstimulation syndrome (OHSS) is the most serious and potentially life threatening iatrogenic complication of controlled ovarian stimulation (COS). It represents an exaggerated response to ovulation induction, characterized by increased capillary permeability which in turn results in accumulation of fluid in the extravascular space and consequent intravascular volume depletion and hemoconcentration. The appearance of the clinical symptoms in the luteal phase derives from stimulation of the corpora lutea by human chorionic gonadotropin (hCG), either by exogenous administration for final oocyte maturation and/or following endogenous production with the establishment of pregnancy.

The introduction of gonadotropin-releasing hormone agonist (GnRHa) to the arsenal of IVF regimens in 1986 resulted in an almost complete disappearance of spontaneous ovulation, from 30% to less than 3%, but caused a dramatic increase in the severe OHSS rate compared with that observed in cycles stimulated with human menopausal gonadotropins (hMG) only. The appearance of this phenomenon stems from the fact that the follicular phase could now be extended without concern for premature luteinizing hormone (LH) surge, yielding a higher number of follicles and corpora lutea - the source of vasoactive substances generating OHSS (55).

These observations provided the background for our Modern Trends review from 1992, which attempted to reclassify the stages of OHSS, to define risk factors and to suggest strategies for prevention and treatment.

Over a quarter of century ago, our review defined a new category of severe OHSS, critical OHSS, which included adult respiratory distress syndrome (ARDS), tense ascites, severe hemoconcentration, and profound leukocytosis. This extreme form is life threatening, with multiple system failure, thromboembolic phenomena necessitating treatment in an intensive care unit, and at times, interruption of pregnancy. Its description was pertinent to its time; since then it has almost completely disappeared, indicating the remarkable improvement in IVF safety over the last quarter of a century.

The patients having primary pretreatment risk factors to develop OHSS emphasized in the review are: patients with polycystic ovaries syndrome (PCOS), those without the complete form of PCOS and with multiple follicles (necklace sign), women aged under 30 years, with lean habitus or low body mass index (BMI) and those with previous episodes of OHSS. Since its publication, the predictive value of these factors was reiterated in numerous publications. Several observations during the last decade suggested that antimüllerian hormone (AMH) serum levels (> 3.6ng/ml) could be employed as a valuable additional tool in assessing the potential to develop OHSS.

Risk factors identified during ovarian stimulation employing GnRHa include high serum estradiol levels (> 3500pg/ml), high number of follicles and oocytes (>20), hCG trigger for oocyte maturation, and/or luteal phase support. It is essential in GnRHa protocols to employ hCG as a surrogate LH. In turn, hCG is a central risk factor for developing OHSS, while withholding its administration will result in cycle cancellation and bring a rapid resolution of the symptoms. The introduction, almost twenty years ago, of the combined use of GnRH-antagonist (GnRH-ant) to protect against premature ovulation, with GnRHa for triggering an LH surge, revolutionized the treatment protocols of high risk patients and resulted in an almost complete disappearance of severe OHSS (56).

In order to further reduce severe OHSS we suggested that “in a small minority of hyperstimulated women, all embryos have to be frozen for later transfer”. In the early nineties of the last century, only a few cryopreservation programs achieved comparable pregnancy rates for fresh and frozen cycles. It was the development of the ultra-rapid freezing by vitrification that transformed this possibility into another vital tool in the struggle to eliminate OHSS (57).

Finally, the hallmarks of treatment suggested in the review are still valid: maintenance of fluid balance, including plasma expanders, anticoagulation and paracentesis. While at the time it was believed that the renin-angiotensin and histamine systems were involved in the pathogenesis of OHSS, vascular endothelial growth factor (VEGF) and other interleukins are currently considered major candidates implicated in its occurrence. These factors are abundant in the ascitic fluid and it is reasonable to perform paracentesis before tense ascites develops, to reduce their concentration and expedite resolution of the symptoms.

In conclusion, the rate of OHSS following COS for IVF decreased dramatically between 1992 and 2019, and the severe form has become a rare phenomenon. This significant transformation evolved from the recognition of risk factors, the application of GnRHa trigger in GnRH-ant cycles, and the development of vitrification as an efficient embryo freezing tool. Uncoupling of the oocyte aspiration cycle from the embryo transfer and pregnancy cycle (freeze all) is the latest step in the evolution of OHSS reduction. A better understanding of mechanisms underlying the syndrome are crucial to its complete eradication.

Disclosure(s): N.L. has nothing to disclose.

Original article available at: https://www.fertstert.org/article/S0015-0282(16)55188-7/fulltext

23. The emotional needs of infertile couples

Susan C. Klock, Ph.D.

Department of Obstetrics and Gynecology and Department of Psychiatry, Northwestern University Feinberg School of Medicine, Chicago, Illinois

There are several aspects of, “The Emotional Needs of Infertile Couples,” that make it a landmark article. First, it is among the first to identify infertile men and women as “one of the most neglected and silent minority groups” because they are “not sick, merely heartsick.” It may seem to someone who does not understand infertility that they have nothing to feel bad about, nothing to make them depressed or anxious. They are not “sick” in the traditional sense because they get up every day and function. But the emotional toll that infertility inflicts is invisible to the outside world but profound and ever-present for those affected by it.

Menning also eloquently describes “the order of feelings” as one goes through the infertility diagnosis and treatment process. The familiar stages of surprise, denial, anger, isolation, guilt and grief are described in context with the losses associated with infertility. These losses include the loss of the imagined child, the loss of control, the loss of genetic continuity, the loss of self-esteem and the potential loss of relationship(s). Menning describes these losses and the emotional responses to them with precision and clarity.

Next Menning describes infertility as a long lasting life crisis that threatens the important life goal of having a child. The experience of infertility and its treatment depletes the emotional, relational, physical and financial resources of the couple or individual. As she notes, usually a crisis is time limited but in the case of infertility it can go on for months or more likely years. It can lead to the development of depression or anxiety disorders. It can also affect the stability of the couple for those who are partnered. The crisis affects members of the couple at different times and each partner copes with the crisis differently creating a chasm in empathy and understanding. Anyone who has listened to a couple as they have described their infertility journey will recognize the truth in Menning’s words as she identifies gender differences in coping and how those can affect the stability of the relationship.

The less obvious but no less important impact of Menning’s article is the change in the interpretation of the psychological aspects of infertility. Beginning in the 1950s, the prevailing psychoanalytic theory posited that psychological stress or conflict was a cause of infertility. This view was so deeply ingrained in the psychology of women and in the medical literature related to infertility that it was common to read about psychogenic infertility that could be cured by psychotherapy. Solve the conflict, solve the infertility, thus making the woman responsible for her own infertility. Menning’s article was one of the most visible articles to change the paradigm to describe infertility and its treatment as a cause of psychological distress. This simple paradigm shift allowed providers to provide support for women and couples from the vantage point that the emotional response (depression, anxiety, relationship discord) was the consequence of the infertility, not the cause. This very simple change in understanding the causal direction of infertility and psychological distress led to a new model for providing psychological support to individuals and couples. Infertility practices began to have a mental health professional on staff or available for referral to provide care for their patients during treatment. RESOLVE and other organizations provided support groups, education and other services to support patients.

In addition to impacting the provision of psychological services to infertile couples and individuals, the paradigm shift also led to a new area for health psychology research which assessed the psychological consequences of infertility and developed evidence-based interventions to improve the psychological adjustment to infertility. Psychosocial research over the last three decades has led to a better understanding of the prevalence of depression and anxiety resulting from infertility; gender differences in coping with infertility and family development after ART based on genetic or nongenetic parenting.

Finally, Menning appeals to providers to appreciate the “whole psychological context” within which the patient presents for treatment. This appeal is even more relevant now as assisted reproduction advances into areas of fertility preservation, oocyte banking, posthumous reproduction and other permutations of assisted reproduction treatment. The assisted reproductive technologies have advanced rapidly over the past three decades but the emotional experience of infertility presented by Menning continues to be true today.

Disclosure(s): S.C.K. has nothing to disclose.

Original article available at: https://www.fertstert.org/article/S0015-0282(16)45031-4/fulltext

24. Estimates of human fertility and pregnancy loss

Pauline Mendola, Ph.D.

Eunice Kennedy Shriver National Institute of Child Health and Human Development, Division of Intramural Population Health Research, Epidemiology Branch, Bethesda, Maryland

The estimates of human fertility and pregnancy loss in a healthy population described by Zinaman and colleagues in Fertility and Sterility in 1996 haven’t changed much after more than 20 years. Our recent population-based prospective pregnancy study report (58) found a 28% loss rate (97/343) which was similar to the 31% observed by Zinaman et al. (36/115). We also found a similar rate of infertility after 12 cycles of attempting pregnancy (14%; 53/393 who completed the protocol) (59) compared to 18% in the Zinaman et al. paper (of 200 couples completing the protocol). Despite changes in the population that have limited fecundability in general, particularly trends towards older maternal age and increasing obesity, this key paper provided detailed assessments of fertility and early pregnancy loss that remain valuable. The paper is particularly notable for measuring common reproductive events that were challenging to observe outside of clinical research studies at that time.

Of course, the measurement and general awareness of fertility and pregnancy loss has changed dramatically over time. The first home pregnancy test kits became available in the late 1970s; remember the e.p.t? It was something like a home chemistry set in a box, complete with purified water, eye dropper, test tube and a little angled mirror to read the result. A ring in the bottom of the tube after about 2 hours indicated a positive result. Those early tests were prone to error, particularly false negative testing, and sensitive to movement since jostling the tube set-up (don’t pick it up to read it…) could defeat the ring formation. By the mid-1990s, home testing for pregnancy was common and the urine dipstick tests were less error-prone but still took 10 to 30 minutes to give a result. The advent of digital pregnancy test kits in the early 2000s made it much easier for women to test for pregnancy as early as a missed period. Now some home tests can be done as early as 4 to 6 days before the expected start of menses, although results before a missed period are still more accurate for positive than negative results. Thin lines, blue lines, pink lines, double lines, tests that spell out “pregnant” and “not pregnant;” tests have gotten progressively easier to do and easier to read. Most tests now give results in three minutes or less and some even have digital countdowns.

In 1996, the serum hCG testing after a missed period conducted by Zinaman and colleagues was still the research standard. Daily urine samples were also assessed to detect very early pregnancy losses based on elevated hCG levels for at least three days followed by a drop with no clinical pregnancy. As home testing got better, interpretation of the results presented some additional challenges. In particular, early implantation failures, or biochemical losses, can be interpreted as “false-positive” tests. While an early loss is disappointing to couples attempting to conceive, it is an indicator of fecundity. As observed by Zinaman et al, women who conceive and have a biochemical loss are likely to have subsequent clinical pregnancies.

Prediction of ovulation and knowledge of the fertile window in the general population have also improved over time but significant knowledge gaps remain here as well, even among couples actively trying to conceive. A potential answer to the knowledge gaps are the multitude of online and mobile apps to track fertility. A recent Google search for “fertility mobile app” yielded more than 50 million results including “best of” ratings for popular apps in each of the past few years. While the quality of information varies a bit by source, putting that basic reproductive health information in the hands of women and couples to allow them to manage their fertility and better understand the likelihood of conception and loss as part of the reproductive process is a good start.

This historical paper remains a key reference on fertility and pregnancy loss in healthy populations. Having this basic information helps couples by providing realistic expectations regarding pregnancy and pregnancy loss and can inform care-seeking decisions if they encounter difficulties in conceiving.

Disclosure(s): P.M. is a Senior Investigator at the Eunice Kennedy Shriver National Institute for Child Health and Human Development (NICHD). This work was supported by the Intramural Research Program of the NICHD but the opinions expressed are those of the authors.

Original article available at: https://www.fertstert.org/article/S0015-0282(16)58144-8/fulltext

25. Assessing the clinical utility of in vitro fertilization with intracytoplasmic sperm injection in human immunodeficiency virus type 1 serodiscordant couples: report of 113 consecutive cycles

Mark V. Sauer, M.D., M.S.

Rutgers Robert Wood Johnson School of Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, New Brunswick, New Jersey

Much has changed for the better regarding the approach to fertility care of HIV-infected individuals since our 2003 report detailing our program at Columbia University was published. Today, patients can readily access services, if not locally, then at least regionally. This was not the case in 1997 when I initiated the program in Manhattan. Previously, Semprini et al. proposed separating sperm from the virus using density gradient “sperm washing” techniques in order to provide a safe alternative to unprotected sex. However, this recommendation was not widely embraced and it was actually criticized as dangerous and experimental (60). Further hampering clinical efforts at providing care were laws that existed in many states that threatened physician caretakers with criminal penalties if they were actively involved in “knowingly inseminating” or even storing sperm from HIV-seropositive patients.

A historic context is always important to consider in assessing the significance of a medical innovation. In the mid-nineteen nineties our society was still beneath the penumbra of the scourge of HIV. The virus was considered a modern-day plague and the fear of transmission prevented most doctors from accepting patients struggling to conceive. Then, as now, nearly one million Americans were infected with HIV, but it was during this time that the advent of effective antiretroviral medications dramatically improved survival, as well as the quality of life, and thereafter came a shift from the label of “terminal illness” to “chronic disease”. Since most HIV patients are of reproductive age, it was common for them to want to start families, and to do so responsibly, taking measures to safeguard the health of their offspring and partners. They turned to their physicians for advice on how best to do so.

My involvement with HIV patients stemmed from a simple patient request for help. A couple asked me to accept them into care after they were denied access in Florida. I elected to accept their request utilizing IVF-ICSI, with modified application to serve a different purpose. It seemed logical that if spermatozoa do not transmit the virus, isolating the individual gametes down to their singular cellular elements would be optimally safe. This belief was supported by the basic and clinical research known about HIV at that time as well as mechanisms underlying HIV replication and modes of infectivity. There were risks that had to be assumed by the patients, who were willing to accept the challenges of this untested approach. Yet, they were willing to do so in order to reap the benefits gained in achieving a family that promised to make their lives better. There were also professional risks to the clinicians and the institutions willing to offer care. For this reason, I enlisted the support of my peers through the institutional review board (IRB) and our medical center ethics committee.

It took many years and many patients to erode most of the prejudice that precluded accepting HIV-infected individuals into clinical practices. Our fertility program at Columbia University represented active resistance to those that continued to promote the dogma that patients of HIV should not have biologic children. Well into the next decade following the publication of the 2003 report, it was still common to see patients travel from all over the country to New York in order to receive care. We embraced this challenge and made every effort to battle the indifference shown to them by local providers that would offer up excuses for not being able to help them. I was shocked how often they were turned away after providers had initiated a costly “fertility work-up” with full knowledge of the underlying seropositive status of the couple.

In 2003, I wrote an “ethical defense” for providing care to HIV-patients with fertility concerns in order to provide a voice for these vulnerable patients who were being ignored by the larger medical community (61). The sixty-one serodiscordant couples reported as human subjects in our Fertility and Sterility paper were not mere data points; they were people struggling to enjoy the normal lives promised by the new antiretrovial drugs. This relatively small clinical trial was launched in the hope of changing practice as well as attitude. It provided a reassuring message heard by a wider audience than just our academic peers.

I believe time and experience has proven that we were right to challenge conventional practice. Today my residents and fellows seem relatively unperturbed when encountering patients with HIV and freely discuss the various options for treatment which now exist. The Ethics Committee of ASRM has a published an opinion that endorses a nondiscriminatory posture for accepting patients with HIV into our practice (62). Most important to me are comments such as those I recently received, accompanying a high school graduation announcement, from two very proud parents and former patients. They said, “Believe in the beauty of your dreams. Thank you for giving us our son and making our family possible.” I think that says it all.

Disclosure(s): M.V.S has nothing to disclose.

Original article available at: https://www.fertstert.org/article/S0015-0282(03)00662-9/fulltext


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Go to the profile of David Seifer
about 3 years ago

ASRM has provided a forum to review 25 important studies produced during the last 75 years. The challenge of selecting these papers is obvious given the enormous progress in our field over this time period. It is important that these papers be cited with appropriate historical context. The study by DeVet et al was noteworthy and novel as it suggested for the first time that AMH as a serum marker of ovarian aging in normo -ovulatory premenopausal women and by extrapolation that AMH could be a marker of the onset of natural menopause. However, our study (1) was noteworthy and novel as it demonstrated for the first time that serum AMH (aka MIS) was predictive of the number of eggs prior to receiving ovulation induction in women with a history of infertility attempting to conceive by ART and thus, the first "proof of concept" to employ serum AMH as a marker of female fertility. This is an important distinction as it represents research in different clinical populations within different clinical contexts with different intents. As practitioners of ART taking care of women and men with infertility is our focus and thus, the context for us investigating AMH prior to ovulation induction as a marker of egg yield in our infertile patients.

As noted on the first page of each study they were submitted to Fertility and Sterility in May of 2001 (May 1, 2001 for DeVet et al and May 11, 2001 for Seifer et al.) but accepted three weeks apart from each other. Acceptance of the study by DeVet et al was October 10, 2001. The study by Seifer et al was accepted September 19, 2001. Yet for some logistic quirk, publication dates were a month apart in February and March 2002, respectively but not in the temporal order of acceptance of publication. Nevertheless, both studies published in Fertility and Sterility were uniquely informative and lead to a rapid wave of AMH investigative studies around the globe in both an ART clinical setting and in the setting of normal physiological ovarian aging. Both important novel findings published almost simultaneously but the study by DeVet et al. offered insight into the onset of an important physiological condition (ie. menopause) while ours provided insight, into how to make IVF more effective in the treatment of infertility as a disease. Early clinical adopters began using AMH in ART in the mid-2000s and it is part of daily clinical practice today. The use of AMH in predicting menopause took a more protracted course and has recently prevailed. Both studies published in 2002 ultimately contributed to changing the mind-set, clinical perspective and practice of those in reproductive medicine going forward when approaching different ART and menopausal clinical scenarios.


Seifer DB, MacLaughlin DT, Christian BP, Feng B, Shelden RM. Early follicular serum mullerian-inhibiting substance levels are associated with ovarian response during assisted reproductive technology cycles. Fertil Steril 77:468-71, 2002.

Go to the profile of Micah J Hill
about 3 years ago

David, thank you for the thoughtful insight on two distinct but linked developments.  The behind the scenes knowledge of the intertwined timing is so interesting.  This entire edition is so fascinating to read!