Fertility Treatment For Women

The Pregnancy Miracle Ebook

The Pregnancy Miracle, Infertility cure book by Lisa Olson is an extensive 279 pages pregnancy book that consists of a simple and effective 5 step holistic & ancient Chinese system. This easy to follow, step-by-step pregnancy book has illustrations and diagrams to ensure everything is easy to follow and understand. This e-book is designed to offer a natural approach for conception. It is based on the expertise of a nutritionist, coupled with her personal experiences and research for many years. The book then spends an additional 200 pages providing an in-depth personal plan, with natural system involving several lifestyle changes, mind setting, whole body treatment, and natural techniques. Lisa Olson spent years developing the Pregnancy Miracle book so that people like her who are experiencing difficulties conceiving can have a chance to have their dreams of a new family member. Her program has helped thousands of women solve their fertility problems, but the program is designed to help men as well. Read more here...

Pregnancy Miracle Overview


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Author: Lisa Olson
Official Website: www.pregnancymiracle.com
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My Pregnancy Miracle Review

Highly Recommended

All of the information that the author discovered has been compiled into a downloadable book so that purchasers of Pregnancy Miracle can begin putting the methods it teaches to use as soon as possible.

When compared to other ebooks and paper publications I have read, I consider this to be the bible for this topic. Get this and you will never regret the decision.

Regulation and licensing of IVF

Regulation and licensing are systems that are imposed on an organization, such as a clinical laboratory or an IVF Center. These systems, which are not optional, are usually created and enforced via legislation and consequently vary widely between countries, and even between states in countries such as Australia and the USA. Licensing bodies (e.g. the Human Fertilisation and Embryology Authority, the HFEA, in the UK) typically issue a licence after an inspection process to confirm that an organization is, indeed, operating in accordance with the law. While this process does create some sort of minimum standards to which the facility or organization will operate, there is often no consideration of performance standards or quality within the terms of the licensing process. Regulations that concern the handling and use of hazardous materials such as flammable solvents, strong acids and alkalis, liquid nitrogen, radioactive materials, etc. All materials used in the IVF lab must be stored,...

Importance of Oxidative Stress and ROS in Male Infertility

Sperm dysfunction is one of the leading causes of infertility. Despite much research, there is limited knowledge about the causes of sperm dysfunction. However, oxidative stress (OS) has been identified as one of the causes of abnormal sperm function. OS refers to the state in which free radicals overwhelm the body's antioxidant capacity 21 an excess of ROS can have harmful effects on the tissues and organs 9, 10 . ROS has been shown to negatively affect sperm quality and function 22, 23 . For normal male fertility, a fine balance between the generation of ROS and its removal is very important. Excess of ROS also has a negative impact on the pregnancy outcome as well as the assisted reproductive techniques 24, 25 . Moreover, excess ROS can damage DNA in spermatozoa, induce cell apoptosis, and cause lipid peroxidation, which leads to morphological abnormalities, decrease in fertility, and increased sperm membrane permeability 26-28 . It is important to effectively detect the amount of...

Ineffective use of testosterone in male infertility

Since testosterone has been used so effectively in the treatment of endocrine insufficiency of the testes, its use has also been attempted in the treatment of idiopathic male infertility. Testosterone rebound was one of the earliest modalities in this regard. The published success rate in terms of pregnancies varied considerably from centre to centre, but remained low overall (Charny and Gordon 1978 Getzoff 1955 Lamensdorf etal. 1975 Rowley and Heller 1972). All studies were uncontrolled trials without placebo and double-blinding and therefore inconclusive. Testosterone rebound therapy cannot be recommended for treatment of infertility and is no longer practiced. More recently, testosterone undecanoate has been tested for the treatment of idiopathic male infertility. However, a significant increase in pregnancy rates could not be demonstrated (Comhaire etal. 1995 Kloer etal. 1980 Pusch 1989). When testosterone undecanoate was given combined with tamoxifen and or hMG, an improvement of...

Female Infertility The Obstruction to Reproduction

For most couples, getting pregnant isn't a problem, but one in five couples experience fertility issues in America today. The risk for infertility among women 35-44 years of age is double that of women 30-34 years of age, and the risk is one-and-a-half times higher for black women than for white women. Doctors usually define infertility as the inability to conceive after a year or more of regular sexual activity without contraception during the time of ovulation. It also encompasses an inability to carry a pregnancy to full term. Needless to say, infertility is an emotionally painful, financially draining, and physically exhausting condition. Getting pregnant isn't as easy as it looks. Indeed, there are a host of intricate processes that must be completed during ovulation, fertilization, and implantation of eggs into the uterus. Most of the couples I see have already been through a battery of tests to determine the possible causes of infertility. These conditions range from failure to...

Unexplained Infertility

Unexplained infertility is diagnosed whenever routine testing methods including semen analysis fail to identify a reason for delay in achieving pregnancy. Other testing methods such as assessment of ROS and DNA fragmentation may reveal the actual cause of infertility in these cases 82 . Higher seminal ROS levels and lower antioxidant levels were shown in men diagnosed with unexplained infertility compared to healthy controls 83 . Moreover, abnormal levels of ROS were seen in 25-40 of men diagnosed with unexplained infertility 84 . Assessment of the sperm DNA fragmentation analysis can also provide the exact etiology in cases with unexplained infertility especially in the presence of normal semen parameters 85 . Since OS is one of the causes of increased sperm DNA damage, both conditions may play a conjoint potentiating role resulting in male infertility. Also, apoptosis markers such as cytochrome c, mitochondrial membrane potential, and caspases 3, 9 have been shown in association...

Oxidative Stress and Female Fertility

Many events related to infertility may occur due to OS in the female reproductive tract, such as endometriosis, hydrosalpinx, polycystic ovarian disease, unexplained infertility, and recurrent pregnancy loss 129 . In addition, apoptosis may cause embryo fragmentation, implantation failure, abortion, or congenital abnormalities in offspring.

Impact of Infertility on the Patient

The problem of infertility is not new. From ancient times, cultures have practiced fertility rites to ensure the continuation of their people. Many societies considered a woman's worth in terms of her ability to have children. The ''barren woman'' was frequently banished. The average time it takes for a woman to conceive is 4 to 5 months. The American Fertility Society defines infertility as the inability to conceive ''after one year of regular coitus without contraception.'' During this time, more than 80 of women conceive. After 3 years of regular sexual intercourse, 98 of women become pregnant. It has been estimated that approximately one of every six couples in the United States has some problem with fertility. Infertility should be considered a problem of both men and women. It was previously thought that infertility was functional (no demonstrable organ disorder) in 30 to 50 of all cases, but it is now recognized that more than 90 of infertile couples have a pathologic cause....

The Influence ofROS and Total Antioxidant Capacity in IVF and ICSI Cycles

Women who have undergone IVF have a tendency toward higher levels of ROS in their follicular fluid than those who conceive naturally 170 . Bedaiwy et al. 173 assessed day 1 culture media ROS effects on fertilization rates, cleavage rates, fragmentation, and blastocyst formation after prolonged culture. The authors compared conventional IVF with ICSI in order to determine which technique produced higher ROS levels. The results showed that slow development, high fragmentation, and reduced formation of morphologically normal blastocysts were associated with increased levels of day 1 ROS. This study did not show any significant difference in fertilization rates and blas-tocyst development rates in IVF cycles, but significant reduction in these outcomes was reported in ICSI cycles with higher day-1 ROS levels 173 , In more recent study, Aurrekoetxea et al. describe, for the first time, serum oxi-dizability and antioxidant status in women undergoing an IVF cycle. The author found that the...

Generation ofROS During Assisted Reproduction Techniques

Literature has documented role of OS in the pathophysiology of infertility and assisted fertility 135, 161, 194 . ROS may originate directly from gametes and embryos (endogenous sources) as well as their surroundings (exogenous sources). Several exogenous factors identified in culture media enhance embryo production of ROS oxygen concentration, the presence of metallic cations, and visible light exposure. Spermatozoa may also aid in the production of ROS during assisted reproduction techniques. Elevated ROS levels generated exogenously or endogenously influence the gametes, gamete interaction, fertilization, and pregnancy rates with IVF ICSI. Oxidative insult to embryos can lead to two-cell block, embryonic arrest, or even embryonic demise 213,214 . Higher levels ofROS in the follicular fluid and semen are associated with poor fertility outcomes with assisted reproduction 171, 174 . In a metaanalysis from our group, ROS in semen have been reported to significantly effect the...

Strategies to Overcome OS in Assisted Reproduction

ROS may originate from the male or female gamete or the embryo or indirectly from the surroundings, which includes the cumulus cells, leucocytes, and culture media. In human IVF ICSI procedures, the clinical pregnancy rates have remained unchanged at 30-40 218 . It has been noted that blastocyst development in vitro always lags behind blasto-cyst development in vivo as there is a variation in the ability of IVF media and its components to scavenge ROS and prevent DNA damage and apoptosis 219 . During ART procedures, it is important to emulate in vivo conditions by avoiding 3. Enzymatic and nonenzymatic antioxidant culture media supplementation Higher implantation and clinical pregnancy rates are reported when antioxidant-supple-mented media is used rather than standard media without antioxidants. Various nonenzymatic antioxidants including beta-mercaptoethano 220 , protein 219 , vitamin E 149 , vitamin C 221 , cysteamine 222 , cysteine 223 , taurine and hypotaurine 224 , and thiols...

Idiopathic Infertility

Infertile men are diagnosed with idiopathic infertility when normal sperm parameters and no other clinical condition that may result in infertility are seen. Oxidative damage may be a contributing factor to infertility in these normozoospermic males. While the exact cause of infertility may be unknown, idiopathic infertility has been correlated with higher levels of ROS and lower antioxidant levels than in fertile men 58 . A study found that men with idiopathic infertility had the second highest level of OS among the clinical diagnoses studied 44 . Therefore, it would be expected that infertile men diagnosed with idiopathic infertility would benefit from antioxi-dant treatments. Idiopathic infertility has also been associated with increased sperm DNA damage. A study by Wang et al. found a relationship between increased sperm damage by ROS and higher levels of cytochrome c and caspases 9 and 3 3 . This may also indicate elevated apoptosis in males with idiopathic infertility. Studies...

Infections of the Male Genital Tract and Infertility 2521 Initial Nosological Gaps

The state of the art in the field of prostatitis and infertility suffers some gaps originating from classification and definitions given by two parallel research groups ending up with two independent consensus conferences. The first, originating mainly from the urologic area (NIH Chronic Prostatitis Collaborative Research Network), was inspired by the clinical aspects of prostatitis (difficult to diagnose and to effectively treat) and includes only two categories (II and IV) associated with male infertility 6, 7 . According to the NIH classification, seminal bacterial infection, corresponding to chronic bacterial prostatitis (category II), has a marginal epidemiologic role, since bacterial prostatitis (acute or chronic) accounts for a low number of patients with prostate symptoms (5-10 ) 8, 9 . The NIH prostatitis classification recognizes a main role to one gland (prostate) and to two factors presence of microbial agents and evidence of inflammation (leukocytes) in the semen,...

Early Loss of a Child Miscarriage and Perinatal Deaths

Parental loss of a child, as discussed in Chapter 4, is one of the most difficult and intense losses to cope with. The age of the child will bring unique issues along with it however, one of the most unrecognized losses within the broader category of parental loss is miscarriage, stillborns, and other early deaths following childbirth. These losses have been called 'lonely' because often the mother has been left to grieve the death of her child alone. Often parents must say goodbye to their child before they even say hello. If the father has not bonded with the child during pregnancy, it is often difficult for him to grieve, or to understand what his wife is experiencing. For all, the grief process is more difficult because what is being grieved often is a dream. How one grieves and the specific issues to be addressed will relate strongly to how the parents had fantasized the child. A wished-for child may have represented various hopes and expectations. Many pregnancies are...

Diagnosis of infertility

Infertility is defined as the inability to conceive after 1 year of unprotected intercourse, with 75 of patients able to conceive after 6 months and 90 of patients able to conceive after 1 year 3 . This inability to conceive can be caused by male or female factors. Twenty percent of cases result from solely male factors, whereas 40 of cases are caused by male and female factors combined therefore, male-factor infertility affects 60 of infertile couples 4 . The evaluation of male infertility begins with a thorough history that includes a sexual history, past medical history, and family history. Pertinent information garnered from the sexual history includes frequency and timing of coitus and potency. A patient's past medical history is equally important and provides information regarding congenital abnormalities, cryptorchidism, inguinal or retroperitoneal surgery, radiation, infections, medications, toxic exposures, and past pregnancies. A family history may reveal cystic fibrosis,...

Role of Caspase PARP and Oxidative Stress in Male Infertility

Abstract The etiology and pathogenesis of male infertility remain not well defined. Oxidative stress has been identified as one of the major causes of male infertility. Integrity of the sperm DNA, which could be caused by oxidative stress, also plays an important role in vivo and in vitro male fertility. Poly (ADP-ribose) polymerase (PARP) is a DNA repair enzyme that has been demonstrated in mature spermatozoa and fertile men. PARP becomes activated in an attempt to repair oxidative DNA strand breaks. Higher levels of cleaved PARP (cPARP) have been reported in infertile men. Caspases play an important role in mediating and upregulating apoptosis. The cleavage of PARP by caspase 3 inactivates PARP in two segments and inhibits the function of PARP as a DNA repair enzyme. Therefore, high levels of cPARP may be considered as a new marker of apoptosis in sperm of infertile men. In this chapter, we define the relationship between caspases, PARP, and oxidative stress and their role in male...

The Role of Obesity in ROS Generation and Male Infertility

Aim To discuss the relationship between obesity and male infertility, specifically exploring the role of reactive oxygen species (ROS) production in obesity and the subsequent generation of oxidative stress, as well as abnormal hypothalamus-pituitary-gonadal regulation associated with obese males. Conclusion The continuing rise and prevalence of both obesity and declining male sperm count all over the world call for additional research and a greater awareness to obesity as a potential etiology of male infertility. Keywords Male infertility Obesity Reactive oxygen species Oxidative stress Hormones Center for Reproductive Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA Center for Reproductive Medicine, Cleveland Clinic, Lerner College of Medicine, 9500 Euclid Avenue, Cleveland, OH 44195, USA e-mail agarwaa ccf.org

Protecting IVF laboratory staff from unfair litigation

As risk management moves from the manufacturing industry to healthcare there is a far greater - or at least more immediately obvious -impact of risk on customers' wellbeing. Although the underlying issue and driving force for risk management is patient safety, the increasing focus on financial risk, not just medical risk, has substantial implications for healthcare workers - and hence IVF Centers. Protection of employees from personal liability is essential if any modern-thinking IVF Center is to function without its staff living in permanent dread of litigation - a concern of everyone, not just clinical embryologists. To this end Centers must have fully-detailed standard operating procedures (SOPs) documented and in place, complemented by comprehensive quality management and risk management programs. Then, so long as staff work within this framework, the Center should have a legal (not just moral) obligation to indemnify its employees against personal responsibility for any adverse...

Cytokines as Potential Diagnostic Markers of Male Infertility

The clinical role of evaluation of cytokines participating in urogenital infections inflammations has been recently found to be the important area of interest. The present routine diagnostics of inflammation in the male reproductive tract is mainly based on the determination of leukocyte concentration and microbiological evaluation of the semen. Because the harmful effect of cytokines on spermatozoa is closely connected with the accompanying leukocytospermia, the evaluation of the leukocyte count in the semen still remains an important but insufficient factor to the diagnosis and treatment monitoring of male genital tract infection inflammation and its particular stages or kinetics. Consideration of additional biomarkers of inflammation, especially in cases of inflammatory conditions which occur without clinical symptoms, seems to be helpful in establishing the proper algorithm 163 . Determination of the levels of proinflammatory cytokines in the seminal plasma using a quantitative...

Identifying high risk IVF laboratories

IVF is an area of rapidly advancing technology, meaning that continual training and proficiency testing are imperative. But these tactics in isolation will not prevent the type of problems that keep appearing in the mass media, and we must recognize that the overall environment in which people work can either support or obstruct both technical training and improvements in operational systems. Is it possible for a hospital or Fertility Center to identify whether their IVF laboratory is at particular risk for adverse events, especially of the high profile kind From experience, the following are the most likely areas where such risk factors might be identified (but it must be stressed that this is by no means an exhaustive risk analysis of an IVF Lab).

Relationship between infertility and testicular cancer

Theoretically, any cause that adversely affects testicular function can result in infertility and testicular tumorigenesis. Many studies evaluating testicular cancer have documented an increased risk for abnormal semen analysis parameters in patients who have testicular tumors. Of 15 patients presenting with germ cell tumors, 10 (66 ) had evidence of abnormal spermatogenesis, including poor motility, low sperm concentration, or low semen volume 5 . Conversely, studies have been published documenting an increased risk for testicular cancer in patients presenting with infertility. This connection is clearly documented in a large population-based study in Denmark including 32,442 men who underwent semen analysis from 1963 to 1995. Men who had abnormal semen analyses had a 1.6-fold increased risk for developing testicular cancer compared with the general Danish population. In evaluation of specific semen analysis parameters, a low sperm concentration, decreased motility, and increased...

Oxidative Stress DNA Damage and Apoptosis in Male Infertility

Abstract Oxidative stress, sperm DNA damage, and apoptosis are associated with male infertility as a cause and as a manifestation. Several clinical conditions and laboratory findings may be indicative of the presence of oxidative stress, sperm DNA damage, and apoptosis. The use of standardized assays for the diagnosis of oxidative stress, sperm DNA damage, and apoptosis should be limited to cases where these conditions are suspected. The identifications of the causative factor for infertility will lead to a specific and subsequently more successful treatment option. In this chapter, we provide a description of the clinical conditions associated with oxidative stress, sperm DNA damage, and apoptosis that lead to male infertility. The different signs and results of laboratory investigations will be provided to highlight manifestations of these conditions. We also describe the impact of oxida-tive stress, sperm DNA damage, and apoptosis on male fertility and the different approaches that...

Clinical Consequences of Oxidative Stress in Male Infertility

Abstract Male infertility affects 40 of infertile couples in the USA and may be attributed to conditions such as varicocele, leukocytospermia, infection, and idiopathic infertility. Such conditions may be associated with elevated levels of reactive oxygen species (ROS), decreased antioxidants, and oxidative stress (OS). OS can lead to male infertility in both an in vitro and in vivo setting. The negative effects of ROS on male fertility present as sperm DNA damage, decreasing motility, apopto-sis, and lipid peroxidation. ROS and antioxidant levels can be measured and quantified in order to detect OS in semen samples. Both oral antioxidant therapy and culture media supplementation have proven to be effective in reducing OS. Future research is still needed in order to better understand the mechanisms involved in oxidative damage in the context of male infertility and to improve the treatments available for patients with OS-mediated male factor infertility. Keywords Male infertility...

Uterine Aspiration for Biopsy or Miscarriage Management

Manual vacuum aspiration (MVA) can be used in the office setting for easy sampling of the uterine endometrium with a 4-mm or 5-mm cannula when a small endometrial biopsy catheter is insufficient (Fig. 28-19). The MVA can also be used in the office for removal of retained products of conception after an incomplete or missed miscarriage up to 12 weeks without the added cost of an emergency room visit, surgical suite, and general anesthesia. The MVA device is a handheld plastic aspirator syringe attached to a plastic cannula of varying sizes. The cannula can be flexible or rigid to allow for provider preference. Vacuum aspiration is safe, quick to perform and less painful than sharp curettage and should be recommended for use in the management of incomplete abortion (Forna and Gulmezoglu, 2001). Figure 28-19 The Ipas manual vacuum aspirator (MVA) is displayed with 4-mm and 5-mm cannulas used for miscarriage management in outpatient setting. Note thumb buttons that close the barrel...

Potential Therapeutic Role of PARP in Male Infertility

The role of PARP in male infertility could be advocated. In a study by Wang et al., men with idiopathic infertility showed a significant positive correlation between ROS levels and caspase-9 and caspase-3, which suggests possible DNA damage and subsequently PARP in these cases 90 . In men with azoospermia, the expression of PARP-1 (enzyme) and poly(ADP-ribose) (PAR) (an indicator for PARP activity) as two markers has been localized in round and elongating sperma-tid. Also, PAR activity has been shown in all of the spermatocytes in maturation arrest patients at the spermatocyte level 91 .

Obesity and Male Infertility

Infertility Obesity Mechanism

BMI has been found to be associated with altered sperm parameters in numerous reports. In a recent study investigating factors related to semen quality, the prevalence of infertility in obese men was found to be three times greater than in male partners of couples with idiopathic or female-factor infertility 12 . Moreover, sperm density and total count was shown to have a statistically significant negative correlation to increasing BMI 12 . Another study looked at normozoospermic partners in an infertile population and reported a reduction in sperm concentration among men with BMI greater than 30 kg m2 when compared to leaner members of the study group 23 . Kort et al. further examined the relationship between sperm parameters and BMI in a generally overweight selection of subjects 24 . After 520 semen samples were subjected to analysis, semen quality and the number of normal sperm per ejaculate exhibited declines with increasing BMI 24 . On the other hand, when obesity was expressed...

Studies on EMR and Male Infertility

Within the last decade, there have been several well-designed and executed studies on the effects of mobile phone radiation on spermatozoa, covering three main areas, clinical epidemiological, human (in vitro) and in vivo animal models. The association between RF-EMR and male infertility was initially suggested by an epidemio-logical study in 2001 where it was speculated that differences in fertility parameters from Chinese males in various professions may be due to EMR exposures 52 . More pertinent epidemiological data from a study in 2005 found negative correlations between mobile phone usage and various attributes of semen quality, particularly motility 53 . Studies on male reproduction in mouse or rat models showing that mobile phone radiation affected testicular histology, including decreased seminiferous tubule diameter, appeared in 1999 54 . but wasn't investigated further until 2003 55 and 2004 56 with the effects of low frequency EMR on murine models. There were some...

Gynaecology And Infertility

Is not targeted at individual patients, but at groups of patients. This can happen where the intervention is an information package for the management of menorrhagia in primary care9 or a clinical guideline for the management of infertility.10 In these studies, randomising patients to receive management using the information package or clinical guidelines would have introduced contamination, since GPs would have been expected to manage both study (information leaflet, clinical guidelines) and control patients. Potentially this could underestimate the true effectiveness of the intervention. Therefore, clusters of patients (e.g. general practices) were randomly allocated to receive intervention (e.g. information leaflets, clinical guidelines) or control. Cluster randomisation should only be carried out when there is a strong justification for doing so. Clustering of outcomes can also occur in infertility trials where alternative treatments are being compared. For example, in randomised...

Creating a quality IVF lab

Creating a quality IVF lab is neither a simple nor short task. Certainly it is easier to create such a lab when one is starting afresh with a new facility, but most IVF labs don't have that opportunity, they have to rebuild and reorganize what they have - usually while having to maintain services with already limited human resources. Nonetheless, it is a daunting task that many Lab Directors will have to face anywhere that accreditation is pursued, but especially within the European Union as the Tissues and Cells Directive is implemented (http europa.eu.int eur-lex en ). There is no single right way of doing this, no cookbook recipe that can be followed to achieve this goal. Each IVF lab will have to develop its own strategic plan in response to its unique combination of circumstances. However, the general principles described in the earlier Chapters of this book will provide the background and framework for doing this, and the techniques and approaches we have described will provide...

OS and In Vitro Infertility

Reactive oxygen and nitrogen species that lead to OS have a negative impact not only on male fertility in natural conception but also on assisted reproductive technologies (ART) in an in vitro setting. In any ART procedure, there is a risk of oxidative damage from sources such as exposure to ambient air 70 . Other sources Studies have shown that the ROS levels in the seminal fluid correlate with fertilizing potential and the IVF rate in procedures such as intrauterine insemination (IUI), in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI) 71, 72 . Also, high ROS levels in day 1 embryo culture media have been related to decreased blastocyst and cleavage rate, low fertilization rate, and increased embryo fragmentation in ICSI cycles. Consistently, high day 1 ROS levels in culture media have been correlated with decreased pregnancy rates in ICSI and IVF 73 . ROS production and sperm DNA damage are associated with apoptosis 3 , which has been shown to be associated...


Infertility is the inability to conceive or to cause pregnancy. Infertility is a common problem found in as many as 10 of all marriages. A couple is said to be infertile when after 1 year of normal intercourse without the use of contraceptives, pregnancy does not occur. It has been estimated that almost 30 of all infertility is attributable to a male factor. Any patient with a history of infertility should be questioned regarding a history of mumps, testicular injury, venereal disease, history of diabetes, history of a varicocele (see Fig. 18-27), exposure to radiation, or any urologic surgical procedure. Diabetic men may be infertile because of retrograde ejaculation, or ejaculation into the urinary bladder. Determine the frequency of sexual intercourse and any difficulty in achieving or maintaining an erection. Document a careful history of general work habits, medications taken, alcohol consumption, and sleeping habits.

Male Infertility

Infertility is defined as failure to achieve pregnancy after 1 year of unprotected intercourse. A specific cause can be identified in approximately 80 of couples, one third of which are female factors alone, one third male factors alone, and one third a combination of both. Unexplained infertility, in which no specific cause can be identified, occurs in approximately 20 of infertile couples. The initial step in evaluation of the male is a thorough medical history, focusing on general health, erectile function, STD history, medications, surgical history, previous successful pregnancy, contraception use, drug or alcohol use, and family history of genetic disease. The first and often only test needed in evaluating male factors is semen analysis. If two consecutive analyses indicate oligospermia or azoospermia, ordering blood tests for testosterone, LH, FSH, and prolactin levels is warranted. Varicocele is the most common cause of male infertility (Griffin and Wilson, 2003)(Table 35-5)....

Mitochondria as a Source of ROS in Mammalian Spermatozoa

Abstract The influence of reactive oxygen species (ROS) on sperm function and male fertility is well documented in contrast, the role of the mitochondria in the generation of aberrant oxidative stress is a recent development. The mitochondria, comprised of complex machinery for energy production, are also equally complex in term of oxidative stress with multiple sites of ROS generation and multiple neutralizing enzymatic and nonenzymatic antioxidants. Knockout mouse models of enzymatic antioxidants do not lead to drastic changes in male fertility however, increases susceptibility to external toxins and aging. Taking into account the numerous intrinsic and external factors that have been related to mitochondria ROS generation including fatty acids, apoptosis, cigarette smoking, and paternal age, it is likely that multiple risk factors will increase the likelihood of excessive mitochondria ROS generation in mammalian spermatozoa. A clinical focus on mitochondria-targeted antioxidant...

Intrinsic Causes of Mitochondrial ROS Generation

There is evidence for the role of mitochondrial ROS in the etiology of male infertility in human spermatozoa. Although the factors responsible for stimulating increased free radical release from the mitochondria of spermatozoa are still unresolved, recent research suggests the involvement for a number of intrinsic factors including FAs and apoptosis. Koppers et al. 87 were the first to reveal that highly significant correlations exist between spontaneous mitochondrial ROS production by human spermatozoa and their free (unesterified) unsaturated FA content for both omega-6 (R2 0.605) and omega-3 (R2 0.615) PUFAs. The findings are also consistent with previous analysis of the FA content of human spermatozoa, which observed an increase in the cellular content of both saturated and unsaturated FAs in spermatozoa from men seeking infertility treatment compared to a cohort of normozoospermic controls

Environmental and External Factors Related to Mitochondrial ROS

The carcinogenic and toxic effects of cigarette smoking on the health of an individual are well documented. Smoking has also been shown to result in an increased likelihood of male infertility, with significantly higher levels of seminal ROS generation 123 and DNA damage 124 found in these men. Previous research has shown a significant elevation in the activity of MnSOD (mitochondrial isozyme) in cigarette smokers 125 , indicating that cigarette smoking may cause increased mitochondrial ROS generation, rather than via a cytosolic or membrane oxidase system. In smokers, the overall mitochondrial ETC function is significantly decreased which also correlates with increased peroxidative damage to lymphocyte membranes 126 . An extremely large Danish study of 2,542 healthy men, without bias towards reproductive history, discovered that compared with nonsmokers, smokers exhibited significantly decreased sperm concentration, semen volume, motility, and total sperm count 127 . Although the...

ITGCN of the Testis Contralateral Testicular Biopsy and Bilateral Testicular Cancer

Skakkeb k 5 was the first to describe the presence of a noninvasive precursor lesion that would progress to invasive TGCTs. He found atypical spermatogonia from testicular biopsies in two infertile patients who went on to develop testicular cancers. Over the past three decades since his early report, it is now well established that with the exception of pediatric testicular tumors (yolk sac, mature teratoma) as well as the rare finding of spermatocytic seminoma, almost all TGCTs arise from ITGCN 5 . The presence of ITGCN is present in the testis years before the ultimate tumor becomes clinically evident leading to speculation that early detection of TGCTs is possible with testicular biopsy and im-munohistological examination 6 . Multiple studies have shown the prevalence of ITGCN to be consistent with the lifetime risk of developing a TGCT 6,7 .

The European Tissues and Cells Directive

On 31 March 2004 the European Union passed Directive 2004 23 EC On setting standards of quality and safety for the donation, procurement, testing, processing, preservation, storage and distribution of human tissues and cells - the Tissues and Cells Directive-which specifically includes reproductive cells and stem cells for human transplantation (European Union, 2004). The extent of the Directive's application is defined in Article 6, which requires that all Tissue Establishments where any of the aforementioned activities are undertaken will be accredited, designated, authorized or licensed by a competent authority of the Member States for the purpose of those activities, with legal compliance required not later than 7 April 2006. Therefore, it seems that not only sperm banks and IVF labs, but also any lab that processes sperm for artificial insemination (e.g. intra-uterineinsemination IUI ) willbeconsidered as Tissues Establishments and will be subject to regulation under this...

Professional healthcare

If you are looking for a new GP, you can obtain a list of doctors in your area from your Community Health Council or local library you could also ask friends and neighbours if they can recommend anyone. When you find a likely practice, ask about their opening hours and how long, on average, you will have to wait for an appointment that is not urgent. In addition, ask whether the practice offers home visits, advice over the telephone, services provided by other healthcare professionals such as nurses, and special services, such as family planning clinics. You may also wish to ask if you can choose a female doctor rather than a male doctor (or vice versa), if you have a strong preference in this matter.

ROS in Cell Physiology and Sperm Activation First Data and Clinical Relevance

Clinical data also support a role for ROS in sperm activation. First, we observed over the years that about 16 of men presenting at the infertility clinic and having normal sperm parameters according to the World Health Organization 47 have recurrent spontaneous sperm hyperactivation in whole semen this appears linked to a lower SOD-like activity (O2'- scavenging capacity) in seminal plasma (by 37 ) and spermatozoa (by 45 ) as compared to what is found in samples from nor-mospermic men 48, 49 . On the other side, we have seen two cases in which an excessively high (2-2.5-fold) O2'- scavenging capacity in seminal plasma was associated with complete failure at capacitation, hyperactivation, and in vitro fertilization (unpublished data). Therefore, imbalance in the scavenging of O2'- seems to lead to fertility problems. Furthermore, the concentration of ROS in the medium after sperm washing correlates positively with success in in vitro fertilization and there is then even a positive...

Targeting the Zona Pellucida

Given the potential permanence of vasectomy, it is not a viable choice for many. Ignoring the facts that some degree of sexism may be attendant to the history of birth control research and that many men and women simply feel that birth control is primarily a woman's responsibility, there are three major physiological reasons for the inequitable emphasis on female rather than male directed approaches. First, since fertilization and conceptus development occur within women, there are a greater number of reproductive events to manipulate to prevent pregnancy. Second, since women have to centers of ''brain control'' of the endocrine events controlling the activities of their ovaries and men have only a single brain center of testic-ular control, it is easier to hormonally interrupt the events controlling female fertility without causing adverse effects on the production of the hormones needed for other body functions. Third, and perhaps most important, it is...

Burden of Disease

Although 75 of genital chlamydial infections in women are asymptomatic, C. trachomatis is a major cause of ure-thritis and cervicitis in women. Additionally, up to 40 of untreated cases of C. trachomatis may progress to pelvic inflammatory disease (PID). PID may result in ectopic pregnancy, infertility, and chronic pelvic pain. About 95 of men with C. trachomatis infection are asymptomatic. Genital infection in men occasionally results in acute urethritis or epididymitis and rarely in chronic complications such as prostatitis and reactive arthritis (Meyers et al., 2007).

Organizational Requirements

People have many technological options available to them for family planning. The legal requirements for such technologies begin with the duty to exercise good judgment when applying new technology or procedures.81 Organizations offering preimplantation genetic diagnosis (PGD) have been sued for failure to perform proper testing.82 Efforts to plan technologically assisted reproduction involve the law of contracts, which has threatened to supplant family law in determinations of parentage. When couples divorce, property, contract and family law have all been brought into the conflict over what to do with stored frozen embryos.83

Pathogenicity of CAG repeat amplification in the androgen receptor

In a recent study, Cram etal. (2000) have investigated CAG repeat numbers in the AR of 92 infertile men and their inheritance in 99 female offspring conceived after intracytoplasmic sperm injection (ICSI). It turned out that a stable inheritance in the female offspring could be detected in more than 95 of the cases investigated. A CAG expansion or contraction of the paternal AR allele was observed only in 4 father-daughter pairs. All alterations were within the normal range of CAG repeat number and no phenotypic consequences were observed. The study indicates a frequency of changes to occur in the order of 5 . The range of repeat numbers for the AR to be stably transmitted is presumably between 15 and 28 CAG. CAG repeats beyond 28 might bear the risk of instability, possibly up to a disease-causing length (Zhang et al. 1994). Single sperm analysis was performed in a patient with spinobulbar muscular atrophy (SBMA) with a CAG repeat number of 47 in the AR (Zhang etal. 1995). The number...

Pregnancy in the Woman with Heart Disease

Before becoming pregnant, a woman may have a congenital heart defect or acquired heart disease. Many congenital defects can now be surgically repaired in infancy, and the first generation of these patients has only recently reached childbear-ing age. They represent a new kind of patient for obstetricians and cardiologists.

The need to use your own processes

When developing a Quality Management System, it is vital that you develop and use your own processes rather than try to follow somebody else's rules. Every IVF Lab or IVF Center is different. There will be local permutations or variations in practice that will preclude you blindly following a system or process that you have borrowed from another clinic. Certainly you can base your methods and systems on those from another IVF lab, but unless you intend to copy that entire Center in the most minute detail, you will always have to adapt them. This subject is discussed in more detail in Chapters 5 and 6.

Reproductive functions

When only fertile men covering the whole range of normal sperm concentrations were involved in respective evaluations, a shorter CAG repeat tract was associated with higher sperm numbers (von Eckardstein etal. 2001 Rajpert-De Meyts et al. 2002). Nevertheless, a marked variation of sperm density in relation to the AR polymorphism was observed. Hence, spermatogenesis is likely to be influenced by the number of CAG repeats within the normal range, but whether this reaches relevance for individuals remains doubtful. The range of sperm concentrations leading to infertility is most likely reached at CAG repeat numbers that are associated with X-SBMA. Furthermore, it can be assumed that the proportion of men with longer CAG repeats among infertile patients may, in case of strict selection criteria excluding all known causes of infertility, appear higher than in a control population. Genetic counselling concerning inheritabilityofthis modulator of spermatogenesis is of very restricted value,...

Parents Right of Reproductive Freedom

The argument most commonly advanced for permitting human cloning is that, at least in some cases, human cloning falls under the range of personal liberties granted in Western societies, specifically under parents' right of reproductive freedom or ''procreative liberty.'' Having a biological connection to one's own children is believed by many to contribute to the most personally satisfying parent-child relationships. Through that link, parents participate in the creation of a person and affirm their love for each other. Raising a child conceived through nuclear transfer cloning techniques could offer an alternative route for realizing these benefits (Strong 1998, 281-282) and cloning techniques in general could be viewed as simply one more of the assisted reproduction technologies. The right to have biologically related children is already believed to permit the use of an assortment of mechanisms for selecting the child's ge Nuclear transfer cloning can also be envisioned as a kind of...

The Positive Impact of Lipid Peroxidation The Induction of Sperm Capacitation

Paradoxically, the redox mechanisms that drive capacitation through the oxidation and subsequent depletion of cholesterol from the sperm plasma membrane may also ultimately damage these cells. Thus oxysterol accumulation has been widely linked with the activation of apoptosis and cell death in other cell types 18 . Of particular interest is the fact that mitochondria appear to be key mediators of oxysterol-induced pathology via mechanisms involving stimulation of the intrinsic apoptotic cascade and activation of excessive ROS generation 19-21 . If this is the case, then we might postulate a dual role for cholesterol oxidation during the life history of a sperm cell 22 . Thus, during capacitation ROS-induced cholesterol oxidation can be considered biologically useful because it facilitates the removal of cholesterol from the sperm plasma membrane and the attainment of a capacitated state. However, if the spermatozoa do not manage to find and fertilize an egg, then the continued...

The Negative Impact of Unsaturated Fatty Acids and Lipid Peroxidation

The association between male infertility and the peroxidation of polyunsaturated fatty acids (PUFA) has been appreciated since the landmark studies of Thaddeus Mann and colleagues at the University of Cambridge. Mann et al. drew attention to the vulnerability of human spermatozoa to lipoperoxidative damage because of their particularly high PUFA content 23 . They also demonstrated that when washed human spermatozoa were treated with as little as 30 nmol of lipid peroxide mL, they become irreversibly immotile within a few minutes. In addition, this seminal paper 23 highlighted the significance of seminal plasma antioxidants in protecting spermatozoa from oxidative damage.

Fatty Acids and the Induction of Lipid Peroxidation

While such data indicate that amphiphilic PUFA can stimulate ROS generation by human spermatozoa, they do not tell us whether a superabundance of free PUFA is critically involved in the pathophysiology of defective sperm function. The possible involvement of excess unsaturated fatty acids in the pathological generation of ROS found in the infertile patient population is suggested by the finding that dysfunctional defective spermatozoa recovered from the low-density region of Percoll gradients are characterized by significantly higher levels of PUFA compared with their normal functional counterparts isolated from the high-density region of such gradients 43 , These studies have recently been extended by Koppers et al. 44 who demonstrated that exposure to unesterified PUFA stimulated a time- and dose-dependent increase in mitochondrial ROS generation in populations in human spermatozoa. Moreover, the result of such exposure was to bring about the reduced motility and high levels of DNA...

Gender in Demography Increasing Attention

Attention to gender has also come from reproductive rights activists. Although such perspectives have been present for some time (Freedman and Isaacs 1993 Cook 1993 Dixon-Mueller 1993 Kabeer 1994), their voices were especially heard during and after the 1994 International Conference on Population and Development in Cairo. This conference, and the discussions surrounding it, put scholars and activists interested in gender, especially those from the Third World, onto the radar screen of demographers. Even in the disagreement of some mainstream demographers and in their concern of what was removed from the population agenda to make room for issues of women and gender (McIntosh and Finkle 1995), we see a new way of dealing with the issues surrounding gender. One of the most important contributions of the reproductive health activists has been the attention given to feminist projects. Feminist research is necessarily political, and the activist work relating to the Cairo conference made...

Total quality management

While there are many definitions of TQM, they all share the common perspective of it being a philosophy rather than a simple management procedure. It must be seen as a process of improvement beyond the status quo that then extends into an all-encompassing program of developing, and fostering, the desire for change and improvement throughout the entire organization. TQM is an all-encompassing quality system, it includes QC, QA and QI within a perpetual reiterative process, but it is still based upon the foundations of inspection and audit (see Figure 3.2). TQM must be seen as a long-term goal, there are no short cuts or quick fixes in implementing TQM. There is no tool or technique that can be seen as a panacea for all the problems and woes of an organization, no turn-key systems that can be plugged into an organization's pre-existing management structure. Achieving a system of continuous improvement can take years, depending on the nature and size of the organization time frames of 8...

Aging and Male Fertility

In 1912, Weinberg noted that the skeletal disorder achondroplasia was prominent in younger rather than older siblings he was the first to suggest the possible link between paternal age and genetic diseases in offspring 4 . Thus, despite the ability of men to father children well into old age, there appears to be a positive relationship between paternal age and genetic disease in their offspring 50 . Older men have greater difficulties in achieving full-term pregnancy with their partners increasing paternal age is associated with a reduction in the quality of spermatozoa, i.e., decline in sperm motility and morphology 51 and a higher incidence of DNA fragmentation 52 there are inconsistent reports as to whether, in man, there is a decline in sperm production rate with advancing age 53 . However, fathers over 40 have both a greater difficulty to conceive 54-56 and their partners have a higher miscarriage rate 57 . With respect to genetic diseases, increased incidences of disorders such...

Models of Germ Cell Aging 741 Mouse Models

The klotho mutant mouse model has been proposed as one that resembles human aging 69 , Disruption of a single gene, klotho, that encodes a secreted protein results in a mutant mouse that manifests phenotypes resembling premature aging 67 . Homozygous klotho mice have shortened life spans to 60.7 days, decreased activity, and displayed infertility and atrophy of the genital organs. The klotho mouse model has been used to investigate the molecular mechanisms of normal human aging as well as human diseases in which there is premature aging or accelerated aging, such as progeria and Werner syndrome, but has not yet been used to investigate mechanisms of male germ cell aging.

Identifying Resistance

We see another kind of resistance in Kenya. There, among the Luo, women's use of contraceptives may be undermining men's control over their families. In that setting, men's dominance has rested on their ability to control important material and symbolic wealth and the connections those various components of wealth and prestige could bring ''Cattle were used primarily as bridewealth, which legitimated control over the women who would produce the children that would perpetuate the husband's lineage'' (Watkins, Rutenberg, and Wilkinson 1997 216). While men continue their economic control and domination today, they have not been able to control women's reproduction in the same way. Watkins and her colleagues attribute this change to the new family planning programs, introduced by outsiders to the culture, which have made contraception easy to obtain. Consequently, Luo women have been able to make decisions about contraception and reproduction that their husbands may disagree with. While...

Aging and DNA Damage and Repair Relationship to Oxidative Stress

There are numerous points at which DNA damage and mutations could arise. Many different types of damage can occur in male germ cells, including single- and double-strand breaks however, one of the main types of damage seen in male germ cells in the aging male is caused by oxidative stress. Oxidative stress is a common pathology seen in men with fertility problems 101, 102 . This type of stress can not only result in damage to proteins and lipids, but also cause DNA (including mtDNA) damage. DNA bases are particularly susceptible to oxidation mediated by ROS. Due to its low redox potential, guanine is highly susceptible to oxidative lesions. The most common DNA lesions resulting from oxidative stress are the oxidized base 8-oxoguanine (8-oxoG) and the oxidized nucleoside 8-oxo-deoxyguanosine (8-oxodG). The 8-oxoG lesion has the ability to mimic the base thymine (T) in the syn conformation and, accordingly, can pair with adenine (A), forming an 8-oxoG A base pair that can allow escape...

The Meaning of Motherhood

Inhorn's insights (1994, 1996) about childless women in urban Egypt is an example of research that is not part of mainstream demography but can inform demographic research. In this society, particularly among poor migrants who have moved from rural to urban centers, women's status and power are so powerfully tied to the bearing and raising of children that to be childless is a disaster. When these women moved to the city, they lost other sources of power, income, and even identity, and those losses made children even more important. Inhorn lived and talked with women who were searching for cures to their infertility and came to understand the cultural necessity of bearing children for women in this part of the world. She notes that ''indeed, it is from the study of infertility that issues of pronatalism, or child desire, are perhaps best understood. Namely, those who are missing children and who therefore have had much cause to reflect on their object of desire are often in the best...

Education and training

Everyone in the organization - the directors, managers and all employees - must be provided with the education to ensure that their general awareness and understanding of quality, its concepts and the necessary attitudes and skills, is sufficient for them to understand the philosophy of continuous quality improvement and to allow them to participate actively in the process. What might seem like a load of jargon at the outset must become a language of quality that is understood by the entire organization. This requires that it be made relevant to running an IVF Center, with explanation given in terms that illustrate its relevance and value.

Involvement and commitment

As a result of this involvement, there is increased recognition that an organization's employees are its greatest asset - one that will appreciate over time. Concern for, and support of, professional development, as well as providing a career structure, are too often ignored in many industries, including IVF labs. We all know that it takes a long time to properly train a new IVF scientist, yet how many of us have ever tried to put a value on this investment Helping people realize their potential is rewarding on many levels. Staff development and retention are integral to accreditation schemes and merely reflect one of the most basic business principles don't allow your competitor to acquire your assets (see Chapter 12 for further discussion of these topics).

Nerve Sparing Retroperitoneal Lymphadenectomy

Historically, the major long-term morbidity of RPL was ejaculatory dysfunction and potential infertility resulting from damage to the sympathetic nerves during dissection. Specifically, injuring the lumbar sympathetic trunks, postganglionic sympathetic fibers, and or nerves of the hypogastric plexus risked loss of seminal emission and consequently dry ejaculation. The traditional bilateral lymphadenectomy results demonstrated a 70 to 100 risk of this complication 2 . The movement to include suprahilar dissection was short lived and this approach was abandoned when no added benefit was realized 3 . The original procedures have since been further modified such that the minimal dissection is performed to spare relevant sympathetic nerves without risking an incomplete cancer resection. The initial strategy for minimizing postoperative ejaculatory dysfunction attributable to sympathetic nerve injury was the downscaling

Embryology And In Vitro Fertilization

In vitro fertilization (IVF) is a technique originally developed as a treatment for infertility. In IVF a number of ova are removed from a woman's ovaries and fertilized outside of her body. When they have developed to the eight-cell stage they are transferred back into her uterus, or the uterus of another woman. A number of variations of the IVF technique have been developed, each with its own acronym. These include GIFT (gamete intrafallopian transfer), ZIFT (zygote intrafallopian transfer), ICSI (intracytoplasmatic sperm injection), The development of IVF opened new possibilities for embryological research, and new possibilities for intervention at the embryonic stage of human life. Some of these possibilities are briefly outlined here. Ova can be donated from one woman to another, or one woman (a so-called surrogate mother) can bear a child for another couple. Ova from aborted female fetuses can be matured and used in IVF procedures. The normal reproductive span of women can be...

Folliclestimulating hormone FSH and spermatogenesis

1997) and inhibition ofboth FSH and LH induced a more pronounced inhibition of spermatogenesis than inhibition of LH alone (McLachlan et al. 2002a 2002b). To date, a role for FSH in immature and adult rat spermatogenesis is unequivocally established (El Shennawy etal. 1998). How critical FSH is for spermatogenesis has also been clearly demonstrated in primate studies. Patients with selective inactivating mutations ofthe FSH- -subunit exhibit hypogonadism and can be azoospermic (Lindstedt etal. 1998 Phillip etal. 1998). Immunization studies against FSH in rhesus monkeys and in bonnet monkey provoked marked testicular involution and even infertility (Moudgal et al. 1997a 1997b Nieschlag et al. 1999). In a hypophysec-tomized man bearing an activating mutation of the FSH receptor, spermatogenesis was sustained (Gromoll etal. 1996).

Replacement Arguments and Personal Identity

The argument thus maintains that children born to single mothers, to lesbian mothers, or after IVF using matured eggs from aborted fetuses could only have been born this way, and that it makes no sense to prohibit or discourage such pregnancies for the sake of the children. regulation stating that destructive embryo research is permitted only prior to 14 days g.a. This similarity in the legal regulations is most likely the result of a direct transfer of the 14-day limit suggested by the British Warnock committee which, with the moral philosopher Mary Warnock in the chair, published a report in 1984 on the ethical issues created by the new reproductive techniques (republished commercially as M. Warnock, Ed., 1985. A Question of Life The Warnock Report on Human Fertilization and Embryology. Basil Blackwell, Oxford). The committee based its recommendation of a 14-day limit on the following argument (reconstructed from the text)

Repertoire of Cytokines in Seminal Plasma

IL-6) are also produced by somatic cells in testis, including the Leydig and Sertoli cells 27 . However, some studies also indicated local production of these factors in the secondary sex glands irrespective of spermatogenesis 53, 54 . Cytokines appear to be also secreted by the epididymis and the prostate gland 55 . Prostate gland, for example, seems to be the main site of origin of IL-6 and IL-2 in the seminal plasma 54, 56-58 . Moreover, the significant correlation between IL-6 and fructose levels observed suggests that the seminal vesicles can be also included in the production of this cytokine 58 . According to some authors, in the male genital system, some cytokines (IL-1 and IL-6) can be produced and secreted not only by somatic cells, but also by germ cells 59, 60 . It is possible that cytokines may act not only as an autocrine factor, but also in a paracrine manner during spermatogenesis, sperm maturation, sperm transport, and even during the fertilization process 61 ....

Is Viability or Birth Important

Embryos can be used in research for a number of purposes ranging from basic embryological research to improvements of IVF techniques. It is often claimed that embryo research is necessary for the further development of IVF techniques, and that the information produced about the earliest development of the human being may prove useful in the understanding of aging and of cancer. The embryos used in embryo research can either be so-called spare embryos that are surplus to requirements in the context of IVF treatments (e.g., because the treatment is a success and there are stored embryos which the parents do not need anymore), or they can be created specifically for research. There has been some debate about whether it is ethically acceptable to create embryos specifically for research. was created as an end in itself it is transformed into a mere means as soon as it is donated to research. The Kantian argument may, however, be more applicable in the context of custody or inheritance...

Relationship of Cytokines with Redox Status of Semen

Oxidative stress in semen has been suggested to be an important factor in the etiology of poor sperm function, especially through peroxidative damage to the sperm plasma membrane and DNA integrity in the sperm nucleus 98 . In many studies, the role of cytokines and oxidative stress in infertile patients was examined, especially together with an infection inflammation in the genital tract 57, 85, 99, 100 . The frequent presence of leukocytes in the semen, including their major subpopulation of neutrophils, is inseparably connected with reactive oxygen intermediate (ROI) production 101, 102 . A condition in which the number of leukocytes exceeds 1 x 106 mL of semen, defined as leukocytospermia, is considered to be the threshold value above which sperm dysfunction may occur. However, rather than the leukocyte number in the semen, their activity may decide on the final effects of oxidative stress on spermatozoa 76, 103 . Many authors have observed correlations between the levels of...

Influence of Cytokines on Sperm Membrane Properties

Proinflammatory cytokines are characterized by their pleiotropic properties, and when they occur together they may act synergistically, additively, or antagonistically on the biological function of the target cell. This is confirmed by the synergis-tic effect in vitro in relation to the harmful influence of some proinflammatory cytokines on biological membranes 88 . In case of cytokines such as IL-6, IL-8, or IL-18, observations in the in vitro system appear to be complementary to evaluation of the male genital tract inflammation in vivo. The evidence of this can be high levels of IL-6, IL-8, or IL-18 observed in the seminal plasma of infertile men reported by many groups 71, 72, 74 . The extended high levels of these cytokines present during persistent infection inflammation in the male genital tract may augment the peroxidation process and affect sperm function with a subsequent development of infertility. Many authors suggest that the measurement of IL-6, IL-8, and or IL-18...

Radiation Therapy

Bone marrow suppression, soreness in the back of the throat with resultant dysphagia, transient loss of taste, transient xerostomia, and occasionally wound dehiscence (usually when there is not an adequate 10- to 14-day interval between surgery and initiation of radiation therapy). Late effects are generally less prominent in adults than in children and include potential pituitary dysfunction, possible infertility, effects on cognition, and possible induction of second malignancies. Although the neu-rocognitive effects in treated adults have not been studied as extensively as in children, there are data to suggest that cranial doses of 30 to 36 Gy may have an impact on cognitive function in survivors, especially on memory, reasoning, visual-spatial ability, and arithmetic calculation skills.40

Political Approaches To Ethics

Although global feminists praise the ways in which multiculturalist feminists have amplified socialist feminist thought, they nonetheless regard even this enriched discussion of women's oppression as incomplete. All too often, feminists focus in a nearly exclusive manner on the gender politics of their own nation. Thus, while U.S. feminists struggle to formulate laws to prevent sexual harrassment and date rape, thousands of women in Central America, for example, are sexually tortured on account of their own, their fathers', their husbands', or their sons' political beliefs. Similarly, while U.S. feminists debate the extent to which contraceptives ought to be funded by the government or distributed in public schools, women in many Asian and African countries have no access to contraception or family planning services from any source.

Complement Regulators And Reproduction

It is not surprising or novel to discover that CReg expressed on the surface of sperm and on the trophoblast function to protect these cells from C attack. However, a surprising alternative role for MCP in fertilisation and reproduction has come to light. It has been known for some time that MCP is found at high levels in the reproductive system in fact, even before its characterisation as a regulator of the C system, MCP was identified by several different groups as an antigen found on the acrosomal region of sperm (172-174). MCP was localised to the inner acrosomal membrane and was only exposed to extracellular fluid following the acrosome reaction, an essential prelude to fertilisation. The cryptic site of expression suggested a role other than C regulation, possibly in the fertilisation process itself. This notion was supported by observations of abnormal MCP on the sperm of infertile men and by studies demonstrating that antibodies to the first SCR in MCP inhibited sperm egg...

What Psychosocial Interventions Are Appropriate For Patients Whose Epilepsy Has Not Been Confirmed

Although a single seizure is usually not diagnosed as epilepsy, a person who has had a seizure will have many of the same initial feelings and concerns as one whose epilepsy has been diagnosed. In particular, fears about seizures and of physical harm have been noted in parents and children with first seizures.1316 Thus, regardless of whether the person has a single seizure or many seizures, attention should be paid to the person's and the family's initial reactions, feelings, and concerns. For example, experiencing a first seizure can be particularly difficult for women who are planning to have children. Some may wish to put their plans to become pregnant on hold until the medical picture is clearer. Other patients may cope better by not embracing the idea of having epilepsy until it is clearly diagnosed. Some patients may have more difficulty coping or obtaining access to care if the terms seizure and epilepsy are not defined appropriately. Education and support tailored to the...

Oxidative Stress in the Seminiferous Tubules and Epididymis

In a study carried out in infertility patients, it was found that co-incubation of sperm suspensions with phytohaemagglutinin-activated polymorphonuclear leukocytes in vitro produces a significant increase in the production of oxygen radicals by immature sperm 32 . The authors of this study conclude that proinflammatory factors produced by activated leukocytes amplify oxygen radical production by immature sperm by 2-3 orders of magnitude. Therefore, in patients in whom there may be an increase in the levels of proinflammatory factors in the epididymis, e.g. inflammatory or infectious processes 33 , an increase in DNA damage may take place. In addition, since it has been suggested that the epididymis is in a chronic pseudoinflammatory state 31 , proinflammatory factors may play an important role in the pathophysiology of oxygen radical-induced sperm DNA damage in the epididymis. This explains, at least in part, the beneficial effects of antibiotics in patients with high levels of sperm...

Misoprostol In Practice

Unfortunately, rapid population growth, economic collapse and the spread of HIV AIDS in some African countries and the endless recruitment of skilled health professions from developing to developed countries will make the road to providing comprehensive obstetric care long and slow. During this interval, widespread access to misoprostol and the education to use it safely during home births have the potential to make a significant contribution - perhaps even the single most important contribution - to reducing the global burden of deaths from postpartum hemorrhage. The only other practical intervention with the potential to reduce postpartum hemorrhage in low-resource settings is realistic access to family planning, as all women who wish to limit childbearing are at risk of postpartum hemorrhage, and the older, higher-parity women, who have the greatest unmet need for family planning, are at even higher risk.

Oxidative Stress DNA Damage and Protamines

Role in configuring a compact and hydrodynamic nucleus which plays a crucial role in protecting the paternal genome during migration through the male and female reproductive tract. The quasi-paracrystalline packaging of the sperm chromatin renders the DNA molecule virtually inaccessible to nucleases or mutagens that may be present in the internal or in the external media where the sperm have to endure for variable periods of time. Variations in the levels of protamination by an unbalanced P1 P2 ratio may result in male infertility. In infertile humans, where these aspects have been more deeply analyzed, these unbalance differentially impacts on the integrity of the DNA and in the reproductive outcome of these couples 59, 60 . It has been recently reported that the P1 P2 ratio in human sperm correlates with the levels of sperm DNA fragmentation and also with the rate of sperm DNA damage after ejaculation. Statistical differences were found between fertile controls and patients with...

Caspase and Capacitation

12.2.4 Caspases and Male Infertility Semen Parameters and Caspase A significant association has been reported between caspase-3 activity and sperm morphology and motility 35 . It has been shown that nonapoptotic sperm that are negative for caspase-3 present with higher quality in terms of normal morphology 36 . Furthermore, spermatozoa of infertile patient have shown an increase in caspase activity 37 . Similarly, a significant negative correlation between sperm motility and viability and caspase-3 activation has been reported 38-43 . In a study that evaluates caspase enzymatic activity, semen fractions of infertile patients had higher caspase enzymatic activity compared to fractions in fertile controls 44 . Although there are significant correlation between caspase activation and the sperm quality regarding motility and vitality values, other contradictory results show no significant correlation between sperm morphology and caspase-3 activation 41 . There are different...

Pregnant BreastFeeding Patients

It is a common misconception that pregnancy protects against depression (i.e., the glow of pregnancy). Depression actually is quite common in pregnancy, especially for women with a history of recurrent depression. Both maternal and fetal well-being must be taken into account when weighing the benefits and risks of using antide-pressant therapy during pregnancy.41 In general, studies have not demonstrated an increased risk of miscarriage or congenital malformations with antidepressant use,41 but the prescribing information for paroxetine was changed recently to reflect the findings of epidemiological studies in which an increased risk of congenital malformations, in

Theoretical Issues

Specifically, substantive behavioral explanations for fertility transition focus on at least one of three elements the nature of fertility decisions, the information and knowledge available to decision makers, and the institutional context for decision making. We first consider high fertility in pre industrial settings. Widespread evidence indicates that the high fertility of many populations coincided with a ''natural fertility'' regime, one in which potential decision makers did not limit their number of births via changed behavior at higher parities (Henry 1961). There are three possible reasons (1) decision makers were motivated to have as many children as possible, (2) decision makers did not know how to limit fertility, or (3) fertility control was not licit. Important behavioral theories focus on each alternative. The fertility transition's second stage views family size declines as resulting from conscious actions by decision makers, specifically decisions to curtail...

Poly ADPRibose Polymerase 1231 PARP Structure and Function

Sperm DNA integrity is critical for successful embryo development and the transmission of intact genetic material to the offspring 2 . During spermatogenesis, protection of the sperm DNA is achieved by tight packaging into a condensed chromatin. Incomplete chromatin condensation and persistence of DNA strand breaks during spermatogenesis are associated with DNA damage and male infertility 65 , PARP, a DNA damage repair enzyme, has been first introduced by Chambon et al. in 1963. It is associated with chromatin and specifically found in the nucleolus 66 . To date, 18 different PARP homologues have been identified, but the structure and function of some are not known yet 67 . Each PARP family member has a catalytic part which contains 50 amino acids that act as the PARP signature 67 . PARP family members have other domains, such as DNA-binding domains (DBDs), ankyrin repeats, WWEs domain, macro domains, and BRCA-1 domain with C terminus which is activated following DNA damage 68 . PARP...

Empirical Findings

As noted earlier, natural fertility results if there are no attempts to control family size. In practice, however, natural fertility is frequently operationalized as involving no contraception or abortion (Henry 1961). Fertility is high in natural fertility populations but how high Females can have children as early as the midteens and can continue until the late 40s. Theoretically, women could have nearly one birth per year. Thus the theoretical maximum fertility, in the absence of all behavioral constraints, could be as high as 35 births On the other end of the natural fertility spectrum lie the Dobe Kung hunter-gathers, residents of the Kalahari Desert in Africa prior to 1975 (Howell 1979, 2000). The reported TFR for this natural fertility population was about 4.5 births per woman. Thus, the question, How can natural fertility populations be so different from each other, and why are even the highest observed rates much lower than the theoretical maximum '' In short, the...

Controversy over Source of Fetal Tissue

An even more troublesome source of fetal material might arise if a human fetus is conceived specifically for the purpose of aborting it for research or therapy. Although there is no documented evidence that this has happened, in at least two cases women have asked if they could become pregnant to produce tissues or organs for another person. In one case, the daughter of an Alzheimer's patient asked to be inseminated with the sperm of her father and, at the appropriate stage, to abort the fetus to provide her father with fetal neural tissue for transplantation. Although there is no evidence at present that this is technically possible, and the women's request was denied, this case demonstrates a possible demand for such applications. Similarly, another woman requested that her midterm fetus be aborted and the kidneys be transplanted to her husband who was dying of end-stage renal disease. There is also concern that increased pressures for fetal tissue could lead to a marketplace for...

Medical Risk Assessment

Hypertension may have many effects on the pregnancy depending on the degree of abnormality. Fetal effects range from none to increased miscarriage, IUGR, abruptio placentae, and fetal death. Underlying blood pressure disorders should be treated appropriately before pregnancy. Some hypertensive, reproductive-age women are treated with angio-tensin-converting enzyme (ACE) inhibitors. This class of therapeutics can cause significant risk to the developing fetus. These medications should be stopped and alternate medications started if needed. Women with preexisting hypertension should be referred for concurrent care with a physician experienced in managing hypertension in pregnancy.

Health Promotion Activities and Information for

Routine fetal heart auscultation, urinalysis, and assessment of maternal weight, blood pressure, and fundal height generally are recommended, although the supportive evidence varies (Kirkham et al., 2005). Women should be offered ABO and Rh blood typing and screening for anemia during the first prenatal visit. Genetic counseling and testing should be offered to couples with a family history of genetic disorders, a previously affected fetus or child, or a history of recurrent miscarriage. All women should be offered prenatal serum marker screening for neural tube defects and aneu-ploidy. Women at increased risk for aneuploidy should be offered amniocentesis or chorionic villus sampling (CVS). Counseling about the limitations and risks of these tests, as well as their psychologic implications, is necessary. Folic acid supplementation beginning in the preconception period and early pregnancy reduces the incidence of neural tube defects. Laboratory testing during the first prenatal visit...

Prenatal Genetic Diagnostic Testing

If specific risk factors for fetal abnormalities are identified in the mother, appropriate counseling and specific diagnostic testing should be offered. The most common reason to offer prenatal genetic diagnosis is advanced maternal age a somewhat linear increase in nondisjunction in meiosis increases the risk of a conception with aneuploidy (abnormal chromosome number). This is one reason why older women have a higher rate of spontaneous first-trimester miscarriage. It is also why older women are more likely to give birth to a child with a chromosomal abnormality, most often Down syndrome (trisomy 21).

Germ Line Gene Therapy

Very closely linked to germ-line gene therapy, in fact one might almost call it passive germ-line therapy, is the technique of selective implantation in in vitro fertilization (IVF). This technique does not directly act on the genome like germ-line gene therapy, but produces the same results. By using genetic screening, it is possible for couples undergoing IVF to select embryos to implant which are free from disease genes (for example, if their families have a history of muscular dystrophy). This would produce a child without the gene for that disease, just as germ-line gene therapy would. This technique is already available and being used by some hospitals, yet although there has been ethical discussion of it, it has not really been of the same tenor as that around germline therapy. The point is that if both selective implantation and germ-line therapy produce the same results, are they ethically different, and if they are different, then there must be something ethically...

Rare Coagulation Disorders Fibrinogen deficiency

The hypo- and dysfibrinogenemias comprise a collection of disorders that are usually dominantly inherited and associated with both bleeding and venous thrombotic manifestations. Women are at risk of recurrent miscarriage, and both antenatal and postnatal hemorrhage. In hypofibrinogenemia, both antigenic and functional fibrinogen levels are reduced. The diagnosis of dysfibrinogenemia is made by demonstrating a prolonged TT with a normal antigenic fibrinogen level.

Methods for the Detection of ROS in Human Sperm Samples

Abstract Male-factor significantly contributes to infertility in couples of reproductive age. Several studies have shown that oxidative stress (OS) is involved in the pathophysiology of male infertility. It is caused by an imbalance between the formation of reactive oxygen species (ROS) and the ability of the antioxidants to scavenge them. There are several methods to measure seminal ROS in the clinical setting, most notably among them is the chemiluminescence assay. This technique measures the global ROS, i.e., both the intra- and extracellular ROS. The measurement of seminal ROS employing the chemiluminescence technique in clinical andrology labs is explained in this chapter. Through a deeper understanding of ROS and its measurement, clinical andrology labs can better assist patients to achieve increased rates of fertility and pregnancy.

Right to an Unaltered Genome

Conception, before any possible person exists), and perhaps, if we do not count a fertilized ovum as a person, germ-line therapy as a whole. Can a person describe themselves as having an altered genome, when in fact what happened was that their parents chose the characteristics that they would have Does this make an ethical difference It certainly makes germ-line gene therapy closer to selective implantation and IVF in ethical terms.

Antiphospholipid Antibodyinduced Pregnancy Loss

Over the last two decades, APS has emerged as a leading cause of pregnancy loss and pregnancy-related morbidity. It is now recognized that recurrent miscarriage occurs in 1 of couples (39-39), that up to 20 of women with recurrent miscarriage have aPL antibodies, and that in approximately 15 of otherwise apparently normal women aPL is the sole explanation for recurrent fetal loss (31, 40). The primary treatment for these patients, anticoagulation throughout pregnancy, is inconvenient, sometimes painful, expensive, and fraught with potential complications, including hemorrhage and osteoporosis. Moreover, it is often ineffective. Thus, the identification of a novel mechanism for pregnancy loss in women with aPL antibodies holds the promise of new, safer and better treatments.

Process mapping tools

Figure 5.4 A map of the standard IVF laboratory process. Off-page connectors relate to the actual oocyte retrieval process obtaining, analyzing and preparing the sperm sample the ancillary process of in-vitro maturation of oocytes and the process whereby specimens are transferred into the cryobank. Figure 5.4 A map of the standard IVF laboratory process. Off-page connectors relate to the actual oocyte retrieval process obtaining, analyzing and preparing the sperm sample the ancillary process of in-vitro maturation of oocytes and the process whereby specimens are transferred into the cryobank. Figure 5.5 A map of the standard IVF laboratory process including the additional complexity of inputs of previously cryopreserved oocytes, zygotes or embryos. Off-page connectors relate to CD the actual oocyte retrieval process obtaining, analyzing and preparing the sperm sample CD the ancillary process of in-vitro maturation of oocytes the process whereby specimens are transferred into the...

Diagnostic Application of Chemiluminescence Assays

Chemiluminescent assays provide clinically significant results that correlate with the quality of the ejaculate and the fertilizing potential of the spermatozoa both in vitro and in vivo. This is especially true in patients presenting with poor sperm quality such as in cases of oligozoospermia, or in samples where low-density immature spermatozoa recovered following sperm preparation using a density gradient technique. Defective sperm populations such as those exhibiting presence of excess residual cytoplasmic are associated with high redox activity 6, 13, 36-38 . This assay can also be used as an important diagnostic screening tool in the evaluating patients with unexplained or idiopathic infertility as these patients demonstrate high ROS levels in their seminal ejaculates.

Indications For Treatment

Varix ligation is indicated in patients with a palpable varix and at least one of the following (i) pain that is not attributable to other intrascrotal pathology (17) (ii) adolescent ipsilateral testis volume loss of 2 ml or greater than 20 of volume (18-21) or (iii) infertility attributable to the male partner based upon abnormal semen analysis or abnormal results of sperm function tests associated with a female partner who is fertile or suffers a treatable cause of subfertility (16). Treatment of varicocele is not indicated for infertility if the male partner has normal semen quality or a subclinical varicocele (16). Men with palpable varicoceles and abnormal semen quality who are not currently attempting conception but are interested in preservation of fertility may wish to undergo varix ligation when informed of the progressive deterioration of semen quality associated with varicocele (5,7,9). Varix ligation is cost-effective in comparison to alternate treatments, which might...

Impact of Hysterectomy

Rebecca also had fibroids and had tried for years to become pregnant but never conceived. Emotionally, she found the hysterectomy decision to be gut-wrenching. Once her surgery was scheduled, she couldn't bear to see a woman with a baby. The finality of what she was going to do was nearly overwhelming.

Laboratory Application of Chemiluminescent Assays

From the above descriptions, it will be evident that while chemiluminescent probes such as luminol and lucigenin cannot yield specific data on ROS generation by human spermatozoa, they are nevertheless sensitive, semiquantitative indicators of redox activity in these cells and many publications have shown that the chemilumi-nescent activity detected in their presence is inversely related to sperm function and significantly elevated in the cases of male infertility 23, 46-54 . A unique prospective study, conducted in the days before assisted conception therapy was readily available, went so far as to demonstrate an excellent relationship between spontaneous pregnancy rates over a 4-year follow-up period and measurements made at the beginning of the study of luminol-dependent chemiluminescent signals generated by the spermatozoa in couples characterized by a normal female factor 55 . The predictive power of the luminol-dependent assay used in this study was all the more impressive...

Process control and process analysis

IVF laboratory have been described previously (Mortimer et al., 1995 Mortimer, 1999 Murray and Mortimer, 1999) and are slowly being adopted by more and more labs (Wikland and Sjoblom, 2000 Mayer et al., 2003). To decide if a process is sub-optimal, and hence a candidate for improvement, we need knowledge of its capabilities - in other words we need one or more benchmarks for its performance (see Chapter 10). Therefore, we are obliged to consider other disciplines such as engineering. Indeed, if we are to be able to identify all the factors that affect how our processes and systems operate in the IVF lab we must consider all of the following. Clearly, in order to write a good SOP that will include the necessary technical procedural detail, plus identifying and controlling the other factors that can impinge upon the process, one must know far more than just how to do the procedure. Knowing why we do things in certain ways - and also perhaps why we don't do them in other ways -requires...

Pharmacologic Therapy

Most women with hyperprolactinemia require dopamine agonist therapy to achieve regular ovulatory cycles and pregnancy. Since restoration of the ovulatory cycle may occur within 1 week of initiating therapy, it is necessary to caution patients regarding their potential to become pregnant.50 Overall, there is reassuring worldwide experience that bromocriptine use during pregnancy does not increase fetal malformations, spontaneous miscarriage, ectopic pregnancy, or multiple births.39,41 Furthermore, no teratogenic effects have been reported in women who received cabergoline during the first and second trimesters of pregnancy.4145 Despite these data, women who become pregnant while on a dopamine agonist should discontinue treatment immediately to minimize fetal exposure. Because cabergoline has a prolonged half-life, women who plan to become pregnant should discontinue the drug at least 1 month before planned conception.

Psychological intervention

As her psychiatrist, I saw her regularly over a period of two to three years as an outpatient and in ward rounds for relatively brief sessions (rarely more than 30 minutes). Over a period of six months, she discussed her understanding of the voices and their development. She talked about how she had become pregnant and had had the pregnancy terminated. Her father had been appalled at this and had made accusations against her, similar in nature to the content of the voices. She herself felt guilty and was unable to discuss the conception of the child, which had resulted from a somewhat coercive relationship with a boyfriend. She would hear the voice of her terminated offspring Christopher and the devil, and also see visions of it saying it looked like its father. She seriously contemplated harming her husband and son. Voices commanded her to drown herself and she attempted suicide by using a plastic bag on the ward, but fortunately was rescued by nursing staff. Unfortunately, although...

ROS and Semen Quality

Abstract Infertility affects an estimate of 50-80 x106 ( 7-15 of men at reproductive age) men globally and annually. Among these men, a large number of patients (25-40 ) suffer from male genital tract infection inflammation, conditions where reactive oxygen species (ROS) and oxidative stress in the semen play prominent roles in the pathogenesis of infertility. Considering the extraordinary high amount of polyunsaturated fatty acids present in the plasma membrane, spermatozoa are exceptionally prone to oxidative damage. This damage may include the plasma membrane including the flagellar structure as well as the DNA. Thereby, sperm functions are damaged. As natural protective mechanisms, several antioxi-dants, enzymatic, non-enzymatic and preventive, are available in the seminal plasma. However, considering that certain essential physiological sperm functions are dependent on a limited amount of ROS, the balance between oxidation and reduction is of utmost importance. Clinically, this...

Classification And Clinical Presentation

Prolactin-secreting tumors are the most common pituitary adenoma, responsible for approximately 27 of pituitary tumors.5 They occur more often in women by nearly 2 1, but autopsy studies reveal an almost equal prevalence of pro-lactinomas in both sexes. Prolactinomas often cause amenor-rhea or galactorrhea and infertility in women of childbearing age. In men, infertility, decreased libido, and impotence are seen. In both men and women, secondary endocrine dysfunction can occur (Table 47-2).

Leukocytes as ROS Producers

A recent study (Mupfiga and Henkel, unpublished data) showed that, as expected, the seminal leukocyte concentration is correlated not only significantly with the seminal ROS production but also with the production of superoxide, the activation of the effector caspases-3 7 in spermatozoa and the percentage of sperm with disrupted mitochondrial membrane potential. These observations give evidence that a high seminal concentration of activated leukocytes, as it is the case in male genital tract infections inflammation, can trigger programmed cell death, apoptosis, by means of activating the caspase system and consequently leading to male infertility.

Mothers Health Babys Risks

A father's health can bring risks to a baby, too. Studies of men in a variety of occupations reveal that prolonged exposure to radiation, anesthetic gases, and other toxic chemicals can alter a father's chromosomes, increasing the risk of miscarriage or genetic defects. And even if the mother doesn't drink alcohol or use drugs, a father who is a heavy drinker or drug user is linked to lower weight newborns. Apparently substances such as cocaine can bind directly to live sperm and cause mutations in them.

Sensitivity of Spermatozoa to Oxidative Damage

The total content of PUFA in human spermatozoa accounts for about 50 of the content of fatty acids. Docosahexaenoic acid (DHA), a PUFA containing six double bonds per molecule 46 is of particular importance as its content represents about 21.5 of the total fatty acid and 43.0 of the unsaturated fatty acid content of human spermatozoa (reviewed in 41 ). The importance of the PUFA content of the sperm plasma membrane in infertile patients with oligozoospermia and or astheno-zoospermia was debated, as contradictory data were presented by different groups. While Zalata et al. 46 , Lenzi et al. 52 and Tavilani et al. 53 showed low PUFA levels in patients with poor sperm motility, Ollero et al. 54 as well as Khosrowbeygi

Pregnancy Nutrition

Pregnancy Nutrition

Are You Expecting? Find Out Everything You Need to Know About Pregnancy and Nutrition Without Having to Buy a Dictionary. This book is among the first books to be written with the expertise of a medical expert and from the viewpoint of the average, everyday, ordinary,

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