Povezanost koncentracije preovulacijskoga i postovulacijskoga progesterona u serumu i ishoda izvantjelesne oplodnje [The relationship between the preovulatory and postovulatory progesterone serum concentration and the outcome of in vitro fertilization]

Aim: To investigate the influence of elevated preovulatory and postovulatory progesterone (P4) on the outcome of in vitro fertilization. Materials and methods: This is a prospectice cohort study which included 400 patients (300 in the control group and 100 in the group with elevated preovulatory P4 – 85 normal responders and 15 high responders). The IVF outcome among patients with normal preovulatory P4 as compared to the patients with elevated preovulatory P4, the IVF outcome among normal and high responders, the influence of the embryo transfer type (BET or FET) among patients with elevated preovulatory P4 on the outcome of IVF procedures and the influence of postovulatory P4 on the IVF outcome have been investigated in this study. Results: Positive IVF outcome has been recorded in about one third of all the performed procedures in the control and the study group, with slightly better outcome with elevated preovulatory P4. Better outcome with FET among normal responders and a discretely better outcome with BET among high responders has been recorded. Better IVF outcome has been recorded with P4 on the 5th day >425,7 nmol/L among all the patients and with P4 on the 5th day >384,6 nmol/L among patients with elevated preovulatory P4. Conclusion: Elevated preovulatory P4 has a slightly protective effect on IVF outcome while the P4 on the 5th day >425,7 nmol/L could be a potential marker for the success of the IVF procedures among all the patients and with P4 on the 5th day >384,6 nmol/L among patients with elevated preovulatory P4

Suvremene prevencijske strategije porasta predovulacijskog progesterona tijekom stimulacije jajnika u postupku izvantjelesne oplodnje

The purpose of this review is to present contemporary measures for preventing the increase in preovulatory progesterone (P) and its adverse effects on ovarian stimulation in in vitro fertilization (IVF). For the last 20 years, the increase of preovulatory P has been a topic of numerous discussions because its role is not fully understood in terms of its impact on pregnancy outcome after IVF. Some studies failed to establish a connection between the preovulatory P increase and successful IVF outcome regardless of the level of P, while, conversely, most other studies have reported on adverse effects of elevated P concentrations. Current strategies to prevent the increase in preovulatory P include an individualized approach with the use of mild stimulation protocols and early application of human chorionic gonadotropin for ovulation induction among good responders, delay in the transfer of fresh embryos from 3rd to 5th day, and cryopreservation of all embryos with the thawed embryo transfer in the natural cycle. Nevertheless, further studies are needed to confirm the current preventive methods or enable the application of new strategies in order to lower or eliminate the detrimental effects of preovulatory P rise during ovarian stimulation in IVF.Svrha ovoga preglednog članka je prikazati suvremene mjere za prevenciju porasta predovulacijskog progesterona (P) i njegovih nepovoljnih učinaka kod stimulacije jajnika u postupku izvantjelesne oplodnje. Unatrag 20-ak godina porast predovulacijskog P tema je brojnih rasprava, jer njegova uloga nije u potpunosti razjašnjena u pogledu utjecaja na ishod trudnoće nakon postupka izvantjelesne oplodnje. Neka istraživanja nisu utvrdila nikakvu povezanost između porasta predovulacijskog P u odnosu na uspješnost postupka izvantjelesne oplodnje neovisno o razini P, dok nasuprot tome, većina drugih istraživanja izvješćuje o nepovoljnim učincima povišene koncentracije P. Suvremene strategije u prevenciji porasta predovulacijskog P uključuju individualizirani pristup primjenom blažih stimulacijskih protokola te raniju primjenu humanog korionskog gonadotropina za indukciju ovulacije kod bolesnica koje dobro reagiraju na stimulaciju, odgodu prijenosa svježih zametaka s 3. na 5. dan i krioprezervaciju svih zametaka uz transfer odmrznutih embrija u prirodnom ciklusu. Neophodna su daljnja istraživanja koja će potvrditi postojeće prevencijske metode ili omogućiti primjenu novih strategija, sa svrhom onemogućavanja nepovoljnog utjecaja porasta predovulacijskog P na ishod trudnoće nakon postupka izvantjelesne oplodnje

Poboljšanje spolne i reprodukcijske funkcije u muškaraca s oštećenjem kralježnične moždine

The aim of the review is to establish sexual and reproductive functions in men with spinal cord lesion (SCL). Many sexual and reproductive dysfunctions may be found in these patients including individual’s low self-esteem, delay of orgasm, erectile or ejaculatory disorder and abnormalities of semen, which are characterized by lower sperm motility or viability. Owing to improvements in physical medicine and rehabilitation, the focus has been shifted from keeping patients alive towards ensuring the quality of life and improvements of sexual dysfunctions and later reproduction. Erectile dysfunction can be treated by using phosphodiesterase-5 inhibitors, intracavernosal injections, vacuum devices and penile prostheses. Semen can be retrieved from anejaculatory patients by medically assisted methods utilizing penile vibratory stimulation, electroejaculation, prostate massage, or surgically. Although there is low chance for pregnancy in natural way in most of SCL patients, fatherhood is possible through the introduction of assisted medical management. By use of various medical, technical and surgical procedures for sperm retrieval combined with assisted reproductive methods, high pregnancy rates have been reported comparable to those in able-bodied subfertile patients. Nevertheless, future studies are needed to improve semen quality and methods of assisted ejaculation in patients with SCL.Svrha ovoga preglednog članka je analizirati spolne i reprodukcijske funkcije u muškaraca s oštećenjem kralježnične moždine (OKM). Mnoge spolne i reprodukcijske funkcije u ovih bolesnika mogu biti oštećene uključujući vlastitu podcjenjenost, nedostatak spolnog zadovoljstva, erekcijsku i ejakulacijsku disfunkciju te nepravilnosti spermiograma koje karakteriziraju slabija pokretljivost i vijabilnost. Zahvaljujući napretku u fizikalnoj medicini i rehabilitaciji pomiče se glavna usmjerenost na omogućavanje preživljenja takvih bolesnika prema osiguranju kvalitete života, poboljšanju spolne disfunkcije i kasnije reprodukcije. Erekcijska disfunkcija može se liječiti primjenom inhibitora fosfodiesteraze-5, intrakavernoznih injekcija, vakumskih uređaja i proteza za penis. U većine muškaraca s anejakulacijom sjeme se može dobiti postupkom medicinski pomognute ejakulacije primjenom vibracijske stimulacije penisa, elektroejakulacije, masaže prostate ili kirurških zahvata. Premda većina muškaraca s OKM ne uspijeva postići trudnoću na prirodan način, stvaranje potomstva ipak je moguće uvođenjem specijalističkog medicinskog liječenja. Primjenom raznih medicinskih, tehničkih i kirurških tehnika za dobivanje spermija u kombinaciji s metodama za pomognutu oplodnju postignute su zavidne stope trudnoća slično kao u subfertilnih osoba bez tjelesnih oštećenja. Ipak, potrebna su daljnja istraživanja za poboljšanje kvalitete sjemena i metoda za pomognutu ejakulaciju u bolesnika s OKM

Je li povećanje incidencije OASIS-a pokazatelj lošije opstetričke skrbi?

In the era of new molecular, epigenetic and proteomic discoveries, birth canal injuries seem like outdated discussion. A vast increase in the incidence of obstetric anal sphincter injuries (OASIS) has been recorded in the last two decades despite advantages in modern medicine and new obstetric methods. This increase might be attributed to the new classification of perineal injury but also to the new imaging methods, including endoanal sonography, which earlier identifies injuries that previously were considered to be occult and actually underwent unrecognized, and which should have been recognized immediately postpartum. OASIS are third and fourth degree perineal injuries that occur during delivery. The reported incidence of OASIS varies from 0.1% to 10.9%. It is well known that third and fourth degree perineal injuries occur more often in primiparae, and in cases of macrosomic newborn, dorsoposterior position of fetal head and shoulder dystocia. The protective role of episiotomy is controversial. Birth canal injury during delivery can happen to any parturient woman. It is important for obstetricians to have this in mind at every delivery. Repercussions of OASIS are serious and can persist for life. They include emotional, psychological, social, physical and sexual disturbances. Therefore, it is very important to recognize the risk factors, diagnose the injury on time and treat it properly by a multidisciplinary team. Accordingly, it can be concluded that the increased incidence of OASIS is a result of better recognition of the risk factors, reduced rates of unrecognized sphincter injuries, adoption of the new classification and better postpartum imagining methods for detection of occult injuries.U eri novih molekularnih, epigenetičkih i proteomskih otkrića porođajne ozljede izgledaju kao zastarjela tema za raspravu. U posljednja dva desetljeća zabilježen je porast ozljeda analnog sfinktera tijekom porođaja unatoč napretcima moderne medicine i novim porođajnim metodama. Ovo povećanje moglo bi se pripisati novoj klasifikaciji perinealnih ozljeda, ali i novim slikovnim metodama uključujući endoanalnu sonografiju koja kvalificira ozljede za koje se smatra da su prije bile okultne, zapravo neprepoznate, a trebale su biti prepoznate odmah nakon porođaja. U opstetričke ozljede analnog sfinktera se ubrajaju treći i četvrti stupanj razdora međice tijekom porođaja. Učestalost ovih ozljeda varira od 0,1% do 10,9%. Poznato je da je razdor međice trećeg i četvrtog stupnja češći u prvorotkinja te u slučajevima makrosomnog novorođenčeta, dorsoposteriornom položaju fetalne glavice i kod distocije ramena. Zaštitna uloga epiziotomije je proturječna. Ozljeda porođajnog kanala se može dogoditi kod bilo koje žene u porođaju, što porodničar uvijek mora imati na umu. Razdori međice trećeg i četvrtog stupnja mogu imati ozbiljne dalekosežne posljedice koje uključuju emocionalne, psihološke, socijalne, fizičke i seksualne poremećaje. Stoga je vrlo važno prepoznati čimbenike rizika, dijagnosticirati ozljedu na vrijeme i zbrinuti ju na odgovarajući način uz multidisciplinarni pristup. Uza sve navedeno može se zaključiti da je povećana učestalost OASIS-a rezultat boljeg prepoznavanja čimbenika rizika, smanjene stope neprepoznate ozljede sfinktera, uvođenja nove klasifikacije i boljih slikovnih metoda koje postpartalno mogu otkriti okultne ozljede

Kisspeptin as a promising oocyte maturation trigger for in vitro fertilisation in humans

The aim of this review is to analyse the effectiveness of exogenous kisspeptin administration as a novel alternative of triggering oocyte maturation, instead of currently used triggers such as human chorionic gonadotropin (hCG) or gonadotropin releasing hormone (GnRH) agonist, in women undergoing in vitro fertilisation (IVF) treatment. Kisspeptin has been considered a master regulator of two modes of GnRH and hence gonadotropin secretion, pulses and surges. Administration of kisspeptin-10 and kisspeptin-54 induces the luteinising hormone (LH) surge required for egg maturation and ovulation in animal investigations and LH release during the preovulatory phase of the menstrual cycle and hypothalamic amenorrhoea in humans. Exogenous kisspeptin-54 has been successfully administered as a promising method of triggering oocyte maturation, following ovarian stimulation with gonadotropins and GnRH antagonists in women undergoing IVF, due to its efficacy considering achieved pregnancy rates compared to hCG and GnRH agonists. Also, its safety in patients at high risk of developing ovarian hyperstimulation syndrome is noteworthy. Nevertheless, further studies would be desirable to establish the optimal trigger of egg maturation and to improve the reproductive outcome for women undergoing IVF treatment

The relationship between the preovulatory and postovulatory progesterone serum concentration and the outcome of in vitro fertilization

Svrha: Ispitati utjecaj povišenog preovulacijskoga i postovulacijskoga progesterona (P4) na ishod izvantjelesne oplodnje. Materijali i metode: Ovo je prospektivno kohortno istraživanje koje je uključilo 400 ispitanica (300 u kontrolnoj skupini i 100 u skupini s povišenim preovulacijskim P4 - 85 normal respondera i 15 high respondera). Uspoređen je ishod IVF postupka kod ispitanica s normalnim vrijednostima P4 u odnosu na ispitanice s povišenim preovulacijskim P4, ishod IVF postupka kod normal i high respondera, utjecaj vrste transfera (BET ili FET) kod ispitanica s povišenim vrijednostima preovulacijskoga P4 na ishod IVF postupka, te utjecaj postovulacijskoga P4 na ishod IVF postupka. Rezultati: Pozitivan ishod IVF postupka zabilježen je u oko jedne trećine od svih učinjenih postupaka kod kontrolne i ispitivane skupine, uz nešto bolji ishod pri povišenim vrijednostima preovulacijskoga P4. Kod normal respondera bolji je ishod pri FET transferu, dok je kod high respondera nešto bolji uspjeh pri BET transferu. Bolji ishod IVF-a zabilježen je pri vrijednosti P4 5. dana >425,7 nmol/L kod svih ispitanica, odnosno pri vrijednosti P4 5. dana >384,6 nmol/L kod ispitanica s povišenim vrijednostima preovulacijskoga P4. Zaključak: Povišene vrijednosti preovulacijskoga P4 imaju blagi protektivni utjecaj na ishod IVF postupka, dok bi vrijednosti P4 5. dana >425,7 nmol/L mogle biti potencijalni biljeg uspješnosti IVF postupka kod svih ispitanica, odnosno, pri vrijednosti P4 5. dana >384,6 nmol/L kod ispitanica s povišenim vrijednostima preovulacijskoga P4.Aim: To investigate the influence of elevated preovulatory and postovulatory progesterone (P4) on the outcome of in vitro fertilization. Materials and methods: This is a prospectice cohort study which included 400 patients (300 in the control group and 100 in the group with elevated preovulatory P4 – 85 normal responders and 15 high responders). The IVF outcome among patients with normal preovulatory P4 as compared to the patients with elevated preovulatory P4, the IVF outcome among normal and high responders, the influence of the embryo transfer type (BET or FET) among patients with elevated preovulatory P4 on the outcome of IVF procedures and the influence of postovulatory P4 on the IVF outcome have been investigated in this study. Results: Positive IVF outcome has been recorded in about one third of all the performed procedures in the control and the study group, with slightly better outcome with elevated preovulatory P4. Better outcome with FET among normal responders and a discretely better outcome with BET among high responders has been recorded. Better IVF outcome has been recorded with P4 on the 5th day >425,7 nmol/L among all the patients and with P4 on the 5th day >384,6 nmol/L among patients with elevated preovulatory P4. Conclusion: Elevated preovulatory P4 has a slightly protective effect on IVF outcome while the P4 on the 5th day >425,7 nmol/L could be a potential marker for the success of the IVF procedures among all the patients and with P4 on the 5th day >384,6 nmol/L among patients with elevated preovulatory P4

The relationship between the preovulatory and postovulatory progesterone serum concentration and the outcome of in vitro fertilization

Svrha: Ispitati utjecaj povišenog preovulacijskoga i postovulacijskoga progesterona (P4) na ishod izvantjelesne oplodnje. Materijali i metode: Ovo je prospektivno kohortno istraživanje koje je uključilo 400 ispitanica (300 u kontrolnoj skupini i 100 u skupini s povišenim preovulacijskim P4 - 85 normal respondera i 15 high respondera). Uspoređen je ishod IVF postupka kod ispitanica s normalnim vrijednostima P4 u odnosu na ispitanice s povišenim preovulacijskim P4, ishod IVF postupka kod normal i high respondera, utjecaj vrste transfera (BET ili FET) kod ispitanica s povišenim vrijednostima preovulacijskoga P4 na ishod IVF postupka, te utjecaj postovulacijskoga P4 na ishod IVF postupka. Rezultati: Pozitivan ishod IVF postupka zabilježen je u oko jedne trećine od svih učinjenih postupaka kod kontrolne i ispitivane skupine, uz nešto bolji ishod pri povišenim vrijednostima preovulacijskoga P4. Kod normal respondera bolji je ishod pri FET transferu, dok je kod high respondera nešto bolji uspjeh pri BET transferu. Bolji ishod IVF-a zabilježen je pri vrijednosti P4 5. dana >425,7 nmol/L kod svih ispitanica, odnosno pri vrijednosti P4 5. dana >384,6 nmol/L kod ispitanica s povišenim vrijednostima preovulacijskoga P4. Zaključak: Povišene vrijednosti preovulacijskoga P4 imaju blagi protektivni utjecaj na ishod IVF postupka, dok bi vrijednosti P4 5. dana >425,7 nmol/L mogle biti potencijalni biljeg uspješnosti IVF postupka kod svih ispitanica, odnosno, pri vrijednosti P4 5. dana >384,6 nmol/L kod ispitanica s povišenim vrijednostima preovulacijskoga P4.Aim: To investigate the influence of elevated preovulatory and postovulatory progesterone (P4) on the outcome of in vitro fertilization. Materials and methods: This is a prospectice cohort study which included 400 patients (300 in the control group and 100 in the group with elevated preovulatory P4 – 85 normal responders and 15 high responders). The IVF outcome among patients with normal preovulatory P4 as compared to the patients with elevated preovulatory P4, the IVF outcome among normal and high responders, the influence of the embryo transfer type (BET or FET) among patients with elevated preovulatory P4 on the outcome of IVF procedures and the influence of postovulatory P4 on the IVF outcome have been investigated in this study. Results: Positive IVF outcome has been recorded in about one third of all the performed procedures in the control and the study group, with slightly better outcome with elevated preovulatory P4. Better outcome with FET among normal responders and a discretely better outcome with BET among high responders has been recorded. Better IVF outcome has been recorded with P4 on the 5th day >425,7 nmol/L among all the patients and with P4 on the 5th day >384,6 nmol/L among patients with elevated preovulatory P4. Conclusion: Elevated preovulatory P4 has a slightly protective effect on IVF outcome while the P4 on the 5th day >425,7 nmol/L could be a potential marker for the success of the IVF procedures among all the patients and with P4 on the 5th day >384,6 nmol/L among patients with elevated preovulatory P4

The relationship between the preovulatory and postovulatory progesterone serum concentration and the outcome of in vitro fertilization

Svrha: Ispitati utjecaj povišenog preovulacijskoga i postovulacijskoga progesterona (P4) na ishod izvantjelesne oplodnje. Materijali i metode: Ovo je prospektivno kohortno istraživanje koje je uključilo 400 ispitanica (300 u kontrolnoj skupini i 100 u skupini s povišenim preovulacijskim P4 - 85 normal respondera i 15 high respondera). Uspoređen je ishod IVF postupka kod ispitanica s normalnim vrijednostima P4 u odnosu na ispitanice s povišenim preovulacijskim P4, ishod IVF postupka kod normal i high respondera, utjecaj vrste transfera (BET ili FET) kod ispitanica s povišenim vrijednostima preovulacijskoga P4 na ishod IVF postupka, te utjecaj postovulacijskoga P4 na ishod IVF postupka. Rezultati: Pozitivan ishod IVF postupka zabilježen je u oko jedne trećine od svih učinjenih postupaka kod kontrolne i ispitivane skupine, uz nešto bolji ishod pri povišenim vrijednostima preovulacijskoga P4. Kod normal respondera bolji je ishod pri FET transferu, dok je kod high respondera nešto bolji uspjeh pri BET transferu. Bolji ishod IVF-a zabilježen je pri vrijednosti P4 5. dana >425,7 nmol/L kod svih ispitanica, odnosno pri vrijednosti P4 5. dana >384,6 nmol/L kod ispitanica s povišenim vrijednostima preovulacijskoga P4. Zaključak: Povišene vrijednosti preovulacijskoga P4 imaju blagi protektivni utjecaj na ishod IVF postupka, dok bi vrijednosti P4 5. dana >425,7 nmol/L mogle biti potencijalni biljeg uspješnosti IVF postupka kod svih ispitanica, odnosno, pri vrijednosti P4 5. dana >384,6 nmol/L kod ispitanica s povišenim vrijednostima preovulacijskoga P4.Aim: To investigate the influence of elevated preovulatory and postovulatory progesterone (P4) on the outcome of in vitro fertilization. Materials and methods: This is a prospectice cohort study which included 400 patients (300 in the control group and 100 in the group with elevated preovulatory P4 – 85 normal responders and 15 high responders). The IVF outcome among patients with normal preovulatory P4 as compared to the patients with elevated preovulatory P4, the IVF outcome among normal and high responders, the influence of the embryo transfer type (BET or FET) among patients with elevated preovulatory P4 on the outcome of IVF procedures and the influence of postovulatory P4 on the IVF outcome have been investigated in this study. Results: Positive IVF outcome has been recorded in about one third of all the performed procedures in the control and the study group, with slightly better outcome with elevated preovulatory P4. Better outcome with FET among normal responders and a discretely better outcome with BET among high responders has been recorded. Better IVF outcome has been recorded with P4 on the 5th day >425,7 nmol/L among all the patients and with P4 on the 5th day >384,6 nmol/L among patients with elevated preovulatory P4. Conclusion: Elevated preovulatory P4 has a slightly protective effect on IVF outcome while the P4 on the 5th day >425,7 nmol/L could be a potential marker for the success of the IVF procedures among all the patients and with P4 on the 5th day >384,6 nmol/L among patients with elevated preovulatory P4

Laboratory and clinical significance of macroprolactinemia in women with hyperprolactinemia

The role of macroprolactinemia in women with hyperprolactinemia is currently controversial and can lead to clinical dilemmas, depending upon the origin of macroprolactin, the presence of hyperprolactinemic symptoms and monomeric prolactin (PRL) levels. Macroprolactinemia is mostly considered an extrapituitary phenomenon of mild and asymptomatic hyperprolactinemia associated with normal concentrations of monomeric PRL and a predominance of macroprolactin confined to the vascular system, which is biologically inactive. Patients can therefore be reassured that macroprolactinemia should be considered a benign clinical condition, resistant to antiprolactinemic drugs, and that no diagnostic investigations or prolonged follow-up should be necessary. However, a significant proportion of macroprolactinemic patients appears to suffer from hyperprolactinemia-related symptoms and radiological pituitary findings commonly associated with true hyperprolactinemia. The symptoms of hyperprolactinemia are correlated to the levels of monomeric PRL excess, which may be explained as coincidental, by dissociation of macroprolactin, or by physiological, pharmacological and pathological causes. The excess of monomeric PRL levels in such cases is of primarily importance and the diagnosis of macroprolactinemia is misleading or inadequate. However, macroprolactinemia of pituitary origin associated with radiological findings of pituitary adenomas may rarely occur with similar hyperprolactinemic manifestations, exclusively due to bioactivity of macroprolactin. Therefore, in such cases with hyperprolactinemic signs and pituitary findings, macroprolactinemia should be considered a pathological biochemical condition of hyperprolactinemia. Accordingly, individualized diagnostic investigations with the introduction of dopamine agonists, or other treatment with prolonged follow-up, should be mandatory. The review analyses the laboratory and clinical significance of macroprolactinemia in hyperprolactinemic women suggesting clinically useful diagnostic and treatment strategies

Improvement of Sexual and Reproductive Function in Men with Spinal Cord Lesion

The aim of the review is to establish sexual and reproductive functions in men with spinal cord lesion (SCL). Many sexual and reproductive dysfunctions may be found in these patients including individual’s low self-esteem, delay of orgasm, erectile or ejaculatory disorder and abnormalities of semen, which are characterized by lower sperm motility or viability. Owing to improvements in physical medicine and rehabilitation, the focus has been shifted from keeping patients alive towards ensuring the quality of life and improvements of sexual dysfunctions and later reproduction. Erectile dysfunction can be treated by using phosphodiesterase-5 inhibitors, intracavernosal injections, vacuum devices and penile prostheses. Semen can be retrieved from anejaculatory patients by medically assisted methods utilizing penile vibratory stimulation, electroejaculation, prostate massage, or surgically. Although there is low chance for pregnancy in natural way in most of SCL patients, fatherhood is possible through the introduction of assisted medical management. By use of various medical, technical and surgical procedures for sperm retrieval combined with assisted reproductive methods, high pregnancy rates have been reported comparable to those in able-bodied subfertile patients. Nevertheless, future studies are needed to improve semen quality and methods of assisted ejaculation in patients with SCL