Sozos J. Fasouliotis

Human umbilical cord blood banking and transplantation: a state of the art

Human umbilical cord blood has proven to be a feasible alternative source of hematopoietic stem cells for pediatric and some adult patients with major hematologic disorders. This has promoted the establishment of cord blood banks for use in unrelated transplants worldwide. The banking of umbilical cord blood offers many advantages: absence of donor risk, absence of donor attrition, immediate availability, and the ability to expand available donor pools in targeted ethnic and racial minorities currently underrepresented in all bone marrow registries. Preliminary clinical experience suggests that, due to the immunological immaturity of cord blood cells, graft versus host disease might be lower than when using bone marrow from adult donors and HLA restrictions might be less stringent. Techniques to improve the efficacy of blood banks are currently under investigation. Closed cord blood collection methods have proven to be superior to open in reducing the risk of microbial contamination. Efficient banking requires volume reduction of cord blood units without significant loss of progenitor cells, in order to decrease storage space and cost, and this may be achieved by using the separation techniques. Cryopreservation and thawing techniques have been established and do not seem to affect the viability and progenitor cell recovery or the feasibility of CD34(+) selection and ex vivo expansion. Nevertheless, many scientific, ethical, and social questions have arisen in connection with cord blood banking that need to be addressed.

Postpartum umbilical cord blood collection for transplantation: A comparison of three methods

OBJECTIVE This study was undertaken to compare 3 methods of collection of human umbilical cord blood. STUDY DESIGN Seventy-five women with uncomplicated vaginal deliveries were divided equally into 3 groups. One of 3 cord blood collection methods was applied to each woman. Method 1 was collection of cord blood into a standard donation blood bag. Methods 2 and 3 used a syringe to perform a sodium chloride solution flush and drain, which included withdrawal of cord blood by a syringe until the delivery of the placenta, followed by flushing through a catheter one of the umbilical arteries with sodium chloride solution and collection of the cord blood either into an open sterile container (method 2) or into a standard donation blood bag (method 3). Analyses included comparisons among the 3 groups of volume collected, total number of white blood cells, and bacterial contamination rates (positive culture results). In addition a correlation was made between the different variables and the collected cord blood nucleated cells. RESULTS Cord blood collection by the blood bag method (method 1), which is presently the standard clinical practice, resulted in a mean blood volume of 76.4 +/- 32.1 mL and a mean total white blood cell count of 835 +/- 507 x 10(6) cells. With collection methods 2 and 3, in which as much blood as possible was withdrawn by syringe while the placenta was still in utero followed by a second collection after infusion of the umbilical artery with sodium chloride solution, the mean volume collected was significantly higher (P <.05) at 174.4 +/- 42.8 mL and 173.7 +/- 41.3 mL, respectively, with significantly higher (P <.001) mean total white blood cell counts of 1624 +/- 887 x 10(6) cells and 1693 +/- 972 x 10(6) cells, respectively. A direct correlation was observed between the cord blood volume collected and placental weight, whereas no correlations were observed with maternal age, pregnancy duration, or the neonates weight. Bacterial contamination was significantly higher (P =.04) in cord blood collections obtained by method 2 (48%) than by methods 1 (16%) and 3 (19%). CONCLUSIONS The syringe-assisted sodium chloride solution flush collection method with a blood bag (method 3) was found to be the most effective method for human umbilical cord blood collection. This method doubles the total white blood cells collected with respect to current yields, which may make cord blood transplantation applicable for adults.

Evaluation and Treatment of Low Responders in Assisted Reproductive Technology: A Challenge to Meet

Purpose: To investigate the various methods of evaluationand treatment of patients with a low response to controlledovarian hyperstimulation in assisted reproductive technologies (ART). Methods: Review and analysis of relevant studies publishedin the last decade, identified through the literature and Medlinesearches. Results: While a universally accepted definition for lowresponders is still lacking, these patients are reported torepresent about 10% of the ART population. Several ovarianreserve screening techniques have been proposed; however,currently the best-characterized and most sensitive screeningtools available are the basal day 3 serum follicle-stimulatinghormone level and the clomiphene citrate challenge test.When abnormal, these tests allow physicians to counselpatients that their prognosis for conception is poor. Althoughthe presence of a normal result does indicate better long-termchances for conception, an age-related decline in fecundityremains and patient age should still be considered whencounseling patients with normal screening results. Severalstimulation protocols have been applied in the low-responsegroup with varying success. Recent studies show that theuse of a minidose gonadotropin-releasing hormone-agonistprotocol may result in significantly decreased cycle cancellationsas well as increased clinical and ongoing pregnancies,and thus is proposed as a first-line therapy. Studies evaluatingsupplementary forms of treatment to the ovulation inductionregimen show improved outcome when pretreating withoral contraceptives, whereas there seems to be no benefitfrom cotreatment with growth hormone or glucocorticoids.Blastocyst culture and transfer and assisted hatching in lowresponders are still under evaluation, whereas natural cyclein vitro fertilization may be used in cases of repeated failuresas a last option before resorting to oocyte donation or adoption.Future possible forms of treatment like in vitro maturationof immature human oocytes, cytoplasm, and nucleartransfer currently are experimental in nature and their efficacyhas still to be proven.Conclusions: The evaluation and treatment of low respondersin ART remains a challenge. Understanding of the underlyingetiology and pathophysiology of this disorder may helpthe clinician to approach it successfully.

Gonadotropin-Releasing Hormone (GnRH)-Antagonist Versus GnRH-Agonist in Ovarian Stimulation of Poor Responders Undergoing IVF

AbstractPurpose: The objective of this study was to compare the efficacy of GnRH-antagonists to GnRH-agonists in ovarian stimulation of poor responders undergoing IVF. Methods: Retrospective analysis of our data revealed that 56 patients underwent treatment with a GnRH-agonist according to the flare-up protocol. Patients failing to achieve an ongoing pregnancy (n=53) were subsequently treated in the next cycle with a GnRH-antagonist according to the multiple-dose protocol. Main outcome measures included the clinical pregnancy and implantation rates. Results: While ovulation induction characteristics and results did not differ between the two protocols, the number of embryos transferred was significantly higher (P=0.046) in the GnRH-antagonist than in the GnRH-agonist stimulation protocol (2.5 ± 1.6 vs. 2.0 ± 1.4, respectively). The clinical pregnancy and implantation rates per transfer in the GnRH-antagonist group appeared higher than in the GnRH-agonist, but did not differ statistically (26.1 and 10.7 compared with 12.2 and 5.9%, respectively). However, the ongoing pregnancy rate per transfer was statistically significantly higher (P=0.03) in the GnRH-antagonist than in the GnRH-agonist group (23.9 vs. 7.3%, respectively). Conclusion: Applying GnRH-antagonists to ovarian stimulation protocols may offer new hope for IVF poor responder patients. However, further controlled randomized prospective studies with larger sample sizes are required to establish these results.

BRCA1 and BRCA2 gene mutations: decision-making dilemmas concerning testing and management.

The identification of the BRCA genes, and their possible etiologic relationship with various forms of inherited cancer, has been recognized universally as a cornerstone in the search of cancers genetic susceptibility. Female BRCA gene mutation carriers are found to carry an increased risk of developing breast or ovarian cancer and to a lesser degree, colon cancer, and male BRCA mutation carriers are also related to an increased risk of breast, colon, or prostate cancer. Although genetic testing promises a possible future presymptomatic determination and treatment of women who are genetically susceptible to cancer, current data reveal certain dilemmas and uncertainties regarding our ability to interpret the results from testing and offer effective management options. In addition, several complex ethical, legal, and social issues have been revealed with the advent of this new information, which also confirm the need for additional research regarding the most effective use of this genetic information and for the establishment of appropriate clinical management strategies.

Maternal–fetal conflict

Advances in prenatal care have brought about a greater understanding as to the special status of the fetus to the point that it is considered a patient in its own regard. Pregnant women generally follow the medical recommendations of their physicians that are intended for the benefit of their baby. Any situation where maternal well-being or wishes contradict fetal benefit constitutes a maternal-fetal conflict. Such situations include a broad range of possible interventions, non-interventions, and coercive influences. In such cases, the attending physician is expected to attain an attitude that involves either the respect of the womans autonomy and right to privacy, which precludes any approach other than to accept her decision, or to modify this absolute for the beneficence of the fetus. Current ethical viewpoints range from absolute respect for maternal autonomy with no persuasion allowed, to gentle persuasion and to others which permit intervention and overriding of the womans autonomy. Court-ordered decisions enforcing the pregnant woman to undergo a procedure in order to improve fetal outcome have been criticized as an invasion of a womans privacy, limitation of her autonomy, and taking away of her right to informed consent.

Ethics and assisted reproduction

In vitro fertilization and assisted reproductive technology have made great progress during the last 20 years. Genetic material donation, human embryo cryopreservation, selective embryo reduction, preimplantation genetic diagnosis and surrogacy are currently practiced in many countries. On the other hand, embryo research is practiced only in a small number of nations, whereas human cloning has thus far been universally condemned. The rapid evolution and progress of all these techniques of assisted reproduction has revealed certain ethical issues that have to be addressed.

Multifetal pregnancy reduction: A review of the world results for the period 1993–1996

The objective of this work was to evaluate the outcome of multifetal pregnancy reduction and to provide an analysis of the ethical dilemmas associated with its application. The study design was based on data on over 1400 completed pregnancies that underwent multifetal pregnancy reduction as reported in the world literature during 1993-1996. The results were: A total of 1453 completed cases of multifetal pregnancy reduction are presented. The total survival rate was estimated to be 87.7%, resulting in a total pregnancy loss rate of 12.3%. The lowest survival rate is found to be in higher-order pregnancies of five or more fetuses (75.2%), whereas pregnancy loss rate seems to be similar for quadruplets, triplets and twins that underwent reduction (11.3%, 8.3% and 13.6%, respectively). A 33.3% of the total pregnancy loss rate occurred within four weeks from the procedure, whereas 66.7% occurred after the four weeks but at 24 weeks of gestation or earlier. The mean gestational age at delivery was estimated to be 33 weeks for pregnancies reduced to triplets, 35.8 weeks for those reduced to twins and 36.9 weeks for singletons, with 5% delivering at less than 28 weeks and 9.6% at 29-32 weeks. We conclude that multifetal pregnancy reduction has been established as an efficient and safe way to improve outcome of multifetal gestations, especially those with four or more fetuses and likely of triplets. As the experience from the procedure increases, it seems that reduction of triplets to twins can be offered to patients with satisfactory results. The reduction to singletons has not yet been established and is being performed only when medical indications exist. Prenatal genetic diagnosis should become an integral part of counselling on multiple pregnancy. Physicians should take whenever possible measures designed to prevent high multiple birth pregnancies. We also note that although multifetal pregnancy reduction improves significantly the outcome of multiple pregnancies, several ethical dilemmas arising from its application are still under dispute.

Cryopreservation of embryos: Medical, ethical, and legal issues

ConclusionThe option of cryopreservation has proven to be an extraordinarily useful procedure in assisted reproductive technology. At present, the best programs report an ∼90% survival rate of cryopreserved material. Furthermore, the pregnancy rate per thawed embryo transfer approximates the pregnancy rate of fresh embryo transfer. It is obviously of the utmost importance that these excellent results not be overshadowed by neglect of the problems of cryopreservation. IVF programs should put emphasis on ethical and legal issues: otherwise there is a danger that the advantages of cryopreservation will be lost.

Markedly elevated levels of inflammatory cytokines in maternal serum and peritoneal washing during arrested labor

Background.  The role of inflammatory cytokines in the pathophysiology of arrested labor is currently unknown. We measured levels of inflammatory cytokines in maternal serum and peritoneal washings in arrested first stage of labor to assess the possible involvement of these mediators in this obstetric disorder.