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Male reproductive health and the environment: an increasing incidence of testicular dysgenesis syndrome
4
FRIDAY,
for her quality of life in relation to the prolongation of suffering. Three different decisions are characteristic in the terminal phase of life: Non treatment decisions: not starting a treatment or ceasing a treatment on the express and serious wish of the patient. Alleviation of pain and symptoms: medical action that is necessary for and in its nature directly intended for the relief of serious suffering, even though this action has the consequence of making death occur more easily. Euthanasia: a deliberate life-shortening medical act performed on a seriously ill patient who has a concrete expectation of death, on her express wishes. Also here the type of decision made is dependent on what the patient wants after adequate counselling. Conclusion: The decision to treat or not to treat is a joint effort of doctor and patient. It is inappropriate to treat if the patient does not want it and when it prolongs pain and suffering. Decisions in this matter can differ depending on other palliation available.
RM5.01
REPRODUCTIVE INFERTILITY
HEALTH
AND PREVENTION
OF
RM5.01.01 MALE REPRODUCTIVE HEALTH AND THE ENVIRONMENT: AN INCREASING INCIDENCE OF TESTICULAR DYSGENESIS SYNDROME. N.E. Skakkebsek, Department of Growth and Reproduction, Copenhagen University Hospital (Rigshospitalet, Section GR-5064), 9 Blegdamsvej, DK-2100 Copenhagen, Denmark Recent reports have focused on different adverse trends in male reproductive health, including rising incidence of testicular cancer; low and probably decreasing semen quality; high and possibly increasing frequencies of undescended testis and hypospadias; and high demand for assisted reproduction. Due to the specialisation in medicine, and different ages at presentation, reproductive problems used to be analysed separately by various professional groups e.g. paediatric endocrinologists, urologists, andrologists and oncologists. We present here new evidence that poor semen quality, testis cancer, ondescended testis and hypospadias are symptoms of an underlying testicular dysgenesis syndrome (TDS), which may be increasingly common due to adverse environmental influences. We recommend that future epidemiological studies on trends in male reproductive health are more broad based and take all symptoms of TDS into account, otherwise important biological information may be lost.
RM5.01.02 SMOKING AND NUTRITIONAL ASPECTS OF INFERTILITY S. Bhattacharva, Dept.OB/GYN, University of Aberdeen, Aberdeen, U.K. Introduction: There has been a surge of interest in preventable aspects of infertility. The possible association between diet and lifestyle factors including smoking and infertility is an important question that has yet to be answered satisfactorily. Objective: The aim of this study was to conduct a systematic review of the literature relating to the association between female infertility and smoking and nutritional factors. Study Methods: A search of the Medline and Embase databases was conducted to identify papers on the association between cigarette smoking, nutritional status and female infertility. Papers exploring the link between nutritional supplements and fertility were also identified. Bibliographies of relevant publications were hand searched. Results: Smoking contributes to female infertility. The odds ratio (OR) for risk of infertility among women who smoke is1.6 (95% CI 1.34 to 1.91). The literature relating to nutritional factors is less clearly defined. Extremes of nutrition are associated with anovulation and infertility. Lifestyle changes leading to loss of weight improve reproductive outcome in obese women. The role of specific dietary factors on female infertility is less well defined. While folate supplementation may improve reproductive outcome it may increase the likelihood of multiple pregnancy. Important differences have been shown between serum and follicular fluid levels of nutrients like triglycerides, nonesterified fatty acids, vitamin B12 and folate suggesting a potentially important role for these in oocyte maturation and fertilisation.
SEPTEMBER
8
Conclusion: Smoking is a risk factor for female infertility. Further work needs to be done to define the effect of nutritional factors and dietary supplements on fertility before useful interventional strategies can be developed.
RM5.01.03 PREVENTION OF PELVIC INFLAMMATORY DISEASE .I. Paavonen, MD, Department of Obstetrics and Gynecology, Helsinki, Finland
University
of
Pelvic inflammatory disease (PID) is the major cause of infertility and adverse pregnancy outcome. PID also causes chronic pelvic pain and increases the risk for hysterectomy. Thus, PID is a major threat to the reproductive health of women worldwide. However, PID is also one of the most neglected areas in modern medicine today, usually managed by physicians with little interest in the condition. There are still critical gaps in our knowledge of PID. For instance, recent studies suggest that large numbers of women with asymptomatic chlamydial infection may develop clinically unrecognized upper genital tract infection known as “silent PID”. This is a major obstacle to strategic plans for prevention of symptomatic PID. Laparoscopy was invented by Swedish investigators for the diagnosis of PID more than 2.5 years ago. Since then, laparoscopy has been generally regarded as the gold standard for the diagnosis of PID. However, the diagnostic performance of laparoscopy has never been properly validated in controlled trials. While acknowledging the potential limitations of laparoscopy other less invasive diagnostic tests have been evaluated as surrogate tests for laparoscopy for the diagnosis of PID, including endometrial biopsy, endovaginal ultrasound with or withour power Doppler or MRI. It is beyond reasonable doubt that CT is the major cause of PID. The role of gonorrhea in the etiology of PID has decreased. The rates of CT in sexually active asymptomatic populations are strikingly high. Therefore, screening for CT has been emphasized in the prevention of PID and associated sequelae. Secondary prevention by screening and case finding may prevent lower genital tract infection from ascending to the upper genital tract and causing PID. Chlamydial infection fills the general prerequisites for disease prevention by screening since these infections are highly prevalent, are associated with significant morbidity, and can be diagnosed and treated. Screening based on first-void urine (FVU) testing by nuclear acid amplification techniques, in combination with single dose therapy with azithromycin may have a major impact on the prevention and control of chlamydial infections and PID. However, only one randomized controlled intervention trial has so far demonstrated that screening and treating asymptomatic women with chlamydial infection significantly reduces the incidence of symptomatic PID. Swedish experience suggests that screening for CT is a powerfool tool in the prevention of short-term and long-term complicatios of PID. Chlamydia rates have decreased by 65 75% since mid-80’s. Subsequently, hospitalizations for PID have also decreased, followed by a significant decrease in ectopic pregnancies, especially in young age groups. However, it still remains to be seen whether secondary prevention of PID by on CT screening also decreases the rate of tubal factor infertility, the most costly long-term complication of chlamydial PID. The Furthermore, at least 10 health economic have consistently shown that CT screening programmes are highly cost-effective which is an important message to healthcare policy makers who make decisions of allocation of healthcare resources. Economic evaluations also help to understand the link between PID and the extremely high cost of treatment of tubal factor infertility. In conclusion, development and implementation of effective intervention programs for prevention and control of PID is one of the major challenges to health care systems. Prevention and control of PID will have a major impact on the reproductive health of women worldwide.
RM5.02 OVULATION
INDUCTION
RM5.02.01 NEW PROTOCOIZ IN OVARIAN STIMULATION THERAPY R. Frvdman, Department of Obstetrics and Gynecology, A. B&l&e Hospital, 157, Rue de la Porte de Trivaox, 92140 Clamart Cedex, France The hyperstimulation protocols have increased the amount of drug injected with the association of gonadotropins and GnRH agonist (GnRH-a). The side effects of the long protocol (used in the majority of the cases) are frequent and not always well tolerated by the patient. The multiple blood drawn and controls are affecting the patients life. The rate of multiple
FRIDAY,
for her quality of life in relation to the prolongation of suffering. Three different decisions are characteristic in the terminal phase of life: Non treatment decisions: not starting a treatment or ceasing a treatment on the express and serious wish of the patient. Alleviation of pain and symptoms: medical action that is necessary for and in its nature directly intended for the relief of serious suffering, even though this action has the consequence of making death occur more easily. Euthanasia: a deliberate life-shortening medical act performed on a seriously ill patient who has a concrete expectation of death, on her express wishes. Also here the type of decision made is dependent on what the patient wants after adequate counselling. Conclusion: The decision to treat or not to treat is a joint effort of doctor and patient. It is inappropriate to treat if the patient does not want it and when it prolongs pain and suffering. Decisions in this matter can differ depending on other palliation available.
RM5.01
REPRODUCTIVE INFERTILITY
HEALTH
AND PREVENTION
OF
RM5.01.01 MALE REPRODUCTIVE HEALTH AND THE ENVIRONMENT: AN INCREASING INCIDENCE OF TESTICULAR DYSGENESIS SYNDROME. N.E. Skakkebsek, Department of Growth and Reproduction, Copenhagen University Hospital (Rigshospitalet, Section GR-5064), 9 Blegdamsvej, DK-2100 Copenhagen, Denmark Recent reports have focused on different adverse trends in male reproductive health, including rising incidence of testicular cancer; low and probably decreasing semen quality; high and possibly increasing frequencies of undescended testis and hypospadias; and high demand for assisted reproduction. Due to the specialisation in medicine, and different ages at presentation, reproductive problems used to be analysed separately by various professional groups e.g. paediatric endocrinologists, urologists, andrologists and oncologists. We present here new evidence that poor semen quality, testis cancer, ondescended testis and hypospadias are symptoms of an underlying testicular dysgenesis syndrome (TDS), which may be increasingly common due to adverse environmental influences. We recommend that future epidemiological studies on trends in male reproductive health are more broad based and take all symptoms of TDS into account, otherwise important biological information may be lost.
RM5.01.02 SMOKING AND NUTRITIONAL ASPECTS OF INFERTILITY S. Bhattacharva, Dept.OB/GYN, University of Aberdeen, Aberdeen, U.K. Introduction: There has been a surge of interest in preventable aspects of infertility. The possible association between diet and lifestyle factors including smoking and infertility is an important question that has yet to be answered satisfactorily. Objective: The aim of this study was to conduct a systematic review of the literature relating to the association between female infertility and smoking and nutritional factors. Study Methods: A search of the Medline and Embase databases was conducted to identify papers on the association between cigarette smoking, nutritional status and female infertility. Papers exploring the link between nutritional supplements and fertility were also identified. Bibliographies of relevant publications were hand searched. Results: Smoking contributes to female infertility. The odds ratio (OR) for risk of infertility among women who smoke is1.6 (95% CI 1.34 to 1.91). The literature relating to nutritional factors is less clearly defined. Extremes of nutrition are associated with anovulation and infertility. Lifestyle changes leading to loss of weight improve reproductive outcome in obese women. The role of specific dietary factors on female infertility is less well defined. While folate supplementation may improve reproductive outcome it may increase the likelihood of multiple pregnancy. Important differences have been shown between serum and follicular fluid levels of nutrients like triglycerides, nonesterified fatty acids, vitamin B12 and folate suggesting a potentially important role for these in oocyte maturation and fertilisation.
SEPTEMBER
8
Conclusion: Smoking is a risk factor for female infertility. Further work needs to be done to define the effect of nutritional factors and dietary supplements on fertility before useful interventional strategies can be developed.
RM5.01.03 PREVENTION OF PELVIC INFLAMMATORY DISEASE .I. Paavonen, MD, Department of Obstetrics and Gynecology, Helsinki, Finland
University
of
Pelvic inflammatory disease (PID) is the major cause of infertility and adverse pregnancy outcome. PID also causes chronic pelvic pain and increases the risk for hysterectomy. Thus, PID is a major threat to the reproductive health of women worldwide. However, PID is also one of the most neglected areas in modern medicine today, usually managed by physicians with little interest in the condition. There are still critical gaps in our knowledge of PID. For instance, recent studies suggest that large numbers of women with asymptomatic chlamydial infection may develop clinically unrecognized upper genital tract infection known as “silent PID”. This is a major obstacle to strategic plans for prevention of symptomatic PID. Laparoscopy was invented by Swedish investigators for the diagnosis of PID more than 2.5 years ago. Since then, laparoscopy has been generally regarded as the gold standard for the diagnosis of PID. However, the diagnostic performance of laparoscopy has never been properly validated in controlled trials. While acknowledging the potential limitations of laparoscopy other less invasive diagnostic tests have been evaluated as surrogate tests for laparoscopy for the diagnosis of PID, including endometrial biopsy, endovaginal ultrasound with or withour power Doppler or MRI. It is beyond reasonable doubt that CT is the major cause of PID. The role of gonorrhea in the etiology of PID has decreased. The rates of CT in sexually active asymptomatic populations are strikingly high. Therefore, screening for CT has been emphasized in the prevention of PID and associated sequelae. Secondary prevention by screening and case finding may prevent lower genital tract infection from ascending to the upper genital tract and causing PID. Chlamydial infection fills the general prerequisites for disease prevention by screening since these infections are highly prevalent, are associated with significant morbidity, and can be diagnosed and treated. Screening based on first-void urine (FVU) testing by nuclear acid amplification techniques, in combination with single dose therapy with azithromycin may have a major impact on the prevention and control of chlamydial infections and PID. However, only one randomized controlled intervention trial has so far demonstrated that screening and treating asymptomatic women with chlamydial infection significantly reduces the incidence of symptomatic PID. Swedish experience suggests that screening for CT is a powerfool tool in the prevention of short-term and long-term complicatios of PID. Chlamydia rates have decreased by 65 75% since mid-80’s. Subsequently, hospitalizations for PID have also decreased, followed by a significant decrease in ectopic pregnancies, especially in young age groups. However, it still remains to be seen whether secondary prevention of PID by on CT screening also decreases the rate of tubal factor infertility, the most costly long-term complication of chlamydial PID. The Furthermore, at least 10 health economic have consistently shown that CT screening programmes are highly cost-effective which is an important message to healthcare policy makers who make decisions of allocation of healthcare resources. Economic evaluations also help to understand the link between PID and the extremely high cost of treatment of tubal factor infertility. In conclusion, development and implementation of effective intervention programs for prevention and control of PID is one of the major challenges to health care systems. Prevention and control of PID will have a major impact on the reproductive health of women worldwide.
RM5.02 OVULATION
INDUCTION
RM5.02.01 NEW PROTOCOIZ IN OVARIAN STIMULATION THERAPY R. Frvdman, Department of Obstetrics and Gynecology, A. B&l&e Hospital, 157, Rue de la Porte de Trivaox, 92140 Clamart Cedex, France The hyperstimulation protocols have increased the amount of drug injected with the association of gonadotropins and GnRH agonist (GnRH-a). The side effects of the long protocol (used in the majority of the cases) are frequent and not always well tolerated by the patient. The multiple blood drawn and controls are affecting the patients life. The rate of multiple