Showing papers in "Best Practice & Research in Clinical Obstetrics & Gynaecology in 2007"

Psychological impact of infertility.

Abstract: The inability to conceive children is experienced as a stressful situation by individuals and couples all around the world. The consequences of infertility are manifold and can include societal repercussions and personal suffering. Advances in assisted reproductive technologies, such as IVF, can offer hope to many couples where treatment is available, although barriers exist in terms of medical coverage and affordability. The medicalization of infertility has unwittingly led to a disregard for the emotional responses that couples experience, which include distress, loss of control, stigmatization, and a disruption in the developmental trajectory of adulthood. Evidence is emerging of an association between stress of fertility treatment and patient drop-out and pregnancy rates. Fortunately, psychological interventions, especially those emphasizing stress management and coping-skills training, have been shown to have beneficial effects for infertility patients. Further research is needed to understand the association between distress and fertility outcome, as well as effective psychosocial interventions.

Asymptomatic bacterial vaginosis and intermediate flora as risk factors for adverse pregnancy outcome

Abstract: We updated a previously published meta-analysis to evaluate bacterial vaginosis (BV) and intermediate vaginal flora as risk factors for adverse pregnancy outcome. Selection criteria were original, published, English-language reports of cohort studies or control groups of clinical trials including women <37 weeks' gestation with intact amniotic membranes. All women had to be screened for BV, diagnosed either by clinical criteria or by criteria based on Gram-stain findings. Outcomes were preterm delivery, late miscarriages, maternal or neonatal infections, and perinatal mortality. Fourteen new studies with results for 10,286 patients were included, so that results for 30,518 patients in 32 studies were available for this meta-analysis. BV more than doubled the risk of preterm delivery in asymptomatic patients (OR: 2.16, 95% CI: 1.56-3.00) and in patients with symptoms of preterm labor (OR: 2.38, 95% CI: 1.02-5.58). BV also significantly increased the risk of late miscarriages (OR: 6.32, 95% CI: 3.65-10.94) and maternal infection (OR: 2.53, 95% CI 1.26-5.08) in asymptomatic patients. No significant results were calculated for the outcomes of neonatal infection or perinatal mortality. Also, intermediate vaginal flora was not significantly associated with any outcome included. The results of this meta-analysis confirm that BV is a risk factor for preterm delivery and maternal infectious morbidity and a strong risk factor for late miscarriage.

Psychological morbidity following miscarriage

Abstract: Emerging evidence has suggested that miscarriage could be associated with significant and possibly enduring psychological consequences. As many as 50% of miscarrying women suffer some form of psychological morbidity in the weeks and months after loss. About 40% of miscarrying women were found to be suffering from symptoms of grief shortly after miscarriage, and pathological grief can follow. Elevated anxiety and depressive symptoms are common, and major depressive disorder has been reported in 10–50% after miscarriage. Psychological symptoms could persist for 6 months to 1 year after miscarriage. The underlying risk factors predisposing a miscarrying woman to psychological morbidity include a history of psychiatric illness, childlessness, lack of social support or poor marital adjustment, prior pregnancy loss, and ambivalence toward the fetus. In addition, care-givers should be aware of the possible moderating effect of clinical practices such as surgical treatment and ultrasound findings on the psychological impact on a miscarrying woman. Unlike in postpartum depression, simple and effective screening measures of psychological morbidity in the context of miscarriage have not been well established. While studies have highlighted that psychological follow-up was highly desired by miscarrying women, and that psychological intervention was potentially beneficial, there is a substantial lack of randomized controlled intervention studies in this area.

Definition and classification of abnormal vaginal flora

Abstract: Studying the vaginal microflora is not only fascinating, with many discoveries to be made, it is also a very practical way to help women get rid of bothersome and sometimes dangerous infections. Gram-stained vaginal preparations, Pap smears, specific cultures, and nucleic acid detection techniques can be used to diagnose the constituents of the vaginal flora, but in trained hands office-based microscopy of a fresh vaginal smear, preferably using a ×400 magnification phase-contrast microscope, allows almost every diagnosis and combination of diagnoses imaginable. In this chapter I will address the pros and cons of the tools that are in use to study vaginal flora, and discuss the different types of bacterial flora and the difficulties encountered in reaching the correct diagnosis of pathological conditions. The ‘intermediate flora' is addressed separately, and a new entity – ‘aerobic vaginitis' – is discussed. Future research should focus on the interaction between infecting microorganisms and host defence mechanisms, as both together generate the pathogenicity of these conditions.

Psychological aspects of perinatal loss

Abstract: After perinatal loss, parents experience painful grief. Fathers and mothers show the same pattern of symptoms, but generally mothers' distress is more intense. Grief should be sympathetically acknowledged by health professionals, and parents should be reassured that their feelings are normal and that recovery may take many months. Intense depression lasting more than 6 months may require psychological treatment. There is some evidence that delaying conception for a year may allow an easier pregnancy psychologically. The common practice of encouraging parents to have contact with a dead infant is not evidence-based and may have adverse effects, including inducing symptoms of post-traumatic stress disorder. A protocol of postnatal follow-up allows parents to get appropriate information about the loss, including possible problems and timing of another pregnancy. The subsequent pregnancy is stressful, and health professionals should recognize that parents may suffer significant anxiety.

Embryo culture medium: which is the best?

Abstract: With the growing move in in-vitro fertilization (IVF) clinics to transfer fewer embryos to women, there is an increasing reliance on the IVF laboratory to maximize embryo viability. Subsequently, there is justified scrutiny on the culture system and the media used to sustain the human embryo in vitro. The transfer of fewer embryos to patients also creates an increased dependence on the ability to cryopreserve embryos successfully. Therefore, in addition to the ability of a culture system to produce a single top-quality embryo for transfer, it is also necessary to enhance the cryotolerance of sibling embryos so that they can survive freezing or vitrification. Therefore, when examining which culture media is the best, it is prudent to not only examine the ability of a culture system to produce a pregnancy with the one or two highest-grade embryos, but also to determine how many embryos from the entire cohort (both fresh and frozen embryos) are capable of producing a live birth. Additionally, research on animal models has demonstrated that stress, and the resultant adaptation to conditions during pre-implantation stages, can affect pregnancy loss and fetal growth. It is therefore important to understand the role of each medium component and to identify possible sources of cellular stress to the embryo that will ultimately affect the function and viability of the conceptus.

Infection and the role of inflammation in preterm premature rupture of the membranes.

Abstract: Spontaneous preterm birth, caused by preterm labor (contractions before 37 weeks' gestation) or preterm premature rupture of the membranes (pPROM) (membrane rupture before the onset of labor) or both account for ∼80% of preterm deliveries. pPROM is associated with 30–40% of preterm deliveries and the incidence of pPROM has increased in the past decade. The question we address here is why some women experience pPROM and some experience preterm labor with no rupture of membranes (ROM) when the etiologic factors associated with both these pathologic complications are the same. To date, studies had evaluated the markers that are commonly elevated in both preterm labor and pPROM. A better understanding of the similarities and differences between the biomolecular pathways leading to each of these conditions may open new avenues for research and intervention. In this chapter we review the role of inflammatory mediators (cytokines and matrix metalloproteinases), and programmed cell death (apoptosis) in preterm labor with no ROM and preterm labor with pPROM to delineate the differences in pathways between the two conditions.

Bio-psycho-socio-cultural perspectives on menopause

Abstract: The menopause transition is a bio-psycho-socio-cultural process. Recent prospective studies highlight the complex ways in which lifestyle and cultural factors influence women's experience of the menopause. For the majority of well women, the menopause is a relatively neutral event, although women living in Western countries in general report more symptoms than those from non-Western cultures. Hot flushes and night sweats are the main symptoms of the menopause, and while the exact physiological causes are unknown, the role of norepinephrine is implicated in lowering the threshold for flushing. Psychological factors - including anxiety, stress, thoughts and beliefs and self-esteem - influence the experience of hot flushes, and a cognitive behavioural model is described which is compatible with a bio-psycho-socio-cultural perspective. Relaxation and cognitive behavioural approaches appear to be acceptable to women, and there is some evidence for their efficacy, but larger controlled trials are needed.

Postnatal depression: an update

Abstract: Apart from causing emotional suffering, postnatal depression strains marriage, undermines the mother's confidence, impairs her social functioning and quality of life, and in serious cases contributes to infant abuses, infanticides and suicidal behaviour. Recent studies also show that postnatal depression adversely affects emotional, behavioural and cognitive development of the newborn. In addition, there is growing awareness that depression can occur during pregnancy, and antenatal depression can adversely affect obstetric and neonatal outcomes. Antenatal depressive symptoms are also the strongest predictor of postnatal depression. This paper reviews the epidemiology, clinical presentation, risk factors, prevention and treatment of perinatal depression. The latest development in research and practice related to this condition are also highlighted.

Asymptomatic bacteriuria in pregnancy.

Abstract: Screening for asymptomatic bacteriuria is a standard of obstetrical care and is included in most antenatal guidelines. There is good evidence that treatment of asymptomatic bacteriuria will decrease the incidence of pyelonephritis. All pregnant women should be screened for asymptomatic bacteriuria, and there are no new data that would indicate otherwise. Antibiotic treatment of asymptomatic bacteriuria is associated with a decrease in the incidence of preterm delivery or low birth weight, but the methodological quality of the studies means any conclusion about the strength of this association needs to be drawn cautiously. A better understanding of the mechanism by which treatment of asymptomatic bacteriuria could prevent preterm delivery is needed. While several rapid screening tests have been evaluated, none perform adequately to replace urine culture for detecting asymptomatic bacteriuria. Until there are data from well-designed trials that establish the optimal duration of therapy for asymptomatic bacteriuria, standard treatment courses are recommended.

Perinatal group B streptococcal disease

Abstract: Group B streptococcus (GBS) is the leading cause of neonatal sepsis and meningitis. Despite optimal treatment of GBS-infected neonates it is associated with significant morbidity and mortality, and prevention strategies are required. As disease occurs rapidly, and is often evident at birth or within 12 hours of birth, antibiotics must be given prior to delivery, and when administered early enough, and at the correct doses, they will prevent the majority of early-onset GBS cases. Prevention is therefore in the hands of obstetricians and midwives. Women at higher risk of delivering infected infants can be identified through one of two strategies: the presence of one or more clinical risk factors, or the presence of GBS on lower vaginal/rectal swabs obtained late in pregnancy. Decisions on which strategy to use will depend on a number of factors. A swab-based approach appears to have higher efficacy but is likely to lead to more antibiotic exposure.

The role of mycoplasmas in pregnancy outcome.

Abstract: Mycoplasma hominis was isolated from a Bartholin's gland abscess 70 years ago, and ureaplasmas were isolated from the genital tract about 20 years later. Subsequently, reports incriminating mycoplasmas in the known adverse outcomes of pregnancy have been legion. Without doubt these genital mycoplasmas are able to invoke an inflammatory response and take part in the cascade of events that culminates in preterm birth. Their role in this and other conditions is becoming clearer, but controversy remains due mainly to investigators often ignoring bacterial vaginosis, with its complex of bacteria, and failing to disentangle their role from that of the genital mycoplasmas. This is a theme that will be highlighted in this chapter, in which an attempt is made to indicate what is indisputable (surprisingly little) and what is not, and where further research would be helpful.

Periodontal disease and pregnancy outcomes: exposure, risk and intervention.

Abstract: Despite the many advances in medicine, the rate of preterm birth has not significantly decreased in the United States over the past several decades. In fact, the rate rose in 2003 to more than 12% of all births in the United States. This equates to over half a million premature births in the United States alone. Consequently, the identification of risk factors for preterm birth which are amenable to intervention would have far-reaching and long-lasting effects. There is emerging evidence of a relationship between periodontal health and adverse pregnancy outcomes, particularly preterm birth/preterm low-birth-weight infants. Therefore this chapter explores the putative association between periodontal disease and infant prematurity, as well as the results of intervention studies which treated periodontal disease in order to reduce the incidence of prematurity. Of 31 published studies, 22 show a positive association between premature birth and periodontal disease. Ongoing studies are addressing the efficacy of periodontal treatment for decreasing the incidence of infant prematurity.

Prevention of birth asphyxia: responding appropriately to cardiotocograph (CTG) traces.

Abstract: Birth asphyxia is a broad term that refers to intrapartum asphyxia sufficient to cause neurological damage in some newborns and, rarely, intrapartum or neonatal death. Cerebral palsy and long-term neurological complications such as learning difficulties and motor impairments may be due to causes other than birth asphyxia. Several intrapartum events may cause asphyxia (i.e. hypoxia and metabolic acidosis) leading to the likelihood of neurological injury. The cardiotocograph (CTG) is a screening tool that is used to assess fetal well-being during labour and to identify the possibility of asphyxia. Abnormality of the CTG, sometimes severe enough to be described as a pathological trace, is commonly termed 'fetal distress', although many fetuses with such traces may not have hypoxia and metabolic acidosis. In current practice, the events are appropriately termed 'pathological CTG trace' or 'acidotic pH' rather than 'fetal distress'. Accurate interpretation of CTG is essential, and it is important to recognize a fetus that shows a pathological CTG in labour that may imply possible hypoxia and birth asphyxia. Considering the wider clinical picture in interpreting the CTG, and taking timely and appropriate action based on the findings, may help prevent birth asphyxia.

Psychological aspects of premenstrual syndrome.

Abstract: Premenstrual syndrome (PMS) is a group of psychological and physical symptoms which regularly occur during the luteal phase of the menstrual cycle and resolve by the end of menstruation. The severe and predominantly psychological form of PMS is called premenstrual dysphoric disorder (PMDD). The exact aetiology of PMS is not known. PMS results from ovulation and appears to be caused by the progesterone produced following ovulation in women who have enhanced sensitivity to this progesterone. The increased sensitivity may be due to neurotransmitter (mainly serotonin) dysfunction. The key diagnostic feature is that the symptoms must be absent in the time between the end of menstruation and ovulation. Prospective symptom rating charts are used for this purpose. Treatment is achieved by suppression of ovulation or reducing progesterone sensitivity with selective serotonin re-uptake inhibitors. In this chapter, the authors describe the aetiology, symptoms, diagnosis and evidence-based management of premenstrual syndrome.

Psychological morbidity and female urinary incontinence

Abstract: Female urinary incontinence is a common yet distressing condition. It affects women of all ages, but is especially common in the elderly. Its prevalence ranges from 15 to 55%, depending on age and population studied. Despite the ubiquity of female urinary incontinence, many incontinent women do not voice their suffering, and urinary incontinence has therefore been dubbed 'the silent epidemic'. The physical impact and social isolation associated with urinary incontinence lead to impairment of quality of life and psychological well-being. It is the aim of this review to discuss the epidemiology and psychological impact of urinary incontinence. The recognition and management of incontinence-related psychological morbidity are also explored.

Epidemiology and environmental factors in preterm labour

Abstract: An epidemiological and environmental approach is the appropriate starting point to understanding preterm labour. Although there are multiple aetiologies it seems likely that anthropometric and environmental risk factors in combination with inherent genetic susceptibilities contribute to an increased risk of preterm labour for certain women. Poct 2pulation-based studies identifying risk factors and quantifying outcomes facilitate informed counselling and provide a framework for developing prediction tools. Carefully conducted case-control and cohort studies identify associations that may contribute to an understanding of causation. A combined approach encompassing epidemiology, pathophysiology and clinical research is required to understand the aetiologies, prevention and optimal management of preterm labour. This review focuses on the epidemiology of preterm labour and the role of environmental factors.

Psychosexual function and impact of gynaecological cancer

Abstract: A diagnosis of gynaecological cancer and its treatment are usually associated with many physical and psychological changes, both as a result of the diagnosis itself and of the usual treatments of surgery, radiotherapy and/or several months of chemotherapy. Patients often experience symptoms such as fatigue, abdominal swelling and pain, and suffer from emotional distress and disturbances of their life style. Sexual functioning can also be affected. Often there are physiological difficulties, such as vaginal dryness, together with psychological distress and relationship problems. This chapter discusses the ways in which gynaecological cancer can impact sexual functioning, and presents findings from a research project that was undertaken to begin to understand how sexual functioning can be affected by ovarian cancer. The article also makes recommendations for how health-care professionals can help women to cope better with psychosexual dysfunction following a diagnosis of a gynaecological cancer.

Outcomes of IVF conceptions: are they different?

Abstract: Perinatal outcomes, such as preterm delivery, low birth weight and some obstetric complications, are increased significantly after in-vitro fertilization (IVF) compared with spontaneously conceived pregnancies The degree of difference is greater for singletons than for twins, especially with regard to preterm delivery which is increased two fold in IVF singletons and by 40% in twins It is difficult to obtain accurate outcome information because of unmeasured confounders such as smoking status and fetal reduction It is also unknown whether IVF technologies or patient infertility is the major contributor to adverse outcomes Birth defects are increased, shown in a number of systematic reviews, and there has been a particular interest in imprinting syndromes Epigenetic modifications may play a larger role in IVF outcomes, as yet unidentified There is no apparent increase in adverse outcomes in children up to adolescence, although further studies are needed to examine longer-term risks, including those for cancer

GnRH agonists vs antagonists.

Abstract: Gonadotropin-releasing hormone (GnRH) agonists were introduced in ovarian stimulation for in-vitro fertilization to suppress the premature surge of luteinizing hormone (LH). Although agonist use is accompanied by a series of disadvantages, including hypoestrogenaemia, cyst formation, a requirement for a prolonged period of downregulation, and an increase in follicle-stimulating hormone (FSH) and LH as soon as the agonist is administered, agonists became well accepted in clinical practice as their use was also associated with increased rates of pregnancy. However, the recent development of side-effect-free GnRH antagonists, characterized by an immediate mode of action and a shorter period of administration. Provides clinicians with flexibility in terms of administration, and offers patients a friendlier method of ovarian stimulation. Comparative studies between the two analogues have suggested that the use of antagonists is associated with a shorter duration of FSH stimulation and a decreased incidence of hospital admission due to the occurrence of ovarian hyperstimulation syndrome, while the probability of a live birth does not depend on the type of analogue used.

Donor gametes: anonymous or identified?

Abstract: The practice of gamete donation has, until recently, been shrouded in secrecy. The stigma associated with infertility and, in particular, donor insemination has been the main factor contributing to this secrecy. Over the last 20 years, this secrecy and the anonymity of the gamete donors has been challenged. In the first instance, the challenge came from governments in some countries legislating to abolish donor anonymity. Counsellors, social workers and psychologists advocating for the interests and needs of children and their families, as well as parents who did not wish to keep gamete donation secret from their children, were also instrumental in the change of policies and practice. Those offspring who know that they were conceived as a result of gamete donation are also calling for an end to the secrecy. This chapter reviews the changes that have occurred and which are still occurring, and reviews the research associated with these changes.

National program for depression associated with childbirth: the Australian experience

Abstract: Routine screening was introduced as a joint research/public-health initiative across 43 health services in Australia, funded by beyondblue, the National Australian Depression Initiative. This program included assessing risk factors and prevalence of depression in perinatal women. Other objectives included increasing awareness of the condition, training of relevant staff, and assessing the feasibility of a screening program. Women were screened antenatally and postnatally with a demographic questionnaire and the Edinburgh Postnatal Depression Scale. A subgroup of women and health professionals was surveyed. Over 40,000 women participated directly in the program. Data and issues for specific groups are presented. There was a high level of acceptability to women and health professionals involved. Screening is acceptable and feasible as part of the mental-health management of perinatal women. It needs to be supplemented with information for women and education and support for staff.

Asymptomatic trichomonas and candida colonization and pregnancy outcome.

Abstract: Trichomonas vaginalis is a sexually transmitted surface pathogen of the lower urogenital tract, and may be associated with asymptomatic vaginal colonization or intensely symptomatic vaginitis. In pregnancy it is associated with an increased risk of preterm delivery. However, a randomized trial of treatment of asymptomatic trichomonas colonization in pregnancy showed an increase in the risk of preterm delivery in treated women. The reasons for this paradox are yet to be fully elucidated. Candida species, on the other hand, may be present – usually in the yeast form – in the vaginal flora of up to 40% of healthy pregnant women. Although candidiasis is not usually associated with chorioamnionitis or preterm delivery, there is some emerging evidence to suggest that screening for and eradication of candida during pregnancy may reduce the risk of preterm delivery. This chapter reviews the impact of these common vaginal infections on pregnancy outcome and appraises the recent evidence on the role of treatment during pregnancy.

Cervical cerclage in the prevention of preterm birth.

Abstract: Cervical cerclage has been used in the management of cervical insufficiency for several decades, yet the indications are uncertain and benefits marginal. It remains a controversial intervention. The diagnosis of cervical insufficiency is traditionally based on a history of recurrent second trimester miscarriages, or very preterm delivery whereby the cervix is unable to retain the pregnancy until term. Cervical cerclage has been the subject of many observational and randomised controlled trials. This article reviews the literature regarding the effectiveness of elective or emergency transvaginal cerclage and transabdominal cerclage.

Antenatal infection/inflammation and fetal tissue injury.

Abstract: There is a clear association between antenatal infection/inflammation and preterm labour, with intrauterine infection complicating up to one third of preterm deliveries. In addition to this, there is now accumulating evidence that intrauterine infection and inflammation can lead to the development of a systemic inflammatory response in the fetus and subsequent tissue injury. The fetal inflammatory response is characterized by funisitis, high levels of pro-inflammatory cytokines in the amniotic fluid and cord blood, and systemic immune activation. This review discusses the evidence for this process and focuses on the clinical and experimental data supporting the hypothesis that these inflammatory processes contribute to brain and lung injury in the newborn.

Perimenopause and depression: strength of association, causal mechanisms and treatment recommendations.

Abstract: Perimenopause represents a significant transition in a woman's life. The evidence to support an association between perimenopause and depression is mixed, yet recent prospective studies have provided stronger evidence to support such an association. Interpretation of study data are complicated by methodological issues, such as a lack of standard definition for perimenopause or depression, reducing comparability. A variety of causal factors, including psychological, genetic and physiological, have been implicated in depression during perimenopause, which lends weight to a multifactorial model. Physicians should consider initiating dialogue about menopause and symptom relief at age 40 and screening perimenopausal women for depressive symptoms. Selective serotonin reuptake inhibitors are a first line of treatment for depression, but hormone therapy could be considered for women experiencing menopausal symptoms unless there are contraindications. Future research should focus on establishing temporality and studying these potential relationships among women of different ethnicities.

Religion, infertility and assisted reproductive technology

Abstract: This chapter describes religion in general before discussing the centrality of its concern for family formation. In light of this, the impact of infertility on religious people is considered. Recognizing religion's cautiously positive attitude towards assisted reproductive technology (ART) as a potential ally in the project of family formation and the relief of infertility, two areas that have caused concern for the religions are discussed: perceived threats to marriage and the sanctity of the human embryo. Throughout the chapter, illustrations are drawn from particular religions, including Christianity, Judaism, Islam, Hinduism and Buddhism. There are striking similarities in their concerns and in the range of their responses to ART. Ways in which medical personnel should take into account the religious dimensions of the experience of infertility in their care for patients are suggested.

Outcome following preterm birth

Abstract: Preterm birth currently occurs in approximately 12% of pregnancies and appears to be increasing despite improvements in obstetric care. Improvements in neonatal care have led to increased survival, particularly at extreme prematurity, but survival may be associated with significant morbidity. This may be acute, reflecting the difficulties in supporting an individual in a hostile extrauterine environment to which they should not be exposed, or chronic, reflecting disturbances to fragile, immature body systems. Brain, lungs, intestines and eyes are particularly vulnerable and damage may be severe. For some infants the consequences of this damage may be permanent disability and impairment. Despite this, the limited information currently available suggests that adult outcomes may be comparable with those for infants born at term.

Biochemical and endocrinological preparation for parturition

Abstract: Preterm delivery is a common obstetric problem occurring in about 1 in 10 of all births. Preterm babies have a high risk of morbidity and mortality. Such births account for 75% of all major neonatal problems. At the other end of the spectrum, prolonged pregnancy is also a subject of concern because it too is associated with increased fetal morbidity and mortality. Despite extensive research, the mechanisms that control the length of human pregnancy and signal the onset of labour have not been fully determined. This chapter will discuss basic principles in the biology of parturition and the regulation of contraction-associated proteins including the oxytocin receptor. The major pathways regulating contractions and the transcriptional regulation of the main genes that are known to be involved in the onset of labour and parturition will be examined. Some new potentially therapeutic strategies for the biochemical management of preterm labour will be discussed.

In-vitro maturation of eggs: is it really useful?

Abstract: In in-vitro maturation (IVM), immature oocytes are collected from small antral follicles and allowed to mature in the laboratory before routine in-vitro fertilization or micro-injection. The authors' experience in IVM is based on the treatment of two main groups of patients: women with polycystic ovaries and women with normal ovaries. Patients with polycystic ovarian syndrome have irregular, mostly anovulatory cycles and are at increased risk for ovarian hyperstimulation syndrome because of their higher sensitivity to gonadotropins. Women with normal ovarian function may wish to avoid the side-effects of hormone injections, and therefore IVM has also been offered to couples with tubal, male factor and unexplained infertility. In all these groups of patients, immature oocytes have successfully been matured, fertilized and embryos transferred. Pregnancy rates have been reported to be between 4% and 54%. More than 300 children have been born and follow-up studies have reported no major concerns about the pregnancies, deliveries or health of the babies. There are still many questions concerning IVM. As the factors regulating follicle selection are poorly understood, no specific markers for the optimal time of immature oocyte collection have been defined. Furthermore, basic knowledge on the complex intracellular processes involved in the cytoplasmic maturation of human oocyte is lacking, making the design of optimal culture conditions for maturation difficult. The possible long-term effects of IVM on the health and development of children needs future study.