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The implantation of a fertilized embryo into the uterine lining is one of the most critical steps in human reproduction, determining the establishment of a successful pregnancy. While traditionally viewed as a purely physiological process, recent research has uncovered the vital role of the immune system in facilitating and regulating implantation. Far from being a passive barrier, the maternal immune system plays an active and complex role in creating the conditions for successful implantation, recognizing the embryo as semi-foreign tissue, and promoting its acceptance and growth.

THE CHALLENGE OF EMBRYO IMPLANTATION

Implantation presents a unique immunological challenge. The embryo, which is genetically distinct from the mother due to paternal DNA, could potentially be recognized as a foreign entity by the maternal immune system, leading to its rejection. However, for pregnancy to occur, the immune system must strike a delicate balance between protecting the mother from potential infections and allowing the embryo to implant and develop. This balance involves a combination of immune tolerance, modulation, and selective activity of immune cells.

KEY IMMUNE CELLS INVOLVED IN IMPLANTATION

Several immune cells are crucial for the process and they contribute both directly and indirectly to embryo acceptance and growth. Among them, the most prominent are:

— Uterine Natural Killer (uNK) cells. These cells are the most abundant immune cells in the endometrium during early pregnancy. Unlike traditional NK cells that destroy infected or abnormal cells, uNK cells exhibit a modified function. They promote the remodeling of uterine blood vessels and secrete cytokines, which support the establishment of a nurturing environment for the embryo. They are critical for ensuring adequate blood flow to the growing placenta, thereby supporting the embryo’s nourishment.

— Macrophages. These immune cells also play an essential role during the process. They contribute to tissue remodeling by clearing apoptotic cells and debris from the uterine lining. Macrophages produce growth factors, such as vascular endothelial growth factor (VEGF), which are essential for angiogenesis (the formation of new blood vessels) around the implantation site. This angiogenesis is vital for providing oxygen and nutrients to the developing embryo.

— Regulatory T Cells (Tregs). Tregs are responsible for inducing immune tolerance during implantation. They prevent the maternal immune system from attacking the embryo by downregulating the immune response against the paternal antigens present in the fetus. Tregs secrete anti-inflammatory cytokines, such as interleukin-10 (IL-10), that create a localized immune-suppressive environment, which is essential for embryo survival during early pregnancy.

IMMUNE MODULATION AND IMPLANTATION

The immune system undergoes a series of changes during the implantation window, the period during which the endometrium is receptive to the embryo. This is referred to as «immune modulation.»

— Cytokine Networks. Cytokines are small signaling proteins that regulate immune responses. During the process, the uterine environment shifts towards an anti-inflammatory state, primarily orchestrated by cytokines like interleukin-10 (IL-10), transforming growth factor-beta (TGF-β), and leukemia inhibitory factor (LIF). These molecules suppress excessive inflammatory responses that could harm the embryo while promoting tissue remodeling and vascular changes necessary for implantation.

— Balance Between Pro-Inflammatory and Anti-Inflammatory Responses. Successful implantation depends on a finely tuned balance between inflammatory and anti-inflammatory signals. Initially, a mild inflammatory response is required to enable the invasion of the trophoblast (the outer layer of the embryo) into the uterine lining. However, after this initial phase, a shift towards an anti-inflammatory environment is necessary to support continued embryo development and avoid immune rejection.

IMMUNE DYSFUNCTION AND IMPLANTATION FAILURE

Immune dysfunction can significantly contribute to implantation failure, leading to infertility or recurrent pregnancy loss. Inadequate immune tolerance, excessive inflammation, or an insufficient number of regulatory T cells can result in the rejection of the embryo. Conditions such as autoimmune disorders, chronic inflammation, and infections may lead to an overactive immune response, preventing successful implantation.

Additionally, abnormal activity or function of uterine NK cells has been linked to failed implantation. Excessive cytotoxicity or a lack of appropriate cytokine production by these cells can interfere with the establishment of a proper blood supply to the embryo, impairing its development.

THERAPEUTIC APPROACHES TO IMMUNE-RELATED IMPLANTATION ISSUES

Given the critical role of the immune system in implantation, researchers and clinicians are increasingly focusing on immunomodulatory therapies to improve the process outcomes, particularly in women with recurrent implantation failure (RIF) or recurrent pregnancy loss (RPL). Some of the emerging therapies include:

— Immunosuppressive Drugs. Low-dose steroids are sometimes used to reduce excessive immune responses during the early stages of pregnancy.

— Intravenous Immunoglobulin (IVIG).  IVIG therapy may help to modulate abnormal immune responses in women experiencing RIF by promoting a more tolerant immune environment.

— Intralipid Therapy. Intralipid infusions, a mixture of fats and nutrients, have been shown to alter NK cell activity, potentially improving the rates in women with immune-related infertility.

— Treg-Enhancing Strategies.  Research is ongoing to identify treatments that can boost the number and activity of regulatory T cells, helping to induce tolerance to the embryo and supporting successful implantation.

NK CELLS AND FERTILITY

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Especially for the readers of «Doctor», Dr. Petrova explained the factors for achieving a successful pregnancy.

Dr. Petrova, when should a couple seek help from a reproductive medicine specialist?

When a couple has regular unprotected sex and the woman is young (up to the age of 36), but no spontaneous pregnancy occurs within a year and a half, then the couple should see a specialist in reproductive medicine without further delay. When a woman is over 36 years old with no pregnancies to date or younger than this age with a previous pregnancy in attempts for a second child, and no pregnancy has occurred within these six months, she should also see a specialist in reproductive medicine. I specify that a consultation does not mean in all cases to start an in vitro procedure. First, necessary diagnostic tests will be assigned to the couple, and only then will the chances of spontaneous pregnancy or the need for assisted reproduction be assessed.

I guess it’s not just the woman who goes to this examination?

Yes, it’s good to have both. But given the commitment of people, often the ladies arrive alone for the consultation. Of course, they carry all the medical documentation from the preliminary examinations and tests, including the man’s spermograms. In most cases, however, both of them arrive because they are both going to make a baby. There are also people who at this stage do not want a child, but wish to be responsible and know the status of their childbearing possibilities. In these cases, we recommend that the woman, on the third day of her period, have sex, thyroid hormones, and the most important – anti-Müllerian hormone, which are used to determine the ovarian reserve. The first recommendation for the man is to have a spermogram. The requirements before the examination itself are 3 to 5 days of sexual abstinence, no alcohol intake during these days and no antibiotic intake in the last month. These primary studies can give us direction in most cases why pregnancy does not occur.

Do you advise couples to change something in their lifestyle that prevents pregnancy?

In a conversation with the couple, it is established which are the lifestyle factors that prevent pregnancy. It strikes me that after sexual contact very often young women immediately go to the bathroom to wash themselves. And in fact, they have to lie down for a certain period of time. Fertility is also adversely affected by the excessive consumption of carbohydrates and the associated obesity. In reality, a very large percentage of young Bulgarians have this problem. Other factors in this category are the use of alcohol, smoking and drugs.

Do the drastic diets that most women undergo prevent pregnancy?

In Bulgaria, it is always fashionable to follow a diet, but not to learn to eat properly. It is very important that we, the doctors, explain to the woman that it is not good to starve for two weeks before the summer vacation in order to look good in a swimsuit. And he must learn to eat wholesomely. The most important meal is breakfast, because in the morning everyone’s insulin rises, which leads to brain hypoglycemia. However, the Bulgarian woman is used to starving or eating only salads in order to lose weight. With such a diet, the stomach is filled with water and minerals, but the brain is starved. Eating should be varied and balanced enough so that the brain does not make large margins between hyperglycemia and hypoglycemia, but maintains a glycemic plateau that will also regulate appetite during the day. If women learn to eat often, but little, for example four times a day, this guarantees good health and a nice figure. Do you research vitamin and mineral deficiencies in couples? Mandatory. In one consultation, in addition to sex hormone tests, a spermogram and a picture of the fallopian tubes, the levels of vitamin D3 and vitamin B12 are examined. They are extremely important vitamins not only for getting pregnant, but also for the proper development of the fetus during the first three months. In my clinical practice, I have found that women suffer massively from deficiencies of beneficial micronutrients because they do not eat well. There are foods that can be used to maintain normal levels of vitamins and minerals without taking supplements. But if they only eat patties and bosa or are starving, they feel full but haven’t had a full meal. It would be very good for them to learn to eat a slow carbohydrate in the morning. There is nothing wrong, in the tradition of Bulgarian culture, to eat stuffed peppers or sarmi, which contain rice, i.e. carbohydrates, for lunch. For an afternoon snack, it is good to eat a fruit or a few raw almonds. And for dinner, focus on light protein — fish or some meat with a salad. If you eat only salad, there is nothing wrong with adding two boiled eggs and olives. They will ensure completeness and balance of the dinner. It strikes me that in our country people do not drink the necessary amount of water.

When should you start assisted reproduction?

If a woman has bilateral tubal obstruction, her only way to get pregnant is through an in vitro procedure. If everything is fine with the woman — tubal patency, hormonal status, as well as the man’s spermogram is good, and both are young people, then insemination begins. By protocol, up to four are made. If even then pregnancy is not achieved, the case of sterility is treated with an unexplained factor and an in vitro procedure is carried out. The third option is when everything is fine in the woman, while in the man two of the four parameters of the spermogram are reduced. In this case, we have a male factor for sterility, and then we go back to the in vitro procedure.

What is an in vitro procedure nowadays?

The woman goes through hormonal stimulation with injections for about 12 days. These are hormones normal to the human body that the body produces anyway. After that, a puncture of the follicles is performed under complete venous anesthesia and ultrasound control. It is good to remove more than four eggs during the puncture. Follicular fluid is given to embryologists, where they look for cumulus complexes. The male secretes material into a cup, which is processed by embryologists. The most viable spermatozoa are selected and the egg cells are fertilized under a microscope, under high optical magnification. The injected eggs are placed in an incubator for several days. Between the third and fifth day after the puncture, the successfully fertilized and dividing egg (embryo) is placed in the woman’s uterine cavity. This is what we call embryo transfer, which is a painless manipulation. The last and most difficult stage is the 12-14 day wait for a blood test and, accordingly, whether pregnancy has been achieved. People need to understand that the human body is a whole and that every system and function is important in achieving pregnancy. It is important whether or not there is a vitamin deficiency, the genetics of the woman and the man, the gynecological status. Also the immunological status, how the metabolism works, what is the amount of fat in the body. With all this in mind and proper preparation done, we can expect success from the in vitro procedure. The procedure itself will not solve the problem if the future parents have not prepared their bodies. The human organism is a wonderful machine that works without fail and as long as we have been told when we have taken care of its health.

The concept of the «implantation window» is pivotal in reproductive biology and fertility treatments. This period refers to the optimal time frame within a menstrual cycle when the endometrium (the lining of the uterus) is receptive to an embryo, enabling successful implantation and subsequent pregnancy. Understanding this window is essential for individuals and couples trying to conceive, as well as for medical professionals assisting in fertility treatments.

THE TIMING OF THE IMPLANTATION WINDOW

The implantation window typically occurs between days 19 and 21 of a regular 28-day menstrual cycle. This period is contingent on the precise synchronization between the embryo’s development and the endometrium’s readiness. Ovulation usually occurs around day 14, and the fertilized egg (now a blastocyst) travels through the fallopian tube to the uterus over the next 5 to 6 days. For implantation to be successful, the endometrium must be in a receptive state when the blastocyst arrives.

BIOLOGICAL MECHANISMS

The transformation of the endometrium into a receptive state is orchestrated by hormonal signals, primarily estrogen and progesterone. After ovulation, the corpus luteum (the remnant of the ovarian follicle) secretes progesterone, which induces a series of changes in the endometrial lining. These changes include increased blood flow, secretion of nutrients, and modifications in cellular structure, collectively referred to as endometrial receptivity. Specific biomarkers, such as the expression of proteins like integrins and mucins, signal that the endometrium is prepared to interact with the embryo.

CLINICAL SIGNIFICANCE

The concept of the implantation window has profound implications for fertility treatments such as in vitro fertilization (IVF). In IVF procedures, the timing of embryo transfer is meticulously planned to coincide with the recipient’s implantation window. Advances in reproductive medicine have led to the development of tests that assess endometrial receptivity, such as the Endometrial Receptivity Array (ERA). This test analyzes gene expression in the endometrium to pinpoint the exact timing of the implantation window, enhancing the chances of successful implantation and pregnancy.

FACTORS AFFECTING THE IMPLANTATION WINDOW

Several factors can influence the timing and quality of the implantation window. Hormonal imbalances, such as those seen in polycystic ovary syndrome (PCOS) or luteal phase defects, can disrupt the endometrial receptivity. Additionally, conditions like endometriosis or uterine fibroids can alter the uterine environment, making implantation more challenging. Lifestyle factors, including stress, diet, and exposure to toxins, also play a role in endometrial health and receptivity.

The implantation window is a critical phase in the journey to conception, representing a brief period when the endometrium is optimally prepared to receive an embryo. A thorough understanding of this window, coupled with advances in medical technology, can significantly improve the outcomes of fertility treatments. As research continues to uncover the intricate details of endometrial receptivity, the prospects for individuals and couples seeking to conceive will undoubtedly become brighter.

IN VITRO AND RECURRENT IMPLANTATION FAILURE: WHAT DO YOU NEED TO KNOW

Vaccination is one of the most significant medical advances in human history, responsible for eradicating or greatly reducing the spread of many infectious diseases.

The decision to vaccinate a child is key not only to their own health, but also to that of their loved ones and the community. Although there are arguments on both sides, the evidence overwhelmingly supports vaccination as a safe and important public health practice.

WHY VACCINATE OUR CHILDREN?

In the first place is the protection of personal health. Vaccines protect children from potentially serious and life-threatening diseases such as measles, hepatitis, tuberculosis and many others. These diseases, although rare in countries with high vaccination rates, can cause serious complications, including brain damage and death. Vaccinating children ensures that they are largely protected against these dangers, giving parents peace of mind.

Vaccinating your child also contributes to herd immunity, which occurs when a significant portion of the population is immune to a disease, thereby reducing its spread. This is especially important to protect those who cannot be vaccinated due to public order. reasons, such as infants, pregnant women, or immunocompromised individuals. Herd immunity thus protects the most vulnerable members of society and can prevent epidemics.

Vaccinating children also has significant benefits for the economy. It reduces health care costs by preventing illnesses that would require expensive medical treatments and hospitalizations. It also reduces the burden on parents who would otherwise be away from work to care for sick children.

Avoiding the development of epidemics through vaccination reduces the strain on the health system. We all remember how during the Covid-19 pandemic it was almost impossible to provide hospital treatment for all who needed it.

WHY ARE SOME PARENTS AGAINST VACCINATION?

Arguments against vaccination are largely based on concerns about personal freedom. Some parents believe that they should have the right to make medical decisions for their children without the intervention of health care institutions. Others distrust pharmaceutical companies or government agencies, believing that the benefits of vaccines are overstated and that the potential risks are downplayed.

DEALING WITH VACCINE HESITATION

Despite the enormous benefits, hesitancy about vaccines persists, fueled by misinformation and concerns about the safety of the preparations. Therefore, we advise you to be extremely careful with the selection of your sources of information. There are many online forums and pages that spread «anti-vax» theories that are not supported by any scientific evidence.

If you have any doubts about a certain vaccine, seek advice from a trusted pediatrician. If necessary, ask for a second or even a third opinion. Each patient is unique, sometimes there really are contraindications to vaccination, but these cases are extremely rare and such a decision should be made only with the approval of a medical specialist who is perfectly familiar with the child’s health condition.

While it is essential to respect individual choices and consider concerns with empathy, the public health consequences of not vaccinating are profound. Refusal to vaccinate not only endangers the child, but also their family and society, undermining collective immunity and potentially leading to outbreaks of preventable diseases.

Iron deficiency anemia is a common condition worldwide, especially among women of childbearing age. When combined with pregnancy, the consequences become even more significant.

Iron plays a key role in the production of hemoglobin, the protein in red blood cells responsible for transporting oxygen throughout the body. During pregnancy, iron needs increase significantly to support fetal growth and development. In addition, blood volume increases during pregnancy, which necessitates the production of more erythrocytes. When iron stores are insufficient, this process is disrupted and this leads to iron deficiency anemia.

CAUSES

Several factors contribute to the development of iron deficiency anemia during pregnancy. These include insufficient dietary iron intake, increased iron requirements due to the growing fetus, and poor absorption of dietary iron. Women who have had heavy menstrual bleeding before pregnancy are at a higher risk of developing anemia.

SYMPTOMS

Symptoms of this condition can range from mild to severe and may include fatigue, weakness, pale skin, shortness of breath, dizziness, and a rapid heart rate. These symptoms often occur in healthy pregnant women. Your doctor’s task is to assess whether you may be anemic in order to prevent possible complications.

Pregnant women with iron-deficiency anemia are at higher risk of complications such as preterm birth (before 37 years), low birth weight, and postpartum hemorrhage.

PREVENTION AND TREATMENT

Prenatal vitamins are routinely prescribed to pregnant women and usually contain enough iron to prevent anemia. However, you should not forget to consume iron-rich foods such as red meat, chicken, fish, beans, lentils, green leafy vegetables and fortified cereals. The absorption of iron from plant sources is higher when combined with foods rich in vitamin C, for example citrus, tomatoes or peppers.

In more severe cases, a balanced diet and vitamins may not be enough. Then additional iron medications can be prescribed in the form of tablets or intravenous infusions.

Not skipping your yearly check-ups, as well as your prenatal appointments help your medical provider diagnose and treat iron deficiency anemia early, which can significantly improve your general health and reduce the risk of complications during pregnancy.

Dr. Dobrinka Petrova: To make dreams come true

New Life Invitro Centre helps people with reproductive problems to become parents

Between 15 and 20% of Bulgarians suffer reproductive problems. New Life Invitro Centre helps both women and men to understand the underlying reason, to treat it adequately and to become parents. The manager of the clinic, Dr Dobrinka Petrova, shares more about the challenge to help create new life.

-Reproductive medicine is a huge responsibility. How does the New Life Invitro Centre meet these high expectations?

-We, at New Life, understand that the creation of new life is a crucial moment for everyone. We aim at the highest standards in reproductive medicine in order to provide our patients with the best chances for success.

The clinic is equipped with modern technologies and has an experienced team of professionals who work with care and precision. Our approach towards treatment is personalized, focusing on each patient’s individual needs. Our goal is to offer the most competent and empathic support while at the same time maintaining high ethical standards and safety of the procedures.

-The physician’s professionalism or the top technologies — what is the most important factor for successful results?

-The successful results from reproductive medicine are an exciting harmony between the team’s professionalism and high technologies. We, at New Life, believe that the two components are entwined and equally important for successful results.

The team’s role is crucial for the diagnosis, planning and execution of treatment strategies. The experience and specialisation of physicians and embryologists create the foundation for the individual and personalised approach towards each patient.

The technological innovations and high technologies offer the tools and opportunities that help for the correct diagnosis and effective treatment. The modern methods of artificial fertilizations and molecular diagnosis improve the chances for successful fertilizations.

For 10 years now we have followed the Israeli practice, as these specialists are masters of modern medicine. We are the first, and so far only, clinic in Bulgaria that implemented know-how from Israel and successfully applied it — as evident from our incredibly high results in the field of in vitro treatment and infertility treatment.

-New Life also partners with international experts in reproductive medicine. Tell us more about your partnership with them?

-Our partnerships with foreign experts make a crucial part of our mission to help our patients in achieving their reproductive goals. Our partnerships allow us to exchange experience, to learn from the best practices and to implement the latest innovations in the field of reproductive medicine. This cooperation not only adds to our own knowledge and skills, but also allows us to offer to our patients the most advanced and effective treatment methods.

SOURCE:

VAGABOND

Before starting an in vitro procedure, both partners undergo a series of fertility and general health tests. These tests not only ensure the safety and effectiveness of the treatment, but also provide valuable insight into potential challenges and strategies to optimize success.

SEROLOGICAL TESTS

The first type of tests that are done are the blood ones for HIV, Hepatitis B, Hepatitis C and Syphilis. These are the most common serious transmissible diseases (transmitted from person to person), which is why the directives on cells and tissues of the European Union, as well as the Bulgarian legislation, require that all in vitro patients be tested for them. A positive result does not always require termination of the procedure. According to the Bulgarian law, the procedure can continue if «the treatment facility has equipment and a validated procedure for processing and separate storage» of the infected biological material.

Blood tests for HIV, Hepatitis B, Hepatitis C and Syphilis should be done NO sooner than 3 months before the day of the procedure (ovarian follicle puncture). If they are older than three months, they are no longer valid.

In the presence of risk factors (e.g. travel to countries with an increased incidence of malaria, cytomegalovirus, etc.), additional blood tests are required.

MICROBIOLOGICAL TESTS

Both the woman and the man undergo a microbiological examination — of vaginal discharge and, respectively, of semen. The test shows whether these secretions contain microorganisms (e.g. bacteria, fungi) and what types. In men, it is mandatory to do urine test for chlamydia. The presence of certain species requires antibiotic/antimycotic treatment before the procedure. Microbiological tests of both partners should be done NO EARLIER than 30 days before the puncture.

HORMONES

Hormonal testing is absolutely essential in evaluating your fertility and determining the next steps in your treatment. They include:

• Follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2) — are tested on day 3-5 of the menstrual cycle.
• Anti-Müllerian hormone — gives important information about the ovarian reserve.
• Prolactin (PRL). It is examined 4 hours after waking up. 2-3 days before the test, there should be no sexual contact and breast stimulation, because this can lead to false positive results. Stress and certain medications also affect the results.

ADDITIONAL TESTS

Depending on your medical history, you will be recommended additional tests, including:

• Thyroid function test (TSH, fT3, fT4, TAT, MAT);
• Oral glucose tolerance test. Its goal is the early detection of insulin resistance and diabetes. If you are already diagnosed with any of these diseases it is necessary that they are well controlled before starting IVF.
• Screening for antiphospholipid syndrome;
• Genetic testing
• Vitamin B12.

WHICH TESTS ARE REQUIRED FOR MEN?

As a first step, you will be required to do is a semen analysis. It is absolutely mandatory because it can diagnose or rule out male factor for infertility. The reproductive medicine specialist can also order additional tests — for example, testosterone.

To obtain the most accurate results, always adhere to the necessary preparation for a certain test. If you have questions or uncertainties, do not hesitate to contact your medical provider.

АНТИМЮЛЕРОВ ХОРМОН

Controlled ovarian hyperstimulation (COH) involves the administration of exogenous hormones to stimulate the ovaries to produce multiple mature follicles simultaneously. Apart from providing more mature eggs, the other purpose of COH is to prevent premature spontaneous ovulation, ensuring a successful follicular puncture.

COH is conducted on the basis of established protocols. The medications used can be tablets or injections that you can administer yourself. Depending on overall health, ovarian reserve, age and many other factors, the most suitable protocol will be selected for you.

As soon as you start taking fertility drugs, your OBGYN will start monitoring the growth and development of your follicles — a procedure called folliculometry. This involves frequent visits to the clinic, so it is important to choose a place to which you have easy and convenient transportation.

OVARIAN RESERVE AND COH

Ovarian reserve is among the most important factors determining the success of the in vitro procedure. It has been found that controlled ovarian hyperstimulation (COH) may be less successful in women with diminished ovarian reserve for several reasons, including:

Decreased response to stimulation: Women with diminished ovarian reserve may respond less well to administered medications due to fewer follicles present in the ovaries.

Ovarian reserve is closely related to egg quality. Women with diminished ovarian reserve may have lower quality eggs, which can affect fertilization rates and embryo development. Poor egg quality can lead to more frequent implantation failures and a higher risk of miscarriage.

In women with diminished ovarian reserve, cancellation of COH could happen more often. One of the reasons is an unsatisfactory response to the medications used. The other reason is the predisposition to ovarian hyperstimulation syndrome. Although it sounds scary, such a decision is reached extremely rarely and only in the presence of absolute indications.

WHAT ARE THE TREATMENT OPTIONS?

The IVF protocols used today have been developed to be successful in the treatment of infertility in women with a variety of problems. Your obstetrician-gynecologist will decide which protocol is most suitable for you depending on your individual case.

In cases of diminished ovarian reserve, you may be offered the use of donor eggs or embryos as an alternative. This bypasses the limitations associated with ovarian reserve and can significantly improve the chances of achieving a successful in vitro pregnancy.

Ovarian reserve plays a critical role in predicting IVF outcomes. It affects the body’s response to ovarian hyperstimulation, the quality of eggs and embryos produced, and ultimately the likelihood of achieving a successful pregnancy. That’s why reproductive medicine specialists pay so much attention to it when creating a treatment plan for couples with infertility.

PREMATURE OVARIAN FAILURE