Total antioxidant capacity-Relevance, methods and clinical implications.

Oxidative stress is pre-empted by an adequate level of antioxidants, which scavenge oxidants when they are produced in excess by different sources, including leukocytes and immature spermatozoa. Enzymatic antioxidants, such as superoxide dismutase, catalase and glutathione peroxidase, and several non-enzymatic antioxidants (proteins, vitamins and minerals), working as oxidant scavengers and cofactors of enzymatic antioxidants have been identified in seminal plasma. The total antioxidant capacity (TAC) is a diagnostic test that can be utilised in the male infertility workup. TAC measures the amount of total antioxidants in seminal plasma. Therefore, it provides an assessment of the reductive potential in seminal plasma. Several studies have investigated the diagnostic application of TAC in various andrology conditions. There is substantial evidence in the literature to show that infertile patients have lower seminal TAC in comparison with fertile men. Moreover, there is a positive correlation between TAC and seminal parameters, such as sperm concentration, motility and morphology. Evaluation of TAC together with reactive oxygen species (ROS) and sperm DNA fragmentation index (DFI) may be beneficial in the diagnosis of male infertility.

Assessing online price transparency of sperm cryopreservation across the United States.

Although the lack of information on the costs and pricing of healthcare services prevails throughout the medical industry, empiric observations have demonstrated that pricing information is even more obscured in the sperm cryopreservation market. Thus, the objectives of our study are to assess and compare online price transparency and the price of sperm cryopreservation across various healthcare settings in the United States. This study examined online pricing published by facilities that have an active registration to store spermatozoa with the Food and Drug Administration. Less than one-fifth of registered facilities display any pricing information online. Price transparency also varies among census regions and facility types. Nationally, the median initial bank fee and annual price of storage are $350 and $385 respectively. Although there were no differences in the initial fee by facility type and census region, the annual price of storing spermatozoa is highest in the Northeast, which could be attributed to laboratory techniques, demographic patterns or insurance coverage. Guidelines from professional societies or different legislation and regulatory requirements across different US states can increase price transparency, which can promote consumer decision-making and decrease the barrier for men seeking fertility preservation.

An online educational model in andrology for student training in the art of scientific writing in the COVID-19 pandemic.

In 2020, the COVID-19 pandemic led to the suspension of the annual Summer Internship at the American Center for Reproductive Medicine (ACRM). To transit it into an online format, an inaugural 6-week 2020 ACRM Online Mentorship Program was developed focusing on five core pillars of andrology research: scientific writing, scientific methodology, plagiarism understanding, soft skills development and mentee basic andrology knowledge. This study aims to determine mentee developmental outcomes based on student surveys and discuss these within the context of the relevant teaching and learning methodology. The mentorship was structured around scientific writing projects established by the team using a student-centred approach, with one-on-one expert mentorship through weekly formative assessments. Furthermore, weekly online meetings were conducted, including expert lectures, formative assessments and social engagement. Data were collected through final assessments and mentee surveys on mentorship outcomes. Results show that mentees (n = 28) reported a significant (p < .0001) improvement in all criteria related to the five core pillars. These results illustrate that the aims of the online mentorship program were achieved through a unique and adaptive online educational model and that our model has demonstrated its effectiveness as an innovative structured educational experience through the COVID-19 crisis.

CRYOPRESERVATION OF PARATHYROID TISSUE: A WHITE PAPER ON ESTABLISHING A LOCAL SERVICE.

Objective: Preservation of parathyroid function is one of the primary tenets of endocrine surgery. For patients with thyroid disease, an inadvertently compromised parathyroid gland is routinely autotransplanted into the neck at the time of surgery. By contrast, for patients with parathyroid disease secondary to hyperplasia, the timing of auto-transplantation needs to be further considered in order to balance the risks between persistent disease and permanent hypocalcemia. Cryopreservation preserves cellular function and permits the storage of parathyroid tissue for potential re-implantation at a later date in patients who develop hypoparathyroidism. Methods: In this paper, we review the process of cryopreservation, with particular emphasis on the regulatory issues involved in establishing a local service, tissue processing, billing and reimbursements, outcome (functionality), and complications. Results: A detailed description of the technique as performed at our institution is described and illustrated. Conclusion: Cryopreservation affords surgical insurance against the disastrous sequelae of permanent hypoparathyroidism. Our techniques are easy to adopt with only a modest initial investment of time and money, particularly for institutions that already cryopreserve other tissue types. Abbreviations: PTH = parathyroid hormone; RMPI = Roswell Park Memorial Institute; RPMI-SSS = RPMI-serum substitute supplement.

Diagnostic application of oxidation-reduction potential assay for measurement of oxidative stress: clinical utility in male factor infertility.

The objectives of this study were to: (i) describe a protocol measuring the oxidation-reduction potential (ORP) by MiOXSYS System as an alternative method of seminal oxidative stress (OS) testing; (ii) establish a reference value for static ORP (sORP) to distinguish between controls and male factor infertility patients; (iii) evaluate intra-observer and inter-observer reliability; and (iv) examine association of sORP with sperm parameters predictive of male factor infertility. Elevated levels of sORP were seen in infertile patients (6.22 ± 1.10 mV/106 sperm/ml) compared with controls (1.59 ± 0.29 mV/106 sperm/ml) (P = 0.004). A sORP cut-off value 1.36 mV/106 sperm/ml identified normal semen and abnormal semen quality with a sensitivity 69.6%, specificity 83.1%, positive predictive value 85.3% and negative predictive value 65.9%. The test demonstrated strong intra-observer (CV 8.39%) and inter-observer reliability (correlations >0.97). Higher sORP levels were associated with poor sperm parameters across the fertility status of subjects. Negative correlations were noted with sperm parameters (concentration, total sperm count, motility and morphology) indicating these male infertility parameters are related to OS. In conclusion, the introduction of ORP as a novel clinical test for assessment of OS will help clinicians to better diagnose and manage male factor infertility patients.

Correlation of head-up tilt table test time interval with future risk of recurrent syncope.

BACKGROUND: Head-up tilt table test (HUTT) is widely used for the investigation of syncope and presyncope. Time required for positive response has a probable relationship to the sensitivity of neural reflex mechanism underlying syncope. METHODS: We evaluated patients with history of syncope. Group A included patients with recurrent syncope defined as two or more episodes of syncope and group B included those with one episode of syncope. Time required for the test to become positive in both the groups was analyzed. Patients with positive HUTT were followed for 1 year. RESULTS: Of 80 patients, 68 eligible study patients were divided into group A (32.35%) and group B (67.65%). HUTT was positive in 41 patients (positivity rate  =  60.29%). Positivity rate was 100% in group A and 41.3% in group B. Median time interval for positive response in groups A and B were 12.5 and 30.0 minutes, respectively. An inverse association was found between recurrent syncope and time interval for positive response (R  =  - 0.282, P  =  0.002). Time interval of less than 19.5 minutes for positive response had 94.5% sensitivity and 97.89% specificity for recurrent syncope. On follow-up, positive association was found between time interval for positive response less than 19.5 minutes and future recurrence of syncope (odds ratio  =  22.75, 95% confidence interval  =  4.37-118.34, P  =  0.000). CONCLUSION: HUTT time interval of less than 19.5 minutes for positive response predicted future recurrence of syncope. Hence, it may serve as an important predictor of future recurrence of syncope.

3D Xplane Echocardiographic Technique for Validation of Mitral Leaflet Separation to Assess Severity of Mitral Stenosis.

BACKGROUND: Determining the severity of mitral stenosis (MS) is important for both prognostic and therapeutic implications. Mitral valve area (MVA) calculation techniques have more limitations. Mitral leaflet separation (MLS) is a precise and operator friendly alternative to planimetry. In contrast to previous researchers, we have used a novel 3D Xplane technique to validate MLS for assessing the severity of MS. 3D Xplane is superior for validation of MLS due to simultaneous real time acquisition of MLS in parasternal long-axis view and corresponding MVA by planimetry in parsternal short-axis view. METHODS: It was a prospective observational single center study. A total of 174 patients with MS were evaluated for MVA estimation by various echocardiographic modalities. Maximum leaflet separation and corresponding planimetered MVA were measured using novel 3D Xplane technique. RESULTS: With 3D Xplane technique, there was strong positive correlation between planimetered MVA and MLS (R = 0.925, P < 0.001), irrespective of coexisting MR (R = 0.886, P < 0.001) or AF (R = 0.912, P < 0.001). Receiver operating characteristic curves of MLS demonstrated AUC for mild and severe MS to be 0.966 and 0.995, respectively. MLS less than 8.62 mm predicted severe MS with 95.5% sensitivity and 94.7% specificity and MLS more than 12.23 mm predicted mild MS with 93.2% sensitivity and 91.4% specificity. CONCLUSION: In our study, a strong correlation between planimetered MVA and MLS was found using 3D Xplane technique. 3D Xplane thus validates and standardizes MLS by excluding errors due to temporal and spatial variations which are important limitations of 2D echocardiography.

Palmar arch anatomy: Ajmer Working Group classification.

INTRODUCTION: Forearm arteries are frequently used as workhorse site for cardiac catheterization, bypass grafting and haemodialysis access. There is paucity of data on palmar circulation in live human being and only cadaveric data are available till date. We, therefore, made an attempt to look at the various patterns of sufficient or insufficient palmar arch circulation and various anomalies of forearm arteries, to discuss their clinical implications. METHODS AND RESULTS: We obtained the forearm and hand arteriograms of patients (n = 302) through radial (n = 200) and ulnar routes (n = 102). Modified Allen's test was normal in all of our patients. On the basis of predetermined parameters angiograms were analysed and findings were divided into three groups. These three groups were further classified as type A, type B, type C superficial palmar arch. CONCLUSION: We concluded that type A superficial palmar arch is most suitable for providing adequate collateral circulation in case of harvesting of forearm vessel, whereas type C superficial palmar arch appears to be highly susceptible for digital ischemia in case of radial or ulnar artery occlusion. Modified Allen's test alone is not justifiable for documenting good collateral circulation and it should be supplemented by other tests to document good collateral circulation before proceeding to any radical procedure.

Feasibility of ulnar artery for cardiac catheterization: AJmer ULnar ARtery (AJULAR) catheterization study.

BACKGROUND: The ulnar artery is rarely selected for cardiac catheterization despite the expanding use of the transradial access (TRA). We tried to compare default transulnar access (TUA) with TRA in terms of feasibility and safety. MATERIALS AND METHODS: This was a prospective, open label, single center, observational study. We analyzed a total of 410 patients with normal Allen's test, who were then scheduled for coronary angiography through TUA with ad hoc PCI if necessary. Procedures were performed by a single operator who had an adequate transradial experience (≥150 transradial coronary procedures per year) but not trained in transulnar procedures. We analyzed observed findings with a retrospective cohort of patients undergoing TRA angiography under a previous study done at our center. We also performed selective ulnar arteriography of 200 patients, through radial route, to predict the bottlenecks of TUA. OBSERVATIONS: There is no statistically significant difference among the number of attempts made till the successful puncture, the total procedure time and the total fluoroscopy time for either radial or ulnar access angiography by an experienced operator (P > 0.05). However, the time taken in arterial access is statistically significant in the initial learning curve for the same (P < 0.05). On the contrary, the arterial access time, the total procedure time, and the total fluoroscopy time, all are statistically significant for the inexperienced operator (P < 0.05). There is a negligible incidence of nonmaneuverable anatomic obstruction in the real-world scenario in TUA, and so fear of the same should not impede the use of this route. Vasospasm in the use of this route is also not different from the radial route, with the experience of the operator. CONCLUSIONS: For an experienced operator, TUA is a safe and also an effective alternative to TRA in terms of feasibility and safety.

Comparative evaluation of effectiveness of three versus four mini-implants for simultaneous intrusion and retraction of maxillary anterior teeth: A 3D FEM study.

OBJECTIVE: To evaluate and compare the displacement pattern of maxillary anterior teeth in the sagittal and vertical planes and evaluate the stress distribution in pdl, bone, teeth of the maxillary anterior region, and around the mini-implants during simultaneous en-masse retraction and intrusion using two, three, and four mini-implants combinations. METHODS: A three-dimensional FEM model of maxillary teeth and periodontal ligament housed in the alveolar bone with extracted first premolarswasgenerated. The models were broadly divided into three groups according to the number of mini-implants. Mini-implants were placed bilaterally between the second premolar and molar in group I, and along with bilateral implants, an additional mid-implant was placed between the central incisors as in group II, whereas in group III, anterior mini-implants were placed in between lateral incisors and canine bilaterally. RESULTS: The two mini-implant model showed the maximum amount of retraction in the sagittal plane followed by three and four mini-implant models. In the vertical plane, all six anterior teeth showed intrusion only in the four mini-implant model. The stress in cortical bone, cancellous bone, PDL, around the mini-implants, and in lateral incisor was maximum in the three mini-implant model, followed by four mini-implants with the least stress in the two mini-implant model. CONCLUSION: The four mini-implant model is better than the three and two mini-implants model as there is a more even distribution of force in the four mini-implants model as compared to the three mini-implants model.

A case series of emphysematous pyelonephritis in COVID-positive patients.

Emphysematous pyelonephritis (EPN) is a rare infectious disease affecting the renal and perirenal tissues, wherein gas formation occurs in the renal parenchyma, perinephric tissues, or collecting systems. It can be life threatening with mortality rates upto 60%. Here, we report a case series of EPN during the COVID pandemic with COVID test-positive patients who were diagnosed based on clinical signs, symptoms, and CT scans. One patient was conservatively managed, one underwent nephrectomy, and the others were treated with percutaneous drainage and pigtailing. Despite being critically ill, all the patients recovered uneventfully. Owning to the rarity of the lesion and variations in the clinical spectrum, the diagnosis of EPN is challenging. EPN requires early diagnosis and prompt management. The interventional technique depends on the clinical status of the patient and the severity of the lesion. Although the threshold of intervention is low in normal clinical practice, in covid patients, we tried to manage patients conservatively and intervened only when unavoidable.

The Pattern and Impact of Hospital-Acquired Infections and Its Outlook in India.

Nosocomial infections form one of the most challenging tasks to deal with in a hospital setting. The burden of hospital-acquired infections (HAI) significantly affects the patient's cost of medical treatment and seriously impacts the economy of a developing country like India. Haphazard antibiotic use for the treatment of these infections has led to the development of resistance among the microbes, and factors that complicate microbial eradication further worsen the scenario. A large percentage of the HAI are preventable by simply following up various protocols which when supported by judicious antibiotic use can declutter the severity of the problem. Organized infection control measures, trained hospital staff, and continuous surveillance of HAI in healthcare settings will help deal with nosocomial infections. Although the ability to deal with HAI in a patient might determine his survival after acquiring a nosocomial infection, prevention remains the best option at all times. Lowering down the burden of nosocomial infections is of utmost importance since it contributes significantly to the overall resource utilization of the hospital and the country. Implementing the use of nanoparticles and nanotechnology in delivering target-specific drugs might be helpful in preventing antibiotic resistance. Taking into account reports of nosocomial infection patterns in various centres of India, the seriousness and consequences of HAI are uncovered in this article.

Incidence, Risk Factors, and Outcomes of Acute Kidney Injury in Preterm Neonates Hospitalized in the Neonatology Unit, North India: A Single-center Experience.

Acute kidney injury (AKI) is common in premature newborns and is associated with high mortality. It is unclear which risk factors lead to AKI in these neonates. We aimed to determine the incidence, risk factors, and outcomes of AKI in preterm neonates in the neonatal intensive care unit (NICU). They were screened and staged for AKI as per the amended neonatal criteria of Kidney Disease Improving Global Outcomes and followed up until discharge or death. Serum creatinine levels and urine output were measured. The incidence of AKI was 18.5% (37/200 neonates). The majority developed non-oliguric AKI. The risk factors significantly associated with AKI in neonates were the presence of sepsis, birth asphyxia, shock, respiratory distress syndrome, and hypothermia. The majority of neonates with AKI had a birthweight <1500 g and a gestational age of <32 weeks and had a higher risk of mortality, in contrast to than those without AKI. Mortality and NICU stay were significantly higher among those with Stage 3 AKI compared with Stage 2 and Stage 1 AKI. To prevent AKI and reduce the burden of high mortality in premature neonates, it is essential to prevent sepsis, birth asphyxia, and respiratory distress syndrome, as well as to detect shock and patent ductus arteriosus as early as possible. There is a need for good antenatal care to reduce the burden of prematurity.

The effects of oxidative stress on female reproduction: a review.

Oxidative stress (OS), a state characterized by an imbalance between pro-oxidant molecules including reactive oxygen and nitrogen species, and antioxidant defenses, has been identified to play a key role in the pathogenesis of subfertility in both males and females. The adverse effects of OS on sperm quality and functions have been well documented. In females, on the other hand, the impact of OS on oocytes and reproductive functions remains unclear. This imbalance between pro-oxidants and antioxidants can lead to a number of reproductive diseases such as endometriosis, polycystic ovary syndrome (PCOS), and unexplained infertility. Pregnancy complications such as spontaneous abortion, recurrent pregnancy loss, and preeclampsia, can also develop in response to OS. Studies have shown that extremes of body weight and lifestyle factors such as cigarette smoking, alcohol use, and recreational drug use can promote excess free radical production, which could affect fertility. Exposures to environmental pollutants are of increasing concern, as they too have been found to trigger oxidative states, possibly contributing to female infertility. This article will review the currently available literature on the roles of reactive species and OS in both normal and abnormal reproductive physiological processes. Antioxidant supplementation may be effective in controlling the production of ROS and continues to be explored as a potential strategy to overcome reproductive disorders associated with infertility. However, investigations conducted to date have been through animal or in vitro studies, which have produced largely conflicting results. The impact of OS on assisted reproductive techniques (ART) will be addressed, in addition to the possible benefits of antioxidant supplementation of ART culture media to increase the likelihood for ART success. Future randomized controlled clinical trials on humans are necessary to elucidate the precise mechanisms through which OS affects female reproductive abilities, and will facilitate further explorations of the possible benefits of antioxidants to treat infertility.

A Review on Glaucoma Drainage Devices and its Complications.

Glaucoma is one of the leading causes of blindness in the world. It is an ocular disorder that may have multiple etiologies and which can present as optic neuropathy and increased intraocular pressure (IOP), but in some cases like normotensive glaucoma, the IOP may remain normal. Its gradually progressive nature makes it important for early diagnosis; although the loss of vision is slow, lost vision can't be restored. Glaucoma drainage implant surgeries are an increasingly popular option in recent days in complicated cases of glaucoma where the previous trabeculectomy had failed and medical management was not responsive. Glaucoma drainage devices (GDD) are of various designs; they are implanted according to the patient condition and surgeons' preference. There are complications after the implantation of a GDD like hypotony, endophthalmitis, migration of the plate, extrusion, erosion of the mucous membrane, etc. In the market, there are various drainage devices present, but some of them are frequently used and popular. In this article, we will discuss some most commonly used GDDs and their complications. Among these, four are the most popular: Molteno, Baerveldt, Krupin, and Ahmed. The failure rate of the GDD is low. In many studies, it has been noted that only half of the GDD remains functional after five years. Therefore, further studies are still being conducted to refine the biomaterials, techniques, and shape of the GDD. The technique of surgery is also very much crucial in the success of GDD implantation. The glaucoma type is an essential factor in deciding the treatment, and the outcome of the surgery also depends on it.

Role of Cytocentrifugation Combined with Nuclear Fast Picroindigocarmine Staining in Detecting Cryptozoospermia in Men Diagnosed with Azoospermia.

PURPOSE: Azoospermia is defined as the absence of spermatozoa in the pellet of a centrifuged semen sample. In fact, when a basic semen analysis fails to detect sperm in the ejaculate, there is still the possibility of detecting rare sperm after centrifugation of the sample and examination of the pellet. In this study, we assessed the role of Cytospin centrifugation in combination with the nuclear fast picroindigocarmine (NF-PIC) staining in identifying sperm in azoospermic samples. MATERIALS AND METHODS: Semen samples of 251 men diagnosed as having azoospermia after standard examination were further analyzed by Cytospin centrifugation in combination with NF-PIC staining. RESULTS: Sperm were detected in 60 men (23.9%), thus changing their diagnosis to cryptozoospermia. CONCLUSIONS: By identifying sperm in the semen of men who were thought to have total azoospermia, the Cytospin NF-PIC test can alter the diagnosis and further treatment of these men.

Standardized Laboratory Procedures, Quality Control and Quality Assurance Are Key Requirements for Accurate Semen Analysis in the Evaluation of Infertile Male.

Semen analysis is a basic test for evaluating male fertility potential, as it plays an essential role in driving the future management and treatment of infertility in couples. Manual semen analysis includes the evaluation of both macroscopic and microscopic parameters, whereas automated semen analysis is conducted through a computer-aided sperm analysis system and can include additional parameters that are not evaluated by manual analysis. Both quality control (QC) and quality assurance (QA) are important to ensure reproducible results for semen analysis, and represent fundamental checks and balances of all stages (pre-analytical, analytical, and post-analytical) of semen analysis. To ensure accuracy and precision, the laboratory technicians' performance should be evaluated biannually. This narrative review aims to describe standardized laboratory procedures for an accurate assessment of semen parameters that incorporate both QC and QA practices.

An expert commentary on essential equipment, supplies and culture media in the assisted reproductive technology laboratory.

The assisted reproductive technology (ART) laboratory is a complex system designed to sustain the fertilization, survival, and culture of the preimplantation embryo to the blastocyst stage. ART outcomes depend on numerous factors, among which are the equipment, supplies and culture media used. The number and type of incubators also may affect ART results. While large incubators may be more suitable for media equilibration, bench-top incubators may provide better embryo culture conditions in separate or smaller chambers and may be coupled with time-lapse systems that allow continuous embryo monitoring. Microscopes are essential for observation, assessment, and micromanipulation. Workstations provide a controlled environment for gamete and embryo handling and their quantity should be adjusted according to the number of ART cycles treated in order to provide a steady and efficient workflow. Continuous maintenance, quality control and monitoring of equipment are essential and quality control devices such as the thermometer, and pH-meter are necessary to maintain optimal culture conditions. Tracking, appropriate delivery and storage conditions, and quality control of all consumables are recommended so that adequate quantity and quality are available for use. Embryo culture media have evolved: preimplantation embryos are cultured either by sequential media or single-step media that can be used for interrupted or uninterrupted culture. There is currently no sufficient evidence that any individual commercially-available culture system is better than others in terms of embryo viability. In this review, we aim to analyze the various parameters that should be taken into account when choosing the essential equipment, consumables and culture media systems that will create optimal culture conditions and provide the most effective patient treatment.

Optimizing embryological aspects of oocyte retrieval, oocyte denudation, and embryo loading for transfer.

Oocyte retrieval, oocyte denudation, and embryo transfer are crucial processes during assisted reproduction technology (ART). Air quality in the ART laboratory, temperature, pH of the media used and the time interval between oocyte retrieval and insemination are all critical factors. Anesthesia is required for oocyte retrieval, however, evidence regarding the potential impact of different methods (general anesthesia, conscious sedation, and local anesthesia) on the clinical outcomes is unclear. The optimal timing of oocyte denudation following retrieval has not been established. Regarding the mechanical denudation process, there is a lack of evidence to demonstrate the safest minimum inner diameter of denuding pipettes used to complete the removal of granulosa cells surrounding the oocytes. During embryo transfer, many clinics worldwide flush the catheter before embryo loading, in an attempt to potentially rinse off any toxic agents; however, there is insufficient evidence to show that flushing the embryo transfer catheter before loading increases the success of ART outcome. Considering the serious gaps in knowledge in ART practice, the aim of this review is to provide an updated overview of the current knowledge regarding the various steps and techniques involved in oocyte retrieval, oocyte denudation, and embryo loading for transfer.

Oocyte quality and embryo selection strategies: a review for the embryologists, by the embryologists.

With the advance of assisted reproduction techniques, and the trend towards blastocyst culture and single embryo transfer, gamete and embryo assessment have gained greater importance in ART treatment. Embryo quality depends mainly on gamete quality and culture conditions. Oocyte maturity identification is necessary in order to plan fertilization timing. Mature oocytes at the metaphase II stage show a higher fertilization rate compared to immature oocytes. Morphology assessment is a critical yet challenging task that may serve as a good prognostic tool for future development and implantation potential if done effectively. Various grading systems have been suggested to assess embryos at pronuclear, cleavage, and blastocyst stages. By identifying the embryo with the highest implantation potential, it is possible to reduce the number of embryos transferred without compromising the chances of a successful pregnancy. Apart from the conventional morphology assessment, there are several invasive or non-invasive methods for embryo selection such as preimplantation genetic testing, morphokinetics, proteomics, metabolomics, oxygen consumption, and measurement of oxidative stress in culture medium. Morphokinetics is a method based on time-lapse technology and continuous monitoring of embryos. In this review, we aimed to describe and compare the most effective and widely used methods for gamete and embryo assessment as well as embryo selection.