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PubMed2002

Prognostic value of the clinical and laboratory evaluation in patients with nonmosaic Klinefelter syndrome who are receiving assisted reproductive therapy.

OBJECTIVE: To characterize clinical and laboratory findings in nonmosaic 47,XXY patients that may help to predict spermatogenetic activity in their testicles. DESIGN: Prospective study. SETTING: Assisted reproductive technology program. PATIENT(S): Twenty patients with nonmosaic Klinefelter syndrome who underwent testicular sperm retrieval for IVF. MAIN OUTCOME MEASURE(S): The correlation between basal FSH, LH and testosterone levels, mean testicular volume, and results of the hCG test and presence or absence of sperm after testicular sperm extraction (TESE). RESULT(S): Sperm was found in nine patients (45%). The mean testicular volume was 7.8 +/- 2.5 mL in men with sperm after TESE and 5.6 +/- 1.2 mL in those without sperm after TESE; corresponding testosterone levels were 3.5 +/- 1.2 ng/mL and 1.7 +/- 0.8 ng/mL. Serum levels of FSH and LH did not significantly differ between groups. After the hCG test, the mean serum testosterone level was 16.0 +/- 6.3 ng/mL in men with sperm after TESE and 6.7 +/- 5.6 ng/mL in those without sperm. CONCLUSION(S): Testicular volume, testosterone levels, and results of the hCG test are important predictive factors of spermatogenesis in patients with nonmosaic Klinefelter syndrome.

Adult↗
PubMed2002

Development to blastocyst is impaired when intracytoplasmic sperm injection is performed with abnormal sperm from infertile mice harboring a mutation in the protein phosphatase 1cgamma gene.

Idiopathic azoospermia, characterized by abnormal spermatogenesis, is commonly treated by performing intracytoplasmic sperm injection (ICSI) with sperm retrieved from testicular biopsies. However, no controlled experiments have been performed using an animal model to assess the efficacy or safety of the procedure. We have performed ICSI with testicular sperm obtained in a similar manner from testes of male mice homozygous for a null mutation in the protein phosphatase 1cgamma gene (PP1cgamma) or those of their wild-type littermates. PP1cgamma mutant testicular sperm are less resistant to sonication than are wild-type sperm and display a range of morphological abnormalities, similar to those reported for testicular sperm from idiopathic azoospermic men. PP1cgamma mutant sperm are unable to support development to the blastocyst stage, resulting in arrested development either before or just after compaction. A comparison of testicular and epididymal sperm from wild-type males revealed that the epididymal sperm caused embryos to fragment at an elevated rate. These results suggest that ICSI with any kind of testicular sperm carries an increased risk of embryo fragmentation and that abnormal testicular sperm has an added risk of embryo wastage at later preimplantation stages.

Animals↗
PubMedDate not supplied

Probability of sperm recovery in non-obstructive azoospermic patients presenting with testes volume less than 10 ml/FSH level exceeding 20 mIU/ml.

We evaluated the sperm recovery rate in non-obstructive azoospermia (NOA) patients presenting with bilateral testicular atrophy characterized by testes volume of less than 10ml and FSH levels exceeding 20 mIU/ml (group NOA-1), and compared the results to those NOA cases displaying unilateral testis volume exceeding 10 ml or FSH levels less than 20 mIU/ml (group NOA-2). Sperm retrieval was conducted in 261 azoospermic patients from April 1995 to December 2002. Forty-six NOA-1 and 37 NOA-2 individuals underwent microdissection TESE or 3-4 standard biopsies. Sperm recovery was achieved in 11 (24%) and 12 (32%) cases in NOA-1 and NOA-2, respectively. All couples received ICSI. Four clinical pregnancies (36.3%) in NOA-1 and two (17%) in NOA-2 resulted. Five subsequent healthy deliveries were obtained. NOA patients presenting with bilateral severe atrophic testes volume and obviously elevated FSH levels exhibited approximately 24% probability of sperm recovery. On the other hand, NOA characterized by testicular atrophy or elevated FSH levels displayed probability of approximately 32%. Differences in sperm recovery were not evident between NOA-1 and NOA-2. No successful pre-operative predictors of sperm recovery were identified.

Adult↗
PubMed2002

Assessment of DNA fragmentation of spermatozoa that were surgically retrieved from men with obstructive azoospermia.

OBJECTIVE: To determine the degree of DNA fragmentation in spermatozoa of men with obstructive azoospermia or anejaculation compared with that of ejaculated spermatozoa from fertile donors. DESIGN: Observational study. SETTING; University Medical Center St. Radboud, Nijmegen. The Netherlands. PATIENT(S): Forty-one patients with obstructive azoospermia or anejaculation and 10 fertile donors. MAIN OUTCOME MEASURE(S): Sperm samples were obtained surgically from the epididymis or testis of men with azoospermia or anejeculation and by ejaculation in fertile patients. DNA fragmentation was analyzed in the total sample and in a motile fraction that was isolated as in routine ICSI procedures. DNA breaks were measured by using the TdT-mediated dUTP nick-end labeling assay. RESULT(S): A higher percentage of cells with DNA breaks was found in men with obstructive azoospermia or anejaculation compared with donors (mean, 18.9% vs. 6.2%). A significant lower degree of DNA fragmentation was observed in the motile fraction from patients compared with donors (0.4% vs. 0.6%). CONCLUSION(S): High percentages of cells with DNA damage were found in sperm samples from men with obstructive azoospermia or anejaculation, but a very low frequency of damage to the DNA was observed in the motile fraction. In an ICSI setting, the use of motile sperm retrieved from epididymis or testis of men with obstructive azoospermia does not seem to pose a higher genetic risk to the progeny than does use of motile ejaculated sperm.

DNA Fragmentation↗
PubMed2000

No-scalpel vasal sperm aspiration and in vitro fertilization for the treatment of anejaculation.

OBJECTIVES: To evaluate the utility of no-scalpel vasal sperm aspiration and in vitro fertilization for the treatment of male infertility due to anejaculation. METHODS: Vasal aspiration was performed using a no-scalpel technique, and the sperm were used for conventional in vitro fertilization in 1 patient and intracytoplasmic sperm injection in 6 patients. RESULTS: The average total sperm count was 6 x 10(6), with the motility between 20% and 95%. No complications have been observed to date. A high fertilization rate (74.6%) and pregnancy rate (5 of 7) was achieved with subsequent intracytoplasmic sperm injection or in vitro fertilization. CONCLUSIONS: No-scalpel vasal sperm aspiration is a simple, effective alternative to sperm retrieval, especially for anejaculatory males.

Adult↗
PubMed2003

[Results of in vitro fertilization in Dutch subfertile couples in Ghent, Belgium, 1993-2002: no patient group with decreased prognosis].

OBJECTIVE: To describe the results of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) of Dutch patients who came to Ghent University Hospital (GHU), Belgium, for treatment, during the period 1993-2002. DESIGN: Retrospective data collection, description and analysis. METHOD: Dutch and Belgian patients were compared with respect to: age, indication for treatment, duration of infertility, stimulation protocol, number of ampoules of gonadotrophins, duration of stimulation, number of follicles, number of oocytes, number of fertilized oocytes, number of transferred embryos, quality of transferred embryos, number of frozen embryos, pregnancy, outcome of pregnancy, duration of pregnancy, sex and weight of the child or children. RESULTS: In the period 1993-2002 (10 years), 6099 treatment cycles were carried out in Belgian and 4801 in Dutch couples in the GHU. The duration of infertility was longer for the Dutch than for the Belgian couples and the Dutch women were on average three years older than the Belgian. The male infertility rate and proportion of ICSI cycles was higher for the Dutch than for the Belgian couples. In 17% of the cycles surgically retrieved sperm was used because of azoospermia. The numbers of follicles, oocytes retrieved, as well as the number of fertilized oocytes were all larger for the Belgian than for the Dutch patients. An equal number of embryos was transferred in both groups (2.24). The ongoing pregnancy rate per cycle was a little lower for the Dutch (23.2%) than for the Belgian couples (25.3%). The percentage multiple pregnancies was not different (27.8% for the Belgian and 25.1% for the Dutch patients). The Dutch singleton babies were born six days later than the Belgian, but the children differed in no other way. From 1996 to 2000 the ongoing pregnancy rate was 23.8% per first cycle for Dutch patients treated in the UHG, as compared to 19.4% in the Netherlands. CONCLUSION: Dutch patients treated in the GHU differed from Belgian patients in that they had a longer duration of infertility and a longer history of previously failed treatments. Although the pregnancy results were slightly lower for Dutch than for Belgian patients, this does not seem to be clinically very relevant, especially not in view of the overall Dutch national results.

Belgium↗
PubMed2005

[Diagnosis of male infertility].

A detailed medical history and clinical examination are important steps in the diagnosis of male infertility. Tests include semen analysis according to WHO standards, laboratory tests (mainly determination of follicle-stimulating hormone) and scrotal sonography. Invasive diagnostic procedures, such as testicular biopsy or investigation of seminal pathway obstruction, are generally combined with therapeutic sperm retrieval for cryopreservation or microsurgical refertilization.

Follicle Stimulating Hormone↗
PubMed2005

Pregnancies and births resulting from in vitro matured oocytes fertilized with testicular spermatozoa.

PURPOSE: In vitro maturation (IVM) of immature human oocytes is an attractive option for the treatment of infertility. Similarly, intracytoplasmic sperm injection (ICSI) followed by testicular fine needle aspiration (TEFNA) is an important treatment for primarily male-factor infertility. This report highlights the combination of these two advanced assisted reproduction techniques, namely IVM and fertilization with TEFNA-retrieved spermatozoa by ICSI to overcome both of male and female infertility problems. METHODS: Before immature oocyte retrieval (IOR), gonadotropin stimulation was given for 3 or 5 days. Following IVM, and mature oocytes were inseminated by ICSI followed by TEFNA. RESULTS: Four couples with five completed treatment cycles were performed, and total of 36 immature oocytes were retrieved. Following 36 to 48 h of culture, 32 (88.89%, 32/36) oocytes became mature. The mature oocytes were inseminated with TEFNA-retrieved sperm, and 18 (56.25%, 18/32) oocytes were fertilized normally following ICSI. Eleven embryos were transferred in five cycles and two pregnancies and two singleton births were achieved in two patients. CONCLUSIONS: This result demonstrates that the successful pregnancies and live births can be established from embryos produced from in vitro matured oocytes that fertilized with testicular sperm.

Adult↗
PubMed1995

Semen extenders to salvage ejaculate in a retrograde ejaculate environment: a potential use in spinal cord-injured men.

Infertility is a well-recognized complication in spinal cord-injured men. Vibratory stimulation and electroejaculation are being used to overcome the inability to ejaculate, but poor sperm quality remains a significant problem. Retrograde ejaculation is known to occur with both sperm retrieval techniques, and may contribute to the poor semen quality. In addition, the amount of retrograde ejaculate produced is generally of sufficient quantity worthy of salvaging. We investigated the effectiveness of various semen media in maintaining the viability of healthy sperm placed in a retrograde ejaculate environment. Six semen extenders, media used to process spermatozoa for artificial insemination and to maintain viability during cryopreservation, were studied. We found that Ham's F-10 with 3.5gm % bovine serum albumin seems to be an effective medium to maintain sperm viability over a wide range of urine concentrations (up to 60% to 80% urine), and potentially, may be useful by its infusion into the bladder before vibratory or electrostimulation to enhance the recovery of greater numbers of viable sperm from the retrograde environment.

Cell Survival↗
PubMed2002

The diagnosis and treatment of the azoospermic patient in the age of intracytoplasmic sperm injection.

Microsurgical reconstruction remains the treatment of choice for men with reconstructable obstructive azoospermia. Sperm retrieval techniques performed with ICSI are highly effective for men in whom reconstruction is not feasible. In men with nonobstructive azoospermia, the optimization of spermatogenesis with hormonal therapy and, when appropriate, microsurgical varicocelectomy can result in the appearance of adequate sperm in the ejaculate for ICSI. In men with persistent nonobstructive azoospermia, TESE with ICSI has provided encouraging results. Caution must be used when this ART is applied in couples in whom genetic aberrations are detected given certain inheritance of these anomalies, as the genetic consequences of this procedure have not been thoroughly elucidated. Just as the possibility of ICSI was thought to be inconceivable several decades ago, the advent of future sentinel discoveries will present the possibility for realization of achievements that now seem incredulous.

Humans↗
PubMed2002

Characterization of the fertility of Kit haplodeficient male mice.

The role of the proto-oncogene Kit expression during gonadal development, then in differentiated spermatogonia has been thoroughly established. The present study was designed to investigate the consequences of a partial defect in Kit gene expression on sperm fertilizing ability, using Kit haplodeficient mice (kitW-lacZ/+). Same inbred mice (kit+/+) were used as controls. Epididymal sperm characteristics and in vivo fertility were assessed, then in vitro-fertilization experiments were carried out for mice of both genotypes. Epididymal sperm count was drastically reduced, and sperm motility was also decreased in kitW-lacZ/+ compared with kit+/+ males. Both in vivo or in vitro fertility were greatly reduced in kitW-lacZ/+ compared with kit+/+ males. By contrast, the fertility of kitW-lacZ/+ females was apparently unaffected. Additionally, a higher number of spermatozoa with undetected acrosomal contents was revealed by fluorescein isothiocyanate-labelled Pisum sativum agglutinin acrosomal staining after epididymal sperm retrieval in kitW-lacZ/+ mice, whereas no difference was observed after induction of acrosomal reaction in mice of either genotype. Ultra-structural data confirmed the higher frequency of abnormal acrosome in spermatozoa of kitW-lacZ/+ mice. Thus, sperm production is impaired in Kit haplodeficient mice both on a quantitative and a qualitative basis. Finally, we show that one single copy of Kit gene is not sufficient to maintain genuine fertility in male mice.

Animals↗
PubMed2002

Retrospective multicentre study on mechanical and enzymatic preparation of fresh and cryopreserved testicular biopsies.

BACKGROUND: Isolation of sperm suitable for ICSI from fresh or frozen-thawed testicular sperm extraction (TESE) can be facilitated by mechanical or enzymatic processing of the samples. METHODS: A retrospective multicentre study was initiated to compare these two approaches. Eleven German centres provided data on their TESE cycles performed during the period 1996/1997. Quality of retrieved sperm, fertilization rates of injected oocytes, embryo quality, resulting pregnancy rates and evolution of pregnancies were evaluated. RESULTS: The percentage of cycles with at least some motile sperm available for injection was higher after mechanical preparation. Independent of the preparation method, fertilization rates were higher for motile compared with immotile sperm or elongated spermatids in all groups and in general higher for cryopreserved versus fresh samples. Embryo quality was significantly better after injection of motile sperm for all treatments and in particular after enzymatic versus mechanical processing of biopsies. Pregnancy rates were identical for embryos derived from sperm prepared mechanically or enzymatically from fresh or cryopreserved testicular samples. The abortion rate (32/172, 18.6%) and the rate of multiple implantations (32/140, 22.9%) were not different from results reported in the literature for ICSI using ejaculated sperm. CONCLUSION: In this retrospective multicentre study, no unequivocal advantage of one over the other preparation method could be identified in 839 ICSI cycles using testicular sperm from 549 patients.

Abortion, Spontaneous↗
PubMed1997

Extended sperm preparation: an alternative to testicular sperm extraction in non-obstructive azoospermia.

Testicular sperm retrieval for the treatment of non-obstructive azoospermia requires the execution of an invasive procedure, with all its possible attending complications and subsequent long-term effects. This study suggests a new non-invasive approach for collection of spermatozoa in these patients: the extended sperm preparation (ESP). ESP consists of conducting a thorough microscopic search through many droplets of ejaculate sediment. ESP was performed for 49 patients; in 17 patients (35%), spermatozoa were found and subsequently used in intracytoplasmic sperm injection (ICSI). Of these preparations, five yielded fewer motile spermatozoa than the number of corresponding oocytes available, and in one patient only non-motile spermatozoa were recovered. The remaining 32 ESP-negative patients underwent testicular sperm extraction (TESE) from testicular biopsy. Spermatozoa were found in 16 of 32 biopsies (50%) and subsequently used in ICSI. Fertilization and cleavage rates were comparable in both ESP and TESE groups, yielding four clinical pregnancies in each group (27 and 29% respectively). Embryo morphology was defined as excellent in significantly more cases in the ESP group than the TESE group, and implantation rate appeared somewhat higher in the ESP group (16%) than the TESE group (13%). The ESP technique yields results similar to TESE, and can be applied in cases of non-obstructive azoospermia as a prerequisite modality enabling us to avoid testicular biopsy in 35% of cases.

Adult↗
PubMed2006

Intracytoplasmic sperm injection by testicular sperm in patients with aspermia or azoospermia after cancer treatment.

The aim of this retrospective study was to evaluate the efficiency of testicular biopsy and intracytoplasmic sperm injection (ICSI) in patients with aspermia or non-obstructive azoospermia (NOA) after cancer treatment. From 1996 to 2003, 30 men with a history of cancer, affected by aspermia or NOA and without sperm cryopreserved before cytotoxic treatment underwent testicular sperm extraction (TESE). In these men, clinical, hormonal and histological characteristics were compared; 13 underwent 39 TESE-ICSI cycles using frozen-thawed testicular spermatozoa (TESE-ICSI group). In the same period, 31 ICSI cycles were performed in 20 men with aspermia or NOA using ejaculated sperm frozen before cancer treatment (ejaculated sperm-ICSI group). Fertilization, blastocyst development, pregnancy and miscarriage rates were compared between the groups. Testicular volume, serum follicle-stimulating hormone level and Johnsen score indicated complete although reduced spermatogenesis in men with aspermia and abnormal spermatogenesis in men with NOA. After TESE, sperm retrieval was positive in 92% of men with aspermia and 58% of men with NOA. In TESE-ICSI patients with NOA a significantly lower proportion of embryos developed to the blastocyst stage than in patients with aspermia and in those after ICSI with frozen-thawed ejaculated sperm (23% vs. 43% and 47%, p = 0.03 and p < 0.01 respectively). In all groups the miscarriage rates were high; in patients with aspermia and NOA, characterized by increased age, the miscarriage rate tended to be higher in spite of similar female age and female indications of infertility. In patients affected by aspermia or NOA after cancer treatment and without sperm cryopreserved before treatment, TESE-ICSI using testicular sperm provide a chance to father a child.

Cell Separation↗
PubMed2004

One versus two inseminations per cycle in intrauterine insemination with sperm from patients' husbands: a systematic review of the literature.

OBJECTIVE: To study the efficacy of performing two inseminations per cycle in IUI with husband's sperm compared with one insemination per cycle. DESIGN: Meta-analysis. SETTING: Randomized and prospective trials comparing two inseminations vs. one insemination per cycle in IUI with husband's sperm, retrieved by MEDLINE and Cochrane Library searches (1966-2001) and a manual search of the abstracts of the European Society of Human Reproduction and Embryology and American Society for Reproductive Medicine annual meetings (1990-2001). PATIENT(S): A total of 865 patients underwent 1156 cycles of IUI with husband's sperm. INTERVENTION(S): After different ovarian stimulation protocols, one or two inseminations were performed. MAIN OUTCOME MEASURE(S): Pregnancy rate per cycle. Detected studies were tested for homogeneity. Because heterogeneity was observed, DerSimonian-Laird relative risk with alleatory effects was used. RESULT(S): Six randomized and prospective trials involving 865 patients and 1156 cycles were identified. There was remarkable heterogeneity among the different studies concerning methodology, especially regarding ovarian cycle management and the timing of inseminations. Although the pregnancy rate per cycle was somewhat higher in the two-inseminations-per-cycle group (14.9% vs. 11.4%), there were no statistically significant differences (relative risk = 1.34; 95% confidence interval 0.90-1.99). CONCLUSION(S): No significant differences were observed when two inseminations per cycle were performed, compared with one insemination. There was great heterogeneity concerning ovarian management and insemination timing. This heterogeneity hampered the analysis. We detected a better pregnancy rate with two inseminations vs. one insemination when clomiphene citrate with or without gonadotropins and 5000 IU of hCG were used. More studies are necessary to ascertain whether this is true or merely an artifact from the multiple subgroups analysis.

Chorionic Gonadotropin↗
PubMed2003

Spermatogenetic disorders in adult rats exposed to tributyltin chloride during puberty.

Adverse effects of tributyltin (TBT) chloride were investigated on the reproductive system in male adult rats as exposed during puberty. Fifty Sprague-Dawley rats at the age of 35 days were assigned to five different groups: negative control receiving vehicle, methyltestosterone (10 mg/kg B.W.), and TBT chloride treatments (5, 10, and 20 mg/kg B.W.). Animals were treated by oral gavage for ten consecutive days and sacrificed at 5 weeks after final treatment. The treatment of TBT chloride at the high dose of 20 mg/kg B.W. significantly decreased homogenization-resistant testicular sperm counts (p<0.05). The TBT chloride treatment at the doses of 10 and 20 mg/kg B.W. also significantly decreased caudal epididymal sperm counts (p<0.01). Some of motion kinematic parameters (motility, mean angular displacement, lateral head displacement, and dance) of sperms retrieved from vasa deference were significantly decreased in rats treated with the TBT chloride at the dose of 20 mg/kg B.W. (p<0.05). These results provide a further evidence that an exposure to TBT chloride during pubertal period in male rats produces spermatogenic disorders characterized by decreasing testicular and epididymal sperm counts and some motion parameters of sperms in the vasa deference.

Animals↗
PubMed2001

Testicular ultrasonography and extended chromosome analysis in men with nonmosaic Klinefelter syndrome: a prospective study of possible predictive factors for successful sperm recovery.

OBJECTIVE: To investigate whether extended chromosome analysis or testicular sonography, including flow Doppler imaging, before diagnostic testicular sperm extraction have predictive value for successful sperm retrieval in men with nonmosaic Klinefelter syndrome. DESIGN: Prospective clinical study. SETTING: IVF clinic and genetics laboratory at a university hospital. PATIENT(S): Nineteen patients with nonmosaic Klinefelter syndrome and azoospermia. INTERVENTION(S): Collection of blood samples; histopathologic examination of testicular tissue; fluorescence in situ hybridization; sonography, including Doppler imaging; and testicular sperm extraction. MAIN OUTCOME MEASURE(S): Testicular volume, serum FSH and serum testosterone levels, percentage of normal XY cells, ultrasound echogenicity, intratesticular blood flow resistance, and sperm recovery. RESULT(S): Testicular volume and levels of serum FSH and serum testosterone levels did not differ significantly. No differences in testicular echogenicity or intratesticular blood flow resistance were found between 47,XXY men in whom sperm recovery was successful and those in whom sperm recovery failed. Significant differences were seen between all patients with the Klinefelter syndrome and controls with normal sperm values. Fluorescence in situ hybridization of peripheral lymphocytes and buccal tissue showed no correlation between frequency of normal 46,XY cells and testicular spermatogenesis. CONCLUSION(S): In azoospermic men with the Klinefelter syndrome, histopathologic findings seem to be predictive for successful sperm recovery. Infertility work-up, including diagnostic testicular sperm recovery, is recommended, and, if possible, viable sperm should be cryopreserved.

Adult↗
PubMed2000

Reproductive issues from the Islamic perspective.

The Islamic faith is regarded by its followers, Muslims, as a complete way of life. A multitude of nationalities practise Islam and also various sects, and as a result there are various interpretations of Qur'anic guidance relating to almost every matter. Only a fully qualified jurist of the highest rank can issue edicts on problems that are not already clearly addressed in the Qur'an. This applies to contemporary issues and any Muslim is at liberty to debate and dialogue with the religious leader to obtain a ruling on a specific question. Marriage is described as half the faith in Islam and to have children is seen as a great blessing. There is no religious objection to an infertile married couple pursuing any form of infertility treatment including in vitro fertilization, surgical sperm retrieval and micro-assisted conception methods. However, there must be strict control to ensure that the gametes belong to the husband and wife. This relationship is described as 'halal' (permitted), whereas any union of gametes outside a marital bond, whether by adultery or in the laboratory, is 'haraam' (forbidden). Therefore, donor sperm pregnancies are strictly forbidden in all schools of Islamic law. The advent of ovum donation and surrogacy has led some Islamic scholars to allow this procedure between co-wives thereby avoiding the 'haraam' relationship between sperm and egg, but there is still debate on the definition of the mother. Similarly, treating any other situation outside a marriage relationship, for example fertilization of an ovum from cryopreserved sperm after divorce of the couple or death of the husband would be 'haraam' and strictly forbidden. The Qur'anic guidance is quite clear that the couple can pursue all permitted treatments but may need to accept that they may not achieve a pregnancy. Adoption is encouraged in Islam with the specific rule that the child must be able to identify its biological father by keeping his name. It must be emphasized that Muslims will vary on their degree of adherence to the faith and the practitioner should present all the options to the couple without assuming which treatments they will or will not accept.

Journal Article↗