Vitamin components in various Amaranthus spp. (modified from [12]).
\\n\\n
More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
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Amaranth is considered as one of the “superfoods” of the coming century due to its exceptional qualities in various aspects. However, the crop is not a novel discovery, and it has faced quite a number of obstacles in order to get to where it is today in terms of nutritional status and acceptance by modern day consumers as a food which is able to provide nutrition. Despite the setbacks and disuse, Amaranth has had three redeeming qualities that have earned its standing as a “superfood.” The grain is resistant to a number of weather conditions. It also contains quite a high nutrient profile, particularly proteins, and the amino acid lysine, making it a viable supplier of micronutrients to populations facing malnourishment around the globe. The third most important quality is the range of climates and conditions it can grow under. Prior to going into details about Amaranth, it is important to look into the history and nature of similar pseudocereals as a whole in order to understand the importance of Amaranth for modern times.
Amaranth, millet, barley, quinoa and buckwheat are some of the nutrient-dense foods found in the world today. Most of these pseudocereals and ancient grains were regarded as poorer in quality. As a result, these grains were shunned as “poor man’s food.” However, due to the recent emergence and awareness of their nutritional values, these pseudocereals and ancient grains are making their way back into the diets of people around the world who determinedly want to revert to healthy diets and lifestyles.
Millet’s origins could be traced to Neolithic China. Foxtail millet (Setaria italica) and common millet (Panicum miliaceum) are recognized as some of the most important and ancient domesticated crops in the world. The world’s earliest known millet remains were found in Cishan around 40 years ago [1]. The storage contained more than 50,000 kg of grain storage pits, which were not easily taxonomically classifiable at that time. However, since then, it has been suggested that the earliest significant system of common millet cultivation was based around this site in Cishan, and the main crop that was being cultivated therein was common millet [2]. The cultivation and widespread use of millet as a food source has been attributed with the development of early Chinese civilizations that surrounded the Yellow river [2]. The oldest noodles unearthed in the world were also made from foxtail millet and common millet and were found near the Qinghai province in China [3]. The noodles dated back to 4000 years ago [3]. Various other types of millets, such as Kodo millet and pearl millet, were further cultivated in regions throughout the world such as Africa and Asia.
Scientists do not necessarily agree on the origins of barley, and the currently accepted theory states that it has been cultivated first in the Near East [4]. The first ancestor of barley is believed to be similar to Hordeum spontaneum, and the earliest remains of barley discovered so far, date back to 8000 B.C., which were found near the Bus Mordeh phase of Ali Kosh, near Deh Luran and Tell Mureybat in Syria [5]. As agriculture spread from Western Asia toward the valley of Indus, so did barley. Archeologists have found detailed tablets on the correct methods of planting barley, and a prescription for a poultice included barley ale from the scribes of Sumer [6].
Barley has also seen extensive use in ancient Egypt, both as a source of nutrition and a medicine [7]. While being used in many forms to decrease the healing time of wounds, it was also used as medicine for eye diseases and phlegm [7]. Most astonishingly, barley has been used as a marker to diagnose pregnancy and for the purposes of prenatal sex determination—the validity of which has not been proven so far [7]. Much like millet, barley spread across the world and still continues to be a main source of food in many of its parts, including India. Barley tea is prepared using the roasted kernels to make a nonalcoholic drink. This is referred to as a medicinally valuable drink throughout literature [8].
Quinoa is another pseudocereal that has high nutritional properties and values. Before the Chilean and Andean countries began importing wheat, quinoa was one of the staple foods in those regions. The findings in Ayacucho, Peru and Uhle give a basis for the domestication of this plant [9]. Quinoa has thus been in cultivation from pre-Colombian times. During the Colonial period, Inca Garcilaso de la Vega has commented as follows on quinoa: “the second of the grains grown on the face of the earth gives what they call ‘quinoa’ and it is known in Spanish as ‘millet’ or small rice: because the grain and color are somewhat similar.” This establishes the fact that quinoa has been associated by the Spaniards of the time with Amaranth, which is noted by Bernabe Cobo with how the quinoa within the Iberian Peninsula is very similar to the grain which grew in Europe. Quinoa species were given different names in the context of the variety. The names differed according to color and included names such as “isualla, “kana llapi” and “cchusllnca” for wild quinoa, red quinoa and yellow quinoa, respectively [9].
The origins of buckwheat also remain debatable. However, Campbell makes a strong argument for the wild ancestor of buckwheat originating from northeastern Yunnan, China [10]. Nevertheless, evidence of buckwheat has been found in the Siba culture, or the Qinghai-Tibet plateau recently, the carbon dating result of which dated from 3610 to 3458 years before the present, making them the oldest found within the country [11]. This supports the fact that buckwheat has originated within China and in particular, the Qinghai-Tibet plateau. From there, buckwheat spread to Europe through Russia, most likely being introduced to Siberia and Germany first. It is not believed that buckwheat was cultivated within India in ancient times, but there is evidence to support that buckwheat was cultivated within the Himalayas.
Out of all the modern day pseudocereals, Amaranth is a strong and upcoming candidate which is foreseen as a remedy to malnutrition and food insecurity. In fact, as mentioned previously, Amaranth is now considered a “superfood” because it is high in protein, dietary fiber, vitamins and minerals. While grains being regularly consumed today possess a high caloric intake, they are micronutrients and protein profiles are not as holistic. A summary of the various nutrient profiles of Amaranthus spp. is shown in Tables 1–3. Popularity in the cultivation and consumption of Amaranth seed in the modern times began almost four decades ago with the rediscovery of its superior nutritional attributes.
Constituent, Amaranthus material | Content |
---|---|
Ascorbic acid | |
A. caudatus leaf methanol extract | 3.86 ± 0.20 mg/100 g |
A. hybridus paste from leaves | 28 ± 1 mg/100 g |
A. lividus stems/leaves/flowers: water/methanol/ethyl acetate extracts | 0.191 ± 0.007/0.196 ± 0.014/nd mg/g dw |
A. hybridus raw/cooked | 321.4 ± 1.0/227.7 ± 0.7 mg/100 g |
A. cruentus dried leaves: water extract | 445 ± 0.21 mg/kg dw |
A. caudatus seeds: raw/cooked/popped/germinated and dried 30°/60°/90° | 29.8/2.3/18.3/13.7/11.4/nd mg/kg |
A. cruentus seeds: raw/cooked/popped/germinated and dried 30°/60°/90° | 23.0/nd/16.1/14.3/10.7/nd mg/kg |
A. cruentus vegetables: market maturity/heading (β-carotene, depending on N fertilizer) | 94.60 ± 5.60 to 78.90 ± 4.50/160.50 ± 7.10 to 149.90 ± 8.20 mg/100 g fw |
A. caudatus seeds: raw/high protein flour/cooked/popped/germinated and dried 30°/60°/90° | 12.5/23.6/1.0/0.7/13.1/9.3/9.1 mg/kg |
A. cruentus seeds: raw/high protein flour/cooked/popped/ germinated and dried 30°/60°/90° | 21.3/44.9/1.2/0.7/22.9/20.2/17.9 mg/kg |
Niacinamide | |
A. caudatus seeds: raw/high protein flour/cooked/popped/germinated and dried 30°/60°/90° | 28.0/66.5/2.4/nd/30.0/23.7/23.8 mg/kg |
A. cruentus seeds: raw/high protein flour/cooked/popped/germinated and dried 30°/60°/90° | 15.9/32.2/0.8/nd/17.1/15.5/15.2 mg/kg |
Pyridoxine | |
A. caudatus seeds: raw/high protein flour/cooked/popped/germinated and dried 30°/60°/90° | 4.5/7.6/2.2/0.5/4.3/4.4/2.5 mg/kg |
A. cruentus seeds: raw/high protein flour/cooked/popped/germinated and 30°/60°/90° | 6.1/8.5/3.1/0.6/5.5/4.5/1.9 mg/kg |
Riboflavin | |
A. caudatus seeds: raw/high protein flour/cooked/popped/germinated and dried 30°/60°/90° | 2.4/4.9/1.0/1.7/5.3/4.6/1.6 mg/kg |
A. cruentus seeds: raw/high protein flour/cooked/popped/germinated and dried 30°/60°/90° | 4.1/6.5/1.6/2.0/8.3/6.5/2.1 mg/kg |
Total folate | |
4 varieties: seeds | 52.8–73.0 μg/100 g dw |
4 samples: whole meal flour unstored/stored 3 months | 59.9–70.6/43.7–61.2 μg/100 g dw |
4 samples: flour fraction/bran fraction unstored | 45.5–53.6/60.5–81.6 μg/100 g dw |
4 samples: noodles/cookies/bread (60% wheat 40% a.) | 38.9/36.3/35.5 μg/100 g dw |
Vitamin components in various Amaranthus spp. (modified from [12]).
Carotenoids | |
A. cruentus: treated vegetables (total) | 11.3 to 24.2 mg/100 g |
A. caudatus: leaf methanol extract (total) | 15.33 mg/100 g |
A. cruentus: dried leaves water extract (total) | 132 ± 8 mg/kg dw |
A. lividus: stems/leaves/flowers: methanol/ethyl acetate extracts (β-carotene) | 1.24 ± 0.020/0.37 ± 0.013 mg/g dw |
A. gangeticus leaves: fresh/pressure cooked 10 min/boiled in water 10 min (β-carotene) | 7.36/5.391/2.4 mg/100 g fw |
A. cruentus vegetables: market maturity/heading (β-carotene, depending on N fertilizer) | 7.45 ± 0.47 to 8.04 ± 0.87/2.48 ± 0.33-4.86 ± 0.57 mg/100 g fw |
Chlorophylls | |
A. cruentus: treated vegetables (chlorophyll a) | 53–132 mg/100 g fw |
A. cruentus: treated vegetables (chlorophyll b) | 18.0–43.7 mg/100 g |
Betacyanins | |
A. spinosus stems: amaranthine/isoamaranthine/betanin/isobetanin | 15.3/5.87/1.77/0.50 mg/100 |
Carotenoids, chlorophyll and phytates in various Amaranthus spp. (modified from [12]).
Phytate | |
A. caudatus (Centenario and Oscar Blanco) raw grain (phytic acid) | 0.3% |
A. caudatus seeds raw/extruded | 82.0 ± 0.10/82.0 ± 0.13 mg 100 g |
A. cruentus seeds | 5.0–5.8 g/kg |
A. hypochondriacus seeds | 5.4–6.2 g/kg |
A. cruentus seed: raw flours/high-protein flour fraction/cooked/popped/germinated (dried at 30,60, and 90°) | 4.0/4.4/3.3/3.4/3.1–3.2 g/kg |
A. caudatus seed: raw flours/ high-protein flour fraction/cooked/popped/germinated (dried at 30, 60 and 90°) | 4.1/4.4/3.3/3.5/3.2–3.3 g/kg |
Amaranthus: eight varieties | 0.52–0.61% |
A. cruentus raw seed flours | 21.1 μmol/g |
Resinols in Amaranthus seed bran | |
(+)-Pinoresinol | 53 μg/100 g |
(−)-Secoisolariciresinol | 98 μg/100 g |
(+)-Lariciresinol | 45 μg/100 g |
(−)-7-Hydroxymatairesinol | 519 μg/100 g |
Syringaresinol | 47 μg/100 g |
Secoisolariciresinol-sesquilignan | 3.7 μg/100 g |
(+)-Medioresinol | 114 μg/100 g |
7-Oxomatairesinol | 207 μg/100 g |
(−)-Matairesinol | 33 μg/100 g |
Todolactol | 19 μg/100 g |
Isohydroxymatairesinol | 20 μg/100 g |
α-Conidendrin | 5.9 μg/100 g |
Nortrachelogenin | 15 μg/100 g |
Lariciresinol-sesquilignan | 21 μg/100 g |
(−)-Arctigenin | 8.2 μg/100 g |
Amines in A. hypochondriacus (Nutrisol) leaves | |
Cinnamoylphenethylamine | 0.48; 0.71 μg/g |
Caffeoyltyramine | 0.16; 0.72 μg/g |
p-Coumaroyltyramine | 5.26; 5.26 μg/g |
Feruloyl-4-O-methyldopamine | 10.87; 7.38 μg/g |
Amines in in A. mantegazzianus (Don Juan) leaves | |
Cinnamoylphenethylamine | 4.47; 22.31 μg/g |
Caffeoyltyramine | 0.53; 10.27 μg/g |
Feruloyl dopamine | 0.60; 5.67 μg/g |
Sinapoyltyramine | 0.65; 0.35 μg/g |
p-Coumaroyltyramine | 114.31; 113.99 μg/g |
Feruloyl-4-O-methyldopamine | 9.49; 31.64 μg/g |
Enterolactone: Amaranthus extracts | 0.52 μg/100 g |
Other nutrients in various Amaranthus spp. (modified from [12]).
As a plant-based food, it is important to highlight and look into the taxonomic information and morphological characteristics of Amaranth for reference and identification purposes. Taxonomically, plants that belong to the Amaranthus genus have been classified as per Table 4 [13].
Kingdom | Plantae—Plants |
---|---|
Subkingdom | Tracheobionta |
Superdivision | Spermatophyta |
Division | Magnoliophyta |
Class | Magnoliopsida |
Subclass | Caryophyllidae |
Order | Caryophyllales |
Family | Amaranthaceae |
Genus | Amaranthus L. |
Taxonomic classification of Amaranthus spp.
The genus Amaranthus has been classified into three subgenera, namely Acnida, Albersia and Amaranthus [14]. However, taxonomic classification within the Amaranthus genus has been regarded as a somewhat difficult task by the scientific community, due to the lack of clearly distinguishing characteristics. Similarities between the large number of species, small, difficult-to-see diagnostic parts, intermediate (hybrid) forms and the broad geographical distribution have been attributed to the general use of multiple synonyms [15]. Due to the need arising for microclassification or infrageneric classification, the Amaranthus genus has been artificially classified into the following, mostly based on the usages [16]:
Vegetable Amaranthus include Amaranthus tricolor var. tricolor, Amaranthus tricolor var. tristis
Grain Amaranthus: Amaranthus hypochondriacus, Amaranthus caudatus, Amaranthus cruentus
Weed Amaranthus: Amaranthus spinosus, Amaranthus viridis, Amaranthus retroflexus
Morphology-wise, the defining characteristics of Amaranth are the inflorescence and the flowers. Hence, taxonomic classification is done mostly by careful examination of the tepal number and morphology. With regards to the general morphology, Amaranth species display erect or spreading annuals with a rough or prickly appearance. Grain amaranths have different colors in regard to flowers, stems and leaves, with shades of purple, orange, red and gold. The seeds are plentiful, while small, and occur in massive numbers, with colors such as cream, gold and pink [17]. The stems are often reddish in color and contain arranged leaves with colorful flowers [18]. The stems are longitudinally grooved and terminate in an apical large branched inflorescence [19]. Grain amaranth plants are dicots with thick, tough stems similar to those of sunflowers. The height can vary between 1.524 and 2.134 m when mature.
Leaves vary in shapes and sizes and are usually either green or purple with slender stalks. These are alternate, usually simple, with entire margins and distinct markings but without stipules, depending on the species. Flowers are either solitary or aggregated in cymes, spikes, or panicles and typically bisexual and actinomorphic. A few species have unisexual flowers. The bracteate flowers are regular with 4–5 petals, often joined. There are 1–5 stamens. The hypogynous ovary has 3–5 joined sepals [20]. The flowers have 0–5 perianth segments and 2–3 styles [20].
Seeds are borne in a utricle, which are classified as dehiscent, semi-dehiscent, or indehiscent types. The amaranth seed is quite small (0.9–1.7 mm diameter) and seed weights vary from 1000 to 3000 seeds/g. Seed colors can vary from cream to gold and pink to black. The tiny, lens shaped seeds are usually pale in color. The seed heads vary from 30 to 112 cm in diameter at the base and varied in height from 13 to 61 cm [20].
The vegetable Amaranthus can be identified by inflorescence features such as mostly or exclusively axillary glomerulus, or short spikes, origin of the flower bud from leaf axil, three tepal lobes, three stamens, brownish black seed, indeterminate growth habit [20]. Grain Amaranthus are characterized by the apical large complex inflorescence comprising aggregates of cymes, five tepal lobes, stamens, seed with variable coat color and well-defined flange, utricle circumscissile [21]. Certain species within weeds show commonalities with the grain and vegetable forms, and some weed species are cultivated as food sources [22].
There is a recurring conflict based around the origins of the grain Amaranth, and the scientific community has introduced a variety of hypotheses around this debate. There are various hypotheses, none of which have been quite adequately tested as of yet. The single progenitor hypothesis [22] claims that the grain amaranths could be the result of a single progenitor species domestication that has been introgressed with other wild amaranths resulting in separate grain species. Another hypothesis claims that multiple different grain species were resultant of separate domestication incidents around separate regions, pertaining to different wild species. A. cruentus is from A. hybridus presumably in Central America, A. hypochondriacus is from A. powellii in Mexico and A. caudatus is from A. quitensis in South America [22]. A third hypothesis proposes that each of the three domesticated species were derived from independent domestication events from genetically different populations of A. hybridus [23].
The initial evidence of Amaranth cultivation dates back to the mid-Holocene period (8000–7000 BP) [24]. In Central America, seeds of A. hypochondriacus and A. cruentus were found which date back 1500 and 6000 years, respectively, from Mexico [25]. The three main grain Amaranth species cultivated throughout different regions in America are A. cruentus, which is cultivated throughout North America, particularly in and around Southern Mexico and Guatemala, A. hypochondriacus, which is cultivated through the western part of America, particularly from southwestern America to central Mexico, as well as A. caudatus, which is cultivated closer to Southern America, particularly near the Andes and Northern Argentina [17].
Amaranth has its history deeply imbedded in the cultures of the pre-Colombian new world. There are reasons to believe that the Aztecs used it extensively. There have been references to tributes of tons of Amaranth grain being sent to Tenochtitlan (present-day Mexico City) for emperor Montezuma [17]. The Aztecs would mix the crushed grain with human blood or milk and consume it during their rituals and festivals [17]. As such, the grain was interwoven with paganism and the rituals of the Aztecs. The Spanish conquistadors were shocked by this and banned the use and cultivation of Amaranth, pushing cultivation into small pockets, and eventually into disuse [17]. Nevertheless, as time went on, the conquistadors would distribute the seed as far as India, Nepal and China. The crop is popular among the hill tribes of these countries, and Amaranth is most intensively cultivated in these areas of higher elevation as of today [17]. Additionally, amaranth has been indoctrinated into Indian culture, earning names such as “rajgira” and “ramdana” (king seed and seed sent from god, respectively) [17]. Indian cuisine such as “laddoo” incorporates a mixture of popped amaranth seeds and honey [17].
Amaranth species such as A. tricolor, A. dubius and A. cruentus are grown as potherbs or vegetables within the African and Southeast Asian regions [26]. Research regarding utilizing Amaranth species as an alternative food crop to support the global demands is already underway, and new advances toward Amaranth cultivation are being carried out in countries such as Lithuania [27]. Furthermore, research has been conducted into cultivating A. hypochondriacus hybrids within the Iranian region as a new food crop, which have been successful [28]. The heat resistance of Amaranth spp. has made it an acceptable food crop for Taiwan which has high rainfall and humidity conditions coupled with temperatures that can reach up to 40°C [29]. Amaranth is grown as a leafy vegetable in Nigeria [30]. Additionally, recent research in Italy has confirmed that the country possesses conditions that A. hypochondriacus derivatives find suitable for cultivation [31]. While specialized research is being carried out around cultivation patterns to obtain optimal results in the Russian republic Dagestan [32]. Others have followed suit, specializing their research in order to obtain optimal conditions for the crop based on the conditions within the land, including such institutes as the Rodale Research Center (RRC), the central source for Amaranth and related research of America, in Pennsylvania, Emmaus. Recent publications include studies into variations in protein content, studies into Genomic reductions, germination characteristics and germplasm conservation.
Due to the demanding needs of the twenty-first century’s population and their need for nourishment, the efficiency of crops such as corn, rice and maize are being questioned. As such, scientists worldwide are making new ventures into the potential of alternative grains that could supply food to the world in the years to come. Quinoa, buckwheat and other forgotten pseudocereals are being presented into the limelight due to their high nutrient content and their ease of growth. Amaranth is at the forefront when it comes to all these aspects.
The first world Amaranth conference was held in 2018, gaining 135 participants from East and Southern African countries where the grain is most needed. Topics discussed were mainly centered on nutrition, production of quality food on African land, processing, and supporting communities to change mentalities developed around Amaranth as a poor man’s crop. The underutilization of the crop seems to be the main issue, especially in countries which need its nutritional benefits the most. However, steps are being taken to change the public’s view and are effective as evident by the attendance of the African continent.
Due to the rising needs of the global population to control world hunger and to provide nutrition for the malnourished, Amaranth becomes a viable selection due to a number of reasons. Its weed-like nature and ability to withstand environmental conditions is one of these reasons. Another is its ability to provide micronutrients and macronutrients at significant amounts as a single crop, as opposed to the current food crops of the world. Amaranth contains lysine at high levels in particular, compared with other cereals and pseudocereals. The third most striking characteristic is its adaptability to change and the wide range of environments it can grow under, making it a competitive crop that can be utilized across the globe in order to cater to both the poor and the rich. This fact alone solidifies its position as a versatile food crop which could eventually become a staple food of the twenty-first century.
The authors wish to thank the Australian College of Business & Technology – Kandy Campus, Peradeniya Road, Kandy, Sri Lanka, for the facilities provided to put this write-up together.
The authors declare no conflicts of interest, financial or otherwise.
Andrology is the medical specialty dealing with men’s health and reproductive system, this including the genital, hormonal, reproductive, sexual, as well as psychological aspects, from birth to adulthood. Regular andrological checkups are essential both to reveal possible problems and to receive thorough advice and information as to ensure that sexual and reproductive functions are well preserved.
Estimates report that about one in three males suffers from andrological diseases, their rates varying according to the age: 27–30% of pediatric male subjects have reproductive and/or sexual conditions, especially cryptorchidism, varicocele, hypogonadism, congenital anomalies of the genitourinary tract, and sexually transmitted diseases. In adulthood, 40% of men are affected by andrological diseases, in particular infertility and sexual problems. The main surgically correctable diseases to prevent hypofertility are varicocele (30%) and undescended testes (<5%) [1, 2, 3].
The origin of many of the andrological conditions appearing during adulthood is to be traced before the age of 18 and sometimes even during gestation. The male gonad is extremely sensitive to external events even during gestation and soon after childbirth up until puberty. The andrological evaluation of pediatric patients is therefore extremely important for the early diagnosis of genital anomalies such as penile alterations or abnormal positions of the testis; early evaluation is helpful also to search for risk factors in terms of male general and sexual health.
Andrology greatly trusts primary prevention to reduce the incidence of andrological diseases and conditions. Clinical studies and primary prevention interventions in andrology should be focused on the most vulnerable crucial phases of male gonad development that can be affected by a variety of external agents.
The preservation of the genital and sexual health of young people also means protecting their fertility, a very important action within the broader scope of the interventions aimed at reducing the drop in the birthrate affecting modern society. Despite few exceptions, the prevention and early diagnosis of the andrological conditions have been neglected worldwide for too long. This has favored an increase in the incidence and prevalence of diseases that are otherwise easy to prevent and treat if diagnosed early.
The data collected during screening procedures in young males show that <5% receive an andrological examination before the age of 20. Female patients of the same age adhere to gynecological screening tests with decidedly higher rates. A real “gender discrimination” about prevention [4].
This leads to an increase in undiagnosed andrological diseases that remain so until adulthood when the treatment becomes more complex for the patient and more expensive for the national healthcare system.
Therefore, it is necessary to promote awareness on this social issue: undergoing regular and well-timed andrological checkups is essential for the early diagnosis of andrological conditions as well as for the general health of men’s sexual and genital functions.
This point in mind, in order to safeguard the reproductive and sexual health of young men, the synergic approach involving pediatricians, general practitioners, doctors at family planning clinics, and andrologists for the adults plays a key role together with the implementation of territorial networks integrating the know-how and expertise of all these health professionals.
This is especially true in the extremely vulnerable period of life generally ranging from 11 to 18 years of age, when young male patients experience the transition to adult life and maturity from the reproductive and sexual point of view.
All this can be achieved also increasing the social awareness on the matter via systematic information and education of the population thanks to campaigns and primary prevention interventions. To this end, research and study of andrological diseases in the pediatric-adolescent patients are crucial, especially research, whose main aim is to anticipate the treatment of all those conditions that can alter the fertility potential of men.
These are the grounds for this study, which compares good clinical practices worldwide for the preservation of male fertility in young patients by comparing the results with the evidence from the scientific research carried out on the treatment of male infertility.
In the last 40 years, the number of spermatozoa in the semen of male patients of childbearing potential has decreased by more than a half [5].
Incorrect lifestyles, pollution, and poor prevention are the main causes of a dramatical drop in the male fertility rates. According to the latest international reports, the rate of male infertility among the couples who seek advice from specialized centers to bear a child is 30–35%, and age is not the only liable factor; correctable causes include varicocele, which accounts for 30–35% of cases, and evidence of previous untreated or poorly followed cryptorchidism (5%) [5, 6, 7].
Medically assisted procreation is suggested as one solution to the human and social problem of sterility. But, as reported by many authors, can assisted procreation be considered as a suitable therapy?
In many countries, assisted procreation is funded from public health insurance. Without this coverage, it would be used much less frequently. What is then more important? The treatment of sterility or the increase in the birthrate? The answer to this question is manifold.
One of the reports by the International Committee for Monitoring Assisted Reproductive Technology (ICMART) re-established that over 1 million ART cycles were performed worldwide in 2002, with a progressive increase compared to the previous years. The progressive increase shows how research and clinical medicine are drastically moving away from the real investigation of infertility [6, 7, 8].
The costs associated with the ART can be divided into direct and indirect costs; the direct costs, which vary according to the mother’s age, are those necessary to “guarantee” a pregnancy, from the medically assisted treatment to childbirth. The indirect costs include the costs directly related to childbirth, to a possibly premature birth, to twin pregnancies, to the management of any complications, and to the management of chronic diseases of the newborn child and of the mother as well [7, 8, 9].
Obviously, the average direct cost of each procedure is calculated by dividing the total number of procedures performed per year by the number of live births. These costs are country-related, with variations of up to tenfold values; direct ART treatment costs show considerable variations among countries, with the USA standing out as the most expensive and Northern European countries and Japan as the least expensive countries. For example, reports show that the costs per live birth are similar for ages 24 (€17,000) and 33 (€ 18,500), after which they begin to increase, with the cost per live birth reaching € 54,000 at age 42.
Indirect costs, especially when associated with multiple gestations, vary from country to country: in 2004 such costs ranged between € 24,377 for a singleton pregnancy and € 35,042 for a twin pregnancy up to 27 days after birth [6, 7, 8, 9].
The first international report on the results of assisted medical procreation (AMP) was published in Paris in 1991 on the occasion of the 7th World IVF Congress. From a scientific point of view, the role of international reports is to monitor the number of procedures as well as to study the efficacy of the treatments indicated.
Every year the procedure registers are updated. The recorded data show a constant increase in these procedures with a steady increase in live births. The latest data, published in 2018 and referring to 2011, show that approximately 1.6 million procedures were performed with approximately 400,000 births worldwide. These figures allow to calculate the costs per year for the national healthcare systems [7, 8, 9].
This research was performed by taking into consideration two aspects separately: infertility and pediatric andrological diseases associated with infertility. Browsing the most important engines for scientific research (PubMed, Scopus, Google Scholar), several keywords were considered: infertility, male, semen, adolescent, varicocele, undescended testes, cryptorchidism, hormone, and assisted medical procreation (Table 1).
Group | Key | Total | >2000 % of paper | Statistical comparison per group |
---|---|---|---|---|
1 | Infertility-male | 46103 | 26296 (57%) | 1/2: p < 0.05 |
2 | Varicocele | 5292 | 2788 (52%) | 1/3: p < 0.05 |
3 | Undescended testes | 10245 | 4250 (41%) | 1/3: p < 0.05 |
4 | Assisted reproduction | 25399 | 20309 (79%) | 1/4: p < 0.05 |
5 | V-adolescence/pediatric age | 1396 147 (real pediatric-adolescent age-range with follow-up) | 776 (55%) | 2/5: p < 0.05 |
6 | Infertility-U | 1195 | 676 (56%) | 6/3: p < 0.05 |
7 | Infertility-semen | 11289 | 6556 (58%) | 1/7: p > 0.05 |
8 | Assisted medical procreation | 6701 | 5635 (84%) | 1/8: p < 0.05 |
9 | Infertility-VAR | 2429 | 1349 (55%) | 1/9: p < 0.05 |
Data from the research: number of papers published per disease and with multiple associations.
Statistical analysis: Statistical analysis was performed using the student t-test. Significance value was set at p < 0.05.
Associations: varicocele and pediatric age/adolescence; infertility and undescended testes; infertility and varicocele; statistical comparison between groups: chi-square test comparing number of total paper published and paper published after 2000 per each -group and sub groups.
We searched with association like: adolescent and infertility; varicocele and semen, etc.
A number of papers and number of the most important associations are explained in the table.
Some considerations are essential: the literature regarding medically assisted procreation should be considered only from 1990 onward, and, from a strictly epidemiological point of view, also for varicocele some distinctions should be made. Varicocele seems to have a clear phenotypic trend, for which it is possible that in some countries the prevalence of the disease is lower than in others, justifying a paucity of literature on this topic. However, when comparing the origin of scientific publications on pediatric varicocele and cryptorchidism, Europe and North America cover about 70% of the overall publications worldwide, reaching 80% of the published literature about infertility and assisted medical procreation. Asia and Africa, on the contrary, show poor preventive research while favoring the research on assisted medical procreation.
The analysis of the data offers some interesting insights:
Most of the literature on the topics of this research was published after the year 2000, with the two maximum rates of 84 and 79% for medically assisted procreation. This can be reasonably associated with the widespread use of the procedures after the 1990s. If such figures are correlated to the other percentages found, they also show how the focus of scientific research has slanted toward the treatment of infertility rather than its prevention.
In absolute numbers, the conditions directly associated with infertility are less studied than the treatment with medically assisted procreation.
A comparison between varicocele and cryptorchidism, namely, the two main male infertility diseases, shows that although varicocele is the first treatable cause of infertility, it is not as much investigated as cryptorchidism, accounting for <5% of the curable causes of infertility. From a purely numerical point of view, cryptorchidism is studied more than varicocele, with varicocele being more investigated after the year 2000. This means that long-term studies on varicocele have been done only in the last 20 years.
A comparison between group 1 (infertility and male), which is the most represented in terms of number of publications pre- and post-2000, and all the other subgroups points out that the “infertility and semen” subgroup is the only comparable group within the main scope of the survey. This indicates that most of the studies on male infertility do not investigate the causes leading to these conditions, because they focus only on their effects
The correlation between infertility and varicocele offers some insights: while in numerical terms, there is little investigation of varicocele in association with infertility, which is one of its effects; more is studied about its treatment (surgical treatment, percutaneous treatment, etc.). It is important to report that since 2000, only 147 papers focused on pediatric-adolescent varicocele and its management with a long time follow-up (>3 years).
About this specific topic, where varicocele is the first treatable cause of infertility in adulthood, we found that a total of 625 articles was published since 2000, matching the mentioned criteria; after our selection only 147 articles resulted providing innovative topics in the pediatric range. As a first consideration, we can state that most publications concentrate in Europe, Asia, and North America (the USA being by far the most represented in North America). The percentage of pediatric works is 27.0% being above average in Europe and North and South America. Asia has a considerable number of published articles even though the percentage of pediatric ones is far below average. Africa and Oceania have, respectively, 2 and 1 pediatric articles.
Then we analyzed the main topic and secondary topics of the selected articles. Prevalence of different categories in each continent was summarized, and the main subjects for Europe are surgical technique, videolaparoscopy, and diagnosis; for North America, surgical technique, diagnosis, and endocrinology; and for Asia, video laparoscopy, endocrinology, and screening.
South America includes 10 articles discussing mainly about fertility and semen analysis, being the only region in which this topic appears to be central. Africa had only two publications in the pediatric field, centered on diagnosis and non-operative treatment. The only pediatric publication published in Oceania was centered on video laparoscopy.
Overall prevalence of topics in the discussed articles was considered as well, and we found that in North America and Asia follow-up prevails as a concomitant topic in many articles, together with complications and relapses. Another topic strongly represented in these regions is endocrinology. On the other side, Europe maintains topics that mainly represented surgical technique and videolaparoscopy, accounting for about 50% of all topics, and then diagnosis is still present, showing little difference between main topic and all mentioned topics in the publications.
Eventually, a study of the topics and their prevalence over years was performed to see the trend of interest. A significant trend in publications could not be evinced, neither overall nor for single continent. Publication numbers by year underwent cyclic changes over the last 20 years with a peak in 2008 including 16 publications about pediatric varicocele.
A natural comment to the number of publication is the fact that pediatric articles, focusing on pure research, account for <1 third of overall articles about varicocele. This could be due to the fact that historically varicocele is considered as an adult pathology; thus not enough interest is found in its pediatric side. Different series of studies report a higher prevalence of varicocele in adult population than in pediatric one. However it must be taken into account the lack, in almost all countries, of pediatric screening programs for varicocele that could give a strong bias about the exact prevalence of the pathology in pediatric population. Moreover the study of varicocele related to infertility is considered more imminent in adult life, when looking for paternity that during adolescence when study of future fertility may seem premature. In fact many studies on varicocele are performed retrospectively when the patient in adult life has not the possibility to become father (see table).
Concerning the major topics of the publications, in the most represented continents, the first interest of research is surgical technique, may it be traditional surgery or videolaparoscopy technique. We can also see that in the first three majorly represented topics and figures either screening or diagnosis this reflects an attention of research to detection and treatment rather than to follow-up or prevention of infertility. Other topics were only minimally represented. It must be stated that healthcare organization of each single country may influence the topics and publications: in fact screening would not be so represented in countries with private healthcare or, on the other hand, countries with increased population density would feel less important the problem of infertility. The prevalence of varicocele according to the literature remains constant in different ethnic groups; thus, differences in publication do not reflect a difference of entity of the disease but rather a different contribution to publications.
In South America the research group for the published articles is the same, and the works represent mainly an evolution of the same study focusing on semen analysis, metabolomics, infertility pathophysiology, and endocrinology.
The three most prevalent topics in North America and Asia underline an attention to study the evolution of the pathology in time even after treatment and to evaluate if the outcomes of surgical treatment meet the standards for good practice. Articles discussing endocrinology often evaluate testicular volume at diagnosis and follow catch-up growth after surgery, trying to give an indication of the best timing to prevent infertility. On the other side, the spectrum of topics in Europe reflects poor attention to prevention of infertility and follow-up after surgery.
Of particular interest is that there is no increasing trend during the years despite an increase in the trend of publications about overall causes of infertility and medically assisted procreation. In fact in delivering a PubMed research, it appears that publications about MAP are more than 30 times higher than those about varicocele.
We must report the fact that Asia appears abundantly below average, but a strong bias is given that the fact that many publications from China were in original language [10, 11, 12, 13, 14, 15, 16, 17].
The same applies to the correlation between undescended testes and infertility if compared to the studies on cryptorchidism alone. Both associations between infertility and disease show a progressive percentage increase in the total number of studies.
This research is intended as a warning to the countries worldwide: when talking about fertility, it is right to give a couple the chance to access medically assisted procreation; consequently, scientific studies to improve its outcomes are reasonable. International reports are therefore necessary and should foster research with increasing outcomes. More space should also be given to investigate and prevent male fertility diseases starting from the pediatric age, especially when they might impair the patient’s future fertile potential [18].
All those involved in the pediatric treatment area should be stimulated to act toward this goal, and each country should bear the responsibility of promoting and financing andrological screening campaigns. At the international level, there are still few opportunities, in terms of funds and staff, for the adolescents to receive andrological counseling. This is then the bottom line: Is medically assisted procreation the cure to one or more diseases, or is it the answer to the lack of a social support network?
When talking about couple infertility, male causes account for about 35–40%, among these, varicocele figures as the first [19].
Thus collective interest, research efforts, and healthcare funding aim to study couple infertility at the time of inability of procreation, correction of varicocele in adult age, and medically assisted procreation. This choice is taken despite the increased risk of chronic irreversible damage of treating varicocele and other pediatric andrological diseases in adult age and despite the costs and risks of MAP with the additional risk of failure of medically assisted procreation.
In conclusion, the research effort and the capital invested in prevention of infertility are not balanced with respect to efforts and investments relied into medical assisted procreation.
The authors declare no conflict of interest.
AMP | Assisted medical procreation |
ART | Assisted reproductive technology |
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She performed research in perioperative autotransfusion and obtained the degree of PhD in 1993 publishing Peri-operative autotransfusion by means of a blood cell separator.\nBlood transfusion had her special interest being the president of the Haemovigilance Chamber TRIP and performing several tasks in local and national blood bank and anticoagulant-blood transfusion guidelines committees. Currently, she is working as an associate professor and up till recently was the dean at the Albert Schweitzer Hospital Dordrecht. She performed (inter)national tasks as vice-president of the Concilium Anaesthesia and related committees. \nShe performed research in several fields, with over 100 publications in (inter)national journals and numerous papers on scientific conferences. \nShe received several awards and is a member of Honour of the Dutch Society of Anaesthesia.",institutionString:null,institution:{name:"Albert Schweitzer Hospital",country:{name:"Gabon"}}},{id:"83089",title:"Prof.",name:"Aaron",middleName:null,surname:"Ojule",slug:"aaron-ojule",fullName:"Aaron Ojule",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Port Harcourt",country:{name:"Nigeria"}}},{id:"295748",title:"Mr.",name:"Abayomi",middleName:null,surname:"Modupe",slug:"abayomi-modupe",fullName:"Abayomi Modupe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/no_image.jpg",biography:null,institutionString:null,institution:{name:"Landmark University",country:{name:"Nigeria"}}},{id:"94191",title:"Prof.",name:"Abbas",middleName:null,surname:"Moustafa",slug:"abbas-moustafa",fullName:"Abbas Moustafa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94191/images/96_n.jpg",biography:"Prof. Moustafa got his doctoral degree in earthquake engineering and structural safety from Indian Institute of Science in 2002. He is currently an associate professor at Department of Civil Engineering, Minia University, Egypt and the chairman of Department of Civil Engineering, High Institute of Engineering and Technology, Giza, Egypt. He is also a consultant engineer and head of structural group at Hamza Associates, Giza, Egypt. Dr. Moustafa was a senior research associate at Vanderbilt University and a JSPS fellow at Kyoto and Nagasaki Universities. He has more than 40 research papers published in international journals and conferences. He acts as an editorial board member and a reviewer for several regional and international journals. His research interest includes earthquake engineering, seismic design, nonlinear dynamics, random vibration, structural reliability, structural health monitoring and uncertainty modeling.",institutionString:null,institution:{name:"Minia University",country:{name:"Egypt"}}},{id:"84562",title:"Dr.",name:"Abbyssinia",middleName:null,surname:"Mushunje",slug:"abbyssinia-mushunje",fullName:"Abbyssinia Mushunje",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Fort Hare",country:{name:"South Africa"}}},{id:"202206",title:"Associate Prof.",name:"Abd Elmoniem",middleName:"Ahmed",surname:"Elzain",slug:"abd-elmoniem-elzain",fullName:"Abd Elmoniem Elzain",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Kassala University",country:{name:"Sudan"}}},{id:"98127",title:"Dr.",name:"Abdallah",middleName:null,surname:"Handoura",slug:"abdallah-handoura",fullName:"Abdallah Handoura",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"École Supérieure des Télécommunications",country:{name:"Morocco"}}},{id:"91404",title:"Prof.",name:"Abdecharif",middleName:null,surname:"Boumaza",slug:"abdecharif-boumaza",fullName:"Abdecharif Boumaza",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Abbès Laghrour University of Khenchela",country:{name:"Algeria"}}},{id:"105795",title:"Prof.",name:"Abdel Ghani",middleName:null,surname:"Aissaoui",slug:"abdel-ghani-aissaoui",fullName:"Abdel Ghani Aissaoui",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/105795/images/system/105795.jpeg",biography:"Abdel Ghani AISSAOUI is a Full Professor of electrical engineering at University of Bechar (ALGERIA). He was born in 1969 in Naama, Algeria. He received his BS degree in 1993, the MS degree in 1997, the PhD degree in 2007 from the Electrical Engineering Institute of Djilali Liabes University of Sidi Bel Abbes (ALGERIA). He is an active member of IRECOM (Interaction Réseaux Electriques - COnvertisseurs Machines) Laboratory and IEEE senior member. He is an editor member for many international journals (IJET, RSE, MER, IJECE, etc.), he serves as a reviewer in international journals (IJAC, ECPS, COMPEL, etc.). He serves as member in technical committee (TPC) and reviewer in international conferences (CHUSER 2011, SHUSER 2012, PECON 2012, SAI 2013, SCSE2013, SDM2014, SEB2014, PEMC2014, PEAM2014, SEB (2014, 2015), ICRERA (2015, 2016, 2017, 2018,-2019), etc.). His current research interest includes power electronics, control of electrical machines, artificial intelligence and Renewable energies.",institutionString:"University of Béchar",institution:{name:"University of Béchar",country:{name:"Algeria"}}},{id:"99749",title:"Dr.",name:"Abdel Hafid",middleName:null,surname:"Essadki",slug:"abdel-hafid-essadki",fullName:"Abdel Hafid Essadki",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"École Nationale Supérieure de Technologie",country:{name:"Algeria"}}},{id:"101208",title:"Prof.",name:"Abdel Karim",middleName:"Mohamad",surname:"El Hemaly",slug:"abdel-karim-el-hemaly",fullName:"Abdel Karim El Hemaly",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/101208/images/733_n.jpg",biography:"OBGYN.net Editorial Advisor Urogynecology.\nAbdel Karim M. A. El-Hemaly, MRCOG, FRCS � Egypt.\n \nAbdel Karim M. A. El-Hemaly\nProfessor OB/GYN & Urogynecology\nFaculty of medicine, Al-Azhar University \nPersonal Information: \nMarried with two children\nWife: Professor Laila A. Moussa MD.\nSons: Mohamad A. M. El-Hemaly Jr. MD. Died March 25-2007\nMostafa A. M. El-Hemaly, Computer Scientist working at Microsoft Seatle, USA. \nQualifications: \n1.\tM.B.-Bch Cairo Univ. June 1963. \n2.\tDiploma Ob./Gyn. Cairo Univ. April 1966. \n3.\tDiploma Surgery Cairo Univ. Oct. 1966. \n4.\tMRCOG London Feb. 1975. \n5.\tF.R.C.S. Glasgow June 1976. \n6.\tPopulation Study Johns Hopkins 1981. \n7.\tGyn. Oncology Johns Hopkins 1983. \n8.\tAdvanced Laparoscopic Surgery, with Prof. Paulson, Alexandria, Virginia USA 1993. \nSocieties & Associations: \n1.\t Member of the Royal College of Ob./Gyn. London. \n2.\tFellow of the Royal College of Surgeons Glasgow UK. \n3.\tMember of the advisory board on urogyn. FIGO. \n4.\tMember of the New York Academy of Sciences. \n5.\tMember of the American Association for the Advancement of Science. \n6.\tFeatured in �Who is Who in the World� from the 16th edition to the 20th edition. \n7.\tFeatured in �Who is Who in Science and Engineering� in the 7th edition. \n8.\tMember of the Egyptian Fertility & Sterility Society. \n9.\tMember of the Egyptian Society of Ob./Gyn. \n10.\tMember of the Egyptian Society of Urogyn. \n\nScientific Publications & Communications:\n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Asim Kurjak, Ahmad G. Serour, Laila A. S. Mousa, Amr M. Zaied, Khalid Z. El Sheikha. \nImaging the Internal Urethral Sphincter and the Vagina in Normal Women and Women Suffering from Stress Urinary Incontinence and Vaginal Prolapse. Gynaecologia Et Perinatologia, Vol18, No 4; 169-286 October-December 2009.\n2- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nFecal Incontinence, A Novel Concept: The Role of the internal Anal sphincter (IAS) in defecation and fecal incontinence. Gynaecologia Et Perinatologia, Vol19, No 2; 79-85 April -June 2010.\n3- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nSurgical Treatment of Stress Urinary Incontinence, Fecal Incontinence and Vaginal Prolapse By A Novel Operation \n"Urethro-Ano-Vaginoplasty"\n Gynaecologia Et Perinatologia, Vol19, No 3; 129-188 July-September 2010.\n4- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n5- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n6- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n7-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n8-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n9-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n10-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n11-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n12- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n13-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n14- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.\n Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/urethro-plasty_01\n\n15-Ibrahim M. Kandil, Abdel Karim M. El Hemaly, Mohamad M. Radwan: Ultrasonic Assessment of the Internal Urethral Sphincter in Stress Urinary Incontinence. The Internet Journal of Gynecology and Obstetrics. 2003. Volume 2 Number 1. \n\n\n16-Abdel Karim M. El Hemaly. Nocturnal Enureses: A Novel Concept on its pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecolgy/?page=articles/nocturnal_enuresis\n\n17- Abdel Karim M. El Hemaly. Nocturnal Enureses: An Update on the pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecology/?page=/ENHLIDH/PUBD/FEATURES/\nPresentations/ Nocturnal_Enuresis/nocturnal_enuresis\n\n18-Maternal Mortality in Egypt, a cry for help and attention. The Second International Conference of the African Society of Organization & Gestosis, 1998, 3rd Annual International Conference of Ob/Gyn Department � Sohag Faculty of Medicine University. Feb. 11-13. Luxor, Egypt. \n19-Postmenopausal Osteprosis. The 2nd annual conference of Health Insurance Organization on Family Planning and its role in primary health care. Zagaziz, Egypt, February 26-27, 1997, Center of Complementary Services for Maternity and childhood care. \n20-Laparoscopic Assisted vaginal hysterectomy. 10th International Annual Congress Modern Trends in Reproductive Techniques 23-24 March 1995. Alexandria, Egypt. \n21-Immunological Studies in Pre-eclamptic Toxaemia. Proceedings of 10th Annual Ain Shams Medical Congress. Cairo, Egypt, March 6-10, 1987. \n22-Socio-demographic factorse affecting acceptability of the long-acting contraceptive injections in a rural Egyptian community. Journal of Biosocial Science 29:305, 1987. \n23-Plasma fibronectin levels hypertension during pregnancy. The Journal of the Egypt. Soc. of Ob./Gyn. 13:1, 17-21, Jan. 1987. \n24-Effect of smoking on pregnancy. Journal of Egypt. Soc. of Ob./Gyn. 12:3, 111-121, Sept 1986. \n25-Socio-demographic aspects of nausea and vomiting in early pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 35-42, Sept. 1986. \n26-Effect of intrapartum oxygen inhalation on maternofetal blood gases and pH. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 57-64, Sept. 1986. \n27-The effect of severe pre-eclampsia on serum transaminases. The Egypt. J. Med. Sci. 7(2): 479-485, 1986. \n28-A study of placental immunoreceptors in pre-eclampsia. The Egypt. J. Med. Sci. 7(2): 211-216, 1986. \n29-Serum human placental lactogen (hpl) in normal, toxaemic and diabetic pregnant women, during pregnancy and its relation to the outcome of pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:2, 11-23, May 1986. \n30-Pregnancy specific B1 Glycoprotein and free estriol in the serum of normal, toxaemic and diabetic pregnant women during pregnancy and after delivery. Journal of the Egypt. Soc. of Ob./Gyn. 12:1, 63-70, Jan. 1986. Also was accepted and presented at Xith World Congress of Gynecology and Obstetrics, Berlin (West), September 15-20, 1985. \n31-Pregnancy and labor in women over the age of forty years. Accepted and presented at Al-Azhar International Medical Conference, Cairo 28-31 Dec. 1985. \n32-Effect of Copper T intra-uterine device on cervico-vaginal flora. Int. J. Gynaecol. Obstet. 23:2, 153-156, April 1985. \n33-Factors affecting the occurrence of post-Caesarean section febrile morbidity. Population Sciences, 6, 139-149, 1985. \n34-Pre-eclamptic toxaemia and its relation to H.L.A. system. Population Sciences, 6, 131-139, 1985. \n35-The menstrual pattern and occurrence of pregnancy one year after discontinuation of Depo-medroxy progesterone acetate as a postpartum contraceptive. Population Sciences, 6, 105-111, 1985. \n36-The menstrual pattern and side effects of Depo-medroxy progesterone acetate as postpartum contraceptive. Population Sciences, 6, 97-105, 1985. \n37-Actinomyces in the vaginas of women with and without intrauterine contraceptive devices. Population Sciences, 6, 77-85, 1985. \n38-Comparative efficacy of ibuprofen and etamsylate in the treatment of I.U.D. menorrhagia. Population Sciences, 6, 63-77, 1985. \n39-Changes in cervical mucus copper and zinc in women using I.U.D.�s. Population Sciences, 6, 35-41, 1985. \n40-Histochemical study of the endometrium of infertile women. Egypt. J. Histol. 8(1) 63-66, 1985. \n41-Genital flora in pre- and post-menopausal women. Egypt. J. Med. Sci. 4(2), 165-172, 1983. \n42-Evaluation of the vaginal rugae and thickness in 8 different groups. Journal of the Egypt. Soc. of Ob./Gyn. 9:2, 101-114, May 1983. \n43-The effect of menopausal status and conjugated oestrogen therapy on serum cholesterol, triglycerides and electrophoretic lipoprotein patterns. Al-Azhar Medical Journal, 12:2, 113-119, April 1983. \n44-Laparoscopic ventrosuspension: A New Technique. Int. J. Gynaecol. Obstet., 20, 129-31, 1982. \n45-The laparoscope: A useful diagnostic tool in general surgery. Al-Azhar Medical Journal, 11:4, 397-401, Oct. 1982. \n46-The value of the laparoscope in the diagnosis of polycystic ovary. Al-Azhar Medical Journal, 11:2, 153-159, April 1982. \n47-An anaesthetic approach to the management of eclampsia. Ain Shams Medical Journal, accepted for publication 1981. \n48-Laparoscopy on patients with previous lower abdominal surgery. Fertility management edited by E. Osman and M. Wahba 1981. \n49-Heart diseases with pregnancy. Population Sciences, 11, 121-130, 1981. \n50-A study of the biosocial factors affecting perinatal mortality in an Egyptian maternity hospital. Population Sciences, 6, 71-90, 1981. \n51-Pregnancy Wastage. Journal of the Egypt. Soc. of Ob./Gyn. 11:3, 57-67, Sept. 1980. \n52-Analysis of maternal deaths in Egyptian maternity hospitals. Population Sciences, 1, 59-65, 1979. \nArticles published on OBGYN.net: \n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n2- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n3- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n4-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n5-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n6-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n7-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n8-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n9- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n10-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n11- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.\n Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/urethro-plasty_01\n\n12-Ibrahim M. Kandil, Abdel Karim M. El Hemaly, Mohamad M. Radwan: Ultrasonic Assessment of the Internal Urethral Sphincter in Stress Urinary Incontinence. The Internet Journal of Gynecology and Obstetrics. 2003. Volume 2 Number 1. \n\n13-Abdel Karim M. El Hemaly. Nocturnal Enureses: A Novel Concept on its pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecolgy/?page=articles/nocturnal_enuresis\n\n14- Abdel Karim M. El Hemaly. 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