Term
diagnostic criteria for RPL |
|
Definition
2+ losses <20 (not counting ectopic, biochemical, molar) |
|
|
Term
what is a sign in the pregnancy that significantly decreases the risk of loss |
|
Definition
|
|
Term
what is the work up for RPL - 7 |
|
Definition
cavity assessment (HSC, SIS, HSC, TVUS, MRI), karyotype (maternal, paternal, fetal tissue perferred), TSH, androgens, HBA1C, PRL, luteal length |
|
|
Term
what are some adjunct labs you could get for RPL if the patient has risks factors or concerning symptoms - 4 |
|
Definition
thrombophilia, APAS, infection, autoimmune |
|
|
Term
risk of pregnancy loss the next pregnancy if you had 3, 4, 5, 6 losses |
|
Definition
3 - 30% 4 - 30% 5 - 40% 6 - 50% |
|
|
Term
what percent of RPL is due to a genetic condition |
|
Definition
|
|
Term
what percent of RPL is due to APAS |
|
Definition
|
|
Term
what percent of RPL is due to a uterine anomaly |
|
Definition
|
|
Term
4 endocrine disorders that cause PRL |
|
Definition
hyperprolactinamia, hypothyroid, diabetes, PCOS |
|
|
Term
|
Definition
age, genetic, uterine anomaly, fibroids, APAS, smoking, alcohol, caffeine, infection, luteal phase deficiency, endocrine, SLE, hyperprolactinemia |
|
|
Term
why do older women have RPL |
|
Definition
mitotic spindle dysfunction increases the risk of aneuploidy |
|
|
Term
risk of aneuploidy at 20, 35, 40, 45yo |
|
Definition
20y 1:250, 35y 1:200, 40y 1:65, 45y 1:25 |
|
|
Term
why do older men have a risk of RPL |
|
Definition
increased (slight) aneuploidy of sperm |
|
|
Term
|
Definition
|
|
Term
#1 chromosomal cause of SAB |
|
Definition
|
|
Term
#1 chromosomal rearrangement causing SAB |
|
Definition
unbalance reciporical translocation |
|
|
Term
what is a reciporical translocation |
|
Definition
exchange of arm of nonhomologous chromosome causing balanced (silent) or unbalanced (SAB risk) translocation |
|
|
Term
what is a robertosonin translocation |
|
Definition
exchange of arm of acrocentric chromosomes (13, 14, 15, 21, 22) causing usually unbalanced translocations which can lead to RPL |
|
|
Term
what has a higher risk of RPL reciporical or robertosonian translocations |
|
Definition
|
|
Term
what are the acrocentric chromosomes |
|
Definition
|
|
Term
what TSH level is associated with SAB |
|
Definition
TSH >4 or TSH >2.5 with TPO antibodies |
|
|
Term
|
Definition
|
|
Term
HBA1C where DM increases SAB |
|
Definition
no increased SAB unless uncontrolled, goal A1C <7 |
|
|
Term
what can decrease SAB in PCOS patients |
|
Definition
|
|
Term
|
Definition
|
|
Term
rate of SAB in thrombophilia |
|
Definition
no definitive link to SAB |
|
|
Term
what is the gold standard, perferred, and other 2 methods for diagnosis of uterine anomalies |
|
Definition
gold standard is LSC, perferred is 3D US less invasive, 2D US has 90% sensitivity, HSG does not see exterior |
|
|
Term
#1 uterine developmental anomaly |
|
Definition
|
|
Term
cause of a uterine septum |
|
Definition
incomplete RESORPTION of the medial septum from paramesonepheric fustion |
|
|
Term
cause of a unicornuate uterus |
|
Definition
failure of one of the mullerian ducts |
|
|
Term
cause of bicornuate uterus |
|
Definition
incomplete FUSION of the mullerian ducts |
|
|
Term
|
Definition
no FUSION of the mullerian ducts |
|
|
Term
|
Definition
|
|
Term
which uterine anomalies cause PTD |
|
Definition
unicornuate, bicornuate, didephius? |
|
|
Term
which uterine anomalies cause SAB and rate |
|
Definition
|
|
Term
how can you tell bicornuate and septate apart |
|
Definition
septate will have a convex fundus with a <1cm indent, bucornuate will have 1cm indent |
|
|
Term
which uteirne anomalies are associated with renal anomalies and what rate |
|
Definition
unicornuate 40%, bicornuate 15%, didelphius ? |
|
|
Term
risk of uterine anomalies if exposed to DES in utero |
|
Definition
|
|
Term
uterine anomalies if exposed to DES in utero - 2 |
|
Definition
T uterus, cockscomb cervical hood |
|
|
Term
which type of fibroid increases SAB |
|
Definition
submucosal, IM insufficient evidence |
|
|
Term
which uterine anomalies increase the risk of malpresentation |
|
Definition
|
|
Term
what is a luteal phase deficiency |
|
Definition
decreased progesterone from corpus luteum before 7wk gestation when the placenta takes over |
|
|
Term
how is luteal phase deficiency diagnosed - 2 |
|
Definition
it isnt, there is no good test. luteal phase <13d, EMBX path >2d from menstural dating |
|
|
Term
if you suspect a luteal phase deficiency what do you need to rule out |
|
Definition
thyroid and prolactin disorders, both shorten the luteal phase |
|
|
Term
management of luteal phase deficiency |
|
Definition
progesterone does not help, nothing to do |
|
|
Term
% of reporductive age women with APAS |
|
Definition
|
|
Term
% of SLE patients with APAS |
|
Definition
|
|
Term
diagnosis of APAS - clinical |
|
Definition
VTE, 3+ SAB <10wk, 1+ loss >10wk, PTD <34w with placental insufficiency or pre-e |
|
|
Term
|
Definition
antiphospholipid Ab, B2 microglobulin, anticardipin Ab (2x >12wk apart, IgG/M) |
|
|
Term
why does APAS cause RPL and VTE |
|
Definition
antibiodies to maternal and trophoblast vessel endothelium, antibodies to trophoblast itself |
|
|
Term
complications of APAS clinically - 7 |
|
Definition
VTE, IUGR, pre-e, RPL, stillbirth, amaurosis fugax, alloimmune thrombocytopenia (50%) |
|
|
Term
infection that is associated with RPL |
|
Definition
|
|
Term
possible infections potentially associated with RPL - 4 |
|
Definition
ureaplasma, mycoplasma, toxoplasma, listeria |
|
|
Term
effects of smoking on fertility - |
|
Definition
increases time to conception, increases SAB, early menopause due to follicle toxicity |
|
|
Term
alcohol level that would contribute to RPL |
|
Definition
|
|
Term
caffeine level that would contribute to RPL |
|
Definition
|
|
Term
APAS DVT prevention - pregnant and history of VTE |
|
Definition
|
|
Term
APAS DVT prevention - has RPL |
|
Definition
|
|
Term
APAS DVT prevention - pregnant and no history of VTE |
|
Definition
|
|
Term
|
Definition
anything without estrogen |
|
|
Term
|
Definition
|
|
Term
% of infertility that is female, male, both, unexplained |
|
Definition
female 40%, male 30%, both 10%, unexplained 20% |
|
|
Term
% of infertile patients with depression |
|
Definition
|
|
Term
% of depression after failed IVF |
|
Definition
|
|
Term
|
Definition
the ability to achieve a clinically recognized pregnancy |
|
|
Term
|
Definition
probability per menstural cycle of achieving a pregnancy |
|
|
Term
|
Definition
ability of a couple to achieve a live birth |
|
|
Term
|
Definition
>1y without contraception and regular intercourse without pregnancy, >6mo if 35yo+ |
|
|
Term
% that will conceive in 3, 6, 12, 24mo |
|
Definition
3 - 57%, 6 - 72%, 12 - 85%, 24 - 93% |
|
|
Term
indications to refer to REI - 6 |
|
Definition
>40yo, >35yo, oligomenorrhea, suspected uterine/tubal disease, stage 3-4 endo, suspected male factor |
|
|
Term
after the LH surge how long until an egg is released |
|
Definition
36-48h, 24h from the peak |
|
|
Term
|
Definition
|
|
Term
how long can a sperm live |
|
Definition
|
|
Term
what is the window of fertility |
|
Definition
the 72h before ovulation is highest rates |
|
|
Term
how can you evaluate ovarian reserve - 4 |
|
Definition
AFC, CD4 FSH/E2/inhibin B, clomiphine challenge, antimullerian hormone |
|
|
Term
ways to evaluate if someone is ovulating |
|
Definition
D1 progesterone >3 (if not repeat it because they could have long cycles) |
|
|
Term
what do you need to evaluate in infertility - 7 |
|
Definition
if their ovulating, ovarian reserve, tubes, uterus, TSH, HBA1C, prenatal labs |
|
|
Term
what are some labs you can consider in an infertility work up if the patient meets criteria - 4 |
|
Definition
thrombophilia, karyotype (abn SA, POF), EMBX if AUB and qualifies, PRL if AUB |
|
|
Term
what is a normal CD4 FSH, E3, inhibin B, is elevation or decrease indication of decreased ovarian reserve |
|
Definition
FSH <10 (increased means less follicles), E2 <60 (increased means there is advanced follicle recruitment in old ovaries), inhibin B should be elevated (if decreased less ability to concieve, non specific) |
|
|
Term
how does a clomiphine challenge work |
|
Definition
CD3 FSH/E2 -> CD 5-9 100mg colmiphine -> CD10 FSH/E2 |
|
|
Term
how is a clomiphine challenge inerperted |
|
Definition
FSH <10 and lower E2 is normal, increased FSH means less follicles |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
made in granulosa cells, recruitment (transitions resting follicles into growing follicles) |
|
|
Term
what are 3 ways to monitor if someone is ovulating |
|
Definition
basal body temp, serum LH, urine LH, cervical mucous |
|
|
Term
what is the best monitoring for ovulation |
|
Definition
serum LH, 1st day of surge will be mid cycle |
|
|
Term
what is the worst way to monitor if someone is ovulating |
|
Definition
basal body temp, its too late, it rises after ovulation and there isnt enough to sex before the egg dies |
|
|
Term
how effective is urine LH at monitoring for ovulation |
|
Definition
less than serum LH but also indicates mid ovulation |
|
|
Term
what can falsley elevate urine LH - 2 |
|
Definition
|
|
Term
how do you use cervical mucous to monitor ovulation |
|
Definition
peaks 2-3d before ovulation |
|
|
Term
why cant you use progestetrone to monitor for ovulation |
|
Definition
it peaks after ovulation, too late |
|
|
Term
5 values indicating decreased ovarian reserve |
|
Definition
AMH <1, FSH >10 CD3, E2 >60 CD3, AFC <5-7, <4 oocytes retreived |
|
|
Term
what does decreased ovarian reserve say about the ability to concieve, risk of SAB, and overall fertility |
|
Definition
it doesnt say anything about any of these things, only the response they will have to stimulation |
|
|
Term
7 causes of decreased ovarian reserve |
|
Definition
fragile X, PCOS, turners, chemo/RT, ovarian surgery, kallmans, hyperprolactin |
|
|
Term
the 5 factors to consider as causes for infertility |
|
Definition
ovarian reserve, tubal, uterine, endometriosis, unexplained |
|
|
Term
% of infertility that is tubal factor |
|
Definition
|
|
Term
#1 cause of tubal factor infertility |
|
Definition
|
|
Term
% that recall having PID and % that have chlamydia Ab and clinical signs of PID |
|
Definition
31% recall it, 79% had it |
|
|
Term
what is a way you can avoid LSC/chromo if someone has a HSG with no flow and it could be tubal spasm |
|
Definition
if they have negative chlamydia antibodies you can consider skipping and assume it was spasm |
|
|
Term
salpingitis accounts for % of ectopic pregnancies |
|
Definition
|
|
Term
risk of ectopic in salpingitis |
|
Definition
|
|
Term
risk of tubal infertility after 1, 2, 3 pelvic infections |
|
Definition
1 - 10%, 2 - 30%, 3 - 75% |
|
|
Term
causes of tubal factor infertility - 4 |
|
Definition
salpingitis, tubal fibrosis/endometriosis, essure/tubal, salpingitis isthmica nodosa, hydrosalpinx |
|
|
Term
hydrosalpinx decreases pregnancy by % |
|
Definition
|
|
Term
what is the recommendation for infertility treatment if salpingitis isthmica nodosa is diagnosed |
|
Definition
IVF is recommended, high risk of ectopic |
|
|
Term
what is salpingitis isthmica nodosa |
|
Definition
diverticula of the mucosa into the mesosalpinx |
|
|
Term
what is the recommended fertility treatment for tubal fibrosis/endometriosis |
|
Definition
could try micro surgical excision/repeair |
|
|
Term
what is the recommended fertility treatment if someone has essure |
|
Definition
|
|
Term
can essure coils poke the baby |
|
Definition
25% are encapsulated, donno |
|
|
Term
what is the fecundity rate of unexplained infertility |
|
Definition
1.8-3.8% depending on age and length of infertility |
|
|
Term
why does endometriosis cause infertility - 4 |
|
Definition
inflammation (increased IL1, IL6, NK), decreased tubal transport |
|
|
Term
4 types of male infertility and their prevalence |
|
Definition
idiopathic 40%, pre-testicular 1%, testicular 40%, post-testicular 20% |
|
|
Term
management of idiopathic male infertility |
|
Definition
|
|
Term
how does clomiphine help with male infertility - 3 |
|
Definition
increases rate of pregnancy, sperm concentration, sperm motility |
|
|
Term
what phsyiologic process causes pre-testicular male infertility |
|
Definition
hypogonadotrophic hypogonadism |
|
|
Term
causes of male hypogonadotrophic hypogonadism - 6 |
|
Definition
kallmans, steroids, testosterone replacement, obesity, hyperprolactinemia, brain mass |
|
|
Term
what brain masses can cause male hypogonadotrophic hypogonadism - 4 |
|
Definition
harmatoma, craniopharyngoma, lymphoma, pituitary tumor |
|
|
Term
why does hyperprolactinemia cause male hypogonadotrophic hypogonadism |
|
Definition
PRL inhibits LH which decreases testosterone which makes less sperm |
|
|
Term
signs of male hyperprolactinemia - 5 |
|
Definition
ED 99%, decreased libido 88%, decreased body hair 40%, gynecomastic 21%, galactorrhea 13% |
|
|
Term
causes of male hyperprolactinemia - 2 |
|
Definition
pituitary tumor, drug induced |
|
|
Term
treatment of male hyperprolactinemia - 2 |
|
Definition
dopamine agonists, testosterone for libido only does not help fertility |
|
|
Term
causes of testicular male infertility - 4 |
|
Definition
karyotype abnormalities, chemo/RT, trauma/torsion, varicocele |
|
|
Term
2 karyotype abnormalities causing male infertility |
|
Definition
kleinfelters syndrome, Y chromosome AZF deletion |
|
|
Term
what % of men with sex chromosome aneuploidy and infertility have kleinfelters |
|
Definition
|
|
Term
how is kleinfelters inherited |
|
Definition
can pass to male offspring |
|
|
Term
how is AZF deletion diagnosed |
|
Definition
|
|
Term
how is AZF deletion sometimes identified |
|
Definition
|
|
Term
3 types of AZF deletion and their sperm prognosis |
|
Definition
A - proximal - azospermia B - central - azospermia C - distal - oligospermia |
|
|
Term
which AZF deletion is inherited |
|
Definition
C is always passed to any son |
|
|
Term
management of infertility if AZF deletion |
|
Definition
AZFc - try testicular extraction AZFa-b - sperm donor |
|
|
Term
|
Definition
dilated panpiniform plexus |
|
|
Term
|
Definition
|
|
Term
varicocele accounts for __% of primary and __% of secondary male infertility |
|
Definition
40% primary, 80% secondary |
|
|
Term
how is infertility managed with varicocele |
|
Definition
surgical treatment improves fertility |
|
|
Term
how are varicoceles graded |
|
Definition
1 - only seen with valsalva 2 - palpable without valsalva 3 - visible when standing |
|
|
Term
5 causes of post-testicular infertility |
|
Definition
absent vas deferens, epididymal obstruction, ejaculatory duct obstruction, erectile dysfunction, ejaculatory dysfunction |
|
|
Term
4 types of ejaculatory dysfunction |
|
Definition
premature, delayed, anorgasmia, retrograde |
|
|
Term
what is retrograde ejaculation |
|
Definition
sperm reflux into the bladder and are affected by the acidic urine |
|
|
Term
3 causes of retrograde ejaculation |
|
Definition
MS, DM neuropathy, cord injury |
|
|
Term
how is retrograde ejaculation diagnosed- 2 |
|
Definition
ejaculate with urine in it, decreased semen <1mL |
|
|
Term
how is retrograde ejaculation treated - 2 |
|
Definition
antihistamines/ephedrine to close the bladder neck, IUI is best for infertility |
|
|
Term
|
Definition
|
|
Term
what other lab value should be abnormal in azospermia |
|
Definition
|
|
Term
testing that needs to be done if azospermia - 5 |
|
Definition
Y chromosome for AZF, CF, testosterone, FSH, HPA imaging if hypogonadotrophic hypogonadism |
|
|
Term
AZF is __% of men with azospermia |
|
Definition
|
|
Term
2 types of tubal microsurgery repair |
|
Definition
HSC catheterization, microsurgical resection |
|
|
Term
method of tubal ligation BTA success in order |
|
Definition
clips > bands > pomeroy > cauterization |
|
|
Term
length a tube must be for BTA |
|
Definition
|
|
Term
area of tube where ligation occured BTA success in order |
|
Definition
|
|
Term
# factor in success of BTA |
|
Definition
|
|
Term
|
Definition
|
|
Term
#1 infertility med for unexplained infertility |
|
Definition
|
|
Term
#1 infertility med for PCOS, why -2 |
|
Definition
letrazone - increases ovulation, increases live birth rate |
|
|
Term
infertility med for hypogonadotrophic patients |
|
Definition
|
|
Term
infertility meds for non hypogognadotrophic patients |
|
Definition
|
|
Term
|
Definition
E2 antagonist, decreases E2 feedback which increases GNRH and thus FSH which causes follicle development |
|
|
Term
|
Definition
50mg/d CD 5-9 can increase up to 200mg |
|
|
Term
|
Definition
multiples, hot flashes, headache, irritability, visual changes |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
aromatase inhibitor decreases testosterone which decreases estrogen, lack of estrogen negative feedback causes increased GNRH and thus FSH which causes follicle development |
|
|
Term
|
Definition
|
|
Term
side effects letrazole - 9 |
|
Definition
headache, hot flashes, mood swings, night sweats, osteoporosis, nausea, constipation, dizziness, fatigue |
|
|
Term
contraindications to clomid - 3 |
|
Definition
breast feeding, pregnancy, <18yo |
|
|
Term
what are gonadotropins (the med) |
|
Definition
|
|
Term
|
Definition
|
|
Term
indications for gonadotropins - 3 |
|
Definition
hypogonadotrophic hypogonadism, PCOS, failed others 3-6C |
|
|
Term
rate of OHSS in infertility tx |
|
Definition
|
|
Term
|
Definition
increased hCG causes increased VEGF which causes vascular permability which causes extravascular fluid, hemoconcentration, and decreased end organ perfusion, all of this can cause VTE too |
|
|
Term
|
Definition
|
|
Term
labs for moderate OHSS - 2 |
|
Definition
|
|
Term
|
Definition
HCT >51%, WBC >25, elevated LFT, CrCl <50, Cr >1.6, Na <135 |
|
|
Term
|
Definition
abdominal pain, distention, nausea, vomiting, diarrhea |
|
|
Term
signs of moderate OHSS - 2 |
|
Definition
|
|
Term
|
Definition
clinical ascites, hydrothorax, dyspnea, oliguira, intractable N/V, hypotension, rapid weight gain, syncope, severe pain |
|
|
Term
signs of critical OHSS - 6 |
|
Definition
aneuria, arrhythmia, VTE, pericardical effusions, hydrothorax, ARDS |
|
|
Term
|
Definition
|
|
Term
risk in OHSS at all stages |
|
Definition
torsion (high in ART, higher in OHSS) |
|
|
Term
|
Definition
supportive, cabergoline to reverse VEGF |
|
|
Term
|
Definition
cancel cycle and withold gonadotrophins when indicated, freeze embryos, cabergoline PPX |
|
|
Term
treatment of unexplained infertility |
|
Definition
patient is ovulating on their own so OI/TI wont work, IUI alone was tried and it didnt work, best is OI/IUI, als decreased smoking, BMI, caffeine |
|
|
Term
fecundity with OI/IUI in unexplained infertility |
|
Definition
|
|
Term
|
Definition
1 - hCG 10d 2 - egg retrevial 30-36h post trigger shot 3 - progesterone for luteal support 4 - embryo transfer 5 - 10-11d take a pregnancy test |
|
|
Term
|
Definition
male factor infertility, PGD, in vitro matured eggs, prior frozen eggs, surgical retrevied sperm |
|
|
Term
|
Definition
imprinting disorders - beckwith-weidman, angelman |
|
|
Term
rate of beckwith weidman with ISCI |
|
Definition
|
|
Term
cause of becjwith weidman |
|
Definition
increased with ISCI, CH 11 methylation error |
|
|
Term
signs of beckwith weidman - 4 |
|
Definition
macrosomia, microglossia, midline abdominal defects, embryonal carcinoma risk |
|
|
Term
|
Definition
multiples 30x, monozygotic twins increased, cardiac defects 1 to 3% (ASD/VSD most common), imprinting disorders, sex chromosome disorders |
|
|
Term
|
Definition
|
|
Term
4 types of sample collection for PGT |
|
Definition
polar body, blastomere, blastocyst trophectoderm, FISH |
|
|
Term
what is the best sample collection for PGT |
|
Definition
blastocyst trophectoderm, 100s of cells |
|
|
Term
why is blastomere sampling not the best collection for PGT |
|
Definition
only samples one cell may not represent |
|
|
Term
what is FISH PGT and its accuracy |
|
Definition
specific chromosome probes, 60% accurate and does not improve live birth rate |
|
|
Term
|
Definition
PGT-M monogenic - single gene disorders PGT-SE - structiral rerangements (translocations, imprinting, disomy) PGT-A aneuploidy - whole chromosome abnormalities |
|
|
Term
how many times can someone donate sperm or eggs |
|
Definition
25 pregnancies allowed per donor per population of 800,000 |
|
|
Term
requirements for a sperm donor - 8 |
|
Definition
17yo min ideally <40yo, psych assessment, determined rights/legal if known donor, full history, quarentine 6mo if annomynouos, negative STI testing, common mutation screening, education on FHX specific mutation screening |
|
|
Term
if a sperm donor is educated on FHX specific mutation screening and declines what does the reciever of the sperm get to know |
|
Definition
that that have a FHX increased risk of mutations and declined genetic testing |
|
|
Term
complications of oocyte retrevial - 5 |
|
Definition
inicreased ovarian cancer if >12C, anesthesia complications, surgical complications, PID, OHSS |
|
|
Term
6 forms of fertility preservation |
|
Definition
oocyte cryopreservation, embryo cryopreservation, ovarian transplant, in-vitro maturation (experimental), ovarian tissue freezing (experimental), GNRH suppression |
|
|
Term
which is better oocyte or embryo cryopreservation and why |
|
Definition
embryo, oocytes have higher cytoplasm and dont thaw as well causing decreased implantation and pregnancy, improvements in slow thaw, virification, and cryoprotectant have improved it to almost the same as embryo though |
|
|
Term
what is an ovarian transplant |
|
Definition
moving ovary out of a radiotherapy field in cancer patient |
|
|
Term
what is in-vitro maturation |
|
Definition
experimental, taking oocytes without stimulation to use after cancer treatment |
|
|
Term
what is ovarian tissue freezing |
|
Definition
freezing part of the ovary and putting it back after cancer treatment |
|
|
Term
what is the concern for ovarian tissue freezing |
|
Definition
|
|
Term
how well does GNRH suppression work for protecting the ovaries during cancer treatments |
|
Definition
not very well, not increasing pregnancy rates, protects oocytes in pre-puberty better though |
|
|
Term
4 types of stem cells which are promising for making embryos |
|
Definition
hematopoetic/marrow strong bias not promising, embryonic (3 gem layers) promising, embryonal cancer (zygotes arrest) not promising, pluoripotent stem cells most promising |
|
|
Term
etihical issues with embryonic stem cells |
|
Definition
not their biologic offspring, embryo could parent multiple offspring |
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Term
concerns with embryonal stem cells |
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Definition
arrest at 6-8 cells likley due to imprinting, cancer so could have mutations |
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Term
concerns for pluoripotent stem cells |
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Definition
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Term
how do pruoripotent stem cells work |
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Definition
retroviral introduction into genes of somatic cells |
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