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   Table of Contents - Current issue
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September-December 2016
Volume 3 | Issue 3
Page Nos. 81-140

Online since Friday, April 21, 2017

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EDITORIAL  

Treating an obese infertile patient – Is there an algorithm for success? Highly accessed article p. 81
Gautam Nandkishore Allahbadia
DOI:10.4103/2348-2907.204666  
The effect of obesity on female reproduction has been well documented to have a significant effect on ovulation, particularly in patients with a predisposition to this, but it can also increase the time required to conceive and the risk of early miscarriage in patients with normal ovulation patterns. Obesity in infertile women increases the costs of fertility treatments, reduces success rates and increases significantly the risks of many complications of pregnancy and for the newborn. Studies suggest that even a modest loss of 5%–10% of body weight can restore ovarian cyclicity. However, there are gaps in knowledge regarding the benefits and cost-effectiveness of a lifestyle modification program versus bariatric surgery targeting obese infertile women and integrated into the in vitro fertilization (IVF) clinics. Polycystic ovary syndrome is a common cause of ovulatory dysfunction impacting women of reproductive age. Factors such as the individual's body weight influence the severity of the phenotype and risk of metabolic comorbidities. Obesity and insulin resistance are thought to potentiate disruptions in antral follicle development that result in chronic anovulation, and as such, have become important therapeutic targets of dietary interventions aimed at weight loss. Obesity is associated with higher doses of ovulation inducing medications to achieve ovulation or stimulation for IVF. Obese women undergoing IVF also have a reduced chance of clinical pregnancy and live birth as compared to normal weight women. Particularly in late reproductive years, the benefits of postponing pregnancy to achieve weight loss must be balanced against the risk of declining fertility with advancing age. Recent research suggests that mild ovarian stimulation might yield healthier oocytes in obese women.
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ORIGINAL ARTICLES Top

Role of testosterone pretreatment in poor ovarian responders undergoing in vitro fertilization/intracytoplasmic injection in comparison with growth hormone p. 90
Pratibha Vishwakarma, Indumathi Joy, Thankam R Varma
DOI:10.4103/2348-2907.204667  
Objective: Androgen can play a synergistic role with follicle-stimulating hormone in promoting the early follicular recruitment, which is critical in Assisted Reproduction Technique program. In patients with poor ovarian response (POR) and poor ovarian reserve may benefit from testosterone gel application and growth hormone. This study was done to assess whether poor responders can benefit from androgen therapy before in vitro fertilization/intracytoplasmic sperm injection and from growth hormone. Study Design: It is a prospective pilot study on 35 patients with previous POR and poor ovarian reserve attending IRM, OPD between January 2015 and December 2015 for 1 year. Materials and Methods: Selected women received transdermal therapy of testosterone gel 12.5 mg over the skin of shoulder and upper arm for 21 days from day 7 to day 27 of cycle during oral contraceptive pills if the cycle was not regular and gel treatment before gonadotropin stimulation cycle for next one cycle. Hormone assessment (total testosterone, sex hormone-binding globulins, and androstenedione level) was done at the beginning and at the end of the gel application. Ovarian stimulation with fixed antagonist protocol was used. The primary outcome is improvement in antral follicle count (AFC), the total number of oocyte retrieved, number of mature oocytes, and good quality of embryos. In this study, implantation rate and clinical pregnancy rate were also assessed. If patient did not respond to testosterone gel, growth hormone was used in next cycle with gonadotropins and same parameters were used. Results: In this study, we found that two drugs are comparable in terms of clinical pregnancy rate, ongoing pregnancy rate, and live-birth rate. We found that number of cryopreserved embryos and cumulative pregnancy rate are more in testosterone group. Fertilization rate and cleavage arrest were similar in both groups. Cancellation rate was less, and duration of gonadotropins treatment was more in testosterone-only group. Significantly increased androstenedione level was seen in improved cycles of testosterone gel treatment. Out of 35 patients with testosterone gel treatment, in 42.9% cases, AFC improved. Conclusion: Testosterone gel treatment is useful in patients with poor ovarian reserve or poor ovarian responders in terms of improving AFC, more number of oocytes, increased number of embryos and increased number of cryopreserved embryos, and hence cumulative pregnancy rate. Growth hormone had equivalent results with testosterone gel with less number but good-quality oocytes and embryos. This is a pilot study, including a small number of patients; hence, further randomized trials are needed before using expensive and injectable drug, i.e., growth hormone in poor responders.
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Sharma's dried tree branch fallopian tubes sign: A new laparoscopic sign in female genital tuberculosis with infertility p. 98
Jai Bhagwan Sharma
DOI:10.4103/2348-2907.204665  
Background: Female genital tuberculosis (FGTB) involves fallopian tubes in 95%–100% cases causing various tubal abnormalities. Objective: To evaluate the laparoscopic findings in FGTB with special reference to a new dried tree branch fallopian tubes sign. Materials and Methods: A total of eighty cases of FGTB diagnosed by demonstration of acid-fast bacilli on microscopy or culture on endometrial or peritoneal biopsy or positive endometrial or peritoneal biopsy or demonstration of epithelioid granuloma on biopsy or positive polymerase chain reaction to Mycobacterium tuberculosis on endometrial biopsy with findings of FGTB on laparoscopy or hysteroscopy were included in this prospective study. Diagnostic laparoscopy was performed in all cases. Results: Definite findings of FGTB such as caseous nodules, tubercles, beaded tubes were seen in 33 (41.2%) cases while probable findings of FGTB such as congested and hyperemic fallopian tubes, hydrosalpinx obstructed tubes, pelvic adhesions, and straw-colored fluid were observed in rest 47 (58.8%) cases. A new dried tree branch fallopian tubes sign was seen in 7 (8.0%) cases being bilateral in 4 (5%) and unilateral in 3 (3.7%) cases. Conclusion: The new sign Sharma's dried tree branch fallopian tubes sign appears to be a useful sign in FGTB. However, larger prospective studies are needed before its routine recommendation in clinical practice.
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Antral follicle count: Is the right ovary more predictive than the left for live birth? p. 104
Samantha Simpson, Ilana B Ressler, Peter Kovacs, Rachel Warwar, Kathleen O'Leary, Rose A Maxwell, Steven R Lindheim
DOI:10.4103/2348-2907.204671  
Objective: The objective of this study was to assess the impact of discordant ovarian antral follicle counts (AFCs) on cycle stimulation and live birth in autologous in vitro fertilization (IVF) cycles. Materials and Methods: This is a retrospective analysis of first-time cycles of 153 patients undergoing gonadotropin-releasing hormone-antagonist IVF. Results: While AFC significantly correlated with cycle stimulation characteristics, only the right ovarian AFC significantly correlated with live birth (r = 0.18, P< 0.02). Right ovarian AFC was significantly greater in live birth cycles (12.3 ± 7.8) compared to cycles without a live birth (9.6 ± 6.0, P< 0.02). Using ≤ 7 as a threshold of low unilateral AFC, concordant low AFC was present in 28% (Group 1: n = 43); discordant low left and normal right in 13% (Group 2: n = 19); discordant low right and normal left in 11% (Group 3: n = 17); and concordant normal in both ovaries in 48% (Group 4: n = 74) of patients. Live birth was similar in Group 2 (36.8%), Group 3 (35.3%), and Group 4 (37.8%), but significantly less in Group 1 (9.3%) (P < 0.05). Conclusion: Live birth was higher with greater right AFC. Using threshold AFC, adverse outcomes were only noted when both ovaries had low counts. Individual AFC may serve as a more specific indicator than total AFC as a marker of ovarian reserve.
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Elevated levels of diabetes-associated peptide hormones in the follicular fluid and serum of obese polycystic ovary syndrome patients are associated with suboptimal ovarian response p. 110
Julie M Sroga-Rios, Alan M Martinez, David R Cool, Krystene B DiPaola, Steven R Lindheim
DOI:10.4103/2348-2907.204672  
Objective: To compare diabetes-associated peptide hormones (DAPHs) and inflammatory markers in the follicular fluid (FF) and serum among polycystic ovary syndrome (PCOS) patients as compared to controls undergoing in vitro fertilization (IVF). Study Design: Levels of DAPHs and inflammatory markers in FF and serum were measured and correlated to IVF cycle outcomes and clinical pregnancy rate in three IVF groups: obese PCOS (n = 8), lean PCOS (n = 12), and controls (n = 11). Methods: Follicular fluid and serum were prosectively collected from obese and lean pcos and control females undergoing IVF. BioFlex ® array was used to analyze all samples from subjects. IVF cycle outcomes were collected on all subjects. Results: Ten DAPHs were assessed. Obese PCOS had higher levels of C-peptide (194.4 ± 163.5 pg/mL, P< 0.03), insulin (172.6 ± 113.6 pg/mL, P< 0.01), and leptin (10,046.1 ± 4920.2 pg/mL, P< 0.05) in FF as compared to lean PCOS and controls. Obese PCOS patients had higher levels of serum leptin (5575.5 ± 1650.2 pg/mL), with a difference in leptin concentrations noted between obese PCOS and controls (P < 0.01) and between obese and lean PCOS patients (P < 0.01). Higher levels of C-peptide (P < 0.04) and leptin (P < 0.01) in the FF were associated with increased total gonadotropin drug usage. There was a trend toward fewer oocytes retrieved (P < 0.06) and significantly lower number of normally fertilized zygotes (P < 0.04), with higher C-peptide levels. A trend toward increased clinical pregnancy rates was noted with lower serum levels of leptin (P < 0.08). Conclusions: DAPHs may play a role in the suboptimal ovarian response seen in obese IVF patients with PCOS as compared to lean PCOS patients and controls. Further studies are needed to understand if the evaluations in DAPH are secondary to obesity itself or are specific to this subset of PCOS patients.
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Relationship between uterine scoring system for reproduction and pregnancy in controlled ovarian stimulation-intrauterine insemination cycles p. 115
R Nayak Navinchandra, Shetty Theertha Shankar, D'souza Kavitha, Mangala Gowri Kamath, Shetty Pradnya Devdas, P Vineela
DOI:10.4103/2348-2907.204669  
Aims: (1) Evaluation of uterine scoring system for reproduction (USSR) score in controlled ovarian stimulation-intrauterine insemination (COS-IUI) cycles. (2) Evaluation of the relationship between USSR score and pregnancy in COS-IUI cycles. Settings and Design: Prospective observational study. Materials and Methods: The study comprised women visiting the department with unexplained infertility for a COS-IUI cycle. A total of 30 cycles were inducted. Baseline transvaginal sonography (TVS) was performed on day 2 of the cycle. Stimulation was performed with clomiphene citrate (50 or 100 mg). On day 5, the recruitment and dominance of follicles were studied by TVS. In the absence of dominance and/or in need of increase in recruitment, urinary gonadotropin was administered. TVS was repeated every 2 days until the dominant follicle was 15 mm and then on a daily basis till follicle reached 18 mm. USSR score was then evaluated and injection. Human chorionic gonadotropin (HCG) 10,000 units was given for follicular rupture. IUI was done 34–36 h posttrigger with prepared semen samples containing at least 15 million motile sperms. Women with serum β HCG values of ≥ 25 IU/ml on the 16th post-IUI day were pregnancy positive. Statistical Analysis: Chi-square test. Results: None had a USSR score of 20. Two had a score of 17–19, two had score of 14–16, 26 had a score of ≤13. Of the 30 women, three conceived. Two of the three had a score of 17 and one had a score of 16. Conclusions: USSR can prove to be a simple, noninvasive, and authentic score to predict the uterine environment and help in the prediction of outcome.
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CASE REPORTS Top

Air embolism during hysteroscopy: Case report of a catastrophic event p. 121
Bhavana Girish, Rimpi Singla
DOI:10.4103/2348-2907.204668  
Diagnostic hysteroscopy is one of the most commonly performed procedures in the evaluation of infertility. Air embolism is an extremely rare but catastrophic and often fatal complication occurring during hysteroscopy. We present a patient who developed massive air embolism during diagnostic hysteroscopy performed under general anesthesia. During the procedure, she developed sudden onset desaturation followed by cardiac arrest. The procedure was immediately stopped, cardiac massage and inotropic support were started, and the patient was shifted to the Intensive Care Unit on ventilator support. Positive end-expiratory pressure and heparin for emboli, midazolam for brain protection, and inotropes were administered. Despite extensive resuscitative efforts, the patient died 4 h after the event.
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Could zona-free blastocyst transfer be the next step in optimizing in vitro fertilization outcomes? A case report of successful outcome after zona-free fresh embryo transfer with preimplantation genetic screening p. 124
Harsha K Bhadarka, Nayana H Patel, Kruti B Patel, Yuvraj D Jadeja
DOI:10.4103/2348-2907.204670  
The objective of this study was to study successful outcome after zona-free fresh embryo transfer with preimplantation genetic screening (PGS) in assisted reproductive technology. The study design was a case report. The study was conducted at in vitro fertilization (IVF) clinic. Patients with multiple IVF failure and miscarriage were included in the study. Zona-free fresh embryo transfer after PGS was intervened. The main outcome measure was live birth after IVF. In a PGS-indicated patient, zona-free chromosomally normal embryo was transferred and live healthy female baby weighing 2.7 kg was delivered.We report a case of natural complete hatching of an embryo after PGS, which was aided by mechanical breach of zona for trophectoderm biopsy. Carefully transferred zona-free embryo in a surrogate resulting in successful pregnancy and live birth which indicates that a good human blastocyst must have ability to expand in vitro and completely hatch out from zona after transfer for implantation.
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ABSTRACTS Top

2nd World Congress on Embryo Transfer and Intrauterine Insemination (WETI 2016) p. 128
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