Background/Aim: Intrauterine insemination (IUI) is widely used for sub-fertile couples. The optimal method of evaluating semen analysis as a predictor of pregnancy is still not concluded. The aim of this study was to determine the best semen analysis parameter to predict pregnancy in IUI treatments and to evaluate when the sperm is insufficient to IUI, and the couple has to proceed with IVF. Materials and Methods: We evaluated all patients who underwent ovulation induction with IUI. The data were analyzed in different combinations to build the best model. Results: The semen analysis parameters that were found as the best predictors for pregnancy include volume, concentration, motility and morphology from the sperm analysis during the infertility evaluation. A cut-off of total motile normal morphology sperm count (TMNC) <4.8 × 10 ⁶ from these parameters yielded very low probability of pregnancy and in those cases it is recommended to refer patients to IVF. Conclusion: The model includes the normal morphology in the formula of total motile sperm count more accurately and significantly predicts pregnancy rate than the data of sperm in the day of IUI. Semen analysis results with TMNC <4.8 × 10 ⁶ should be considered as a threshold for referral to IVF.

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Female Genital Tuberculosis is a common cause of infertility in Asia and Africa due to tubal, endometrial and ovarian factors. In-vitro fertilization and embryo transfer is the only hope in women having tubal blockage but receptive endometrium. However, surrogacy or adoption may be needed if endometrium is also involved.

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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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We report a rare case of delayed implantation of frozen-thawed embryo transfer in a hormone-controlled cycle due to delayed window of implantation (WOI). Synchronizing embryo growth with the endometrial hormonal environment is important for successful implantation. Initially, our patient underwent multiple unsuccessful endometrium-matched blastocyst transfers after five days of progesterone treatment. We found that day 3 embryo and two-day delayed blastocyst transfers were more successful than the normal blastocyst transfer. Finally she underwent two successful single embryo implants that resulted in pregnancies. We suggest that a delay in the WOI may have been the cause for the recurrent implantation failure.

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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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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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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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Background: Previous trials have shown that neither conventional IVF nor natural cycle IVF is an effective treatment option for poor ovarian responders. However, none of the trials has examined the efficacy of accumulating embryos with serial minimal stimulation cycles, vitrifying the resulting embryos and transferring them in a remote cycle (IVF Lite protocol). Women with poor ovarian reserves, who commonly do not respond to conventional stimulation protocols, are left with few options when planning a family. The current study was undertaken to evaluate the efficacy of serial minimal stimulation in vitro fertilization (msIVF) cycles with vitrification of embryos for treatment of poor ovarian responders (PORs) as compared to conventional IVF protocols. Materials and Methods: This is a retrospective data analysis of PORs from June 2010 to November 2012. A total of 222 patients were included in the study. Ninety-seven patients underwent serial minimal stimulation cycles with vitrification and embryo banking (IVF Lite Group) and 125 patients underwent conventional controlled ovarian stimulation for IVF. The patients identified as PORs based on the Bologna criteria were included in the analysis. In the IVF Lite group, embryos were vitrified using Cryotec vitrfication protocol on Day 3. Once six embryos were banked with us, a frozen embryo transfer was planned. A maximum of 3 embryos were transferred. Main outcome measure was the clinical pregnancy rate defined as positive fetal heartbeat at 12 weeks of pregnancy. Results: There was no significant difference in the number of metaphase II (MII) oocytes retrieved between the both groups. The difference in the number of gonadotropins units required to produce one MII oocyte between the two groups was statistically highly significant: 680.4 units for the IVF Lite group and 4956.2 units for the conventional IVF group. The IVF Lite group had a higher percentage of good grade embryos. In the IVF Lite group, each patient underwent an average of 2.96 cycles of embryo accumulation before planning a frozen embryo transfer. An average of 6.2 embryos were accumulated for each patient. The clinical pregnancy rate (CPR) per embryo transfer was higher in the IVF Lite group (27.81%) than the conventional IVF group (15.15%). The CPR per patient was much higher in the IVF Lite (48.45%) than the conventional IVF group (24.0%). Conclusion: The results obtained in the current study demonstrate that the IVF Lite protocol consisting of ms-IVF, ACCU-VIT and rET is a very successful approach in treating poor responders. Very favorable rates of pregnancy can be achieved with IVF Lite protocol.

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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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Oral contraceptive (OC) pills are commonly used in patients undergoing in vitro fertilization to schedule cycle starts. This often helps with staff scheduling and efficiency. In this paper, the use of OC pre-treatment in assisted reproductive cycles will be discussed. The focus will be on the use of OC in gonadotropin releasing hormone (GnRH) antagonist cycles, GnRH agonist cycles, poor responders and finally in high responders. A recent meta-analysis of six randomized control trials concluded that in cycles with GnRH-antagonist protocols, OC pre-treatment: (1) Increases the duration of stimulation, (2) increases the total dose of gonadotropins and (3) resulted in a small but significant reduction in pregnancy rates. All these studies used pure follicle stimulating hormone for controlled ovarian hyperstimulation. These conclusions, however, may not be valid in cycles where the birth control pill free interval is 5 days, and there is use of combination protocols (luteinizing hormone or human menopausal gonadotropin add back). 17β-estradiol (E2, 4 mg/d) pre-treatment is a viable alternative to using OC. However, in these patients, gonadotropin stimulation should be started on the first day of estrogen discontinuation. In GnRH agonist cycles, pre-treatment with OC reduces the formation of functional ovarian cysts and may reduce the incidence of ovarian hyperstimulation syndrome.

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The purpose of this study was to critically evaluate the effect of sequential embryo transfer in randomized patients undergoing assisted in vitro conception. A randomized prospective study was conducted and the outcomes of 505 patients were analyzed, of which 107 women underwent sequential embryo transfer on day 3 and day 5 (D3/D5 group), 283 women underwent day-3 embryo transfer only (D3 control group) and 115 women underwent day-5 embryo transfer only (D5 control group) in the assisted reproduction center of Lilavati Hospital, Mumbai from March 2012 to March 2013. The results showed that the clinical pregnancy rate of the D3/D5 group was significantly higher than that of the D3 group (48.5% versus 29.3%), whereas the clinical pregnancy rates of the D3/D5 and D5 groups were not significantly different (48.5% vs. 53.0%). Day-3/day-5 sequential embryo transfer yields satisfactory clinical pregnancy rates in a subset of patients with repeated implantation failures (35.2%), while avoiding cycle cancellation that happened with about 11% patients that were meant for blastocyst only transfer.

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Paraovarian cysts constitute approximately 10% of all adnexal masses. Here, we present a case of a 7-week pregnant woman with a paraovarian cyst. The cyst was approximately the size of a 24-week pregnancy. The patient came with acute abdominal pain due to torsion of the paraovarian cyst. The conception following clomiphene citrate (CC) was a part of the treatment of infertility. In this case, CC was started without any investigations. From this case, we would like to suggest that even before starting a simple treatment such as clomiphene for infertility, a baseline ultrasound is essential.

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Hysterosalpingography (HSG) is an integral component of infertility investigation. Certain technical artifacts can lead to misdiagnosis. Intravasation of contrast is seen in 0.4-6.9% cases. Radiologists as well as gynecologists should be aware of this phenomenon as it can potentially be misinterpreted as free intraperitoneal spillage. Venous intravasation was seen during HSG in a 33-year-old woman with primary infertility and initially misdiagnosed. No serious systemic complications were noted. The tubal block was later confirmed on laparoscopy and chromopertubation. A review of literature was performed to identify potential risk factors, for example, tuberculosis, recent endometrial curettage, uterine anomalies, etc. Certain measures such as slow instillation of contrast have also been proposed for prevention of this phenomenon.

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A viable human blastocyst must demonstrate the capacity to expand in vitro and hatch out from its protective zona pellucida after transfer, in order to implant into the endometrial lining. Some blastocysts, however, experience hatching difficulties and remain enclosed within their zonae, preventing implantation after transfer to the uterus. Successful pregnancies have been reported by transferring embryos that have been treated to partially remove the zonae by chemical intervention (e.g. pronase or acid Tyrode's) or mechanical intervention (e.g. by laser or use of assisted hatching pipettes). Complete zonae removal has also been reported prior to embryo transfer. This is a report of a case where expanded blastocysts naturally hatched in vitro and completely escaped from their zonae on day 5 of preimplantation development. The careful transfer of these fully expanded hatched blastocysts on the same day resulted in a successful clinical pregnancy.

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Diminished ovarian reserve (DOR) is defined as reduced capacity of the ovaries to produce oocytes; the oocytes produced are of poorer quality leading to the formation of poor quality embryos. The most severe form of DOR can be represented as premature ovarian failure (POF). There are various reasons leading to DOR, the most important factor being increasing age, others being endometriosis and surgeries on the ovary. POF can be due to chromosomal aberrations or secondary to chemotherapy, radiotherapy, infections, or surgeries involving the ovaries. Patients with DOR may present with infertility and menstrual cycle abnormalities; patients with sudden onset POF may also present with hot flushes and vaginal dryness. There are various tests for finding out ones's ovarian reserve, the most widely used being follicle-stimulating hormone (FSH), anti-Mullerian hormone, and antral follicle count. It is important to know a patient's ovarian reserve before recruiting her for in vitro fertilization. Various modalities have been tried to improve the outcome in candidates with DOR undergoing assisted reproductive technology. This includes high-dose FSH treatment, luteinizing hormone supplementation, GnRH antagonist cycle, and use of adjuvant treatments such as estrogen priming, growth hormone, L-arginine, and dehydroepiandrosterone. Patients who are planned for chemotherapy or radiotherapy may undergo oocyte or embryo cryopreservation before the cancer treatment. To conclude, patients with DOR and POF should be provided with good counseling and emotional support.

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Introduction: Endometriosis is a clinical disease that is associated with poor outcomes in in vitro fertilization programs with a decrease in oocyte retrieval, oocyte quality, implantation and pregnancy rates.Based on the observations that the majority of the oocytes obtained in patients diagnosed with endometriosis have some characteristics, we conducted a retrospective study to reveal a more definite picture and to establish a simple way of prediction of the outcome. Materials and Methods: The patients were triaged in two groups based on the diagnosis of endometriosis. After denudation, the oocytes were examined by inverted microscope with ×200 magnification just before intracytoplasmic sperm injection. Oocytes with a centrally dark and granular cytoplasm were diagnosed to have degenerative signs. Results: Data of 792 patients were reviewed retrospectively. The percentage of oocytes with degenerative signs is significantly higher in endometriosis (27.4%) group compared with control group (7.9%) ( P < 0.001). Although, there is a tendency to lower pregnancy rate in endometriosis group (38.7%) the difference is not statistically significant (50.4%) ( P = 0.077). Conclusion: The oocytes have a characteristic appearance of dark and granular ooplasm in endometriosis cases. This finding can be used as a clue in cases in which the presumptive diagnosis has not verified by laparoscopy. The typical morphology also has an adverse effect on clinical outcome.

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Introduction: Ovaries are said to be supernumerary when an additional ovary is situated separate from the two other ovaries. Objective: To discuss a case of a supernumerary ovary found incidentally at laparotomy in a young girl with unilateral ovarian torsion and its implications in clinical practice. Background: A supernumerary ovary consists of ovarian tissue completely separated from the eutopic ovary with its own pedicle and blood supply. Differential diagnosis includes accessory ovaries which are located nearby and are connected to the eutopic ovary and its associated blood supply. Design: Case study. Case: A 14-year-old student was referred to our clinic with ruptured ovarian torsion and underwent unilateral oophorectomy for the same. An incidental additional ovary was found on the contralateral side. She was discharged on day 5 of stay and is doing well on follow-up. Conclusion: Supernumerary ovary although rare has significant implications for surgeons and gynecologists alike. Clinical Relevance: Situations in which a supernumerary functional ovary becomes relevant include ovarian torsion or malignancy in adolescents or women with reproductive potential wherein an ovary needs to be sacrificed, as in our case. The additional ovary if located in the pelvis may provide the necessary follicles for future fertility. Care should also be taken in case of ovum acquisition for artificial reproductive techniques.

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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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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 16^th 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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