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   Table of Contents - Current issue
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July-December 2019
Volume 6 | Issue 2
Page Nos. 57-139

Online since Friday, December 27, 2019

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EDITORIAL  

Artificial intelligence in assisted reproductive technology—current scenario and future implications p. 57
Kuldeep Jain
DOI:10.4103/fsr.fsr_40_19  
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REVIEW ARTICLES Top

Fertility preservation in Females—where are we today? p. 61
Rupali
DOI:10.4103/fsr.fsr_33_19  
With improvement in the survival rates of cancer, Fertility Preservation is the need of the hour. The modalities for fertility preservation vary from the classical method of ovarian transposition to simple treatments like giving drugs to reduce the chances of gonadotoxicity to oocyte and ovarian tissue cryopreservation. Various factors influence the decision of the treatment in cases of cancer survivors primarily being the age of the patient and the time in hand to do the treatment. This article is a review of the options of treatment available and increasing the awareness amongst the other clinicians.
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Impact of semen parameter on IUI p. 69
Pinkee Saxena, Surveen Ghumman
DOI:10.4103/fsr.fsr_37_19  
Intrauterine insemination (IUI) is a commonly performed procedure in the treatment of infertility. Its outcome depends on multiple factors. Semen is an important predictor for the success of IUI. Various semen parameters like sperm concentration, motility, morphology, and number of motile sperms inseminated determine the outcome of IUI. Advanced sperm function tests are required in addition to the standard semen analysis in few infertile patients.
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ORIGINAL ARTICLES Top

Role of endometrial scratching among recurrent implantation failure patients undergoing in vitro fertilisation/ICSI p. 77
Simmi Arora, Sanjay Makwana, Akshay Alawadi
DOI:10.4103/fsr.fsr_6_19  
Aim and Objectives: This article assesses the effect of endometrial scratching on improving rate of implantation in recurrent implantation failure patients and evaluates the potential and safety of endometrial scratching performed once before embryo transfer in women undergoing in vitro fertilisation. Study Design: This was a prospective interventional study. Study Period: This study was conducted from August 2018 to March 2019. Study Setting: Fertility Research Centre. Material and Methods: In this randomised control trial study, 100 patients each with at least two implantation failures were randomly assigned into two groups. In the case group (50 patients), endometrial scratching was performed in mid-luteal phase of the cycle prior to controlled ovarian hyperstimulation with disposable pipelle catheter and embryo transfer (day 3) performed in the next cycle. Clinical pregnancy and implantation rates were compared thereafter. Statistical Analysis: Data were analysed using Social Science System (SPSS) version 17.0 using appropriate statistical tests. Results: Clinical pregnancy was 38% in the scratching group and 30% in the non-scratching group while implantation rate was 15.8% and 11.5% in scratching and non-scratching group, respectively. Conclusion: Endometrial scratching was found to be very safe and a cost-effective technique in women undergoing in vitro fertilisation, and when it was performed in the mid-luteal phase of the previous cycle, it showed increase in chance of clinical pregnancy and implantation rate to some extent. However, as this study was performed on a smaller group, its reliability in clinical practice needs further research by randomised control trials on a larger study group.
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A prospective study to correlate serum progesterone levels and clinical pregnancy outcome in frozen embryo transfer cycles p. 82
Rachita Chawla, KU Kunjimoideen
DOI:10.4103/fsr.fsr_5_19  
Methods: Total 100 patients were included in the study and divided into two groups (A and B). Blood levels of p4 were measured when beginning progesterone and on the day of Frozen embryo transfer (FET) in one group and were supplemented if levels were less than 10 ng/mL. No measurement of serum p4 was undertaken in the other group (B). Statistical tests like chi square test and Mann-Whitney test were applied and SPSS version 23 was used. Outcome: Clinical pregnancy outcome. Results: Clinical pregnancy rate was 32.69% in group A vs 24% in the other group which is non-significant. Conclusion: Serum p4 should be between 1.5 and 24 ng/mL on the starting day for a positive result. Level in blood on the day of starting progesterone to obtain a positive clinical pregnancy was 0.21 ng/mL and should not exceed 0.96 ng/mL.
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Training on transabdominal ultrasound guidance during embryo transfer and proficiency evaluation of training p. 89
Divyalakshmi Arumugam, Umesh N Jindal, Sanjeev Maheshwari
DOI:10.4103/fsr.fsr_16_19  
Background: Embryo transfer (ET) is the crucial and final step in in-vitro fertilisation (IVF) process which has major impact on IVF outcome. ET technique has been standardized at present and done under ultrasound guidance. But there are no standardised steps described for the transabdominal ultrasound guidance during ET. Aims: To define the steps of transabdominal ultrasound guidance during ET using a training module; to evaluate the proficiency and learning curve of training; and to assess the impact on trial ET performance after training. Settings and design: A prospective study was conducted in a tertiary assisted reproductive technology (ART) centre, northern India between August 2018 and February 2019. Materials and methods: Ultrasound guidance during trial ET was evaluated for 12 doctors who participated in the study on 234 patients. Ultrasound guidance evaluation included scores for USG assessment of trajectory, catheter type prediction, difficulty prediction, ultrasound visualisation during trial ET and trial ET performance. Transabdominal ultrasound guidance training was given to all doctors after 10 pre-training evaluations followed by post-training evaluations. Pre- and post-training mean scores for each doctor and overall were compared using SPSS-21. Results: Mean scores showed improvement in all parameters, including trial ET performance for the doctors included in study. Overall, these differences were statistically significant. six doctors (50%) were declared trained in transabdominal ultrasound guidance during trial ET. Conclusion: The training module was effective in defining the steps of transabdominal ultrasound guidance during trial ET and improving the trial ET performance.
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Comparative study of intrauterine infusion of autologous platelet rich plasma in unresponsive thin endometrium in frozen ET cycle p. 99
Zeepee Godha, K.D. Nayar, Meenal Singh, Shweta Gupta, Monica Gupta, Princy Mittal
DOI:10.4103/fsr.fsr_22_19  
Aims: Study of intrauterine infusion of autologous platelet rich plasma in unresponsive thin endometrium in frozen ET cycle .Thin endometrium still remains a big challenge for clinicians, creating so much burden in the form of cycle cancellation, unplanned freezing of embryo and even need for surrogacy. Intrauterine infusion of platelet-rich plasma (PRP) is newer modality of treatment in thin endometrium, in various studies showing promising results. Material and methods: Our study was prospective randomised controlled trial done from 1 August 2018 to 31 May 2019 at a tertiary infertility centre, New Delhi, India. 30 patients undergoing frozen embryo transfer with history of thin endometriun (less than 7 mm) with normal hysteroscopic examination were enrolled. Patients with platelet count less than 1.50000/dl, uncorrected asherman syndrome, submucosal polyp, fibroid or congenital uterine anomaly and with history of systemic diseases were excluded from study. From day 2 of menses tab estradiol valerate was started in dose of 6–8 mg/day. It was increased up to 12 mg/day gradually after reviewing endometrial thickness serially. Patients with thin endometrium on day 10/11 received PRP on day 11 and repeat dose after 48 hours if endometrial thickness was less than 7 mm. Frozen embryo transfer was done in patients who achieved endometrial thickness 7 mm or more. Results: The mean pre-treatment endometrial thickness was 5.42 mm, which significantly increased to 6.64 mm, post treatment (P < 0.001). 8 patients out of 30 in our study could not achieve an optimal pattern of endometrium after treatment and embryo transfer was postponed. The positive beta human chorionic gonadotropin rate was 46.66%, and clinical pregnancy rate was 33.33% which is not statistically significant. Conclusion: In this study, we found PRP has effective role in thin endometrial cases.
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Comparison of a “freeze-all” strategy versus a “fresh transfer” strategy among poor responders in Assisted Reproductive Technology (ART)—An observational study p. 104
Manvi Tyagi, Jayesh Amin
DOI:10.4103/fsr.fsr_9_19  
Introduction: In recent years, frozen embryo transfer has been used by many and it may be a viable alternative to frozen embryo transfer (FET). So far, most of the studies were done to prove effectiveness of “freeze all” strategy in normal responder, very few had focused this policy on poor responder. Aims: To find clinical pregnancy rate (CPR) in frozen cycle versus fresh cycle embryo transfer (ET) in poor responder. Settings and design: Prospective observational study performed at our private fertility clinic. Methods and materials: From August 2018 to April 2019, a total of 102 poor responder patients who met POSEIDON criteria were included in the study out of which 50 were in FET group and 52 were in frozen thaw group. Controlled ovarian stimulation (COS) with gonadotropin releasing hormones (GnRH) antagonist protocol was done. Measured primary outcome was CPR in both groups. Statistical analysis used: Paired t test, chi square test, Z test, and Student t test were used. Results: Statistical analysis showed that the CPR in the frozen embryo group was 46.15%, while in the FET group it was 24.0%. The proportional comparison among the two groups was found to be statistically significant (P = 0.016), showing a higher CPR in the FET group. Conclusion: Success of IVF treatment can be improved in poor responder by implementing “freeze all” policy. RCT with large number of patients should be carried out to confirm this finding.
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A prospective and retrospective analysis of POSEIDON stratification to predict low prognosis patients during ART cycles in Indian population p. 109
Renu Lamba, Sonia Malik, Vandana Bhatia, Ved Prakash
DOI:10.4103/fsr.fsr_24_19  
Objective: A Prospective and retrospective analysis of POSEIDON stratification to predict low prognosis patients during assisted reproductive technique (ART) cycles in Indian Population. Design: Bidirectional Study (Prospective as well as Retrospective). Setting: Southend fertility and IVF centre, New Delhi. Patient Selection: All Low prognosis patients according to POSEIDON stratification. Duration of Study: 06 Months. Outcome: Prevalence of Low prognosis patients in Indian Population and Clinical Pregnancy Rate in whom fresh embryo transfer was done. Results: In this bidirectional study we enrolled a total 456 patients who underwent ovarian stimulation for ART at Southend Fertility and IVF Centre from Jan 2017 to Dec 2018. Out of these patients 218 (47%) patients were classified as ‘low prognosis’ according to the POSEIDON criteria. Overall in all four groups Clinical Pregnancy rate was approximately 20.6% in low prognosis patients who underwent fresh ET. Conclusion: Providing IVF pregnancy with autologous oocytes to low ovarian responders is the most challenging part of fertility care. The new POSEIDON concept is helping the clinicians in medical management and in counselling patients what to expect, helping in reducing time to pregnancy.
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Independent effect of body mass index on clinical pregnancy rate in single blastocyst frozen embryo transfer cycle in Asian women p. 115
Tejashri M Shrotri, Neeti Tiwari, Shweta Mittal Gupta, Ruma Satwik, Gaurav Majumdar, Abha Majumdar
DOI:10.4103/fsr.fsr_14_19  
Introduction: There are limited studies in literature regarding the effect of body mass index (BMI) on clinical pregnancy rate following frozen-thawed embryo transfers. Objective: We aim to study the independent effect of BMI on clinical pregnancy rate in single blastocyst frozen-embryo transfer cycle in Asian women. Material and methods: It is a prospective observational study involving 167 women who underwent single, good quality frozen-blastocyst transfer following a uniform protocol. Stimulation was done by hormone replacement therapy in all cycles. The study population was divided into various cohorts as per the BMI classification for Asian adult population (normal: 18.5–22.9, pre-obese: 23–24.9, obese I: 25–29.9, obese II: ≥30). Results: The positive β-HCG rate was 48.93% in normal BMI women, 55.31% in pre-obese, 50% in obese I, and 38.4% in obese II BMI groups. The clinical pregnancy rate was 36.17% in normal BMI women, 48.93% in pre-obese, 45% in obese I, and 30.07% in obese II BMI groups. The difference between various BMI subgroups as regards to positive β-HCG as well as clinical pregnancy is not statistically significant. Women with BMI ≥ 30 had numerically low clinical pregnancy rate, in comparison to those with lower BMI sub-groups. However, this difference was not statistically significant. Conclusion: This study concludes that BMI did not affect clinical pregnancy rate among women following a uniform protocol, single good quality frozen blastocyst transfer in Asian women. The increased difficulty during transfer for women with higher BMI suggests that body habitus may be responsible for difficult transfers, although this may not translate into a worse clinical pregnancy rate. A study with larger sample size may be needed to confirm these findings.
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Age-dependent decline of anti-Müllerian hormone (AMH) in a large population of Indian fertile women as measured using the automated VIDAS® AMH assay p. 120
Jasneet Kaur, Nalini Mahajan, Bruno Mougin, Emile Eichenlaub
DOI:10.4103/fsr.fsr_35_19  
Background: Serum anti-Müllerian hormone (AMH) testing is now routine practice to assess the ovarian follicular reserve and to predict the response to controlled ovarian stimulation (COS) for assisted reproductive technique (ART). Reference values for a new AMH assay should take into account possible genetics and environmental factors that can be observed in a given population/geographical region such as India. Objectives: Primary objective was to observe the inter-individual variability of AMH in a large sized cohort of fertile Indian women as measured with the automated VIDAS® AMH assay, to model the age-dependent decline of AMH across the reproductive age range and to establish the reference values for this assay for an Indian female population. Secondary objective was to study the possible relationships between AMH and other parameters such as Vitamin D status and body mass index (BMI). Materials and methods: Serum AMH and Vitamin D concentrations were measured using VIDAS® AMH and VIDAS® 25 OH Vitamin D Total assays, in a cohort of 975 fertile Indian women aged 19–50 years. Correlations between AMH and age, Vitamin D, and BMI were also analyzed. Results: Reference AMH values for the VIDAS® AMH assay are reported as an AMH/age nomogram, including a model fitting the age-dependent decline of the hormone. For 66.26% of these women, a Vitamin D deficiency was observed. Discussion and conclusion: Reference values representative of Indian women are reported using VIDAS® AMH assay that can help the clinicians for the management of their Indian patients consulting for endocrinology and fertility disorders across the reproductive age range. The cross-sectional data analysis of the Vitamin D status has shown a predominant deficiency for these fertile women.
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Demography, expectations and experiences of oocyte donors in northern India − an interview-based study p. 126
Nikita Jindal, Abha Majumdar, Ruma Satwik
DOI:10.4103/fsr.fsr_19_19  
Study question: Oocyte donation is an increasingly popular treatment option for pregnancy and parenthood in women with poor ovarian reserve or advanced age. Indian literature still lacks a formal study focusing on expectations and experiences of oocyte donors. Aim: To assess demography, expectations and experiences of oocyte donors in northern India by an interview-based questionnaire. Material and Methods: This is a prospective cross-sectional study at a tertiary care IVF centre from August 2018 to January 2019. Sample size was 65 oocyte donors found fit and willing for egg donation. Interviews were taken using structured questionnaire at the time of registration and after successful oocyte retrieval. Results: Mean age of donors was 25 years. Most of the donors were housewives (70%) and rest were in a private job. Only 29% of donors were educated above tenth standard. Almost all the donors (96%) were commercial donors introduced by paid agents or friends. Most of the donors had very poor understanding of details of the oocyte retrieval procedure. Only 36% of donors felt that compensation given is adequate, rest expected a higher compensation. Average compensation given to donors was INR 15,000–25,000, which was 5000–10,000 less than their expectations. All donors were satisfied with the procedure and did not feel exploited or anxious or depressed but few complained of discomfort experienced in visits and minimal complications like pain, nausea, and fever. None of the donors developed signs/symptoms of OHSS. Average number of oocytes retrieved per donor was 17. Mean dose of gonadotropins required per donor was 1495 IU. Conclusion: Our findings show that the oocyte donation has an overall good acceptance and satisfaction among the donors. However there is a need to impart more detailed information to donors in order to prevent their possible exploitation.
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Effect of stimulation phase length (SPL) on IVF/ICSI outcomes: a prospective study p. 133
Deepmala Deepmala, Kuldeep Jain, Bharti Jain
DOI:10.4103/fsr.fsr_15_19  
Aim/Objectives: To determine whether SPL influences number of follicles on trigger day, oocyte retrieved at ovum pick up, grade A/B oocyte cumulus complex (OCC), M2 oocytes, fertilisation-rate, cleavage-rate, endometrial thickness, and clinical-pregnancy-rate (CPR) in IVF/ICSI cycles. Settings/Design: A prospective observational study conducted over a period of six months at an IVF/ICSI centre. Methods/Material: 152 patients enrolled for IVF/ICSI cycles except those undergoing frozen embryo transfer, donor oocyte/sperm, and surrogacy program. 16 patients were further excluded due to cycle cancellation and data of 136 patients were analysed. Individualised patient treatment with individualised controlled ovarian stimulation planned for each patient according to their clinical, ultrasound, and hormonal profile. The study parameter (stimulation phase length (SPL)) was further subdivided into short (<10 days), medium (10-12 days), and long (>12 days) and its associations with outcome parameters studied. Statistics: SPSS program for windows, version 17.0 used. Continuous variables compared using ANOVA. Spearman’s correlation was used to find the association among various variables. Categorical variables were compared using Chi square test. P < 0.05 indicates significant difference. Results: The number of follicles and oocytes retrieved were significantly higher in medium SPL (P < 0.05). But there were no significant differences in number of grade A/B OCC or M2 oocytes among all three SPL groups (P > 0.05). There was no association between SPL and fertilisation rate, cleavage rate, or endometrial thickness. The CPR was 41.91% (57/136). The CPR was 31.6%, 46.7%, and 37.5% in short, medium, and long SPL, respectively. Though CPR appears higher in medium SPL but it is not statistically significant (P > 0.05). Conclusions: Optimising SPL between 10 and 12 days may serve as non-invasive marker for follicle/oocyte quantity but not quality. SPL cannot predict IVF/ICSI outcomes.
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