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CASE REPORTS
Pregnancy in a lady with premature ovarian failure following dehydroepiandrosterone (DHEA) treatment
Siddhartha Chatterjee, Rajib Gon Chowdhury, Sandip Dey, Debidas Ganguly
January-June 2015, 2(1):40-42
DOI:10.4103/2394-4285.180507  
Poor responders are real challenges for infertility physicians, as they produce lesser numbers of oocytes after ovulation stimulation. Fertility begins to decline after 30 years of age in women. Hence, in elderly women, diminution of ovarian reserve is a reality. Diminished ovarian reserve (DOR) may be found in young women as well. Ovarian reserve test (ORT) are many, but among them, estimation of follicle-stimulating Hormone (FSH), antral follicle count (AFC) by ultrasound, and estimation of anti-Müllerian Hormone (AMH) are far more standardized. In recent years, one of the androgens called dehydroepiandrosterone (DHEA) has been tried to elevate ovulatory response in DOR patients. DHEA mostly brings the sleeping follicular pool to functional pool and prevents apoptosis of many follicles, thereby, promoting ovulatory response of ovaries with diminished ovarian functions. One such case with premature ovarian failure (POF) has been presented here, who conceived after DHEA treatment. Though escape ovulation can happen in postmenopausal patients, here the lady conceived with DHEA treatment 7 years after achieving premature menopause, during which she suffered from complete secondary amenorrhea.
  11,061 302 -
PCOS GUIDELINE
Management of Polycystic Ovary Syndrome in India
Sonia Malik, Kuldeep Jain, Pankaj Talwar, Sudha Prasad, Bharti Dhorepatil, Gouri Devi, Ashok Khurana, Vandana Bhatia, Nomita Chandiok, Alka Kriplani, Duru Shah, Geeta Sinha, Jyoti Unni, Madhuri Patil, Meeta Singh, Phagun Shah, Ratnabali Chakraborty, SM Bhattacharya, Siddarth Chatterjee, Sukumar Barik, Rama Vaidya, Subhash Kumar Wangnoo, Ambrish Mithal, Mohd Ashraf Ganie, Binayak Sinha, Jayashree Gopal, Waman Khadilkar, Rahul Nagpal, VK Khanna, Nitin Verma, Ahmed Zaheer, Bindu Sthalekar, Latika Arya, Niti Khunger, Rekha Sheth, Dhiraj Bhatia, Varun Duggal, Anuradha Khadilkar, Beena Joshi
January-June 2014, 1(1):23-43
DOI:10.4103/2394-4285.146798  
  9,776 1,162 -
CASE REPORTS
Dysmenorrhea membranacea: A case report and review of the literature
Pragati S Upasham, Swapnil V Sirmukaddam, Anita Sharan
January-June 2014, 1(1):56-57
DOI:10.4103/2394-4285.146709  
Dysmenorrhoea membranacea is a rare condition in which there is spontaneous expulsion of the fragments of endometrium in a cylindrical piece retaining the shape of the uterus. Here we present a case of dysmenorrhoea membranacea in 53 year old female patient who was on hormonal therapy for her irregular menstrual history, presented with the history of menorrhagia and passage of clots since one month.. Patient was subjected to D&C , during PV examination there was an expulsion of this endometrial cast. On histopathology it was diagnosed as dysmenorrhoea membranacea. It is an uncommon diagnosis, predominantly occurring in second and third decade of life. We also reviewed the literature associated with this lesion.
  6,399 421 -
REVIEW ARTICLES
Emerging role of Color Doppler in Infertility Management: A Public Health perspective
Saumya Pandey, Gita Khanna, Aparna Bajpai, Anil Khanna
July-December 2014, 1(2):87-91
DOI:10.4103/2394-4285.162778  
Color Doppler is emerging as a valuable diagnostic imaging modality in the field of reproductive medicine, primarily infertility. Reproductive disorders, including infertility and spontaneous abortions/miscarriages, have emerged as major public health problem(s) worldwide. Color Doppler energy imaging is a high throughput technology based on the total integral of energy frequency spectrum. We extracted the most relevant articles (comprehensive reviews and original research articles) for inclusion in our review by performing a comprehensive literature search using the Pubmed (last accessed on 2015 April 28) scientific database. Color Doppler is a high-throughput, sophisticated imaging technique for the assessment of uterine anomalies, intrauterine pathology, tubal patency, polycystic ovaries, ovarian follicular monitoring, endometrial receptivity, failed and/or ectopic pregnancy, male infertility, and uterine, endometrial, and ovarian vascularity. Assessments of the uteroovarian pulsatility indices (PIs), resistance indices (RIs), and endometrial color signals are important determinants of in vitro fertilization (IVF) cycles and pregnancy rates. With our clinical/scientific research experience in the field of reproductive medicine, we strongly believe that an overall public health model needs to be designed in managing infertility patients; therefore, major issues such as cost-effectiveness and technical artifacts should be addressed so as to achieve an accurate clinical diagnosis, successful IVF outcome/pregnancy, and overall patient satisfaction in a clinical research setting. Simple, safe, efficient, and affordable diagnostic modalities should be incorporated at infertility clinics coupled with well-designed patient counseling sessions and community-based public health awareness campaigns conducted so as to reduce the morbidity and mortality rates associated with reproductive disorders.
  5,978 594 1
EDITORIAL
How safe is your IVF program?
Kuldeep Jain
July-December 2014, 1(2):63-66
DOI:10.4103/2394-4285.162773  
  2,570 2,919 -
ORIGINAL ARTICLES
Spontaneous conception following anti-tubercular treatment for sub-fertile women with multiple imaging markers suggesting genital tuberculosis
Nikita Naredi, Pankaj Talwar, Nagaraj Narayan, Seema Rai, Shakti Vardhan, Subrat Panda
January-June 2014, 1(1):44-49
DOI:10.4103/2394-4285.146704  
Background: Female genital tuberculosis (FGTB) primarily an asymptomatic disease is one of the most important causes of female infertility in developing countries. Damage to the pelvic organs after genital tuberculosis (GTB) is a well recognized entity .It is thus prudent to diagnose and treat GTB as early as possible to prevent or at least to minimize the damage to the genital organs. Although diagnosis of GTB has been a challenge, its detection and treatment cannot be based on single test and multiple markers must be utilised with the clinical background and early treatment instituted. Objective: The present study was aimed to diagnose or predict GTB based primarily on imaging modalities in the form of hysterosalpingography, pelvic ultrasound and supported by the basic laboratory investigations like Mantoux test, Erythrocyte Sedimentation rate (ESR) . Once the diagnosis or prediction of GTB was made, an early institution of anti tubercular therapy was done and patients were followed up to observe the spontaneous pregnancy rate. Material And Methods: This was a prospective study wherein the patients underwent complete evaluation for infertility including a hysterosalpingograhy and pelvic ultrasonography. The patients were considered to be positive for genital tuberculosis if three or more of the following were found on evaluation: raised ESR ( ≥ 20mm/first hour), Mantoux test positive ( induration ≥ 10 mm), HSG picture or Ultrasonological picture suggestive of GTB. Observation: It was seen that out of the 400 women who were included; 265 women (Group A) were adjudged to have genital tuberculosis as per our study protocol and thus were started on ATT whereas 135 (group B) were not put on antitubercular therapy. Within this duration (during or after completion of ATT), 157(59.2%) conceived spontaneously in group A, on the other hand only 27(20%) women conceived spontaneously in group B. This difference was found to be statistically significant (P Value<0.0001). Conclusion: Although Genital tuberculosis poses a great diagnostic challenge because of its varied presentations, diverse imaging pictures, and myriads of tests with its own limitations, it is advisable not to resort to all of them. Tests which are simple, feasible, specific and sensitive, and facilitates early diagnosis should be carried out. Institution of anti-tubercular treatment should be done in early disease, thus enhancing the chance of pregnancy and preventing irreversible damage to the genital organs.
  5,114 344 -
REVIEW ARTICLES
In Vitro Maturation
Jayant G Mehta
January-June 2014, 1(1):7-15
DOI:10.4103/2394-4285.146700  
In vitro maturation (IVM) of the human oocytes has recently found an important niche among assisted reproductive techniques (ART). Even though the ovarian stimulation protocols continue to evolve and last for few days, they are still not patient-friendly. The development of several follicles is associated with a high risk of ovarian hyperstimulation syndrome (OHSS), leading to hospitalization that can be fatal. Natural IVF cycles, mild stimulation with low dose gonadotrophins and IVM of human oocytes ready for fertilisation now offer an alternative to the traditional IVF treatment. Infertile women with polycystic ovaries or polycystic ovarian syndrome (PCOS) form the main category of patients who would benefit from IVM. However, concern exists that IVM may interfere at the epigenetic level and in particular with genomic imprinting. For normal embryonic development, timely acquisition of correct imprinting patterns in oocytes and maintenance of genomic imprinting after fertilisation is required. It is therefore necessary that patients undergoing IVM be offered preimplantation genetics screening (PGS) prior to embryo transfers. This review considers our current understanding of in-vitro maturation of human oocytes and its importance in clinical applications.
  4,465 612 -
Morphological assessment of embryo quality during assisted reproduction: A systematic review
Athanasios Papathanasiou, Bayan Osmani, Pek Joo Teoh, Abha Maheshwari
July-December 2014, 1(2):67-80
DOI:10.4103/2394-4285.162776  
Background: Various parameters of embryo morphology have been routinely used to select the embryo/s with maximum implantation potential during in vitro fertilization (IVF). Hence, there is a dilemma in clinical practice as to which morphological scoring system/test to use. We performed a systemic review to determine the predictive power as well as the clinical and cost-effectiveness of existing morphological tests of embryo quality described in an IVF setting. Materials and Methods: The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines for systematic review were followed. A mixed-method analysis was performed. Qualitative and quantitative techniques were used to synthesize the final results. A narrative summary approach was used for initial data exploration and description, followed by the pooling of data, where appropriate, using Meta-DiSc software. Receiver operating characteristic (ROC) curves were plotted wherever appropriate, and the area under the curve (AUROC) was determined. Results: Day 3, day 5, and early cleavage (EC) all had similar discriminatory value for predicting implantation (AUC 0.66, 067, and 0.63 respectively). There was no evidence of improvement in pregnancy rates due to routinely doing EC. No studies were identified that determined the cost-effectiveness of any of the tests. Conclusions: All tests have low accuracy. They lack the discriminatory power to identify an embryo that will/will not lead to implantation. Appropriately designed studies are required to assess the predictive value and the clinical and cost-effectiveness of novel embryo scoring technologies.
  3,202 1,126 1
CASE REPORTS
IUI in hypogonadotropic hypogonadism: Do not give up
Seema Rai, Nagaraja Narayana, Prashant Sharma, Pankaj Talwar
July-December 2014, 1(2):112-113
DOI:10.4103/2394-4285.162788  
Ovulation is dependent on the presence of a functioning hypothalamic-pituitary-ovarian (HPO) axis. Estimates of chronic anovulation rates range from 6-15% of women during the reproductive years.Potential causes of anovulation are PCOS, hyperprolactinemia,thyroid dysfunction, stress etc. Idiopathic hypogonadotropichypogonadism (IHH) is rare cause of anovulation. Idiopathic hypogonadotropichypogonadism (IHH) is a collection of genetic mutations that result in delay of puberty, infertility, and low gonadotropins.Women with IHH have hypoestrogenism, amenorrhea, and low gonadotropin levels. Ovulation induction is the method for treating anovulatory infertility. For patients with hypogonadotrophichypogonadism, the treatment involves administration of both FSH and LH, while HCG is injected for follicle rupture. Such patients need high dosage and longer duration of stimulation than other patients.
  3,864 276 -
EDITORIALS
Editors view point
Kuldeep Jain
July-December 2015, 2(2):89-89
DOI:10.4103/2394-4285.196775  
  1,055 3,032 -
REVIEW ARTICLE
Genital tuberculosis and infertility
Jai B Sharma, Sona Dharmendra, Shefali Agarwal, Eshani Sharma
January-June 2016, 3(1):6-18
DOI:10.4103/fsr.fsr_2_17  
Female genital tuberculosis (TB) is an important cause of significant morbidity, short- and long-term sequelae especially in infertility in which incidence varies from 5 to 15% cases in India. The causative agent is Mycobacterium tuberculosis. The fallopian tubes are mainly involved in 90 to 100% cases, endometrium in 60 to 80% cases, ovaries in 30% cases, and cervix in 15% cases of genital TB. Vagina and vulva TB is rare involving 1 to 2% cases. Diagnosis is made by detection of acid fast bacilli on microscopy or culture on endometrial biopsy or on histopathological detection of epithelioid granuloma on biopsy. Polymerase chain reaction (PCR) may be false positive and alone is not sufficient to make the diagnosis. Laparoscopy and hysteroscopy is the gold standard for the diagnosis of the disease. Treatment is by giving daily therapy of rifampicin (R), isoniazid (H), pyrazinamide (Z), and ethambutol (E) for 2 months followed by rifampicin (R) and isoniazid (H) daily for 4 months. Three weekly dosing throughout therapy (RHZE thrice weekly for 2 months followed by RH thrice weekly for 4 months) can be given as Directly Observed Treatment Short Course. Surgery is rarely required only for drainage of abscesses. Role of in vitro fertilization and embryo transfer is required in women whose fallopian tubes are damaged but endometrium is healthy. Surrogacy or adoption is needed for women whose endometrium is damaged.
  3,615 297 -
ORIGINAL ARTICLES
Findings in diagnostic laparoscopy in patients with unexplained infertility
Shilpa Bhandari, Aparna Singh, Pallavi Agrawal, Ishita Ganguli
January-June 2015, 2(1):29-33
DOI:10.4103/2394-4285.180497  
Objective: Infertility is a growing concern of the society. In many cases the exact cause of infertility may not be elucidated, whether it is the tubal factor, male factor, uterine factor, or a combination. This adds to the emotional trauma of the couple. Many previous reports have tried to decipher the cause and the best line of management for these cases of unexplained infertility. The choice often lies between a diagnostic approach favoring laparoscopic evaluation and a therapeutic approach favoring the use of assisted reproductive techniques. This paper aims to understand the role of diagnostic hysterolaparoscopy in cases of unexplained infertility, the optimum time to perform it, and its role in changing the future management plan. Design: This was a retrospective study. Patients and Methods: Data of the identified patients were collected from patient case records and they included factors such as age, duration and type of infertility, clinical examination findings, and gynecological ultrasound. Previous treatment history included details of ovulation stimulation, intrauterine insemination (IUI), and other treatment. Intraoperative findings such as presence of peritubal adhesions, endometriosis, tubal pathology, perihepatic adhesions, and hysteroscopic findings were recorded. Results: Our study shows that performing diagnostic hysterolaparoscopy in cases of unexplained infertility is of advantage, especially in patients who have had two or more failed IUI in the past. Conclusion: Performing diagnostic hysterolaparoscopy prior to ovulation induction/IUI has not shown any significant advantage.
  3,020 285 -
EDITORIALS
“Freeze all” protocol – Has the debate concluded?
Surveen Ghumman
July-December 2015, 2(2):90-94
DOI:10.4103/2394-4285.196783  
  2,126 1,084 -
REVIEW ARTICLES
Role of iron in the oxidative stress in the pathophysiology of endometriosis: A new concept to know the potential therapeutic benefit
Pratap Kumar, Vishnu Ashok
January-June 2014, 1(1):19-22
DOI:10.4103/2394-4285.146702  
Endometriosis is a multifactorial disease characterized by inflammatory changes in the pelvic cavity and symptoms of pain, infertility, and menstrual irregularities. Several theories have been proposed since Samson's theory of retrograde menstrual flow. Iron has been found to be one of the major factors involved in the above-mentioned theory. Abundant retrograde flow of blood into the pelvic peritoneum, followed by the destruction and consumption of the free red cells by the macrophages results in an iron overload both intra-and extracellular. Being a strong catalyst to the formation of free radicals, iron contributes significantly to the rise in the levels of reactive oxygen species, which cause the oxidative stress (OS). Besides stimulating the formation of free radicals and contributing to OS, increased iron in the macrophages also activates a sustained and overstimulated inflammatory response that is responsible for much of the symptoms seen in endometriosis; in particular infertility, due to extensive intraperitoneal adhesions. While genetic factors play a role in determining a woman's response to OS, lifestyle also plays an important part. Dietary deficiency of vitamin C, vitamin E, and micronutrients such as selenium and manganese results in an acquired deficiency of antioxidants and an exaggerated response to the OS. Consumption of fresh fruits, green vegetables, etc. that are rich in antioxidants has been shown to be beneficial in alleviating the symptoms of endometriosis as well as in improving pregnancy rates. Theoretical advantages seem to be present in localized iron chelation as a method of medical management of endometriosis; however, further studies need to be conducted to confirm that the benefits outweigh the risks.
  2,785 350 -
ORIGINAL ARTICLES
Laparoscopic ovarian drilling for infertile PCOS women who are resistant to oral ovulation-inducing drugs
Papa Dasari
January-June 2015, 2(1):15-18
DOI:10.4103/2394-4285.180488  
Background: Gonadotrophin treatment to achieve pregnancy in infertile individuals with polycystic ovarian syndrome (PCOS) who are resistant to ovulation induction drugs is costly, time consuming and associated with hyperstimulation and multiple pregnancy. Aim: The aim was to determine the pregnancy rate after laparoscopic ovarian drilling (LOD) in infertile PCOS cases resistant to oral ovulation-inducing drugs. Setting and Design: The setting was a tertiary care center without assisted reproductive techniques (ART) facilities catering to patients with general gynecological problems from all socioeconomic strata. This was a prospective observational study involving women resistant to oral ovulation induction drugs. Period of Study: The period of the study was from 2008 to 2012. Materials and Methods: Forty-eight infertile PCOS cases who did not achieve pregnancy after three or more cycles of clomiphene citrate (CC)/CC and metformin combination and letrozole. LOD was carried out by electrical diathermy. Results: The overall pregnancy rate was 66%. Thirteen percent conceived in the same cycle, 11% in the second cycle, and 6% in the third cycle. Spontaneous abortion occurred in 10% and the live birth rate was 90%. Conclusion : Ovarian drilling may be considered as a good option for oral drug-resistant PCOS cases, as 66% achieved pregnancy with this procedure.
  2,775 287 1
CLINICAL PRACTICE GUIDELINE
Good clinical practice recommendations on management of infertility in patients from India with polycystic ovary syndrome
Sonia Malik, Sohani Verma, Kuldeep Jain, Pankaj Talwar, Bharati Dhorepatil, Gouri Devi, Umesh Jindal, Sudha Prasad, Kanad Dev Nayar, Neena Malhotra, Neeta Singh, Geeta Radhakrishnan, Rashmi Sharma, Leena Wadhwa, Nomita Chandhiok, Gita Khanna, Sushma Sinha, Pondicherry Marudachalam Gopinath
July-December 2015, 2(2):107-132
DOI:10.4103/2394-4285.196786  
  2,654 389 -
ORIGINAL ARTICLES
Ideal value of serum anti-Mullerian hormone as a predictor of ovarian reserve and outcome in assisted reproductive technology
Pratap Kumar, Subasri Sambandam Ravichandran
January-June 2015, 2(1):24-28
DOI:10.4103/2394-4285.180495  
Title of the article: Ideal value of serum anti-Mullerian hormone as a predictor of ovarian reserve and outcome in assisted reproductive technology. Aims: To evaluate serum AMH as a marker of ovarian reserve and reproductive outcome. Settings and Design: Division of Reproductive Medicine, Kasturba Medical College, Manipal University, Manipal, Karnataka, India. Methods and Material: A prospective two year analysis of 84 women undergoing ART with AMH, FSH and AFC measurements was analysed on day 2 of the cycle. The study group was Group I - <0.7, Group II - 0.7 - 3.5, Group III - >3.5 ng/ml. Outcome measures such as the mature oocytes, quality embryos and pregnancy rates were compared between these groups. Statistical analysis used: Non parametric test (Kruskal Wallis), Exact test and ROC curves was used. Results: AMH levels correlated best with age (P = 0.012), antral follicles (P = 0.001), follicles retrieved (P = 0.002) and oocytes obtained (P = 0.041). The number of mature embryos were higher in Group II & III than Group I (P = 0.312). AMH levels were significantly lower in canceled cycles than completed cycles (P = 0.010). The occurrence of OHSS was higher (61%) in Group III and 10% in in Group II (P = 0.001). Conclusions: AMH value of 0.7-3.5 was better than FSH in prediction of number of oocytes. Both FSH and AMH were not good predictors of pregnancy.
  2,858 180 -
EDITORIAL
Stem cells—The new agents in infertility treatment: The light at the end of the tunnel?
Gita Radhakrishnan
July-December 2017, 4(2):70-73
DOI:10.4103/fsr.fsr_16_18  
  2,711 252 -
ORIGINAL ARTICLE
Tamoxifen for ovulation induction in infertile PCOS women who did not conceive with 3 or more cycles of clomiphene citrate: A prospective clinical study
Avanthi Gadipudi, Paapa Dasari, Haritha Sagili
January-June 2017, 4(1):22-29
DOI:10.4103/fsr.fsr_5_17  
Objectives: To assess the ovulatory, pregnancy rates and side effects of tamoxifen (TMX) in women who are infertile with polycystic ovarian syndrome (PCOS) and who did not conceive with three cycles of clomiphene citrate (CC). Study Design: A prospective interventional study. Population: Seventy-four women who were infertile with PCOS and who did not achieve pregnancy after a minimum of three cycles of CC were included in the study. Materials and Methods: TMX was given orally from Day 2 to Day 6 of the menstrual cycle, with a dose of 40 mg in the 1st cycle and 80 mg in the subsequent two cycles. Transvaginal ultrasound was used for follicular monitoring from Day 10 and on every alternate day till the day of ovulation or till the 20th day of the cycle. Statistical Analysis: Ovulation rates with different doses were compared using McNemar test. Kruskal–Wallis test was used to find out differences in maximum follicular diameter and endometrial thickness (ET) between 3 cycles. Results: The mean maximum follicular diameter was 16 ± 5.2 mm, and the mean ET was 8.9 ± 1.7 mm with an ovulatory rate of 41.90% with 40 mg of TMX. Mean increase in the maximum follicular diameters with 80 mg of TMX was higher when compared with 40 mg (P value − 0.000) of TMX. Increasing the dose of TMX in cycles 2 and 3 resulted in a statistically significant increase in the ovulatory rates; however, it was not so with ET. There were no clinical pregnancies, and minor side effects occurred in 14.1% of the participants. Conclusion: TMX induced ovulation only in 56% of the participants, and optimum ET was achieved in 92.7% of the participants; in addition, there were no pregnancies. Hence, TMX is not a useful ovulation inducing agent for CC failure/CC-resistant PCOS.
  2,785 149 -
ORIGINAL ARTICLES
Psychological evaluation of infertile couples: Results of a questionnaire survey
Elamurugan Sujindra, Arounassalame Bupathy, Rajendiran Praveena, Thangamani Sivasankari
January-June 2015, 2(1):34-36
DOI:10.4103/2394-4285.180499  
Introduction: Infertility is a global problem with a wide range of sociocultural, emotional, physical, and financial problems. This study aims to identify couples, with an unfulfilled desire for a child, who require psychological support. Materials and Methods: In this study, a total of 158 couples were selected who filled up the questionnaire. The questionnaire comprised 19 questions, 15 in the psychological evaluation test (PET) to detect emotional reactions to the infertility-related stressors and four close-ended questions to find out the couple's attitudes toward childbearing and their future. The data were statistically analyzed by Mann-Whitney U test and Fischer's exact test, with the level of significance at 5%. Results: The mean age of the men was 35.2 ± 3.5 years, while that of the women was 28.4 ± 2.8 years. Male infertility was diagnosed in 28 couples, female infertility in 47, both male and female infertility in 12, and the remaining 71 couples were either not diagnosed or had unexplained infertility. The mean years of married life was 5.6 ± 3.2 years. Of all the couples, 148 were diagnosed with primary infertility and 10 had secondary infertility. The mean positron emission tomography (PET) score for women and men of 28.3 ± 8.4 and 25.6 ± 7.2, respectively, was not statistically significant. Conclusion: Both women and men give great importance to the inability to bear a child; they were supportive of their spouse, but social stimuli provoked their stress. Women were more emotional and sensitive when personal feelings were considered. PET score >30 required additional psychological support to cope with normal life.
  2,693 229 -
REVIEW ARTICLES
Fertility preservation for ovarian or uterine cancer patients with reference to assisted reproduction technology
Ethiraj Balaji Prasath
January-June 2014, 1(1):16-18
DOI:10.4103/2394-4285.146701  
Fertility preservation has been paid much attention recently, as the survival rate of cancer patients after therapy has increased significantly. Cryopreservation of gametes or embryos has been practiced prior to cancer therapy, to preserve fertility, as various modes of cancer therapy are gonadotoxic, reducing reproductive potential of cancer survivors. Although cryopreserving semen or testicular tissue has been the prominent means of fertility preservation for men, it has been still experimental for pre-pubertal boys. Treating by Assisted reproduction Techniques with cryopreservation of oocytes or embryos is the promising way of fertility preservation in women prior to cancer therapy. Livebirths have been reported after auto transplantation of cryopreserved ovarian cortex. Such an approach may not be practical in women with ovarian or endometrial or Estrogen sensitive breast cancer as transplantation of ovarian cortex may reintroduce the disease. Oophorectomy in such patients is not uncommon leading to total infertility of patients. Alternative approaches are available to preserve fertility of such women. Harvesting oocytes for cryopreservation in women without male partners or embryos after in vitro maturation and ICSI of harvested oocytes in women with male partners have been reported as modern means of fertility preservation in ovarian cancer patients. Efficacy of such approaches is reviewed in this article.
  2,505 382 -
Prevention of ovarian hyperstimulation syndrome
Raj Mathur
July-December 2014, 1(2):81-86
DOI:10.4103/2394-4285.162777  
Ovarian hyperstimulation syndrome (OHSS) is a potentially serious complication of ovarian stimulation for fertility treatment. Risk factors include polycystic ovaries, high ovarian reserve, and excessive ovarian response to stimulation. It is important to be aware of the risk of OHSS, even in so called "low-risk" situations. An understanding of the pathophysiology of OHSS may help clinicians to target preventative measures in women who are at risk. Ovarian stimulation regimes based on an individualized reserve assessment may help reduce the incidence of OHSS. Gonadotropin-releasing hormone (GnRH) antagonist regimes are associated with a lower risk than GnRH agonist regimes and the risk may be further reduced if a GnRH agonist trigger is used in place of human chorionic gonadotropin (hCG). Other methods of reducing hCG exposure include avoiding hCG luteal support, cryopreservation of all embryos, and avoidance of multiple pregnancy. However, the only method that guarantees avoidance of OHSS in high-response cycles is cycle cancellation. Clinicians should be aware of the potential value of coasting and dopamine agonists, as measures to reduce risk in the presence of an excessive ovarian response.
  2,443 441 -
ORIGINAL ARTICLES
Comparison of the efficacy of letrozole and low-dose gonadotropin combination with clomiphene and low-dose gonadotropin combination as a controlled ovarian stimulation regime prior to intrauterine insemination in patients with unexplained infertility
Kiran Chaudhary, Vanita Suri, Lakhbir Kaur Dhaliwal, Shalini Gainder
July-December 2014, 1(2):98-103
DOI:10.4103/2394-4285.162781  
Objective: To evaluate and compare the effects of letrozole and low-dose gonadotropin combination with clomiphene citrate (CC) and low-dose gonadotropin combination prior to intrauterine insemination (IUI) in patients with unexplained infertility. Design: Prospective, randomized, clinical study. Setting: Academic tertiary institute. Patient(s): A total of 94 patients in the age group of 21-37 years with unexplained infertility were randomized using computer-generated random number table to receive follicle-stimulating hormone (FSH) injection and human menopausal gonadotropin (hMG) injection, along with either letrozole or CC. Intervention(s): All the patients received 150 IU of purified urinary FSH on day 2 of the cycle and from day 3 to day 7 of the cycle 5.0 mg/d of letrozole or 100 mg/d of CC were administered; this was followed by administration of 150 IU of hMG on day 9. Ovulation was triggered with human chorionic gonadotropin (hCG) injection (5,000 IU) when the dominant follicle(s) reached 18 mm in diameter. A single IUI was performed 36 h later. The luteal phase was supplemented with micronized progesterone vaginally. Main Outcome Measure(s): Pregnancy rates and the incidence of multiple pregnancies were our primary outcome. The secondary outcome included the number of dominant follicles, grade of perifollicular blood flow, endometrial thickness, endometrial blood flow pattern, side effects, and complications. Result(s): There were no differences in demographic characteristics between the two groups. Pregnancy occurred in four out of 47 patients (120 cycles) in the letrozole group (pregnancy rate: 8.5% per patient and 3.3% per cycle) and eight out of 47 patients (121 cycles) (pregnancy rate: 17% per patient and 6.6% per cycle) in the CC group; the differences were not statistically significant. None of the regimes resulted in a multiple gestation gestation. The number of follicles per cycle was significantly higher in the CC + gonadotropin group as compared to the letrozole + gonadotropin group (1.77 ± 0.99 vs. 1.39 ± 0.617, P < 0.001). There was no statistically significant difference in perifollicular blood flow, endometrial thickness, and endometrial blood flow pattern between the two groups. No side effects were observed in either group. There was one case of ectopic gestation in the CC group. Conclusion(s): The use of lower dose of gonadotropins and oral agents together resulted in decreased medication costs, lesser monitoring [ultrasound (USG) visits], and good primary and secondary outcomes. However, more randomized controlled trials are needed to prove the efficacy of one regime over the other.
  2,517 254 1
EDITORIAL
Reducing dropout rates in ART: A need of hour
Kuldeep Jain,
January-June 2014, 1(1):2-4
DOI:10.4103/2394-4285.146698  
  2,334 403 -
CASE REPORTS
Embryo reduction in a myomatous uterus and polypectomy during embryo transfer: Challenges well overcome
Nikita Naredi, Nagaraj Narayana, Pankaj Talwar, Seema Rai
July-December 2014, 1(2):109-111
DOI:10.4103/2394-4285.162786  
Fibroids of the uterus, the most common benign pelvic tumors in women, as a sole cause of infertility has been debatable, as the incidence of fibroids as the cause of infertility in the absence of other obvious causes has been reported to be just 2-3%. Thus the management of myomas in the setting of infertility has also been controversial. However myomectomy has been considered ideal in a woman with sub fertility because the surgical removal of fibroid has definitely demonstrated improvement in pregnancy rate especially after assisted reproduction. Assisted Reproductive Technologies have resulted in an increase in the incidence of higher order multiple pregnancies which in turn is complicated by increased perinatal morbidity and mortality. Thus embryo reduction is offered to decrease the complication of prematurity and preterm birth due to multiple gestation. The technique of multifetal pregnancy reduction is not without risks especially in the presence of other pathology like multiple myomas. Herein we present a case of long duration infertility in the presence of multiple fibroids uterus which gets complicated by triplet gestation after IVF. Embryo reduction in the presence of these myomas is is a challenge both to the clinician in terms of the procedure and the patient because of the risks but subsequently has a successful pregnancy outcome.
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