Journal of Human Reproductive Science
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    Table of Contents - Current issue
Coverpage
October-December 2018
Volume 11 | Issue 4
Page Nos. 303-387

Online since Friday, December 28, 2018

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EDITORIAL  

From the editors desk p. 303
Madhuri Patil
DOI:10.4103/jhrs.JHRS_164_18  
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REVIEW ARTICLES Top

Preimplantation genetic testing: Its evolution, where are we today? p. 306
Firuza Rajesh Parikh, Arundhati Sitaram Athalye, Nandkishor Jagannath Naik, Dattatray Jayaram Naik, Rupesh Ramesh Sanap, Prochi Fali Madon
DOI:10.4103/jhrs.JHRS_132_18  
Preimplantation genetic testing (PGT) is an early form of prenatal genetic diagnosis where abnormal embryos are identified, thereby allowing transfer of genetically normal embryos. This technology has become an integral part of Assisted Reproductive Technology (ART) procedures. Initial experiments with animals as early as 1890 and those in the mid and later part of the last century paved the forward path of ART and PGT. This review article covers the evolution of PGT and is a pointer toward current and fast-evolving technology, allowing scientists and doctors to better comprehend human reproduction, and ensure healthy pregnancy outcomes.
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Psychosocial aspects of therapeutic donor insemination p. 315
Ansha Patel, P. S. V. N. Sharma, Pratap Kumar
DOI:10.4103/jhrs.JHRS_108_18  
The experience of delays in conception or possibility of remaining childless has the potential to create considerable psychological discomfort. In couples with severe male factor infertility, therapeutic intrauterine insemination using donor sperms (TDI) is offered as a treatment, second to in vitro fertilization using donor sperms. TDI is lucrative, less invasive, and a hopeful treatment. However, there are intricacies associated with it. Its immediate outcomes involve limited success rates, nonresponse, and chances of implantation failures, miscarriages, and multifetal pregnancies. Due to this, couples experience distress when they are advised to undergo three to six cycles of TDI in order to meet the expectations of having a baby. TDI has long-term issues on the triad comprising the “recipients,” the “donors,” and the “the children born out of TDI.” Nevertheless, managing psychosocial needs for couples undergoing TDI and other treatments in Indian clinics are grey areas of the conventional treatment pathway. The present review expands on the psychological issues and needs in couples opting for TDI.
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“In cycles of dreams, despair, and desperation:” Research perspectives on infertility specific distress in patients undergoing fertility treatments p. 320
Ansha Patel, P. S. V. N. Sharma, Pratap Kumar
DOI:10.4103/jhrs.JHRS_42_18  
“Emotional distress in infertility” is a broad expression that loosely denotes anxiety, depression, grief, crisis, depleting psychological well-being, and all forms of affective and interpersonal disturbances faced by individuals with infertility. The distress is usually associated with involuntary childlessness as it is an unwelcoming event. The developmental crisis associated with childlessness poses a threat to one's sense of self at all levels (individual, family and social). Distress may begin before or during treatments as a person experiences the loss of control over attaining parenthood, anxiety or dejection after the diagnosis, treatments, its complications particularly its limited success rates. This paper reviews the basic concepts, theoretical models related to infertility specific distress (ISD). It elaborates on the effects of individual and treatment-specific variables on ISD with special highlights gathered from the national and international research.
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ORIGINAL ARTICLES Top

Examination of Y-chromosomal microdeletions and partial microdeletions in idiopathic infertility in East Hungarian patients p. 329
Attila Mokánszki, Anikó Ujfalusi, Éva Gombos, István Balogh
DOI:10.4103/jhrs.JHRS_12_18  
Purpose: The aim of this study was to establish the Y chromosome microdeletion and partial AZFc microdeletion/duplication frequency firstly in East Hungarian population and to gain information about the molecular mechanism of the heterogeneous phenotype identified in males bearing partial AZFc deletions and duplications. Materials and Methods: Exactly determined sequences of azoospermia factor (AZF) region were amplified. Lack of amplification was detected for deletion. To determine the copy number of DAZ and CDY1 genes, we performed a quantitative analysis. The primers flank an insertion/deletion difference, which permitted the polymerase chain reaction products to be separated by polyacrylamide gel electrophoresis. Statistical Analysis Used: Mann–Whitney/Wilcoxon two-sample test, Kruskal–Wallis test, and two-sample t-probe were used for statistical analysis. Results: AZFbc deletion was detected only in the azoospermic cases; AZFc deletion occurred significantly more frequently among azoospermic patients, than among oligozoospermic males. The frequency of gr/gr deletions was significantly higher in the oligozoospermic patients than in the normospermic group. The b2/b3 deletion and partial duplications were not different among our groups, while b1/b3 deletion was found only in the azoospermic group. In infertile males and in normozoospermic controls, similar Y haplogroup distribution was detected with the highest frequency of haplogroup P. The gr/gr deletion with P haplogroup was more frequent in the oligozoospermic group than in the normozoospermic males. The b2/b3 deletion with E haplogroup was the most frequent, found only in the normozoospermic group. Conclusions: Y microdeletion screening has prognostic value and can affect the clinical therapy. In case of Y chromosome molecular genetic aberrations, genetic counseling makes sense also for other males in the family because these types of aberrations are transmittable (from father to son 100% transmission).
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A study on balanced chromosomal translocations in couples with recurrent pregnancy loss p. 337
Pritti K Priya, Vineet V Mishra, Priyankur Roy, Hetvi Patel
DOI:10.4103/jhrs.JHRS_132_17  
Background: Recurrent pregnancy loss (RPL) is an obstetric complication that affects couples in their reproductive age. Chromosomal abnormalities, mainly balanced rearrangements, could commonly be present in couples with RPL. Aim: The purpose of this study is to evaluate the contribution of chromosomal abnormalities and balanced reciprocal translocations, in particular occurring in either of the partners, resulting in RPL. Materials and Methods: A retrospective cytogenetic study was carried out on 152 individuals (76 couples) having a history of RPL. The cases were analyzed using G-banding and fluorescence in situ hybridization, wherever necessary. Results: Chromosomal abnormalities were observed in 3.2% of the total RPL cases, of which balanced translocations were observed in 4 (80%) individuals and marker chromosome was detected in 1 (20%) individual. All balanced translocations comprised reciprocal translocations, and no cases of Robertsonian translocations were detected in our study. Among reciprocal translocation carriers, three were male and one was female. Polymorphic variants were noted in 8 (5.3%) individuals. Conclusions: Chromosomal analysis is an important etiological investigation in couples with RPL. Balanced translocations are the most commonly detected chromosomal abnormalities in such couples. Thus, these couples are the best candidates for offering prenatal genetic diagnosis, thereby ensuring a better reproductive outcome.
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Circulating levels of vitamin D3 and leptin in lean infertile women with polycystic ovary syndrome p. 343
Ayman Shehata Dawood, Adel Elgergawy, Ahmed Elhalwagy
DOI:10.4103/jhrs.JHRS_40_18  
Objective: The objective of this study is to measure levels of Vitamin D3 and leptin and assess their relation of each to the pathogenesis of polycystic ovary syndrome (PCOS). Design: This was a cohort observational study. Settings: This study was conducted at the Department of Obstetrics and Gynecology, Tanta University. Materials and Methods: Ninety lean women were enrolled in this study and were allocated into two groups with 45 patients in each group: the first group (study group) who are lean women with PCOS and the second group (control group) who are the lean infertile patients without PCOS. Blood samples were collected and tested for study parameters. Results: There were no significant differences regarding demographic characteristics between both groups. The differences were in ovarian volume and hormonal profiles. Serum leptin was found to be significantly increased in lean PCOS than in control groups. Vitamin D3 levels were found to be lower in the lean PCOS group than in control group. Conclusion: Lean PCOS women are a unique group with specific hormonal profiles different from the typical PCOS profiles. Leptin and Vitamin D3 may have a role in the pathogenesis of lean PCOS, but large studies are still required regarding this unique group.
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Effect of insulin sensitizers on raised serum anti-mullerian hormone levels in infertile women with polycystic ovarian syndrome p. 348
Neeti Chhabra, Sonia Malik
DOI:10.4103/jhrs.JHRS_59_17  
Context: Increased circulating insulin levels contribute to hyperandrogenism in polycystic ovarian syndrome (PCOS) which causes a derangement in folliculogenesis, thus contributing to polycystic morphogenesis of the ovaries and a higher than normal anti-Mullerian hormone (AMH). A high AMH is an indicator of either stubborn anovulation or a predictor of ovarian hyperstimulation syndrome. Hence, it is postulated that the use of insulin sensitizers will reduce insulin resistance, hyperandrogenism, and subsequently serum AMH levels and will convert anovulatory cycles to ovulatory. Aim: To study the effect of insulin sensitizers on raised serum AMH levels in infertile women with PCOS. Settings and Design: This was a prospective interventional randomized single tertiary center study. Methodology: The study was conducted from August 2015 to April 2016. Infertile patients with PCOS as defined by the Rotterdam criteria with raised AMH (>5 ng/ml) levels were enrolled in the study under strict inclusion and exclusion criteria. The sample size was 105 patients. Cycle regularity, day 2–antral follicle count (AFC), luteinizing hormone, AMH levels, modified Ferriman–Gallwey score (mFGS), and acne score were recorded before starting the intervention. Patients were randomized into three equal groups of 35 each. Group A received metformin alone, Group B metformin plus myoinositol, and Group C only myoinositol. After completion of 3 months of pretreatment, the same parameters were rechecked. Statistical Analysis Used: Univariate analysis and Chi-square test were used for statistical analysis. Results: Of 105 patients, 95 completed treatment and the rest 10 dropped out. There was a reduction in AMH in all groups of insulin sensitizers with significant fall in the metformin only group. Cycle regularity, reduction in AFC, mFGS, and grade of acne were also obtained. Conclusions: Therapy with insulin sensitizers in PCOS women with raised AMH reduces the AMH levels, converts irregular menstrual cycles to regular, and reduces clinical hyperandrogenism.
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Window of implantation is significantly displaced in patients with adenomyosis with previous implantation failure as determined by endometrial receptivity assay p. 353
Nalini Mahajan, Simrandeep Kaur, Maria Ruiz Alonso
DOI:10.4103/jhrs.JHRS_52_18  
Background: Adenomyosis is associated with implantation failure and poor reproductive performance in IVF/ICSI cycles. Aims: To compare if window of implantation (WOI) is displaced in patients having adenomyosis compared to controls using endometrial receptivity array (ERA) test. Settings and Design: Retrospective Case control study. 374 patients with previous one or more IVF failures who underwent ERA test between 2013-2016 at our centre were enrolled. Patients were divided into two groups; Group A-36 patients with adenomyosis (study group) and Group B- 338 patients without adenomyosis (controls). Statistical Analysis: Normality assumptions for continuous variables were tested using Kolmogorov Smirnov test. Mean values of two groups were compared using Student's t-independent test. Frequency data by categories were compared using Chi-square/Fisher's exact test. Risk ratio and 95% confidence limits were calculated. P < 0.05 was considered for statistical significance. Results: WOI was displaced (Non Receptive ERA) significantly in adenomyosis 47.2% (17/36) compared to controls 21.6% (73/338) (P < 0.001, CI-8.7%-42.5%) making risk ratio of displaced WOI in adenomyosis versus controls to be 2:1. The incidence of RIF was 66.6% in adenomyosis compared to 34.9% in controls (P < 0.001, CI- 15.5%-47.9%). Pregnancy rate after personalized embryo transfer in adenomyosis group was 62.5%, signifying displaced WOI as a cause of implantation failure in adenomyosis patients with previous implantation failure. Conclusions: Our study suggests it is prudent to evaluate Endometrial receptivity before embryo transfer in patients with adenomyosis to avoid wastage of good embryos.
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Knowledge about age-related decline in fertility and oocyte cryopreservation: A national survey p. 359
Karissa C Hammer, Alyssa N Kahan, Louis F Fogg, Mark A Walker, Jennifer E Hirshfeld-Cytron
DOI:10.4103/jhrs.JHRS_158_17  
Context: Women worldwide are delaying childbearing, but are they aware of the age-related decline in fertility? Aims: The aim of this study is to investigate awareness of age-related decline in fertility and oocyte cryopreservation. Settings and Design: A primary analysis of a cross-sectional electronic survey with a nationally representative sample of nulliparous women aged 25–45 years. Subjects and Methods: A national online survey performed March 4–March 9, 2016. Statistical Analysis Used: A linear regression model and ANOVA tests were performed. Results: A total of 1213 women completed the survey. A significant difference was discovered in fecundity knowledge between women who identified as in a partnership compared to those who did not. Partnered women were more likely to respond “know a lot” about the age-related decline in fertility, whereas unpartnered women were more likely to respond “never heard of it” (P < 0.01). Partnered women are also more likely to respond that they would have made different life choices had they been more knowledgeable about fertility at a younger age (P = 0.01). The majority of the survey population had heard of oocyte cryopreservation but did not know much about it. Conclusions: Slightly over half of participants had an understanding of the natural age-related decline in fertility. Having a partner significantly increased the likelihood that a woman reported more knowledge about fertility. More effort is necessary to educate all women on assisted reproductive technologies and the natural age-related decline in fertility, specifically single women of childbearing age.
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Effect of body mass index on the efficacy of paracervical block for ultrasound-guided transvaginal oocyte retrieval as assessed by requirement of rescue propofol p. 365
Dipti Saxena, Rajeev Rai, Atul Dixit, Shilpa Bhandari, Sadhana Sanwatsarkar
DOI:10.4103/jhrs.JHRS_86_18  
Background and Aims: Oocyte retrieval is the only vital aspect of in vitro fertilization requiring anesthesia. Previous studies have shown the inconclusive role of paracervical block (PCB) in transvaginal oocyte retrieval (TVOR) under ultrasound guidance. This study was planned to observe the role and efficacy of PCB as measured by the amount of propofol used as rescue in patients undergoing TVOR and grading it on the basis of body mass index (BMI). Methods: This prospective, comparative study, conducted over 1 year, recruited 140 American Society of Anesthesiologists I and II patients and divided into two groups as follows: Group A received PCB with 20 ml of 1% lignocaine and Group B received no PCB. Total propofol consumed, BMI, time taken, oocytes retrieved, postprocedure visual analog scale score, and complications were noted. In both the groups, patients were then divided into underweight, normal, overweight, and obese according to BMI. Statistical analysis was done using Statistical Package Mini Tab Version 17.0. The primary objective was to study the efficacy of PCB as estimated by amount of propofol required during the procedure. The secondary aim was to assess the effect of BMI on the efficacy of PCB. Results: Propofol requirement was found to be significantly more (P < 0.05) in Group B patients (172.14 ± 64.15) in comparison to Group A (132.14 ± 66.11). Amount of propofol required in normal BMI and overweight patients was significantly higher in Group B. No significant difference was observed in underweight, and obese patients in both the groups. Conclusion: PCB reduces the consumption of propofol in normal BMI patients. Underweight and obese population do not benefit from PCB.
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Comparison of obstetric outcomes of pregnancies after donor-oocyte In vitro fertilization and self-oocyte In vitro fertilization: A retrospective cohort study p. 370
Vikas Yadav, Priyanka Bakolia, Neena Malhotra, Reeta Mahey, Neeta Singh, Alka Kriplani
DOI:10.4103/jhrs.JHRS_115_17  
Aims:The aim of this study is to evaluate and compare multiple obstetric and perinatal outcomes between donor-oocyte in vitro fertilization (IVF) and self-oocyte IVF group. Settings and Design: This study was done in a tertiary care center with ART unit. This was a retrospective comparative cohort study. Materials and Methods: The present study comprised all women between 20 and 45 years who conceived from oocyte donation (n = 78) between December 1, 2010, and December 31, 2016, and compared with all women who underwent self-oocyte IVF (n = 112). The process involved controlled ovarian stimulation and retrieval of the donor oocytes, preparation of recipient endometrium, and pregnancy management. Obstetric and perinatal outcomes were compared. Statistical Analysis Used: Chi-square test was used for categorical variables. Analysis for confounding variables was performed using multivariable linear and logistic regression analysis. Results: Baseline characteristics between the two groups were comparable. Miscarriage, first-trimester bleeding, pregnancy-induced hypertension (PIH), and gestational diabetes mellitus were significantly higher in donor-oocyte IVF group compared to self-oocyte cycles (P = 0.001). Using multiple logistic regression analysis, age class adjusted PIH incidence was significantly higher in donor-oocyte group as compared to self-oocyte group (P = 0.010). There was no significant variation in perinatal outcomes between the donor- and self-oocyte IVF cycles (P > 0.05). Conclusion: Oocyte donation should be treated as an independent risk factor for PIH.
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Predictors of infertility stress among couples diagnosed in a public center for assisted reproductive technology p. 376
Asmaa Zaidouni, Ouasmani Fatima, Benbella Amal, Aboulmakarim Siham, Hardizi Houyam, Kasouati Jalal, Bezad Rachid
DOI:10.4103/jhrs.JHRS_93_18  
Background: All around the world, infertility, in many ways, is recognized as a stressful and a critical experience that can have impact on social and marital life of a couple. Infertility stress may affect the treatment and its outcome for such couples. The objective of the present study is to assess the predictors of high stress of infertility among married couples. Materials and Methods: This cross-sectional study was conducted on 120 couples (240 patients) who were diagnosed with primary and secondary infertility from June 2017 to June 2018. A psychological self-assessment questionnaire (Perceived Stress Scale-10) was used as a tool to evaluate the presence of high infertility stress among couples after obtaining their consent. Furthermore, other socioepidemiological data of patients were collected. Statistical Analysis: Data were analyzed using SPSS software (version 20). Univariate statistical analysis was used followed by multiple logistic regressions between high infertility stress and the predictor variables. Results and Discussion: The prevalence of high infertility stress was 53.3% among women and 40.8% among men. For women, multivariate analysis showed leading associations of high infertility stress with level of education, infertility type, infertility duration, and etiologies of infertility. However, for men, multivariate analysis showed leading associations between high infertility stress and alcohol status and inadequate sleep and infertility type.
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Seroprevalance of rubella in an urban infertility clinic – observations and challenges ahead p. 384
Aby Kottal Koshy, Jijo George Varghese, Jeethu Issac
DOI:10.4103/jhrs.JHRS_16_18  
Background:Rubella is a contagious viral illness that can be prevented by vaccination. Currently, vaccination is being offered to children and adolescents. Since an infection in pregnancy can have teratogenic effects, identification of susceptive women and vaccination before conception would be ideal. Aims: The aim of this study is to estimate the deficiency in immunity against Rubella in women planning conception. Settings and Design: Retrospective data collected from all women who attended a private assisted reproduction center for evaluation of infertility or for pre-pregnancy counseling between January 2012 and October 2017. Materials and Methods: Women underwent measurement of the rubella-specific immunoglobulin G using enzyme-linked fluorescent assay. Statistical Analysis: Data between age groups were compared using the Chi-squared test. P < 0.05 was considered statistically significant. Results: Of the 1671 cases analyzed, 418 lacked sufficient immunity and therefore needed vaccination. Conclusions: One in four women was at risk of developing rubella during pregnancy. It is important to screen and vaccinate susceptible women to reduce the risk of congenital rubella syndrome.
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