Journal of Human Reproductive Science
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    Table of Contents - Current issue
Coverpage
July-September 2017
Volume 10 | Issue 3
Page Nos. 151-237

Online since Thursday, October 12, 2017

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EDITORIAL  

From the Editor’s Desk p. 151
Madhuri Patil
DOI:10.4103/jhrs.JHRS_143_17  
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REVIEW ARTICLES Top

Debates regarding lean patients with polycystic ovary syndrome: A narrative review p. 154
Manu Goyal, Ayman S Dawood
DOI:10.4103/jhrs.JHRS_77_17  
Polycystic ovary syndrome (PCOS) is a complex syndrome showing the clinical features of an endocrine/metabolic disorder, including hyperinsulinemia and hyperandrogenism. Two phenotypes are present, either lean or obese, with different biochemical, hormonal, and metabolic profiles. Evidence suggests many treatment modalities that can be applied. However, many of these modalities were found to be not suitable for the lean phenotype of PCOS. Much contradictory research was found regarding lean patients with PCOS. The aim of this narrative review is to shed light on the debate prevailing regarding characteristics, as well as metabolic, hematological, and potential management modalities. Literature review was performed from January 1, 2000 to March 31, 2017 with specific word search such as lean PCOS, hormonal abnormalities in lean PCOS, and the management of lean PCOS. All retrieved articles were carefully assessed, and data were obtained. We could conclude that the debate is still prevailing regarding this specific lean population with PCOS, especially with regard to their characteristics and management modalities. Further studies are still required to resolve this debate on the presence of PCOS in lean women.
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Oral health and erectile dysfunction Highly accessed article p. 162
Vijendra P Singh, Sunil K Nettemu, Sowmya Nettem, Rajesh Hosadurga, Sangeeta U Nayak
DOI:10.4103/jhrs.JHRS_87_17  
Ample evidence strongly supports the fact that periodontal disease is a major risk factor for various systemic diseases namely cardio-vascular disease, diabetes mellitus, etc. Recently, investigators focussed on exploring the link between chronic periodontitis (CP) and erectile dysfunction (ED) by contributing to the endothelial dysfunction. Both the diseases share common risk factors. Various studies conducted in different parts of the world in recent years reported the evidence linking this relationship as well as improvement in ED with periodontal treatment. Systemic exposure to the periodontal pathogen and periodontal infection-induced systemic inflammation was thought to associate with these conditions. The objective of this review was to highlight the evidence of the link between CP and ED and the importance of oral health in preventing the systemic conditions.
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ORIGINAL ARTICLES Top

Correlations between anthropometry and lipid profile in women with PCOS p. 167
Donthu Kiranmayee, Kothapalli Kavya, Yalamanchali Himabindu, Manne Sriharibabu, Gadi Leela Jaya Madhuri, Swargam Venu
DOI:10.4103/jhrs.JHRS_108_16  
Background: Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in reproductive age women and is associated with both reproductive and metabolic abnormalities. Recent studies have demonstrated an early onset of abnormal cardiovascular risk profile in women with PCOS. Abnormal lipid profile patterns are common in women with PCOS, and these abnormalities are not uniform in all populations. Anthropometry is a simple and commonly used research tool for assessing metabolic risk in women with PCOS. Therefore, this study examined the correlations between anthropometric parameters and lipid profile in women with PCOS. Objectives: The objectives of the study were (1) To study the anthropometric profile of women with PCOS, (2) To examine the lipid profile pattern of these women with PCOS and (3) To see whether there exists any correlation between these anthropometric parameters and lipid profile. Materials and Methods: This observational cross-sectional study examined anthropometry and lipid profile in 86 married women with PCOS in the age group of 18–35 years and correlated them by using Pearson’s correlation coefficient. Results: More than 80% of the women with PCOS demonstrated abnormal anthropometric parameters, and in more than 70% women, lipid abnormalities such as low levels of high-density lipoprotein (HDL) cholesterol and high levels of triglycerides and low-density lipoprotein cholesterol were observed. Significant positive correlations were seen between body mass index (BMI) and triglycerides (P ≤ 0.001) and waist circumference (WC) and triglycerides (P ≤ 0.029). Negative correlations were observed between BMI and HDL cholesterol (P ≤ 0.013). Conclusion: This study revealed that BMI and WC are the most important anthropometric parameters correlated to dyslipidemia in the south Indian women with PCOS.
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A study of controlled ovarian stimulation with clomiphene citrate or letrozole in combination with gonadotropins and IUI in unexplained infertility p. 173
Madhusmita Hembram, Ratna Biswas, Anju Jain
DOI:10.4103/jhrs.JHRS_120_16  
Aim: To compare the effect of clomiphene citrate (CC) + human menopausal gonadotropin (hMG) with letrozole + hMG on size, number of follicles, endometrial thickness, serum levels of oestradiol and progesterone and pregnancy rate. Settings and Design: Non-randomised interventional study. Patients and Methods: A total number of 60 patients in the age group of 20–35 years with unexplained infertility were divided into two groups, 30 in each. Group A received CC + hMG and group B received letrozole + hMG. In both the groups, ovulation was triggered by hCG followed by intrauterine insemination. Results: The number of follicles on day 8 were significantly higher in the CC + hMG group than that in the letrozole + hMG group. Serum oestradiol level was significantly higher in the CC + hMG group on day 10 and on the day of hCG administration. Pregnancy rate in the CC + hMG group was 23.3% and 13.3% in the letrozole + hMG group. Conclusion: The sequential protocol was cost-effective. CC + hMG could be a preferred ovarian stimulation protocol in couples with unexplained infertility with the added advantage of having no significant complications in properly monitored cycles.
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Hysterosalpingographic (HSG) pattern of infertility in women of reproductive age p. 178
Chinwe R Onwuchekwa, Vaduneme K Oriji
DOI:10.4103/jhrs.JHRS_121_16  
Background: Infertility is a complex disorder with significant medical, psychological and economic problems. Aims: The aim of the study is to evaluate the structural abnormalities of the uterus and fallopian tubes in infertile women as elucidated by hysterosalpingography. Setting and Design: A retrospective study, conducted at the Radiology and Obstetric and Gynaecologic Departments of a tertiary health care institution. Materials and Methods: Evaluation of all consecutive patients in whom hysterosalpingographic (HSG) was performed for infertility between July 2013 and June 2015 in the Department of Radiology. For the biodata, indications for the investigation and the HSG findings were obtained. Statistical Analysis: The data were analyzed using IBM Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA) for Windows, version 20 software. Results: A total of 299 patients were evaluated. Of these, 250 were for infertility with primary and secondary infertility constituting 18.4 and 81.6%, respectively. Seventy percent of the cases for infertility had abnormalities on the HSG. Normal uterine cavity was found in 123 (49.2%) cases. Uterine filling defects were the most common uterine abnormality. Fallopian tube occlusion, loculated contrast material spillage and hydrosalpinx were more common on the right, and bilateral tubal occlusion was seen only in 11.2%. All cases of intravasation were associated with either unilateral or bilateral fallopian tube blockage or irregularity of the uterus. Conclusion: There was a high incidence of tubal disease in the women presenting with infertility. This was commonly as a result of infection and inflammatory process. This study showed that HSG is very vital in detecting birth canal pathologies; hence, the facility for this important procedure, especially fluoroscopy, should be made available in the health centres for adequate assessment of the women with infertility.
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A prospective randomized study comparing unipolar versus bipolar hysteroscopic myomectomy in infertile women p. 185
Kallol K Roy, Sandeep Metta, Yamini Kansal, Sunesh Kumar, Seema Singhal, Perumal Vanamail
DOI:10.4103/jhrs.JHRS_134_16  
Study Objective: To compare the operative and reproductive outcome of hysteroscopic myomectomy using unipolar resectoscope versus bipolar resectoscope in patients with infertility and menorrhagia. Design: Randomized, prospective, parallel, comparative, single-blinded study. Design Classification: Canadian Task Force classification I. Setting: Tertiary care institute. Patients: Sixty women with submucous myoma and infertility. Interventions: Hysteroscopic myomectomy performed with unipolar resectoscope or bipolar resectoscope. Measurements: Primary outcome measures were the pregnancy-related indicators. Secondary outcome measures were the operative parameters, harmful outcomes related to the procedure, and comparison of improvement levels in the menstrual pattern after surgery between the two groups. Main Results: A total of 60 patients were randomized into two groups of equal size. Baseline characteristics were not significantly different between the two groups. Reduction in sodium level from pre- to postsurgery was significantly (P = 0.001) higher in the unipolar group. Nine patients (30%) in the unipolar group had hyponatremia in the postoperative period compared to none in the bipolar group (P = 0.002). However, there was no significant difference in the other operative parameters between the two groups. In both the groups, a significant improvement in the menstrual symptoms was observed after myomectomy. Pregnancy-related outcomes were similar in both the groups. Conclusion: The use of bipolar resectoscope for hysteroscopic myomectomy is associated with lesser risk of hyponatremia compared to unipolar resectoscope. Bipolar resectoscopic myomectomy is found to be an effective and safer alternative to unipolar resectoscopy with similar reproductive outcome.
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Expression of the bone morphogenetic protein-2 (BMP2) in the human cumulus cells as a biomarker of oocytes and embryo quality p. 194
Sirin B Demiray, Ozlem Yilmaz, Ege N.T. Goker, Erol Tavmergen, Nilufer Calimlioglu, Ugur Sezerman, Huseyin O Soykam, Gulperi Oktem
DOI:10.4103/jhrs.JHRS_21_17  
Background: The members of the transforming growth factor-B superfamily, as the bone morphogenetic proteins (BMPs) subfamily and anti-Müllerian hormone (AMH), play a role during follicular development, and the bone morphogenetic protein-2 (BMP2), AMH, and THY1 are expressed in ovaries. Aim: This study was designed to define whether or not the expressions of these proteins in human cumulus cells (CCs) can be used as predictors of the oocyte and embryo competence. Settings and Design: The study included nine female patients who were diagnosed as idiopathic infertility, aged 25–33 years (median 30 years) and underwent Assisted Reproductive Technologies. Materials and Methods: The CCs from 60 oocyte–cumulus complexes obtained from the nine patients were evaluated with immunofluorescence staining in respect of BMPs, AMH and THY1 markers. The CCs surrounding the same oocytes were evaluated separately according to the oocyte and embryo quality. Statistical Analysis: Quantitative data were statistically analyzed for differences using the two-sided Mann–Whitney U test (P < 0.05). Results and Conclusions: Significant differences in immunofluorescence staining were observed in oocyte quality and embryo quality for the BMP2 only (P < 0.05). No significant differences were observed for AMH or CD90/THY1. Conclusion: These results demonstrated that there is a significant difference in the expression of BMP2 in the CCs of good quality oocytes and subsequently a good embryo.
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Single blastocyst transfer: The key to reduce multiple pregnancy rates without compromising the live birth rate p. 201
Uma M Sundhararaj, Monali V Madne, Reeta Biliangady, Sumana Gurunath, Ambika G Swamy, Indu S.T. Gopal
DOI:10.4103/jhrs.JHRS_130_16  
Background: Historically, to achieve higher pregnancy rates, multiple embryos were transferred after an in-vitro fertilisation (IVF). However, this practice is being reassessed, because it leads to multiple pregnancies that is known to cause adverse maternal and fetal outcomes. Aim: To compare the pregnancy outcomes in fresh IVF or intracytoplasmic sperm injection (ICSI) cycles among women undergoing elective single blastocyst transfer (eSBT) vs. those undergoing double blastocyst transfer (DBT). Settings and Design: It is a retrospective data analysis of 582 patients undergoing fresh IVF/ICSI cycles performed from January 2012 to June 2015. Materials and Methods: Patients, who underwent IVF/ICSI and developed more than one blastocyst, were included in the study. Donor cycles were excluded from the study. All the embryos were cultured to blastocyst stage in sequential media followed by transfer of two blastocysts (DBT) or eSBT and cryopreservation of the remaining. Statistical Analysis: Statistical analysis was performed using chi square test. Results: Out of 582 patients, in 149 patients one blastocyst was transferred and in 433 patients two blastocysts were transferred. There was no statistical difference in the biochemical pregnancy rate, clinical pregnancy rate and live birth rate in both the groups. Statistics demonstrated a significant drop in miscarriage rate in eSBT group. There was no incidence of twins in eSBT group, whereas twin birth rate per clinical pregnancy was 29.02% in DBT group. Conclusion: Single blastocyst transfer is an effective method to reduce the risk of multiple births without compromising the pregnancy outcomes. Given the promising potential of vitrification; the remaining blastocyst can be cryopreserved.
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Autologous intrauterine platelet-rich plasma instillation for suboptimal endometrium in frozen embryo transfer cycles: A pilot study p. 208
Sunita R Tandulwadkar, Manasi V Naralkar, Akash D Surana, M Selvakarthick, Avinash H Kharat
DOI:10.4103/jhrs.JHRS_28_17  
Introduction: This pilot study was to evaluate the effectiveness of intrauterine infusion of autologous platelet-rich plasma (PRP) in infertile women undergoing frozen embryo transfer cycles with suboptimal endometrium. Material and Methods: Intrauterine instillation of autologous PRP was done in 68 women between 22 and 40 years, over 8 months, with suboptimal endometrial growth, and patients with repeated cycle cancellations, in addition to Estradiol valerate. Frozen embryo transfer was performed when the endometrium reached an optimal pattern in terms of thickness, appearance, and vascularity. Results: The mean pre-PRP endometrial thickness (ET) was 5 mm which significantly increased to 7.22 mm post-PRP. There was a significant increase in vascularity, seen by the number of vascular signals seen on Power Doppler, reaching the zones 3 and 4 of the endometrium. The positive beta Human Chorionic Gonadotropin (hCG) rate was 60.93% and the clinical pregnancy rate was 45.31%. A total of 13 women are in the second trimester, 13 are in the first trimester with a healthy intrauterine pregnancy, one patient had an ectopic gestation, three had blighted ova, two had missed abortions, and two biochemical pregnancies. Conclusion: This study suggests that the use of autologous PRP holds promise in the treatment of women with suboptimal ET and vascularity for embryo transfer. It would help to reduce the incidence of cycle cancellations and thus even help reduce the financial and psychological burden of repeated cancelled cycles.
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Sexual functioning, beliefs about sexual functioning and quality of life of women with infertility problems p. 213
Prathibha Agustus, Manjula Munivenkatappa, Padmini Prasad
DOI:10.4103/jhrs.JHRS_137_16  
Background: The study was conducted in the background of paucity of studies examining the sexual and psychosocial functioning of women with infertility. Aims: The study explored sexual functioning in women with infertility problems, their beliefs about sexuality and their quality of life. Settings and Design: A single group exploratory design with non-probability purposive sampling was used. A total of 30 participants diagnosed with primary infertility were included in the study. Materials and Methods: The data were obtained by individual administration of the following tools: Semi-structured interview schedule, Female Sexual Functioning Inventory, Sexual Dysfunctional Beliefs Questionnaire, World Health Organization Quality of Life Scale − BREF Version and General Health Questionnaire-12. The data obtained were analyzed using descriptive statistics and non-parametric tests. Results: About half of the participants had sexual dysfunction. Pain-related problems were most commonly reported (50%). Factors contributing to dysfunction included inadequate knowledge about sex, sexual stimulation and sexual communication. Along with inadequate self-image, negative childhood experiences, financial difficulties and marital discord in parents influenced the perception of self. Majority of the women had dysfunctional beliefs about sexuality (56%), and greater beliefs were found to be in the domain of sexual conservatism. The overall quality of life was poor, and 56% of women experienced psychological distress. There was significant positive correlation between sexual conservatism and experience of pain and overall sexual functioning. Conclusion: Women with infertility bear dysfunctional beliefs and suffer from problems in sexual functioning, have low quality of life and high psychological distress.
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Infertility stress in couples undergoing intrauterine insemination and in vitro fertilization treatments p. 221
Manisha Awtani, Kamayani Mathur, Sandeep Shah, Manish Banker
DOI:10.4103/jhrs.JHRS_39_17  
Aim: The main aim of the study was to assess the stress levels of husbands and wives undergoing intrauterine insemination (IUI) and in vitro fertilization (IVF) treatments, and also to observe whether the stress levels differed between the methods of treatments. Materials and Methods: This research focused on 120 infertile couples who underwent IUI and In Vitro Fertilization-Intra Sperm Cytoplasmic sperm Injection (IVF-ICSI) at an infertility clinic from April 2014 to November 2014. Sixty couples who underwent each method of treatment were selected using purposive sampling technique. Fertility Problem Inventory (Newton et al., 1999) was used to collect the data after obtaining their consent. Statistical Analysis: Statistical analysis was performed at descriptive (mean, standard deviation, and Kolmogorov test) and inferential (analysis of variance, ANOVA) levels. Results and Conclusion: The prevalence of global stress was very high in couples undergoing IUI and IVF treatments, as found by descriptive analysis [mean = 149.95, standard deviation (SD) = 29.76]. Considering the various subscales, stress related to the need for parenthood was found to be high (mean = 45.95, SD = 9.53). Infertility stress (global) was higher among wives when compared to their husbands (f = 9.408; P = 0.002), and the same was noted on the domains of need for parenthood (f = 10.145; P = 0.002), social concern (f = 11.107; P = 0.001), and sexual concern (f = 4.013; P = 0.046). No difference in the levels of global stress was observed when both the modes of treatments were compared (f = 0.180, P = 0.672). For couples, infertility stress showed no significant difference irrespective of whether they underwent IUI or IVF.
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CASE REPORTS Top

Ectopic ovary with dermoid cyst as a result of possible asymptomatic autoamputation p. 226
Bimal Mathew John
DOI:10.4103/jhrs.JHRS_67_17  
A 32-year-old woman, who presented for laparoscopic sterilization after two full-term normal deliveries, was incidentally diagnosed to have a left-sided complex cyst in the pouch of Douglas (POD). She had no history of previous surgeries or any symptoms of lower abdominal pain, nausea, or vomiting in the past. She underwent laparoscopy, and the left ovary and distal portion of the fallopian tube were absent in their normal position. An ectopic left ovary with dermoid cyst was noted in the POD. The right ovary and tube were in their normal position. I attribute this to be a very rare case of asymptomatic torsion and autoamputation of the ovary resulting in an ectopic ovary.
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Successful reproductive outcome after laparoscopic Strassmann’s metroplasty p. 231
S.D.S. Karthik, Alka Kriplani, Reeta Mahey, Garima Kachhawa
DOI:10.4103/jhrs.JHRS_11_17  
Mullerian anomalies cause a significant impact on the reproductive outcomes. A bicornuate uterus is a type of lateral fusion defect, which constitutes 26% of all uterine anomalies. Strassmann’s metroplasty is a unification procedure performed to correct the two smaller uterine cavities into a more spacious single cavity. Improved reproductive performance was reported after unification metroplasty. Laparoscopic route can be adopted for this procedure with all the advantages of minimally invasive surgery. Here, we report a success story of a woman who suffered with six miscarriages and secondary infertility who underwent laparoscopic Strassmann’s metroplasty in a tertiary care center and later delivered a baby by caesarean section.
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Large-volume paracentesis, up to 27 L, with adjuvant vaginal cabergoline in the case of severe ovarian hyperstimulation syndrome with successful pregnancy outcome: A case report p. 235
Nupur Agarwal, Sanghamitra Ghosh, Shikha Bathwal, Baidyanath Chakravarty
DOI:10.4103/jhrs.JHRS_13_17  
Severe ovarian hyperstimulation syndrome (OHSS) is a potentially life-threatening complication of assisted reproductive technology. Herein, we report the case of an infertile couple, with the husband being azoospermic, who underwent in-vitro fertilisation and intracytoplasmic sperm injection at our institute. The woman presented with late OHSS 7 days after embryo transfer. Inpatient management was performed with intensive surveillance. Oral cabergoline was started prophylactically but was replaced by the vaginal route due to intolerance. Transvaginal paracentesis was performed five times over 20 days, and a total of 27 L of ascitic fluid was drained. The patient improved substantially and had a further uneventful pregnancy course. This case report helped us theorise that large-volume paracentesis is safe and efficacious in the management of severe OHSS. In addition, the vaginal route of cabergoline administration is more favourable than the oral route in view of lesser side effects and better patient compliance.
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