Journal of Human Reproductive Science
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    Table of Contents - Current issue
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April-June 2021
Volume 14 | Issue 2
Page Nos. 103-214

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EDITORIAL  

Editorial commentary Highly accessed article p. 103
Padma Rekha Jirge
DOI:10.4103/jhrs.jhrs_84_21  
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REVIEW ARTICLE Top

Clinical andrologists: Do we really need them in the era of ART? Highly accessed article p. 105
Prashant Motiram Mulawkar, Pankaj N Maheshwari, Sumeet Gopal Agrawal
DOI:10.4103/jhrs.jhrs_66_21  
Infertility is on a rise, and so is the availability of assisted reproductive technique (ART) centres. The sole aim of these centers is to help these unfortunate couples achieve pregnancy. Hence, the concentration of the treatment is on the female partner, while the male is relegated to just being a source for sperm. In the era of intracytoplasmic sperm injection, when pregnancy is possible even with a single mature sperm, evaluation and management of male factor infertility (MFI) is often neglected. MFI and poor semen parameters are markers of male health. He could be suffering from erectile or ejaculatory issues or with correctable obstructive azoospermia. A simple timely varicocele correction may help resolve the issue. It is important to understand that MFI is not a disease but may be a symptom of major underlying clinical condition like testicular or brain tumors. Infertility treatment could be the only occasion when a male seeks health-care evaluation. India has a large pool of qualified urologists trained in andrological care. In contrast, gynecologists may not be trained in the management of male patients, hence there is an important place for andrological services to be an integral part of ART centers. Andrologists would offer minimal andrological evaluation and condition-specific treatment. This could avoid or reduce the need for invasive and expensive ART. Andrologists could also choose the most appropriate mode of sperm retrieval. Undoubtedly, availability of andrological services would improve the overall quality of care, reduce the costs and complications, and would also be medicolegally safe.
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ORIGINAL ARTICLES Top

Observable protective activities of quercetin on aluminum chloride-induced testicular toxicity in adult male Wistar Rat p. 113
John Afees Olanrewaju, Toluwani Gabriel Akinpade, Sunday Yinka Olatunji, Joshua Oladele Owolabi, Joseph Igbo Enya, Stephen Taiye Adelodun, Sunday Oluseyi Fabiyi, Ayodele Babajide Desalu
DOI:10.4103/jhrs.jhrs_190_20  
Background: Aluminum chloride (AlCl3 ) present in many manufactured consumable is considered as a toxic element. Aim: Our study evaluates the toxic effects induced by AlCl3 on the testes as well as the therapeutic tendency of Quercetin (QUE) agent as an antioxidant. Setting and Design: In the department of Anatomy of Medical School. Methods and Materials: Thirty-two male Wistar rats weighing approximately 170 ± 10 g were assigned into four groups with eight each, fed with rat chow and water ad-libitum. Group A served as control and was given distilled water throughout; Group B was given only QUE (200 mg/kg body weight) for 21 days; Group C was given only AlCl3 (300 mg/kg body weight) for 14 days; and Group D was given AlCl3 (300 mg/kg body weight) for 14 days followed with QUE (200 mg/kg body weight) for 21 days. Substance administrations were done orally. Statistical analysis: One-way analysis of variance was used to analyze the data, in GraphPad Prism 6.0 being the statistical software. Results: AlCl3 significantly reduced the relative organ (testes) weight, correlating the decrease in sperm count, sperm motility and sperm viability. Furthermore, there was a decrease in luteinizing hormone with an increase in follicle-stimulating hormone which accounted for a significant reduction in testosterone level that plays a great role in spermatogenesis, following AlCl3 treatment. The cytoarchitecture of the testes showed degenerative changes in the seminiferous tubules and leydin cells, nitric oxide synthases immunoreactivity was intense in the seminiferous epithelium of rat in Group C. Conclusion: These suggest that QUE antioxidant property could reverse the decrease in sperm status, hormonal effects, and functional deficit induced by aluminum chloride on the testes of Wistar rats.
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Hydrogen peroxide has adverse effects on human sperm quality parameters, induces apoptosis, and reduces survival p. 121
Dwi Ari Pujianto, Mona Oktarina, Ida Ayu Sharma Sharaswati, Yulhasri
DOI:10.4103/jhrs.jhrs_241_20  
Background: One of the causes of male fertility disorders is the exposure of oxidative stress on the human sperm. Understanding the mechanism of disturbance is important to develop a better treatment for infertile or subfertile patients. Aims: The aim of this study was to analyze the effects of hydrogen peroxide (H2O2) on human sperm quality parameters and cell survival. Settings and Design: This study used an experimental design. Materials and Methods: Sperm cells from 15 donors were washed in a Percoll gradient and dissolved in Biggers, Whitter, and Whittingham medium. Cells were incubated with H2O2 at various concentrations from 0 to 250 μM for 2 h. Sperm viability was examined by eosin assay, sperm kinetic by computer-assisted sperm analyzer, sperm penetration by cervical mucus penetration assay, and membrane integrity by hypo-osmotic swelling test. Sperm capacitation, apoptosis, and cell survival were analyzed using western immunoblotting. Statistical Analysis Used: One-way ANOVA on SPSS 21 combined with post hoc LSD test was used to analyze differences among the groups. A P < 0.05 was considered significant. Results: Sperm viability and kinetic were significantly reduced at H2O2 concentrations of 200 and 250 μM. H2O2 reduced sperm capability to penetrate cervical mucus and also damage cell membrane integrity at all concentrations used. H2O2 significantly inhibited sperm capacitation, indicated by reduced total tyrosine phosphorylation. H2O2 exposure stimulated activation of caspase 3 and significantly reduced phosphorylated AKT at all concentrations used. Conclusions: H2O2 comprehensively inhibits sperm qualities related to the capacity to fertilize oocyte, stimulates caspase activity, and inhibits cell survival.
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Assessment and establishment of correlation between reactive oxidation species, citric acid, and fructose level in infertile male individuals: A machine-learning approach p. 129
Golnaz Shemshaki, Ashitha S Niranjana Murthy, Suttur S Malini
DOI:10.4103/jhrs.jhrs_26_21  
Background: Biochemical complexity of seminal plasma and obesity has an important role in male infertility (MI); so far, it has not been possible to provide evidence of clinical significance for all of them. Aims: Our goal here is to evaluate the correlation between biochemical markers with semen parameters, which might play a role in MI. Study Setting and Design: We enlisted 100 infertile men as patients and 50 fertile men as controls to evaluate the sperm parameters and biochemical markers in ascertaining MI. Materials and Methods: Semen analyses, seminal fructose, citric acid, and reactive oxidation species (ROS) were measured in 100 patients and 50 controls. Statistical Analysis: Descriptive statistics, an independent t-test, Pearson correlation, and machine-learning approaches were used to integrate the various biochemical and seminal parameters measured to quantify the inter-relatedness between these measurements. Results: Pearson correlation results showed a significant positive correlation between body mass index (BMI) and fructose levels. Citric acid had a positive correlation with sperm count, morphology, motility, and volume but displayed a negative correlation with BMI and basal metabolic rate (BMR). However, BMI and BMR had a positive correlation with ROS. Sperm count, morphology, and motility were negative correlations with ROS. The machine-learning approach detected that pH was the most critical parameter with an inverse effect on citric acid, and BMI and motility were the most critical parameter for ROS. Conclusion: We recommend that evaluation of biochemical markers of seminal fluid may benefit in understanding the etiology of MI based on the functionality of accessory glands and ROS levels.
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Serum irisin levels and its association with blood glucose and insulin indices in diagnosing insulin resistance in adolescents with polycystic ovarian syndrome p. 137
Bhawina Sharan, Haritha Sagili, Sadish Kumar Kamalanathan, Subitha Lakshminarayanan
DOI:10.4103/jhrs.jhrs_191_20  
Context: Irisin, a new myokine, has been found to be a biological marker of insulin resistance (IR). There is conflicting evidence on serum irisin level in adult women with polycystic ovarian syndrome (PCOS), and data are lacking in adolescents with PCOS. Aims: We aimed to evaluate serum Irisin levels and study its association with indices using blood glucose and insulin levels in adolescents with PCOS. Settings and Design: This case–control study was conducted in the gynecology outpatient department. Materials and Methods: This study was carried out from August 2015 to June 2017. Eighty-two adolescent girls aged 15–19 years were included in the study. Fasting irisin, insulin,blood glucose; 2nd-h insulin (HOMA2-IR), and Quantitative Insulin Sensitivity Check Index (QUICKI) for all participants with addition of 2nd-h blood glucose for cases. Statistical Analysis: A correlation between serum irisin level and various biochemical parameters was done using Pearson's correlation. Results: Fasting serum irisin was significantly higher among PCOS cases (8.43 [5.84, 13.11]) when compared to controls 4.90 (2.37, 9.09), median (interquartile range) (P = 0.002). Serum irisin was found to have a significant moderate positive correlation with 2nd-h blood glucose, fasting/2nd-h insulin, and HOMA2-IR. A significant moderate negative correlation was observed between irisin and QUICKI. Conclusions: Serum irisin levels were significantly elevated in adolescents with PCOS when compared to the controls. A significant correlation of serum irisin with blood glucose and insulin indices indicates that serum irisin could serve as a marker of IR and may help in its diagnosis in adolescents with PCOS.
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Reduced angiopoietin-2 as a predictive biomarker for clomiphene citrate resistance in polycystic ovary syndrome p. 144
Luxmipratha Rajendiran, Hanumanthappa Nandeesha, Thyagaraju Chitra
DOI:10.4103/jhrs.jhrs_179_20  
Background: Even though angiopoeitin-2 and interleukin (IL)-23 are known to be altered in polycystic ovary syndrome (PCOS), their association with clomiphene citrate (CC) resistance has not been studied. Aim: The objective of the study was to investigate whether angiopoietin-2 levels are associated with inflammation and CC resistance in PCOS. Settings and Design: This study was conducted in a tertiary care hospital. Materials and Methods: Eighty-one women diagnosed with PCOS and on treatment with CC were enrolled in the study. Angiopoeitin-2 and IL -23 were analyzed in all the subjects. Results: Angiopoietin-2 was significantly reduced (P = 0.018), and body mass index (BMI) (P = 0.049) and duration of infertility (0.006) were significantly increased in PCOS women with CC resistance compared to those who are sensitive to CC. In CC resistant PCOS, IL-23 predicts reduction in angiopoietin-2 levels (P = 0.010). Among angiopoietin-2, IL-23, BMI, and duration of infertility, we found that angiopoeitn-2 (P = 0.020) and duration of infertility (0.036) can predict resistance to CC therapy among PCOS subjects. Conclusion: We conclude that reduced angiopoietin-2 levels predict CC resistance in women with PCOS.
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The use of pooled consecutive ejaculates in moderate male factor infertility to increase intrauterine insemination success p. 149
Sumana Gurunath, Swathi Gundlapalli, John Louis
DOI:10.4103/jhrs.jhrs_27_21  
Background: Male factor is a predominant cause of infertility. Success rates of intrauterine insemination(IUI) for male factor depend upon minimum semen parameters such as progressive motility > 30%, strict morphology > 4%, total motile count in the native sample (TMSC) >5 million and inseminating motile count (IMC) > 5 million. Couples with parameters lesser than these are usually advised IVF-ICSI. In developing countries, affordability for IVF is an important deterrent to its widespread utilisation. Aims: To evaluate pregnancy rates after the use of a pooled consecutive ejaculate in infertile men with semen parameters of < 5 million TMSC, and to compare with pregnancy rates achieved among couples with semen parameters > 5 million TMSC after processing of a single ejaculate. Settings and Design: Private infertility practice. Retrospective study from Oct 2012 to June 2019. Methods and Materials: All consecutive patients (n=1979) who underwent IUI in the given study period were included. Patients undergoing donor sperm insemination and low IMC (<1 mill) were excluded from the study. The study group (n=128) included patients in whom the total motile sperm count (TMSC) of the native sample was < 5 million. The control group (n=1851) included patients with normal semen parameters. All participants of the study group with TMSC < 5 million were asked to give a second ejaculate within an hour or two of producing the first. The pooled consecutive ejaculates were used for sample processing and insemination. The primary outcome measure was clinical pregnancy rate. The secondary outcome measures were semen quality of the second ejaculate, TMSC and IMC of both groups. Statistical Analysis: Quantitative parameters were compared using Independent sample t-test and Mann Whitney u test. Multivariate binary logistic regression analysis was performed to test the association between the explanatory variables and outcome variable. P value < 0.05 was considered statistically significant. Results: 6.47% (128/1979) of men were required to give a consecutive ejaculate. The initial ejaculate had significantly higher volume (2ml vs 1 ml; P < 0.001); but lower concentration (8 million/ml vs 19 million/ml; P <0.001) and lower progressive motility (25% vs 35%; P <0.001) in comparison with the second. The final IMC of the pooled ejaculate was 9.01 million vs 21.6 million in the control group (P<0.001). The clinical pregnancy rate was comparable between the control group and the consecutive ejaculate group (15.4% vs 15.63%; P =0.94). Conclusion: Consecutive semen samples produced immediately after the first have significantly lower volume but higher sperm count and progressive motility. In couples with moderate male factor infertility with semen parameters inadequate for IUI, pooled consecutive ejaculates yield higher inseminating motile counts which enhance IUI success rates.
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Impact of intrauterine administration of human chorionic gonadotropin before intrauterine insemination in infertile women: A randomized controlled trial p. 156
Leena Wadhwa, Anupama Rani
DOI:10.4103/jhrs.jhrs_196_20  
Background: Implantation is the rate-limiting step in the success of both intrauterine Insemination (IUI) and in vitro fertilization cycles. Numerous interventions that target various local signals have been tried to improve the implantation and clinical pregnancy rate (CPR). The most significant of these signals is human chorionic gonadotropin (hCG) which acts as immunomodulator and improves implantation by decidualization of the endometrial stromal cells, trophoblast invasion, proliferation of uterine natural killer cells, stimulation of endometrial angiogenesis, and maintenance of progesterone secretion by the corpus luteum. Aim: The aim of the study is to evaluate the effect of intrauterine hCG administration before IUI on CPR. Settings and Design: A prospective parallel randomized control study was done from September 2017 to February 2019. Materials and Methods: A total of 200 eligible women planned for IUI were randomly divided just before IUI into 2 groups. A computer-generated randomization list with block size of 10 with 1:1 allocation was used to randomize the patients. Experimental group received 0.5 ml containing 500 IU hCG, on the other hand control group received 0.5 ml of normal saline 2–3 min before IUI in single sitting. The main outcomes were CPR, miscarriage rate, and ongoing pregnancy rate. Statistical Analysis: It was performed using statistical software version SPSS 17.0. Results: Patient's demographic and baseline characteristics were comparable in both the groups. CPR in experimental group was significantly high compared to control group (26% vs. 9%, P = 0.002). Ongoing pregnancy rate was also significantly higher in experimental group (23%) compared to control group (7%) (P = 0.003). No significant difference in miscarriage rate was seen between the two groups. No cases of ectopic pregnancy, ovarian hyperstimulation syndrome, or multiple pregnancy were reported. Conclusion: Intrauterine hCG administration is a simple procedure that can be used to improve pregnancy outcome in IUI cycles. Clinical Trial Registration Number CTRI/2017/12/010729.
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The use of vaginal lubricants and ultrasound gels can have deleterious effects on sperm function p. 162
Maria Jose Soriano, Inmaculada Molina Botella, Sara Sadeghi, Andrea Palomar Rios, Sebastia Balasch, Saturnino Lujan, Nuria Pellicer, Jose Maria Rubio
DOI:10.4103/jhrs.JHRS_128_18  
Context: Some vaginal lubricants and ultrasound gels are known to be detrimental to sperm function and therefore could negatively affect fertility. Aims: The aim of the current study was to develop a sperm motility index (SMI) to test the sperm toxicity of ultrasound gels and vaginal lubricants used in reproductive medicine. Settings and Design: Two ultrasound gels (Aquasonic® and Kefus®) and five vaginal lubricants (Vaginesil™, Velastisa®, K-Y Jelly®, Control®, and Durex®) were studied. Three different concentrations (1%, 5%, and 10%) of each lubricant were tested. Subjects and Methods: SMI was calculated dividing the percentage of progressively motile sperm in each tested gel by that in the control at 0.5, 1, 2, and 24 h of incubation at 5% of CO2 and 37°C. SMI values <0.75 indicate sperm toxicity. Statistical Analysis Used: The main outcome measured was SMI for each concentration and time of incubation. Results: Only Durex® did not show any deleterious effect on sperm quality. The rest of lubricants presented different degrees of toxicity. Vaginesil™ resulted in toxic for all concentrations and incubation periods (SMI < 0.12). Control® and Velastisa® presented toxicity at 10% after 2 h, while K-Y Jelly® showed toxicity at 10% from 1 h of incubation. Regarding ultrasound gels, Aquasonic® showed toxic effects after only 0.5 h (SMI = 0.70 ± 0.15), while Kefus® showed slightly toxic effects after 2 h (SMI 0.69 ± 0.07). Conclusions: SMI is an accurate tool to evaluate sperm toxicity. One of the main strengths of the article is the inclusion of representative semen samples and known products used worldwide. This study has a relevant clinical translation since it highlights the importance of evaluating the possible sperm toxicity of simple products used in reproductive medicine.
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Effect of endometrial thickness and duration of estrogen supplementation on In Vitro fertilization-intracytoplasmic sperm injection outcomes in fresh ovum/embryo donation cycles p. 167
Jayesh Amrutlal Patel, Azadeh Jayesh Patel, Jwal Manish Banker, Sandeep I Shah, Manish Banker
DOI:10.4103/jhrs.JHRS_60_20  
Background: There is no consensus regarding optimal endometrial thickness and duration of estrogen supplementation in embryo transfer cycles, at present. Aims: To observe the effect of endometrial thickness and/or duration of estrogen supplementation on in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) outcomes in fresh ovum/embryo donation cycles. Settings and Design: This was a retrospective observational study. The study was conducted from January 2015 to November 2017. Subjects and Methods: Nine hundred and fifty seven fresh blastocyst transfer cycles in the recipients of oocyte/embryo donation regardless of reproductive history and diagnosis conducted at Nova IVF Fertility, Ahmedabad, Gujarat, India. Of these, 315 women had single embryo transfer (SET), while 642 had double embryo transfer (DET). Only fresh blastocysts derived from oocytes of young donors (≤30 years) and transferred in a uniform hormone replacement therapy (HRT) cycle were included. The effect of endometrial thickness and duration of estrogen on live birth rate (LBR) and other IVF/ICSI outcomes were analyzed. Statistical Analysis: Univariate logistic regression. Results: A significant improvement in LBR was noted in the recipients with each millimeter increase in endometrial thickness starting from 6 mm after transfer of either single (odds ratio [OR] = 1.3, P = 0.003) or double (OR = 1.14, P = 0.0218) blastocysts. Lower LBR was observed in recipients having SET and who received estrogen supplementation of <10 days (OR = 0.72; P = 0.02). Implantation rate and clinical pregnancy rate also improved significantly with endometrial thickness, but there was no change in clinical abortion rate and ectopic pregnancy rate. Conclusions: After minimizing the possible oocyte factor by including only donor oocytes and that of COH using a uniform HRT protocol, LBR improved with each millimeter increase in endometrial thickness starting from 6 mm. Shorter duration of estrogen supplementation (<10 days) reduced the chances of live birth in recipients after transfer of a single blastocyst.
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The spectrum of chromosomal abnormalities and endocrine profile of male infertility with nonobstructive semen abnormality: A case–control study p. 175
Paresh Singhal, Ganesh Pendkur, Rituraj Singh Parihar, Sharanjit Singh, Barun Kumar Chakrabarty, SK Raghavendra
DOI:10.4103/jhrs.jhrs_165_20  
Background: Primary infertility is a common occurrence which affects approximately 15% of couples who desire to begin their family. Chromosomal abnormalities are well-established causes of pregnancy loss but may also have a role in explaining the cause of male infertility, especially with nonobstructive semen abnormalities. Hence, awareness regarding safety of artificial reproductive technology in these individuals due to underlying sperm aneuploidy is required. Aims: The aims of the study are to determine the prevalence of chromosomal abnormalities in primary infertile males with nonobstructive semen abnormalities and correlate with their endocrine profile. Study Design: A case–control study, in which 100 males with primary infertility and non-obstructive semen abnormalities were evaluated for chromosomal abnormality and hormonal profile; and were compared with 50 healthy males with normal semen analysis and at least one biological child. Materials and Methods: Blood T-lymphocytes were cultured using RPMI-1640 medium for obtaining metaphases and chromosomal analysis. Statistical Analysis: SPSS software and Student's t-test were used. A p < 0.05 was considered statistically significant. Results: Azoospermia (81%) was the most common nonobstructive semen abnormality. Overall prevalence of major chromosomal abnormalities and polymorphic variants was 16% and 7%, respectively. Klinefelter syndrome was the most common sex chromosomal numerical abnormality seen in 6.17% of cases with azoospermia. All healthy control males had 46, XY karyotype. Higher levels of follicle-stimulating hormone and luteinizing hormone and lower levels of testosterone along with testicular volumes were observed in infertile males with abnormal karyotype (p < 0.05). Conclusion: Primary infertile males with nonobstructive semen abnormality have high frequency of chromosomal aberrations, which justify the requirement of cytogenetic testing in these patients.
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Marital duration, and fertility-related stress as predictors of quality of life: Gender differences among primary infertile couples p. 184
Swarnali Bose, Bharati Roy, Shreekantiah Umesh
DOI:10.4103/jhrs.jhrs_233_20  
Context: Infertility is a global public health issue, and the current data suggest that the problem is growing. Various infertility-related issues are responsible for poorer mental health and well-being in couples with primary infertility. Aim: The present study aimed to understand the gender differences of psychological factors related to infertility in couples with primary infertility. Furthermore, an attempt was also made to understand gender-specific associations that could interact with the fertility-related quality of life (FertiQoL). Settings and Design: This cross-sectional hospital-based study included 100 married couples with the diagnosis of primary infertility, irrespective of the cause of infertility. The study was conducted at Infertility centers in the Eastern region of India. Subject and Methods: One hundred men and women (n = 100 couples) with the diagnosis of primary infertility were recruited in the study. The fertility problem inventory and FertiQoL were used to measure the couples fertility-related stress and FertiQoL, respectively. Statistical Analysis Used: Descriptive statistics, independent t-statistics, Pearson correlation, linear regression, and mediation analysis were conducted. Results: A significantly higher social and sexual concern of infertility and “need for parenthood” were found in women. Men had a significantly better quality of life compared to women. Significant negative predictors of quality of life were noted for both men and women separately. Fertility stress was a significant mediating factor between marital duration and global FertiQoL in men. However, women showed a direct negative association between marital duration and FertiQoL. Conclusions: The study provides important insights into the couple's experiences with various infertility problems that may potentially be addressed during psychotherapy or during infertility counseling.
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Cytogenetic screening in couples with recurrent pregnancy loss: A single-center study and review of literature p. 191
Rim Frikha, Fatma Turki, Nouha Abdelmoula, Tarek Rebai
DOI:10.4103/jhrs.JHRS_74_19  
Context: Recurrent pregnancy loss (RPL) is a devastating reproductive problem that affects more than 2% of couples who are trying to conceive. Chromosomal rearrangements in either carrier are a major cause of clinically recognized abortion. Aims: The purpose of this study is to report the prevalence of chromosome abnormalities in RPL and provide clinical characteristics of couples with two and more miscarriages. Settings and Design: Genetic counseling in laboratory of histology housed in a Faculty of Medicine of Sfax. Materials and Methods: Karyotype was generated from the peripheral blood lymphocyte cultures and the cytogenetic analysis was performed using R-bands after heat denaturation and Giemsa (RHG) banding. A multiplex polymerase chain reaction wherever necessary was done. Statistical Analysis Used: SPSS version 17. Results: A total of 104 couples with RPL were carried out in this study. The frequency of chromosomal rearrangements was 11.5%, three times more prevalent in men than women (P = 0.08). In addition, the prevalence of chromosomal anomalies increases according to the number of miscarriages (from 4.8% to 7.6%, with 2 or ≥3 miscarriages, respectively; P = 0.9). Finally, a particular familial adverse reproductive background was found in these carriers (P = 0.03). Conclusions: These data highlight that an RPL evaluation is appropriate after the second miscarriage and that cytogenetic evaluation is necessary for an accurate approach to elucidate the causes of RPL. Moreover, familial adverse reproductive backgrounds have an impact of being carrier of chromosome abnormalities and a larger study is mandatory to define reproductive characteristics of carriers.
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CASE REPORTS Top

Spontaneous ruptured bilateral tubal ectopic pregnancy following natural conception: A rare case report p. 196
Amobi Bobbie Chukwujioke Iwe, Johnbosco Ifunanya Nwafor, Obiora Godfrey Asiegbu, Joshua Adeniyi Adebayo, Bridget Nkiruka Uche-Nwidagu, Vincent Chidiebere Ali
DOI:10.4103/jhrs.JHRS_87_20  
Ectopic pregnancy complicates 0.25%–2% of all pregnancies and is one of the most common causes of first-trimester maternal mortality in developing countries due to late diagnosis. Spontaneous ruptured bilateral tubal ectopic pregnancies are extremely rare, with very limited data on its occurrence in the literature. In a spontaneous conception, the preoperative diagnosis is difficult to make but an important one to consider at surgery for presumed unilateral tubal ectopic pregnancy because missing the diagnosis can lead to mortality. We report a case of a 38-year-old multipara with a history of amenorrhea of 8 weeks and 2 days and complaints of vaginal spotting of 4-day duration and sudden onset of abdominal pain of 4 h before presentation. On admission, a preoperative diagnosis of ruptured left tubal ectopic pregnancy was made following ultrasound findings of left adnexal mass and hemoperitoneum. However, both fallopian tubes were found to harbor ectopic gestational sac with bleeding rents on the tubal walls at surgery. She subsequently had exploratory laparotomy and bilateral salpingectomy with good outcome. In low-resource settings, ectopic pregnancy is associated with poor maternal outcome due to late presentation. Diagnosis of ruptured bilateral tubal ectopic pregnancy is difficult before surgery. Therefore, examination of both tubes at laparotomy for ectopic pregnancy should be routine and mandatory to avoid missing the diagnosis.
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Catch me while you scan: Primary ovarian pregnancy p. 200
Sweta Singh, Prashanta Kumar Rout, Pavithra Ayyanar
DOI:10.4103/jhrs.JHRS_50_20  
Primary ovarian pregnancy is rare, accounting for 0.5%–3.0% of all ectopic gestations. It was earlier diagnosed by the classical Spiegelberg's criteria. Ultrasonographic diagnostic criteria have now been described for preoperative diagnosis. We report a case of primary ovarian pregnancy in a 30-year-old woman, where the diagnosis was made preoperatively, and discuss the challenges in diagnosis and management for optimal patient outcomes.
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Primary myelin oligodendrocyte glycoprotein-immunoglobulin G-associated optic neuritis presenting after a frozen embryo transfer p. 203
Dana Rebecca Siegel, Thanh-Ha Luu, Malgorzata E Skaznik-Wikiel
DOI:10.4103/jhrs.jhrs_30_21  
Myelin oligodendrocyte glycoprotein (MOG)-immunoglobulin G-associated optic neuritis (ON) is a newly recognized antibody-mediated demyelinating disease of the central nervous system, resulting in acute visual loss and pain with eye movement. The effects of pregnancy on disease pathogenesis remain incompletely understood. Herein, we present a novel association between a frozen embryo transfer (FET) and the first manifestation of MOG-ON in a previously healthy patient with unexplained infertility. The patient presented with acute bilateral visual loss 3 weeks after a single FET and was found to test positive for MOG antibodies with an otherwise unremarkable workup. The patient's vision returned to baseline with high-dose intravenous methylprednisolone and therapeutic plasma exchange. This is the first published case highlighting an association between MOG-ON and assisted reproductive technology (ART) in a patient without prior risk factors. Further studies are needed to clarify the effects of ART and pregnancy in general on disease pathogenesis.
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Persistent idiopathic prolactin elevation merits macroprolactin estimation: A case report and review of literature p. 206
Krishnaprabha Gautam, Kripa Elizabeth Cherian, Arun Jose, TK Aleyamma, Nitin Kapoor, Thomas Vizhalil Paul
DOI:10.4103/jhrs.jhrs_168_20  
The prevalence of hyperprolactinemia ranges from about 0.4% in an unselected adult population to as high as 9%–17% in women with reproductive disorders. It may cause infertility in about 11% of the oligospermic males. Rarely, the cause of persistently elevated prolactin remains obscure even after thorough work up. Macroprolactinemia is biologically inactive, high-molecular-weight form of prolactin resulting from its binding to immunoglobulin G, causing a decrease in its clearance. We report the case of a 35-year-old female, detected to have hyperprolactinemia on multiple tests, during routine work up for primary infertility. Secondary causes for the same were ruled out. A magnetic resonance imaging (MRI) of the brain excluded a prolactinoma. This prompted an estimation of prolactin levels after polyethylene glycol precipitation which showed a decrease to 5.58 ng/mL, with <40% recovery, confirming the presence of macroprolactin. Thus, persistently elevated prolactin levels in the background of negative neurological imaging necessitate the estimation of macroprolactin.
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Polycystic ovary syndrome and COVID-19: An emerging risk factor p. 211
Shashank R Joshi
DOI:10.4103/jhrs.jhrs_79_21  
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Should women with polycystic ovarian syndrome be prioritized to receive the COVID vaccine? p. 213
Duru Shah
DOI:10.4103/jhrs.jhrs_78_21  
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