Journal of Human Reproductive Science
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    Table of Contents - Current issue
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January-March 2021
Volume 14 | Issue 1
Page Nos. 1-100

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EDITORIAL  

Editorial Commentary Highly accessed article p. 1
Padma Rekha Jirge
DOI:10.4103/jhrs.jhrs_45_21  
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ORIGINAL ARTICLES Top

Assessment of impact of infertility & its treatment on quality of life of infertile couples using fertility quality of life questionnaire Highly accessed article p. 3
Geeta Shripad Wadadekar, Dattaprasad Balasaheb Inamdar, Vandana Ravindra Nimbargi
DOI:10.4103/jhrs.jhrs_163_20  
Background: With rising trends of infertility in India, it is no longer just a medical concern, but is rapidly becoming a public health issue due to its social and interpersonal ramifications. Limited data is available regarding quality of life of the infertile couples. Aim: The aim of this study was to understand the quality of life (QOL) of Indian infertile couples using the fertility QOL (FertiQoL) tool and to find the correlation between the values of the core and treatment FertiQoL and various sociodemographic and clinical factors. Study Setting and Design: This cross-sectional study was conducted at fertility clinic at an urban tertiary care center. Materials and Methods: Over a period of 12 months, 274 completed questionnaires obtained from 137 couples were selected for the analysis. Demographic and clinical characteristics of all the patients were recorded. Data analysis was performed using the Statistical Package for the Social Sciences software version 25:0. IBM Chicago, USA. Results: Women had worse QOL than their male partners. They scored lower than men on emotional and mind body subscales. Women showed positive and uniform trend in mean scores of all core FertiQoL subscales with age and education. Rural population had poorer QOL. Patients with primary infertility had poorer QOL except in the relational domain. Couples, in whom both partners had some pathology, had the worse QOL compared to female factor, male factor or unexplained infertility. Conclusion: Our study is a step in the direction to establish the baseline QOL objectively in Indian couples with infertility.
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Inflammatory markers in peripheral blood cells cannot predict intrauterine insemination outcome: A retrospective cohort study p. 11
Meryem Kuru Pekcan, A Seval Ozgu-Erdinc, Nafiye Yilmaz, Aytekin Tokmak, Yaprak Engin-Ustun
DOI:10.4103/jhrs.jhrs_216_20  
Background: Although infertility is known as a chronic inflammatory condition, the effect of the increased inflammatory response on IUI success is not clear. Systemic inflammation can be calculated by applying various hematological markers. Aims: We aimed to evaluate the ability of hematologic parameters of inflammation in predicting intrauterine insemination (IUI) outcome. Study Setting and Design: A total of 334 infertile couples included in this retrospective cohort study. The study population comprised of all couples who were candidates for ovulation induction and IUI due to polycystic ovary syndrome (PCOS) (n = 147) or unexplained infertility (UI) (n = 187). Materials and Methods: The inflammatory parameters in the complete blood count parameters, such as neutrophil-lymphocyte ratio, platelet lymphocyte ratio, platelet distribution width, plateletcrit were obtained on IUI day and compared between the two groups. The predictive values of these markers for IUI outcome were calculated. Results: There were 44 pregnancies (13.2%) in the whole study cohort. There were no significant differences between the pregnant and nonpregnant groups regarding the evaluated parameters (all P > 0.05). Also, no significant difference was observed between the patients with PCOS and UI in terms of those parameters. The area under receiver operating characteristic (ROC) curve analysis revealed that none of the inflammatory markers can predict pregnancy in intrauterine insemination cycles. Further prospective studies are needed to verify our findings. Conclusion: We found no relationship between the hematologic inflammatory markers and IUI outcome.Therefore these markers cannot be used for prediction of pregnancy.
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Administration of cinnamon and lagersroemia speciosa extract on lipid profile of polycystic ovarian syndrome women with high body mass index p. 16
Wiryawan Permadi, Andon Hestiantoro, Mulyanusa Amarullah Ritonga, Ade Indri Ferrina, Wulan Ardhana Iswari, Kanadi Sumapraia, Raden Muharram, Tono Djuwantono, Budi Wiweko, Raymond Tjandrawinata
DOI:10.4103/jhrs.JHRS_141_20  
Background: Hyperinsulinemia, a common feature in PCOS, have been found to contribute to metabolic disturbance, such as dyslipidaemia and diabetes mellitus type 2. Oral anti-diabetic medications have been prescribed to alleviate this effect. We sought to fnd whether DLBS3233, an insulin sensitizer, could alleviate dyslipidaemia in women with PCOS with high BMI. Aim: This study aimed to investigate the effect of DLBS3233, an herbal combination of C burmanii and L spesiosa extract, on lipid profle, insulin resistance, and free testosterone of women with PCOS with high BMI. Study Setting and Design: This was a controlled trial conducted in Dr. Cipto Mangunkusumo Hospital, Jakarta, and Dr Hasan Sadikin Hospital, Bandung, Indonesia.Materials and Methods: A controlled trial was conducted on 62 volunteers diagnosed with PCOS according to Rotterdam criteria and exhibited insulin resistance as signifed by HOMA-IR > 2.0; baseline lipid profile (LDL, HDL, Triglyceride and Total cholesterol) and free testosterone concentration were obtained. Participants were given 100 mg of DLBS3233 in the morning, and volunteers were followed up monthly, with laboratory tests conducted at the third and sixth months. Data were analysed through intention-to-treat analysis, separating high BMI (≥25 kg/m2) subjects. Statistical Analysis: Repeated-measures model. Results: DLBS3233 improved lipid profle and insulin sensitivity by reducing triglycerides, HOMA-IR, and free testosterone in subjects with high BMI. Limitations and Implications: The current study does not compare the effect of DLBS3233 with a control group. A larger study with a proper control group would have to be conducted to have more conclusive results. Conclusion: This study showed that DLBS3233 holds promise as a novel therapy to improve lipid profle for women with PCOS.
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Do basal luteinizing hormone and luteinizing hormone/follicle-stimulating hormone ratio have significance in prognosticating the outcome of In vitro fertilization cycles in polycystic ovary syndrome? p. 21
Neeta Singh, Neha Mishra, Yogita Dogra
DOI:10.4103/jhrs.JHRS_96_20  
Context: Tonic hypersecretion of luteinizing hormone (LH) appears to impact both fertility and pregnancy outcomes in women with polycystic ovary syndrome (PCOS). Aim: Whether high basal day 2/3 serum LH levels and day 2/3 LH/follicle-stimulating hormone (FSH) ratio affect in vitro fertilization (IVF) cycle outcomes in PCOS patients undergoing controlled ovarian hyperstimulation using gonadotropin-releasing hormone (GnRH) antagonists. Settings and Design: A retrospective cohort study was conducted in Assisted Reproductive Technique Center, Department of Obstetrics and Gynaecology, at a tertiary care institute, on PCOS patients undergoing IVF/intracytoplasmic sperm injection (ICSI) using GnRH antagonist protocol with human chorionic gonadotropin trigger between January 2014 to December 2019. Methods and Material: Data related to patient's age, body mass index, day 2/3 serum FSH, serum LH, day 2/3 LH/FSH ratio, and infertility treatment-related variables were collected from the patient record files. IVF cycle characteristics, number of oocytes retrieved, number of embryos transferred were also recorded. The clinical pregnancy rate per embryo transfer was calculated. Statistical Analysis: Statistical software SPSS IBM version 24.0 was used to analyze the data. Descriptive statistics such as mean, standard deviation , and range values were calculated. To compare the difference between the groups, the paired t-test was applied for continuous variables and the Chi-square test for categorical variables. A value of P < 0.05 was considered statistically significant. Results: High basal day 2/3 LH level and day 2/3 LH/FSH ratio have no statistically significant effect on embryos formed, embryo transferred, and clinical pregnancy rate. However, fertilization rates were significantly less in these groups. Conclusion: The elevated basal day 2/3 LH and LH/FSH ratio do not impair the outcome of GnRH antagonist protocol treated IVF/ICSI cycles in PCOS women.
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Progesterone/Oestradiol ratio can better predict intracytoplasmic sperm injection outcomes than absolute progesterone level p. 28
Reda S Hussein, Ihab Elnashar, Hisham A Abou-Taleb, Yulian Zhao, Ahmed M Abdelmagied, Ahmed M Abbas, Osama S Abdalmageed, Ahmed A Abdelaleem, Tarek A Farghaly, Ahmed A Youssef, Esraa Badran, Mostafa N Ibrahim, Ahmed F Amin
DOI:10.4103/jhrs.JHRS_57_20  
Background: Several parameters were proposed to predict the impact of premature luteinization on intracytoplasmic sperm injection (ICSI) outcomes such as isolated progesterone (P) level, progesterone to oocyte ratio, and progesterone/estradiol ratio (P/E2). Aim: The aim of this study is to compare the predictive value of P/E2 ratio and isolated P level on the ovulation triggering day for pregnancy outcomes in fresh GnRH antagonist ICSI cycles. Settings and Design: A retrospective cohort study conducted in a university-affiliated in vitro fertilization center between January 2017 and April 2019. Methods: The study included women who underwent their first- or second-ranked GnRH antagonist ICSI cycles with day-3 embryo transfer. P/E2 ratio was calculated as (P [ng/mL] × 1000)/E2 (pg/mL). Cutoff values of ≥1.5 ng/ml for high P (HP) and ≥0.55 for HP/E2 ratio were chosen based on the literature. Statistical Analysis: A receiver operating curve was performed to detect the predictability of serum P/E2 and P for the ongoing pregnancy rate. First, patients were divided according to either P level (low P < 1.5 ng/mL and HP ≥1.5 ng/mL) or P/E2 ratio (low P/E2 <0.55 and HP/E2 ≥ 0.55). Patients were further divided into four subgroups: (Group A: HP and HP/E2 ratio, Group B: low P and low P/E2 ratio, Group C: HP only, and Group D: HP/E2 only). A multivariate regression analysis models were used to account for the effect of the cycle confounders on the likelihood of pregnancy. Results: A total of 402 ICSI cycles were analyzed. The area under the curve was 0.67 and 0.59 for P/E2 and P, respectively. P/E2 showed a significant association with ongoing pregnancy (adjusted odds ratios [aOR]: 0.409, 95% confidence interval [CI] 0.222–0.753, P = 0.004) while HP revealed no significant predictive value (aOR: 0.542, 95% CI 0.284–1.036, P = 0.064) after the multivariate analysis. Conclusions: P elevation may not present as an independent predictor for cycle outcomes. P/E2 ratio has a better prognostic value than P alone in predicting pregnancy of GnRH antagonist cycles.
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Genuine empty follicle syndrome: role of double trigger and delayed oocyte retrieval (DTDO) p. 36
Abdul Majiyd Noushin, Sankalp Singh, Aluvilayil Sonia, Swati Singh, Reema Basheer, Raiza Ashraf, Ahmed N Waseem, Mohamed Ashraf
DOI:10.4103/jhrs.jhrs_230_20  
Background: Empty follicle syndrome (EFS) is a condition of undetermined etiology where no oocytes are retrieved in an ART cycle despite adequate response to ovarian stimulation and diligent follicular aspiration. Because of the rarity of this condition, no much published strategies are available to tackle this. Aim: The aim of this study was to evaluate whether sequential administration of gonadotropin-releasing hormone agonist (GnRHa) and human chorionic gonadotropin (hCG) as a trigger at 40 h and 36 h, respectively, before oocyte retrieval (OCR) could correct genuine empty follicle syndrome (GEFS). Study Setting and Design: This retrospective observational cohort study was conducted in a tertiary fertility center over a period of 6 years from January 2014 to December 2019. Patients with a history of GEFS were administered GnRHa and recombinant hCG subcutaneously at 40 h and 36 h, respectively, before OCR, i.e., double trigger and delayed oocyte retrieval (DTDO) (n = 13). The primary outcome measures studied were number of mature oocytes retrieved, oocyte maturation index (OMI), number of fertilized oocytes, and number of embryos available for embryo transfer. The secondary outcome measures were clinical pregnancy rate (CPR), miscarriage rate (MR) and live birth rate (LBR) per first frozen embryo transfer (FET) cycle, incidence of inadvertent premature ovulation, and ovarian hyperstimulation syndrome. Statistical Analysis: Comparison between the groups was analysed by Fisher's exact test and paired t-test. Results: Patients in the DTDO group showed a significant improvement (P < 0.01) in the number of mature oocytes retrieved, OMI, number of fertilized oocytes, and number of embryos available for embryo transfer. In the first FET cycle, CPR (44.44%), LBR (44.44%), and MR (11.11%) were observed in the DTDO group. Conclusion: Our findings implicate that double trigger and delayed OCR (DTDO) is a safe and efficacious treatment strategy for GEFS.
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Association of follicular fluid advanced glycation end-products with oocyte response and clinical pregnancy in assisted reproduction cycles p. 42
Ramesh Parameswara Iyer, Fessy Louis Thalakkattoor, Avani Pillai, Parvathy Tharadevi, Sajitha Krishnan, Aparna Nagaraj
DOI:10.4103/jhrs.JHRS_130_20  
Context: Advanced glycation end-products (AGEs) are toxic metabolic end-products of lipids, nucleic acids, and proteins. Their accumulation in the ovaries can alter the follicular microenvironment and affect stimulation response. Aims: We aimed to study the association of AGEs in follicular fluid (FF AGE) with oocyte response and clinical pregnancy in ART-Assisted Reproductive Technology cycles. Settings and Design: This prospective study involved 84 individuals undergoing ART. Methods and Material: FF was collected during oocyte retrieval, and the level of AGEs was measured by enzyme-linked immunosorbent assay. Oocyte response was grouped as below target (<7 MII oocytes) or above target response (≥7 MII). Statistical Analysis Used: The association of FF AGE with the oocyte response and clinical pregnancy rate was analyzed by Mann–Whitney U-test. The strength of association of FF AGE with the outcome variables was analyzed with receiver operating characteristic (ROC) curve. Results: The median FF AGE was 17.6 (8.5) μg/ml. It was significantly higher in the below target than the normal ovarian response group (18.5 [17.8] vs. 16.3 [7.8] μg/ml, P = 0.046). Similarly, it was significantly higher in those who did not conceive (19.9 [7.3] vs. 13.5 [5.9] μg/ml, P < 0.001). The cutoff of FF AGE obtained by ROC curve analysis was 16.5 μg/ml above which there were significantly lower oocyte response and clinical pregnancy. Conclusions: Elevated FF AGE can be a significant negative predictor of clinical pregnancy and ovarian response to stimulation in ART cycles. The FF AGE level above the cutoff value of 16.5 μg/ml was associated with significantly lower oocyte response and clinical pregnancy.
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Perinatal outcomes using ejaculate versus surgical sperm retrieval in patients undergoing intracytoplasmic sperm injection for male infertility – A retrospective analysis of 628 cycles p. 49
Mogili Krishna Deepti, Karuppusami Reka, Parimala Chinta, Muthukumar Karthikeyan, Aleyamma Thayparmbil Kunjummen, Mohan Shashikant Kamath
DOI:10.4103/jhrs.jhrs_197_20  
Background: Men with azoospermia undergoing a surgical sperm retrieval are anxious about the well-being of the baby. It is therefore important to study the perinatal outcomes in this group compared to the ejaculate sample group. Aim: The aim of the study was to compare the perinatal outcomes between ejaculate and surgical sperm retrieval (SSR) groups in couples undergoing intracytoplasmic sperm injection for male factor. Study Setting and Design: This was a retrospective cohort study conducted in a university-level infertility unit. Materials and Methods: It is a retrospective cohort study analysis of 628 assisted reproductive technique (ART) cycles with male factor and combined (male and female) factor infertility over a period of 5 years (January 2011–December 2015). All women who underwent a fresh embryo ART cycle were followed up. The study population included the ejaculate and SSR groups. The perinatal outcomes of these two groups were compared. The congenital anomaly risks among the two groups were also analyzed. Statistical Analysis: Chi-square test, Fisher's exact test and Logistic regression Results: A total of 628 ART cycles were included in the current study, of which 478 cycles used ejaculate sperm, while SSR was done in 150 cycles. The analysis was restricted to singletons, and the risk of preterm birth was 22.9% in the ejaculate group, 5.9% in the epididymal group, and 12% in the testicular group (epididymal vs. ejaculate odds ratio [OR], 0.21; 95% confidence interval [CI]: 0.02–1.66) (testicular vs. ejaculate OR, 0.46; 95% CI: 0.12–1.65). The risk of low birth weight was 23.7% in the ejaculate group, 11.8% in the epididymal group, and 20.0% in the testicular group (epididymal vs. ejaculate OR, 0.42; 95% CI: 0.09–1.9) (testicular vs. ejaculate OR, 0.80; 95% CI: 0.27–2.3). The incidence of congenital anomalies was 7.3% in the ejaculate group, 0 in the epididymal group, and 3.5% in the testicular group (epididymal vs. ejaculate OR, 0.28; 95% CI: 0.01–5.2) (testicular vs. ejaculate OR, 0.63; 95% CI: 0.10–3.7) which was not significantly different. Conclusion: The current study showed no significant differences in the risk of adverse perinatal outcomes in the ejaculate group versus the surgically retrieved sperm groups.
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Effect of laparoscopic ovarian cystectomy on ovarian reserve in benign ovarian cysts p. 56
Madeti Usharani Sireesha, Thyagaraju Chitra, Murali Subbaiah, Hanumanthappa Nandeesha
DOI:10.4103/jhrs.JHRS_94_20  
Background: Laparoscopic cystectomy is one of the common modes of treatment for benign ovarian cysts. The data related to the effect of cystectomy on ovarian reserve are limited. Aim: The aim of this study was to investigate the effect of laparoscopic ovarian cystectomy on anti-Mullerian hormone (AMH) levels in benign ovarian cysts. Settings and Design: It was a prospective clinical study conducted in a tertiary care hospital from March 2017 to August 2018. Materials and Methods: Seventy-two benign ovarian cyst patients who were admitted for cystectomy were enrolled in the study. Serum AMH levels were estimated in all the patients at baseline, 1 week, and 3 months after cystectomy. Statistical Analysis: Paired t-test was used to assess the differences in AMH levels before and after laparoscopic cystectomy. Results: AMH was significantly reduced after 1 week (P < 0.05) and 3 months (P < 0.05) of cystectomy compared to preoperative levels in both endometriotic and nonendometriotic cysts. The percentage of reduction in the AMH values measured on the 7th postoperative day was found to be greater with endometriotic cysts (54%) followed by mucinous cystadenoma (32%). On day 90, greater recoveries of the AMH values to the baseline AMH levels were observed with cystic teratoma (83% of the baseline AMH levels). Conclusions: Laparoscopic ovarian cystectomy reduces AMH levels immediately after surgery, and improvement in AMH level was observed after 3 months.
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A prospective randomized comparative clinical trial of hysteroscopic septal resection using conventional resectoscope versus mini-resectoscope p. 61
Kallol Kumar Roy, SM Anusha, Rakhi Rai, Anamika Das, Rinchen Zangmo, Seema Singhal
DOI:10.4103/jhrs.JHRS_12_20  
Context: Hysteroscopic metroplasty (HM) is the gold standard treatment for women with septate uterus with recurrent pregnancy loss. Miniresectoscope requires less cervical dilatation as compared to conventional resectoscope. Very few studies are available in the literature on use of miniresectoscope for operative purpose. Aim of the Study: This study aimed to compare operative and postoperative outcome parameters using conventional versus mini resectoscope (MR) for hysteroscopic septal resection (HSR). Study Settings and Design: This was a prospective randomized controlled trial conducted in the Department of Obstetrics and Gynaecology from July 2017 to May 2019. Materials and Methods: Forty patients fulfilling the inclusion criteria were recruited and randomized into two groups. In Group A (20 patients), HSR was done using conventional resectoscope (CR) and in Group B (20 patients), MR was used. The various parameters recorded were cervical dilatation time, operating time, intraoperative complications, postoperative pain, and hospital stay and reproductive outcome post surgery in both groups. Results: Data analysis was carried out using SPSS IBM software version 20.0. The mean operating time was comparable but cervical dilatation time was significantly more in Group A. The duration of hospital stay was significantly less in Group B. There were no differences in adequacy of vision in both the groups but area of field was less in MR group. Four out of nine patients with infertility conceived after surgery. 65% in Group A and 70% in Group B conceived during follow up. Conclusion: Our study showed that hysteroscopic metroplasty with MR, has comparable efficacy to CR in terms of good vision and septal resectability with added advantages of shorter cervical dilatation time, ease of entry of resectoscope, shorter operative time and significantly reduced postoperative morbidity in terms of less pain. However, the field of vision is less and resection time is more, hence more expertise is required. Further larger randomized trials are required.
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Comparison of expression of chemokine receptor 4 in maternal decidua and chorionic villi in women with spontaneous miscarriages and women opting for termination of viable pregnancies p. 68
Anamika Das, Nisha Rani Agrawal, Rinchen Zangmo, Kallol Kumar Roy, Kiran Singh, Renu Bala
DOI:10.4103/jhrs.JHRS_64_20  
Background: Early pregnancy losses can be a distressing experience both for the parents and the treating clinician. We aim to explore the role of chemokine receptor 4 (CXCR4) in early pregnancy losses by comparing its expression among patients with spontaneous miscarriages and patients undergoing termination of viable pregnancies for unwanted pregnancies. Aim: The aim of the study was to investigate the expression of CXCR4 in early pregnancy losses and correlate the various clinical parameters with differential expression of the above receptor in the chorionic villi and maternal decidua. Study and Setting: The present study is a case-“control study done in a tertiary care center. Methodology: Fifty patients attending outdoor and antenatal clinic of the hospital aged 18-“40 years with spontaneous miscarriage under 20 weeks of gestational age were included as cases and compared with fifty females of comparable age group (18-“40 years) seeking medical termination of pregnancy as controls. Chorionic villi and decidua obtained from the cases and controls were analyzed for CXCR4 expression. Statistical Analysis: The results were analyzed using mean ± standard deviation, percentiles values, Chi-square test, and P value to determine the association of CXCR4 expression in decidua and chorionic villi of cases versus controls. Results: CXCR4 expression was significantly downregulated in cases as compared to the controls with P < 0.001. The mean normalized ratio of CXCR4 expression to housekeeping gene (β Actin) expression in the case group was 1.607 ± 1.108 and in the control group, it was 2.506 ± 1.457. There was a strong correlation between the expression of CXCR4 and maternal age. With increasing age, the expression of CXCR4 was more downregulated in both the cases and control groups (P < 0.001). The expression of CXCR4 was elevated in controls as compared to cases in <30 years age group (P = 0.009). CXCR4 expression was higher in primigravida than in multigravida (P = 0.001), and as the number of previous miscarriages increased, the expression of CXCR4 was found to be decreased (P = 0.021). Conclusion: CXCR4 expression is significantly reduced in women with spontaneous miscarriages in comparison with viable pregnancies. and possibly, therapies targeted at increasing the expression of CXCR4 can be used as a treatment modality for management of spontaneous miscarriages.
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The prevalence of specific gene polymorphisms related to thrombophilia in Egyptian women with recurrent pregnancy loss p. 73
Noha Mahmoud Issa, Dalia A Moaty El-Neily, Sally S El Tawab, Lama M El-Attar
DOI:10.4103/jhrs.JHRS_24_20  
Background: Despite the enhanced progress in identifying a number of leading causes to fetal miscarriage, still some women suffer from recurrent pregnancy loss (RPL) for unknown cause. A hidden genetic influence of coexisting hereditary thrombophilia was assumed to have a role. Aim: The aim was to investigate the association between unexplained RPL and thrombophilic gene variants of angiotensin I-converting enzyme (ACE) (rs4646994) and β -fibrinogen (rs1800790) genes. Settings and Design: The present case–control study was conducted on unexplained RPL in eighty women and eighty matched controls with no history of previous pregnancy loss. Materials and Methods: Analysis of extracted DNA was performed using polymerase chain reaction-restriction fragment length polymorphism method. Statistical Analysis: The frequency of genotypes and alleles was compared between groups using Chi-square test or Fisher's exact test. Risk assessment was made by odds ratio (OR) at a 95% confidence interval (CI). Results: Women with RPL group had higher frequency of DD than controls (47.5%, 31.25%, respectively, P = 0.086). D allele frequency was 0.67 and 0.54 in the control (P = 0.022). D allele carriers were at higher risk of RPL than the control as OR was 1.694 at 95% CI from 1.08 to 2.67. There was no association between the rs1800790 variant of β -fibrinogen gene and RPL. Conclusion: Females who are carriers for D allele of ACE I/D gene polymorphism are more liable to suffer from RPL. Screening for hereditary thrombophilia in females who are planning to conceive and have a history of RPL of unidentified cause is of great value to provide proper management and genetic counseling to high-risk couples.
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Current awareness and attitude toward fertility preservation in Indonesia: A nationwide survey among health-care providers p. 81
Sarrah Ayuandari, Nurida Khasanah, Ismi W Riyanti, Agung Dewanto, Diannisa Ikarumi Enisar Sangun, Budi Wiweko
DOI:10.4103/jhrs.jhrs_239_20  
Context: Fertility preservation (FP) is necessary for cancer patients who develop infertility due to chemotherapy and radiotherapy. In Indonesia, many systematic steps and long-term continued actions must be taken to establish FP units since there has been an increasing incidence of cancer among people under 45 years old. Aims: This study aimed at a comprehensive evaluation on the awareness and practices of health-care providers (HCPs) toward FP. Settings and Design: This was a descriptive cross-sectional study. Subjects and Methods: A validated nationwide online survey was completed by 160 HCPs as a representative sample from 11 provinces in 2017 that provide medical care to cancer patients at hospitals or clinics. Statistical Analysis Used: Descriptive statistics, analysis of variance, logistic regression, and Pearson correlation tests were used for the statistical analysis. Results: Respondents were specialists (59.4%) and other HCPs (40.6%). Around 60% of the HCPs who performed cancer therapies already discussed the fertility issues with their patients. Meanwhile, the HCPs (60.7%) also tended not to consult and refer their patients to fertility experts (P < 0.05). However, those who discussed the risk of infertility with patients tended to consult with and refer them to a fertility consultant for further FP procedure as the follow-up for their discussions (odds ratio = 8.98, confidence interval 95%, P < 0.05). Conclusions: In Indonesia, FP awareness of the HCPs who performed cancer therapy was high. Nevertheless, attitudes to refer patients to fertility experts for possible FP management still need to be improved.
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CASE REPORTS Top

Premature ovarian failure related to trisomy X: Two case reports with an aberrant 47, XXX karyotype p. 87
Paresh Singhal, Sharanjit Singh, Praveen Kumar, Nikita Naredi
DOI:10.4103/jhrs.JHRS_59_20  
Trisomy X syndrome is a sex chromosome aneuploidy with a variable clinical presentation at different stages of life. We present two asyndromic females with primary infertility and features of premature ovarian failure (POF). The first case was a nonmosaic trisomy X with poor ovarian reserve on pelvic ultrasound and elevated gonadotropins, while the second case was a mosaic trisomy X who had partly preserved ovarian reserve with normal gonadotropins. The 47,XXX syndrome is a relatively uncommon presentation of POF, leading to infertility and can be missed clinically because of its variable presentation. Therefore, we suggest that genetic testing should be a part of early workup in young women presenting with primary infertility and POF for detecting chromosomal aneuploidies, which will require genetic counseling and alter the management.
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Successful pregnancy after frozen embryo transfer after recurrent endometrial collection in a patient with mosaic turner syndrome p. 91
Nidhi Goyal, K Jayakrishnan
DOI:10.4103/jhrs.JHRS_83_20  
A 36-year-old female with Mosaic Turner Syndrome presented for oocyte donation program. She developed endometrial collection each time she was started on estradiol valerate for endometrial preparation. All causes of the endometrial collection were ruled out and empirical antibiotics given. Finally, the patient developed a satisfactory endometrium of 5.7 mm with no endometrial collection after being given low dose estradiol-estrogel (Transdermal application) and five doses of subcutaneous injections on granulocyte-colony-stimulating factor. The patient conceived after embryo transfer and is in follow-up.
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Chemotherapy can interfere in implantation in in-vitro fertilization p. 94
Manish Banker, Parul Arora, Jwal Banker, Sandeep Shah
DOI:10.4103/jhrs.JHRS_69_20  
Improvement in cancer treatments has allowed more women to plan a pregnancy once the disease is cured. The effects of chemotherapy on ovaries are well proven but those on the uterus, especially the endometrium and embryo implantation are still unknown. Usage of newer tyrosine kinase inhibitors such as nilotinib has revolutionized the management of leukemias. Although nilotinib has been reported to be safe in pregnancy, further studies are needed to evaluate its effect on the process of embryo implantation, especially in women undergoing in-vitro fertilization. We report a case where successful pregnancy outcome was achieved after stoppage of nilotinib before embryo transfer in a woman who had previous four failed attempts while on nilotinib and no other obvious cause of implantation failure. Despite optimal endometrial thickness and receptivity, the pale appearance of endometrium on hysteroscopy was attributed to be a possible effect of nilotinib and prompted us to withhold it.
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Obstetric antiphospholipid syndrome: An approach from glycans of the immunoglobulin G p. 97
Angela Maria Alvarez, Alejandra Maria Gomez-Gutierrez, Julio Cesar Bueno-Sanchez, Carolina Rua-Molina, Angela Patricia Cadavid
DOI:10.4103/jhrs.JHRS_21_20  
This is a case report of women with pregnancy morbidity (PM), some of them associated with antiphospholipid syndrome (APS), in which the glycan patterns of immunoglobulin G (IgG) were investigated based on the theory of alteration of glycosylation in autoimmunity. We used lectin blot to determine changes in terminal glycosylation of polyclonal IgG from women with antiphospholipid (aPL) antibodies and PM plus vascular thrombosis (PM/VT) and seronegative-obstetric APS (SN-OAPS). In addition, we analyzed IgG from women with PM without aPL (PM/aPL-) and healthy women, as controls. Even though the SN-OAPS and PM/VT groups share the PM, only the SN-OAPS group showed a decreased expression of galactose compared to the healthy group. We also found the presence of mannosylated oligosaccharides in IgG from all patients being significantly higher in IgG from women of the PM/aPL- group. The differences in glycans presented here could relate to pathological mechanisms of PM associated with APS.
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