Journal of Human Reproductive Science
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   2012| May-August  | Volume 5 | Issue 2  
    Online since September 14, 2012

 
 
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ORIGINAL ARTICLES
Anti-mullerian hormone cut-off values for predicting poor ovarian response to exogenous ovarian stimulation in in-vitro fertilization
Ruma Satwik, Mohinder Kochhar, Shweta M Gupta, Abha Majumdar
May-August 2012, 5(2):206-212
DOI:10.4103/0974-1208.101023  PMID:23162361
Objectives: (a) To establish the cut-off levels for anti-Mullerian hormone (AMH) in a population of Indian women that would determine poor response. (b) To determine which among the three ie.,: age, follicle stimulating hormone (FSH), or AMH, is the better determinant of ovarian reserve. Study Design: Prospective observational study. Setting: In vitro fertilization (IVF) unit of a tertiary hospital. Materials and Methods: The inclusion criterion was all women who presented to the center for in-vitro fertilization/Intracytoplasmic sperm injection (IVF/ICSI). The exclusion criteria were age >45 years, major medical illnesses precluding IVF or pregnancy, FSH more than 20 IU/L, and failure to obtain consent. The interventions including baseline pelvic scan, day 2/3 FSH, luteinizing hormone (LH), estradiol estimations, and AMH measurement on any random day of cycle were done. Subjects underwent IVF according to long agonist or antagonist protocol regimen. Oocyte recovery was correlated with studied variables. The primary outcome measure was the number of oocytes aspirated (OCR). Three categories of ovarian response were defined: poor response, OCR ≤ 3; average response, OCR between 4 and 15; hyperresponse, OCR > 15. Results: Of the 198 patients enrolled, poor, average, and hyperresponse were observed in 23%, 63%, and 14% respectively. Correlation coefficient for AMH with ovarian response was r = 0.591. Area under the curve (AUCs) for poor response for AMH, subject's age, and FSH were 0.768, 0.624, and 0.635, respectively. The discriminatory level of AMH for prediction of absolute poor response was 2 pmoL/l, with 98% specificity and 20% sensitivity. Conclusions: AMH fares better than age and FSH in predicting the overall ovarian response and poor response, though it cannot be the absolute predictor of non-responder status. A level of 2 pmol/l is discriminatory for poor response.
  7 4,090 194
REVIEW ARTICLES
Effects of metformin use in pregnant patients with polycystic ovary syndrome
Pratap Kumar, Kashif Khan
May-August 2012, 5(2):166-169
DOI:10.4103/0974-1208.101012  PMID:23162354
Use of metformin throughout pregnancy in women with polycystic ovary syndrome (PCOS) has shown to reduce the rates of early pregnancy loss, preterm labor, and prevention of fetal growth restriction. Metformin has been shown to have encouraging effects on several metabolic aspects of polycystic ovarian syndrome, such as insulin sensitivity, plasma glucose concentration and lipid profile and since women with PCOS are more likely than healthy women to suffer from pregnancy-related problems like early pregnancy loss, gestational diabetes mellitus and hypertensive states in pregnancy, the use of metformin therapy in these patients throughout pregnancy may have beneficial effects on early pregnancy loss and development of gestational diabetes.
  4 5,195 289
ORIGINAL ARTICLES
The role of Allium cepa on aluminum-induced reproductive dysfunction in experimental male rat models
Serah F Ige, Roland E Akhigbe
May-August 2012, 5(2):200-205
DOI:10.4103/0974-1208.101022  PMID:23162360
Aim: Reproductive toxicity is a major challenge associated with aluminum (Al) exposure. Studies that associated Al with reproductive dysfunction did not account for the possible influence of Allium cepa extract. This study, therefore, investigates the influence of A. cepa on aluminum-induced reproductive dysfunction. Materials and Methods: Six male rats per group were assigned to one of the following four treatment groups: The control animals were on control diet. A. cepa-treated rats received 1 ml of the extract/100 g body weight (BW), Al-treated rats received 100 mg AlCl 3 /kg BW, and A.cepa+Al received 1 ml of the extract/100 g BW plus 100 mg AlCl 3 /kg BW. Rats were orally administered their respective doses. A. cepa treatment was for 8 weeks, while Al treatment was for the last 3 days of the experimental period. Results: Results obtained showed that Al significantly decreased (P < 0.05) plasma testosterone, follicular stimulating hormone (FSH), luteinizing hormone (LH), sperm count, motility, morphology and viability, superoxide dismutase (SOD) and catalase (CAT) activities, while lipid peroxidation index [malondialdehyde (MDA)] was significantly (P < 0.05) increased. Reproductive hormones (except testosterone), sperm qualities, and enzymatic antioxidants were significantly (P < 0.05) increased in A. cepa-treated rats and A. cepa plus Al-treated rats, while MDA was significantly (P < 0.05) improved. Weights of testes were comparable in all groups. Conclusion: It is thus suggested that Al exerts reproductive dysfunction by oxidative damage. A. cepa antagonizes the toxic effects of AlCl 3 and improves the antioxidant status and sperm quality of male rat. However, testosterone level did not increase with A. cepa treatment.
  3 3,121 147
REVIEW ARTICLES
Ectopic pregnancy after infertility treatment
Madhuri Patil
May-August 2012, 5(2):154-165
DOI:10.4103/0974-1208.101011  PMID:23162353
Early pregnancy complications are more common in women who conceive after infertility treatment. Most of these occur before 12 weeks of gestation and include miscarriage, vaginal bleeding, intrauterine hematoma, vanishing twin, and ectopic pregnancy (EP). The incidence of EPs following infertility treatment is much higher compared with that in spontaneous pregnancies. The occurrence of an EP is very distressing to an infertile couple, who has lots of hopes pinned on the treatment outcome, especially because of the cost incurred and the physical and mental trauma both have gone through during the treatment process. The association between infertility and EP is complex, as it can be a consequence of infertility as well as a cause. The two principal risk factors for an EP are genital tract infections and tubal surgeries. Though several etiologies are proposed, but patients with tubal factor infertility are at an increased risk of an EP. Earlier diagnosis of EP helps to improve prognosis and optimize subsequent fertility. It is pivotal to evaluate the likelihood of subsequent occurrence of an EP and be too vigilant when treating. The correct choice of the treatment modality should be made to prevent the recurrence. The early prediction of the pregnancy outcome therefore has great importance for both the couple and clinician. Today with the help of sensitive beta human chorionic gonadotropin (β-hCG) assays and transvaginal sonography, one can diagnose an EP prior to symptoms, and conservative treatment for the preservation of the fallopian tube is possible. Conservative management in the form of expectant and medical management should be considered as a first-line treatment modality, provided that the overall clinical picture suggests that it is safe to do so. If not, laparoscopic management of EPs appears to be the favored approach of management as compared to laparotomy.
  3 7,322 299
CASE REPORTS
Heterotopic pregnancy with successful pregnancy outcome
Nasreen Noor, Imam Bano, Shazia Parveen
May-August 2012, 5(2):213-214
DOI:10.4103/0974-1208.101024  PMID:23162362
A heterotopic pregnancy is a rare complication of pregnancy, in which both extra-uterine and intrauterine gestation occur simultaneously. We hereby report a case of ruptured heterotopic pregnancy presenting at 6weeks of gestation and was managed with immediate laparatomy. The intrauterine pregnancy course was uneventful with delivery of a healthy baby at term by Caesarean section.
  1 2,600 101
Heterotropic pregnancy: Rare occurrence of a 12- week ruptured right isthmo-cornual ectopic along with a viable intrauterine pregnancy
Priya Selvaraj, Kamala Selvaraj
May-August 2012, 5(2):223-225
DOI:10.4103/0974-1208.101028  PMID:23162366
Heterotropic pregnancy, although a rare condition, is associated with a greater frequency in assisted reproduction. It occurs in approximately 1 in 100 pregnancies conceived by in vitro fertilization (IVF) particularly when multiple embryos are transferred into the uterus. We report a case of heterotropic pregnancy following IVF with the rupture of an isthmo-cornual pregnancy at 12 weeks of gestation with uneventful progression of the intrauterine pregnancy. Laparotomy was performed for the excision of the isthmo-cornual pregnancy. The intrauterine pregnancy continued uneventfully. A female baby was delivered by elective cesarean section at 33 weeks.
  1 5,976 74
LETTERS TO EDITOR
Alcohol and fertility
Dilip Gude
May-August 2012, 5(2):226-227
DOI:10.4103/0974-1208.101030  PMID:23162368
  1 2,361 115
ORIGINAL ARTICLES
A prospective study of GnRH long agonist versus flexible GnRH antagonist protocol in PCOS: Indian experience
Harpreet Kaur, Deepika Krishna, Nivedita Shetty, Sandhya Krishnan, MS Srinivas, Kamini Arvind Rao
May-August 2012, 5(2):181-186
DOI:10.4103/0974-1208.101019  
Background: Polycystic ovarian syndrome is a common endocrine disorder of reproductive age women. Many controlled ovarian stimulation (COS) strategies have been offered for the treatment of patients with PCOS undergoing in vitro fertilization, but the optimal protocol is still a controversy. There is no compelling evidence for the advantage of one stimulation protocol over the other. Materials and Methods: This is a single-center prospective controlled study comparing long agonist and antagonist protocol in PCOS women. Results: There was no significant difference in live birth rate and clinical pregnancy rate. Rate of ovarian hyperstimulation syndrome was significantly higher in the agonist group. Number of oocytes retrieved, number of follicles and peak estradiol levels were significantly more in the agonist group. Conclusion: The GnRH antagonist protocol is an equally effective but safer protocol in PCOS patients compared with the long agonist protocol.
  1 2,763 128
Assessment of oocyte quality in polycystic ovarian syndrome and endometriosis by spindle imaging and reactive oxygen species levels in follicular fluid and its relationship with IVF-ET outcome
Shweta Rajani, Ratna Chattopadhyay, Sourendra K Goswami, Sanghamitra Ghosh, Sunita Sharma, Baidyanath Chakravarty
May-August 2012, 5(2):187-193
DOI:10.4103/0974-1208.101020  PMID:23162358
Objectives: The aim of this study is to examine meiotic spindle in oocytes along with reactive oxygen species (ROS) levels in follicular fluid of women undergoing IVF and to correlate these findings with embryo quality and pregnancy outcome. Materials and Methods: 167 women aged 25-35 years with endometriosis (Group A), polycystic ovarian syndrome (PCOS) (Group B) and tubal block (Group C) were included. Long protocol downregulation using recombinant follicular stimulating hormone was used for ovarian stimulation. Aspirated follicular fluid containing mature oocytes were analyzed for ROS levels and the oocytes were assessed for the presence of meiotic spindle using Cri-OosightTM Polscope. Fertilization, embryo quality, endometrial assessment, and final pregnancy outcome were assessed. Results: Meiotic spindles were visualized in a higher proportion of mature oocytes retrieved from women with endometriosis (66%) as compared to those with PCOS (50.5%) and tubal block (62.3%). ROS levels were also observed to be significantly less in the follicular fluid of oocytes in women with endometriosis (Group A) as compared to the other two groups (P ≤ 0.001). However, pregnancy rates were observed to be lower in Group A (32%) than Groups B (39%) and C (44%), respectively. Within each group, oocytes with spindle visualization yielded a higher number of Grade 1 embryos (P < 0.05) as well as lower ROS levels in follicular fluid (P ≤ 0.001) as compared to those where spindle could not be visualized. Conclusions: There was good correlation between spindle imaging and ROS levels as reliable predictors of oocyte assessment. Women with endometriosis had low ROS levels and good spindle imaging results suggesting a possible role of endometrial receptivity accounting for lower pregnancy rates in these women. Poor oocyte quality, as reflected by higher mean ROS levels and low number of oocytes with spindle visualization, could be the factor impeding pregnancy in women with PCOS as compared to women with tubal block.
  1 3,679 191
Overt leptin response to controlled ovarian hyperstimulation negatively correlates with pregnancy outcome in in vitro fertilization­-embryo transfer cycle
Jana Chakrabarti, Ratna Chatterjee, Sourendrakanta Goswami, Baidyanath Chakravarty, Syed Nazrul Kabir
May-August 2012, 5(2):194-199
DOI:10.4103/0974-1208.101021  PMID:23162359
Context: A critical body mass of adipose tissue is essential for the normal development of female reproductive functions. Leptin, an adipocyte-derived hormone encoded by the 'Ob' gene has been proposed as a peripheral signal indicating the adequacy of nutritional status for reproductive functions. It is reported as a direct regulator of gametogenic and steroidogenic potential of ovary. Though leptin is widely present in reproductive tissues, its relationship to reproductive hormones is still poorly understood. Aims: Present investigation attempts to explore ovarian response to secretory profile of leptin and its impact on pregnancy outcome in women undergoing controlled ovarian hyperstimulation for in vitro fertilization and embryo transfer (IVF-ET). Settings and Design: Patients enrolled for IVF-ET underwent pituitary-ovarian suppression by 'Long Protocol' GnRH-agonist downregulation followed by ovarian stimulation. Materials and Methods: Sera were procured at different phases of IVF-ET for the assay of estradiol, progesterone, human chorionic gonadotropin, and for leptin. Ovarian follicular fluids were also assayed for leptin. Luteinized granulosa cells were cultured in vitro to evaluate their steroidogenic potential. Statistical Analysis Used: Statistical analyses were done by student's t-test, ANOVA, and Chi-square tests as applicable. All results were expressed as Mean ± SE. P values < 0.05 were considered significant. Results: Positive correlation was observed between serum and ovarian follicular fluid leptin. A negative correlation was noted between the serum leptin levels and endometrial thickness. Conclusions: Elevated leptin response may exert adverse impacts on pregnancy success during IVF-ET possibly by modulating uterine receptivity.
  1 2,995 92
CASE REPORTS
Persistent mullerian duct syndrome in a patient with bilateral cryptorchid testes with seminoma
Shrinivasan Chamrajan, Nidhi H Vala, Jatin R Desai, Niraj N Bhatt
May-August 2012, 5(2):215-217
DOI:10.4103/0974-1208.101025  PMID:23162363
Persistent mullerian duct syndrome (PMDS) is a rare form of male pseudohermaphroditism in which mullerian duct derivatives are present in an otherwise normally differentiated 46 XY male. We report a case of a 33-year-old male with PMDS operated for postchemotherapy seminoma. A diagnosis of PMDS was made on subsequent histopathological evaluation.
  - 2,775 69
A rare cause for primary amenorrhoea
Kaderthambi Hajamohideen Noorul Ameen, Rakesh Pinninti
May-August 2012, 5(2):218-220
DOI:10.4103/0974-1208.101026  PMID:23162364
  - 2,579 91
A rare case of recurrent pregnancy loss associated with high-titer positivity for perinuclear anti-neutrophilic cytoplasmic antibodies
Akhila Vasudeva, Raviraja V Acharya, Pratap Kumar
May-August 2012, 5(2):221-222
DOI:10.4103/0974-1208.101027  PMID:23162365
We present a case of recurrent pregnancy loss associated with unusual constellation of utoimmunity-related features such as hypertension, severe hrombocytopenia, hypothyroidism and persistent high titers of perinuclear antineutrophilic cytoplasmic antibodies. Her clinical features did not fit into a particular diagnosis of vasculitides, systemic lupus erythematosis (SLE) or other known autoimmune diseases where this autoantibody is found in high titers. We report the unusual association of this autoantibody with recurrent early fetal demise in this case.
  - 2,026 78
EDITORIAL
From the Editor's desk
Kamini Rao
May-August 2012, 5(2):153-153
DOI:10.4103/0974-1208.101009  PMID:23162352
  - 1,976 153
LETTERS TO EDITOR
Kisspeptin: Role in reproduction and implications for infertility management
Priya B Chittawar
May-August 2012, 5(2):226-226
DOI:10.4103/0974-1208.101029  PMID:23162367
  - 1,928 135
OBITUARIES
Dr. Sulochana Gunasheela

May-August 2012, 5(2):229-229
  - 1,702 41
Dr. Mandakini Anand Parihar

May-August 2012, 5(2):230-230
  - 1,568 32
ORIGINAL ARTICLES
Letrozole in a low-cost in vitro fertilization protocol in intracytoplasmic sperm injection cycles for male factor infertility: A randomized controlled trial
Shiuli Mukherjee, Sunita Sharma, Baidya Nath Chakravarty
May-August 2012, 5(2):170-174
DOI:10.4103/0974-1208.101014  PMID:23162355
Introduction: Letrozole, a selective aromatase inhibitor, reduces the total dose of gonadotrophin required for inducing follicular maturation. We evaluated if incorporation of letrozole could be an effective alternative for low-cost in vitro fertilization (IVF) protocol particularly in intracytoplasmic sperm injection (ICSI) cycles where male factor infertility is the sole indication for IVF. Materials and Methods: It is a randomized controlled single-blind trial. 94 women with history of severe male factor infertility were selected. 42 women (study group) received letrozole, 5 mg daily from day 3-7 and recombinant FSH (rFSH) 75IU/day from day 5 continuously till hCG injection. 52 women (control group) underwent continuous stimulation by rFSH (150-225IU/day) from day 2. GnRH-antagonist (Inj. Orgalutran 0.25 ml sub-cutaneous) was started at maximum follicle size of 14 in both groups. Ovulation was triggered by 10,000IU of hCG followed by IVF-ET. Main outcome measures were total dose of rFSH (IU/cycle), terminal E2 (pg/ml), number of mature follicles, number of oocyte retrieved, transferable embryo, endometrial thickness, pregnancy rate and mean expenditure. Statistical analysis is done by using SPSS11. Results :0 As compared to control group (1756 ± 75IU), the study group i.e., Let-rFSH received (625 ± 98IU) significantly lower (P = 0.0001) total dose of rFSH. Terminal E2 was significantly lower (P = 0.0001) in study group than control (830 ± 36 vs. 1076 ± 41 pg/ml) with significant increment in endometrial thickness (P = 0.0008) in study group, (9.1 ± 0.32 vs. 8.7 ± 0.69) which maintained an improved pregnancy rate though nonsignificant. The risk of hyperstimulation had significantly (P = 0.01) reduced in study group than control (0 vs. 7).Treatment outcome in all other aspects including pregnancy rate were statistically comparable. Per cycle mean expenditure was reduced by 34% in study group than control. Conclusion: Adjunctive use of letrozole may be an effective mean of low-cost IVF therapy.
  - 3,580 171
Evaluation of the rabbit as an experimental model for human uterine synechia
Mohamed Khrouf, Olivier Morel, Ali Hafiz, Pascale Chavatte-Palmer, Hervé Fernandez
May-August 2012, 5(2):175-180
DOI:10.4103/0974-1208.101017  PMID:23162356
Context: Pathogenesis of uterine synechia remains unsolved, the causal relationship between synechia and infertility is not clearly established. Aims: To evaluate the rabbit as an experimental model for Asherman's syndrome using the endometrial curettage as trigger mechanism then to evaluate its impact on fertility. Settings and Design: Experimental study Materials and Methods: 13 female rabbits. All submitted traumatic endometrial curettage. Animals of Group 1 (n = 7) were sacrificed at various times following surgery (day 7, 15 and 30), animals of Group 2 (n = 6) were bred and sacrificed during pregnancy. Main outcome were synechia occurring, number of implanted fetus, lumen surface/ global horn perimeter ratio (LS-GHP ratio) and epithelium thickness. Statistical Analysis: Means were compared using Student 't' test (P < 0.05 was considered significant). Number of implantation sites of two horns were compared with the Wilcoxon test. Results: No synechia have been observed. Examinations at Day 7, 15 and 30 demonstrate a complete regeneration of endometrium. We observed a significant diminished LS-GHP ratio at day 7 (0.042 ± 0.004 vs 0.074 ± 0.002 mm; P = 0.013) with a higher simple columnar epithelium compared to control (16.6 ± 3.39 vs 10.98 ± 1.7; P = 0.001). We observed a diminished ovum implantation in traumatized horns, even if it was not statistically significant. Conclusion: Even if no intrauterine adhesion were observed, this model represents a pathogenesis condition in the rabbit similar to intrauterine adhesions observed in the human with negative impact on implantation.
  - 4,142 116
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