Journal of Human Reproductive Science
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   2013| October-December  | Volume 6 | Issue 4  
    Online since February 3, 2014

 
 
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CASE REPORTS
Diagnosis and management of cervical ectopic pregnancy
Sweta Singh
October-December 2013, 6(4):273-276
DOI:10.4103/0974-1208.126312  PMID:24672169
Cervical ectopic pregnancy (CP) is a rare condition with an incidence of less than 0.1% of all ectopic pregnancies. It is associated with a high morbidity and mortality potential. Timely intervention is required to preserve fertility and avoid the need for a hysterectomy. A case of CP is reported and the challenges in the diagnosis and management are discussed.
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ORIGINAL ARTICLES
Melatonin and its correlation with testosterone in polycystic ovarian syndrome
Priyanka Jain, Madhu Jain, Chandana Haldar, Tej Bali Singh, Shuchi Jain
October-December 2013, 6(4):253-258
DOI:10.4103/0974-1208.126295  PMID:24672165
Context: Polycystic ovarian syndrome (PCOS) is considered to be the most common endocrine disorder affecting women. Melatonin, a small lipophilic indoleamine, and reproductive hormones may be interrelated. Melatonin influences sex steroid production at different stages of ovarian follicular maturation as melatonin receptors have been demonstrated at multiple sites in ovary and in intrafollicular fluid. It plays role as an antioxidant and free radical scavanger which protects follicles from oxidative stress, rescuing them from atresia, leading to complete follicular maturation and ovulation. Aims: To study the role of melatonin in PCOS and to investigate its correlation with testosterone in patients suffering from PCOS. Settings and Design: A total of 50 women with PCOS (Rotterdam criteria, 2003) and 50 age and weight matched healthy controls were selected and serum melatonin estimation was done in both the groups and correlated with serum total testosterone levels. Materials and Methods: In a case-control study, detailed history, clinical examination and hormonal evaluation [basal levels of leutinizing hormone, follicle-stimulating hormone, thyroid-stimulating hormone, prolactin, insulin, total testosterone, progesterone and melatonin] were carried out in all the participants including both cases and controls. For melatonin estimation, blood samples were collected between 12:00 am and 04:00 am on day 2 nd of menstrual cycle and analyzed by using commercially available enzyme-linked immunosorbent assay kit. Statistical Analysis: Student's t-test was used to compare the significant difference in mean values between cases and control groups. Chi-square test was used to test the significant association between the qualitative variables. Linear correlation coefficient and regression analysis were done to see the amount and direction of relationship between quantitative variables. Results: The mean melatonin level was observed to be significantly increased in patients (63.27 ΁ 10.97 pg/mL) than in controls (32.51 ΁ 7.55 pg/mL). Melatonin was found to be raised in all the cases of PCOS (above cut-off value of ≥45 pg/mL, P < 0.001). Total testosterone level was also raised in 72% of patients. Melatonin levels were found to be positively associated with increased testosterone (P < 0.001). In regression analysis using melatonin as dependent variable and testosterone as an independent variable, the value of R2 Χ 100 (percent variation) was found to be 72.1%. Conclusions: Women with PCOS have significantly raised serum melatonin levels and hyperandrogenemia along with increased number of atretic follicles. Further studies are required to establish a definite role of melatonin in PCOS cases with disturbed hormonal milieu. This could open up the way for therapeutic role of melatonin in treatment of patients suffering from PCOS.
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CASE REPORTS
A rare case of Turner's syndrome presenting with Mullerian agenesis
Suresh Vaddadi, Ramana S. V. Murthy, CH Rahul, Vinod L Kumar
October-December 2013, 6(4):277-279
DOI:10.4103/0974-1208.126313  PMID:24672170
Turner's syndrome also called as Ullrich Turner's syndrome, is a disease of unclear pathogenesis characterized by complete or partial absence of one sex chromosome, with or without cell line mosaicism in a phenotypic female with short stature. Various anomalies result in a constellation of features, of which the most disturbing is primary amenorrhea due to gonadal dysgenesis. Hormone therapy in these patients can often result in successful menstruation, and scope for subsequent pregnancy because of anatomically normal uterus and vagina. Coexisting Mullerian agenesis in these patients can jeopardize the chances of future pregnancy as they have associated structural abnormalities of the uterus and vagina. We report a rare case of middle-aged female with Turner's syndrome and Mullerian agenesis having absent secondary sexual characters and missing uterus with incompletely formed vagina.
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EDITORIAL
From the editors desk
Madhuri Patil
October-December 2013, 6(4):219-219
DOI:10.4103/0974-1208.126281  PMID:24672158
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ORIGINAL ARTICLES
The combined use of antimullerian hormone and age to predict the ovarian response to controlled ovarian hyperstimulation in poor responders: A novel approach
Yadava Bapurao Jeve
October-December 2013, 6(4):259-262
DOI:10.4103/0974-1208.126298  PMID:24672166
Context: Reduced ovarian response to stimulation represents one of the most intractable problems in infertility treatment. As failed cycle can cause considerable amount of emotional and economical loss, there are various attempts made to predict ovarian response. Aims: To evaluate different factors influencing outcome of assisted reproduction in women with predicted reduced response (antimullerian hormone between 1 and 5 pmol/L) and to develop a model using of AMH and age to predict the number of oocytes in poor responders. Settings and Design: Retrospective study in a teaching hospital. Materials and Methods: We analyzed 85 cycles (57 women) with predicted reduced response with serum AMH value between 1 and 5 pmol/L. Standard ovarian stimulation protocol was used. Primary outcome measures were clinical pregnancy rates and oocytes retrieved. Statistical Analysis Used: Data were analyzed using Microsoft excel and MetlabR software. Results: Clinical pregnancy rate/ET was 20.33%, in this group. AMH and age was analyzed using linear regression model which produced an equation to give predicted oocyte count if AMH and age are known. (Oocytes = age × (-ß) + Serum AMH × α) (Constant ß=0.0102 and α = 1.0407). Conclusions: Combined use of serum AMH and age to predict ovarian response within reduced responder group should be further evaluated. For first time, we suggested combining both factors to predict ovarian response using a simple equation which allow developing tailored strategy.
  - 2,134 118
Anesthetic management for oocyte retrieval: An exploratory analysis comparing outcome in in vitro fertilization cycles with and without pre-implantation genetic diagnosis
Alexander Ioscovich, Talia Eldar-Geva, Marina Weitman, Gheona Altarescu, Alina Rivilis, Deborah Elstein
October-December 2013, 6(4):263-266
DOI:10.4103/0974-1208.126303  PMID:24672167
Purpose: To date, there has been no comparison of outcomes in women undergoing anesthesia for in vitro fertilization (IVF) oocyte retrieval for the purpose of pre-implantation genetic diagnosis (PGD) because of their or their partner's genetic disease relative to the outcome in women requiring IVF because of fertility issues. Materials and Methods: A prospective observational study, wherein all demographic and anesthetic management data were collected from IVF and PGD units' records for a 6-month period. Descriptive analyses and parametric tests were employed. Results: There were 307 cases IVF and 76 cases PGD: most (97.4% and 99.7%, respectively) received general anesthesia with propofol and fentanyl ± dipyrone (90.5% and 93.3%, respectively) with no adverse effects. The only statistically significant difference between IVF and PGD groups that was potentially clinically significant was post-procedure recovery time (23.0 ± 20.4 vs. 29.4 ± 35.8 min, respectively; P < 0.0001), but is explainable as greater caution by Anesthesiologists for higher-risk PGD cases having autosomal dominant diseases that may impact anesthesia management (myotonic dystrophy, neurofibromatosis, Marfan's); two of these cases also recovered in the general post-anesthesia care unit, as a precaution for early diagnosis and treatment of potential post-procedural complication. Conclusions: Results of this first-ever survey of anesthesia for PGD compared with IVF cases imply that propofol-and-fentanyl-based anesthesia is safe and can be recommended, bearing in mind that with patients who have autosomal dominant diseases impacting anesthetic management it is prudent to be more cautious post-recovery.
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Reproductive parameters and oxidative stress status of male rats fed with low and high salt diet
Bolanle O Iranloye, Gabriel O Oludare, Ayodele O Morakinyo, Naomi A Esume, Lucy C Ekeh
October-December 2013, 6(4):267-272
DOI:10.4103/0974-1208.126308  PMID:24672168
Background: Deficiency of minerals and micronutrients has been reported to impair the process of spermatogenesis. Historically, salt has been used by women on their husbands to increase their libido, however, the role of salt diet on sperm parameters are yet to be ascertained. AIM: The present study was designed to determine the effect of low and high salt diet on sperm parameters, oxidative status and reproductive hormone levels of male rats. Materials and Methods: A total of 18 rats were divided into three groups: Group I: (control) received 0.3% salt diet, Group II: low salt (received 0.14% salt diet) and Group III: high salt (received 8% salt diet). All animals were treated for 6 weeks; after which epididymal sperm parameters; oxidative stress markers (malondialdehyde, glutathione, catalase and superoxide dismutase) in the testes and epididymal tissues, as well as follicle stimulating hormone (FSH), luteinizing hormone (LH) and testosterone levels were determined. Results: The results showed decreased sperm count in the low salt diet rats while increased sperm count was observed in the high salt diet treated rats. Both low salt and high salt diet fed rats exhibited increased abnormal sperm cells and increased epididymal oxidative stress when compared with their respective control. FSH and testosterone levels were increased in the high salt fed rats while LH level was decreased when compared with the control values. Conclusion: This study suggests that both low and high salt diet play a negative role in the fertility of male rats.
  - 3,128 124
Semen preparation techniques in intrauterine insemination: A comparison of non-temperature and temperature controlled centrifugation in cases of unexplained infertility
Priya Selvaraj, Kamala Selvaraj, S Kalaichelvi, R Mahalakshmi
October-December 2013, 6(4):241-244
DOI:10.4103/0974-1208.126289  PMID:24672162
Aim: The aim of the following study is to compare pregnancy rates between the use of non-temperature and temperature controlled centrifugation on semen preparation technique in intrauterine insemination. Materials and Methods: The retrospective study was conducted on 671 patients of idiopathic infertility who underwent homologous artificial insemination at Fertility Research Center from the period of January 2007 to September 2012. The couples were randomized into two groups namely, Group A-patients (n = 303) being treated with sperm prepared by using non-temperature controlled centrifuge and Group B-Patients (n = 368) being treated with sperm prepared by temperature (37°C) controlled centrifuge. Results and Conclusion: The clinical pregnancy rate Group A was 13.86% and Group B was 12.77%. The clinical pregnancy fetal loss rate between the two groups was 38% and 42% respectively. The delivery rate per transfer was 62% and 58% respectively. No statistically significant difference was found between these two groups.
  - 2,455 179
Predictive value of early serum beta-human chorionic gonadotrophin for the successful outcome in women undergoing in vitro fertilization
Neeta Singh, Manu Goyal, Neena Malhotra, Abanish Tiwari, Shreenivas Badiger
October-December 2013, 6(4):245-247
DOI:10.4103/0974-1208.126291  PMID:24672163
Aims: Pregnancies achieved by in vitro fertilization (IVF) are at increased risk of adverse outcome. The main objective of this study was to evaluate the predictive value of β-human chorionic gonadotrophin (β-HCG) and age of the patient for the successful outcome in IVF. Materials and Methods: A retrospective study was done in 139 pregnancies after IVF at single IVF center from June 2007 to July 2012. The age of the patient and initial serum values of β-HCG on day 14 of embryo transfer were correlated with ongoing pregnancy (>12 weeks gestation). Results: The β-HCG level on day 14 of more than 347 mIU/ml has a sensitivity of 72.2% and specificity of 73.6% in prediction of pregnancy beyond 12 weeks period of gestation. Positive likelihood ratio (LR) is 2.74 and negative LR is 0.37, (receiver operating characteristic area = 0.79). Discussion: In IVF cycles, there is a lot of stress on the couples while the cycle is going on. There was a positive correlation between the higher values of early serum β-HCG levels and ongoing pregnancy. Hence, it can be used as an independent predictor of a successful outcome of IVF cycle. Conclusion: We concluded from our study that early serum β-HCG can be used as a predictor of a successful outcome in IVF.
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Calcium gluconate infusion is as effective as the vascular endothelial growth factor antagonist cabergoline for the prevention of ovarian hyperstimulation syndrome
Nikita Naredi, Sandeep Karunakaran
October-December 2013, 6(4):248-252
DOI:10.4103/0974-1208.126293  PMID:24672164
Background: Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic and potentially life-threatening disease process, which may occur in healthy young women undergoing controlled ovarian hyperstimulation for assisted reproduction. As the treatment is largely empirical, prevention forms the mainstay of management. Objective: The present study was aimed to evaluate the effectiveness of intravenous (IV) calcium gluconate infusion in comparison to the dopamine agonist cabergoline (Cb2) in preventing OHSS in high risk patients undergoing assisted reproductive technique cycles. Materials and Methods: It was a comparative study wherein the 202 high risk patients undergoing in vitro-fertilization over a period of 18 months after meeting the strict inclusion and the exclusion criteria, were randomly divided into two groups (98 subjects in Group I and 104 in Group II). Women in Group I were administered IV calcium gluconate while the remaining 104 received the dopamine agonist Cb2. The 104 patients belonging to Group II were started Cb2 0.5 mg/day from the day of ovulation trigger and continued until the next 8 days while the 98 high risk patients from Group I were infused with 10 ml of 10% calcium gluconate solution in 200 ml physiologic saline within 30 min of ovum pick up and continued thereafter on day 1, day 2 and day 3. Results: The occurrence of OHSS was seen in only nine patients (in the calcium infusion group, when compared with 16 patients (9.2% vs. 15.4%) who were administered Cb2, but it was not statistically significant. However, only one had severe OHSS in Group I, whereas two women were diagnosed as severe OHSS belonging to the Cb2 arm. Conclusion: Our results document that calcium infusion can effectively prevent severe OHSS and decreases OHSS occurrence rates when used for high-risk patients, but does not suggest its superiority over Cb2. With comparable success rates, either of them can be employed as a preventive strategy for OHSS.
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REVIEW ARTICLES
Should mild stimulation be the order of the day?
Nalini Mahajan
October-December 2013, 6(4):220-226
DOI:10.4103/0974-1208.126282  PMID:24672159
Mild stimulation protocols aim to reduce the physical, financial and emotional burden associated with the conventional IVF protocol without compromising the pregnancy rate. Such protocols help to decrease the complications and the discomfort related to the prolonged administration of agonist and large doses of gonadotrophins, by limiting the number of oocytes recruited to no more than eight. The per cycle pregnancy rates are lower though the cumulative pregnancy rate in a year is equivalent. This CPR comes by going through earlier repeat cycles. Whether this reduces the physical, emotional or financial burden remains a matter of debate. There is need to standardize these protocol and do more trials to compare the two effectively. Till such time there is a clear benefit above the conventional protocol it will not be the protocol of choice with most physicians.
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Luteinizing hormone and follicle stimulating hormone synergy: A review of role in controlled ovarian hyper-stimulation
Gottumukkala Achyuta Rama Raju, Rahul Chavan, Mamata Deenadayal, Devika Gunasheela, Rohit Gutgutia, Geetha Haripriya, Mirudhubashini Govindarajan, Nayana Hitesh Patel, Ameet Shashikant Patki
October-December 2013, 6(4):227-234
DOI:10.4103/0974-1208.126285  PMID:24672160
Luteinizing hormone (LH) in synergy with follicle stimulating hormone (FSH) stimulates normal follicular growth and ovulation. FSH is frequently used in assisted reproductive technology (ART). Recent studies have facilitated better understanding on the complementary role of the LH to FSH in regulation of the follicle; however, role of LH in stimulation of follicle, optimal dosage of LH in stimulation and its importance in advanced aged patients has been a topic of discussion among medical fraternity. Though the administration of exogenous LH with FSH is obligatory for controlled ovarian stimulation in patients with hypogonadotropic hypogonadism, there is still a paucity of information of its usage in other patient population. In this review we looked in to the multiple roles that LH plays complementary to FSH to better understand the LH requirement in patients undergoing ART.
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Assisted reproductive technology in India: A 3 year retrospective data analysis
Narendra Malhotra, Duru Shah, Rishma Pai, HD Pai, Manish Bankar
October-December 2013, 6(4):235-240
DOI:10.4103/0974-1208.126286  PMID:24672161
Assisted reproductive technology (ART) has grown by leaps and bounds in the last few years. India has one of the highest growths in the ART centers and the number of ART cycles performed every year. Very soon India will be the leader in the world of ART in terms of a number of cycles. With the advances of technology and availability of techniques even in tier II and tier III cities our country, the results still vary dramatically. There is no standardization of protocols and reporting is very inadequate. Furthermore, there are only ART guidelines and no law still exists. Our first and the biggest challenge is to document the tremendous work being done in India and on the basis of analysis of this work, a proper registry can be made and guidance given to all on standardization and improvement. This is the 8 th edition of National ART Registry of India being presented and analyzed.
  - 2,797 156
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