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   Table of Contents - Current issue
July-December 2022
Volume 9 | Issue 2
Page Nos. 75-131

Online since Friday, December 30, 2022

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Lessons from India p. 75
Gedis Grudzinskas
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Infertility − What do we mean? Highly accessed article p. 77
M. A. Fathimunissa, Pandiyan Natarajan, Radha Pandiyan
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GnRH agonist trigger in modern reproductive medicine practice − when, why, and how? p. 80
Deepti Gupta, Akanksha Sood, Raj Mathur
The use of gonadotropin-releasing hormone (GnRH) antagonist protocols in assisted conception is a major advance in modern reproductive medicine practice. Specifically, the application of GnRH agonist (GnRHa) as the final trigger for oocyte maturation in cycles where GnRH antagonist has been used is associated with a significant reduction in the risk of developing one of the most serious iatrogenic complications of assisted conception, ovarian hyperstimulation syndrome. GnRHa trigger has been shown to be as effective as human chorionic gonadotropin trigger with respect to oocyte yield and maturity in both autologous and donor cycles in multiple studies. This trigger, however, results in poor corpus luteum development and consequently luteal phase dysfunction and impaired endometrial receptivity. In this review, we address the indications, contraindications, outcomes, and practical considerations when using the GnRHa trigger.
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Role of growth hormone in ART cycles in poor responders: A literature review p. 87
Garima Kapoor, Shahida Naghma
Growth hormone (GH) has been used as an adjunct in the field of female infertility treatment for more than 25 years, although, apart from treating women with GH deficiency its role has not yet been clarified. In the current shift of trend of delaying marriage and childbearing due to career and various other reasons, many women across the world are opting for assisted reproductive techniques (ART). This poses a challenge to the ART experts due to diminished ovarian reserve with advancing age in women. Over the years, the definition of poor responder has also evolved and after the Bologna criteria in 2011 and Poseidon classification, most of the recent studies have used a uniform criterion to define poor responders. The current review recruited studies conducted over the past decade, to ensure uniform criterion for poor responders. After a thorough literature search, 12 studies were selected for review based on the selection criteria a total of 1774 women were included in the intervention group while 3167 women were included in the control group. The review lead us to the conclusion that GH adjuvant therapy in poor responders reduced the dose/duration of gonadotropin used, increased endometrial thickness, improved the number of M II oocytes retrieved, embryos formed, clinical pregnancy rate. However, it has not shown to improve live birth rates in ART cycles. Since there is some evidence that GH adjuvant therapy may benefit young Poor Ovarian Response (POR), more number of large clinical trials need to be performed for further subgroup analysis and benefitting these women seeking ART.
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A simple non-invasive method of spermatozoa retrieval from the bladder (SPERB) in patients with retrograde ejaculation p. 97
S Sowbarnika, Radha Pandiyan, Puvithra Thanikachalam, N Pandiyan
Retrograde ejaculation is very commonly seen in men presenting with aspermia. Despite having normal spermatogenesis, these men present with infertility as the ejaculate is retrograded into the urinary bladder, due to various causes. Diagnosing this condition involves thorough history taking followed by examination of post-masturbatory/coital urine. Retrieval of spermatozoa from the bladder maintaining its vitality is crucial in providing fertility treatment. Various methods employed in retrieving motile spermatozoa from the bladder in literature is either invasive or cumbersome causing inconvenience to the couple. Here, a simple and non-invasive spermatozoa retrieval from the bladder (SPERB) technique is described in detail. Case report of the couple who conceived using spermatozoa retrieved by this method is discussed.
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Efficacy of Co-Q10, vitamin D3, selenomethionine, astaxanthin in reduction of sperm DNA p. 105
Dhiraj Singh Ranawat, Vivek Dave, Chhavi Pandya, Asha Arora
High sperm DNA fragmentation can cause decreased fertility and implantation rate or can cause recurrent implantation failure. If fetus is born, it can lead to genetic abnormalities in the fetus such as Down syndrome, Edward syndrome, or Patau syndrome revealed by Schlegel.[1] The mechanisms examined include: apoptosis in the seminiferous tubule epithelium, defects in chromatin remodeling during the process of spermiogenesis, oxygen radical-induced DNA damage during sperm migration from the seminiferous tubules to the epididymis, the activation of sperm caspases and endonucleases, damage induced by chemotherapy and radiotherapy, and the effect of environmental toxicants. The objective of the study is to evaluate the efficacy of the combination of coenzyme-Q10 (Co-Q10) (100 mg), vitamin D3 (2000 I.U.), selenomethionine (400 mcg), astaxanthin (8 mg) tablet in reduction of sperm DNA fragmentation in males who visited the hospital. The result shows that factors affecting men with high levels of DNA fragmentation will have significantly lower odds of conceiving naturally or through procedures such as intrauterine insemination and IVF. Therefore, in men with high levels of DNA fragmentation, reduced with age and were found to have improvement with 6% to 7% in the age group 30 to 40, > 40 respectively. The Institutional Ethics Committee approved the study procedure (Ref No: SRMC/RP/4505). Context: Aim The aim of the study is to evaluate the effect of combination of Co-Q10 (100 mg), vitamin D3 (2000 I.U.), selenomethionine (400 mcg), astaxanthin (8 mg) on sperm DNA fragmentation index (DFI). Settings and Design: A type of prospective cohort study in which health conditions are measured before and after the treatment. Methods and Material: Patients were recruited after obtaining a written informed consent. On first visit, patient information was taken according to patient information sheet. Patients were counseled to take medication containing antioxidant and vitamin (Co-Q10, vitamin D3, selenomethionine and astaxanthin) for 3-month duration, twice-daily according to general information sheet and fill IPCC (Investigational product compliance card). On the next visit after 3 months, patient information is recorded; and semen examination and sperm DFI were done to note any changes. Statistical analysis used: To calculate sample sizes for comparing two means, we have taken confidence interval 95%, power 80%, and ratio of sample size for before and after group as 1. Mean and standard deviation were taken from published data for both the groups as 22.1 ± 7.7 before treatment and 9.1 ± 7.2 after treatment. Results: The percent wise distribution of infertile patients was 31.84%, 31.92%, 31.46% from the age group 20 to 30, 30 to 40, and > 40. The maximum number of patients were from the age group 30 to 40 and > 40; hence, control patients were selected from the same age group with percentage 25.01% and 25.35%, respectively. Conclusions: Efficacy of Co-Q10, vitamin D3, astaxanthin, and selenomethionine combination in male subjects with raised sperm DFI improved the outcome of assisted reproductive technique. There is decrease in DFI measured in percentage after giving CoQ, which was significant.
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Does dual trigger with gonadotropin-releasing hormone agonist and low-dose human chorionic gonadotropin improves clinical outcomes in normal responders in gonadotropin-releasing hormone (GnRH) antagonist IVF-ICSI Cycles p. 111
Kanad Dev Nayar, Shweta Gupta, Sabina Sanan, Sumita Agarwal, Gaurav Kant, Kapil Nayar
Objective: To study and compare the effectiveness of dual trigger with gonadotropin-releasing hormone agonist (GnRHa) and low dose human chorionic gonadotropin (hCG) for final oocyte maturation versus human chorionic gonadotropin trigger for improving clinical outcomes in GnRH Antagonist IVF-ICSI Cycles in normal responder patients. Materials and Methods: A prospective comparative study was conducted at a tertiary care infertility centre. Eighty (80) normoresponders who were to undergo IVF-ICSI cycles were included in the study. Patients in both groups underwent controlled ovarian hyperstimulation using GnRH antagonist protocoI. Group 1/Study (n = 40) patients were given Inj Leuprolide acetate and low dose highly purified injection hCG. Group 2/ control group received standard dose of highly purified injection hCG. Day 3 fresh embryo transfers were performed. Primary outcome measured was clinical pregnancy rate and secondary outcomes measured were: implantation rate, miscarriage rate, number of MII oocytes, number of embryos formed, risk of OHSS. Results: In group 1 the clinical pregnancy rate and implantation rate were higher than in group 2, 52.50% vs 47.50% and 29.67% vs 26.08% but the difference was not statistically significant. There were significantly higher number of MII oocytes retrieved (10.63±5.46 Vz 8.10±5.74) and higher number of embryos formed (8.2±3.4 Vz 6.8±3.6) in group1 than in group 2. Conclusion: Though there was increased clinical pregnancy rate and implantation rate in dual trigger group but it was not statistically significant. There was significant increase in MII oocytes and number of embryos formed in the dual trigger group.
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Impact of day 5 vs. day 6 blastocyst transfer on the pregnancy outcome of frozen-thawed donor recipient cycles p. 119
Shweta Mittal, Bhawani Shekhar
Objective: To compare pregnancy outcome and early pregnancy loss in day 5 versus day 6 frozen-thawed donor recipient embryo transfer cycles. Methods: 414 consecutive donor recipient cycles were analysed who had undergone frozen-thawed elective single blastocyst transfer cycles (FET), were non-preimplantation genetic tested (PGT) embryos. High-grade blastocysts were vitrified on day 5 (n = 335) or day 6 (n = 79). Post embryo transfer progesterone supplementation was commenced when endometrial thickness >7 mm was reached after hormone replacement. Frozen blastocysts thawed were assessed for survival, clinical pregnancy, and early pregnancy in both the groups (day 5 [Group A] versus day 6 [Group B]). Statistical analysis was done using chi-square test. Results: All parameters like mean age of oocyte donor (25.03 vs. 24.97 years, p = 0.986), endometrial thickness (8.06 mm vs. 8.23 mm, p = 0.961), and embryo survival (97% vs. 98%, p = 0.776) were comparable in both the groups. Clinical pregnancy rate was found to be similar between Group A versus Group B (50.74% vs. 49.36%, p = 0.825, OR 1.05, CI 0.645–1.724). Clinical miscarriage rate in Group B was 33.33% as compared to 17.05% in Group A, p = 0.022, OR 2.43, CI 1.12–5.28) and was statistically significant. Conclusion: Pregnancy potential of high‐grade blastocysts frozen on day 5 or day 6 seems to be comparable. Younger age of donors had low expected pregnancy loss rates; however, the miscarriage rate was significantly higher in day 6 embryos. Thus, raises an important question if these cycles would perform better if PGT-A is offered when only day 6 embryos are available for transfer.
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Primary tubercular cervicitis with atypical presentation: A case report p. 124
Parul Garg
Tuberculosis (TB) is a common infection in the developing countries and involves almost all body organs. Genital TB is usually secondary to pulmonary or extragenital TB and most commonly involves the upper genital tract. Primary tubercular cervicitis is very rare. Here is a unique case report of primary tubercular cervicitis with atypical presentation (endocervical TB and normal appearing ectocervix with normal Papanicolaou test). A lady of reproductive age group presented with primary infertility for 5 years and secondary amenorrhea for 2 years with yellowish discharge per vaginum for 2 years which stopped 5 months back. Hysteroscopic findings revealed endocervical mass which was excised and histopathology of endocervical tissue mass showed tubercular cervicitis. Antitubercular drugs were started for 6 months and she responded well. She conceived with in vitro fertilization technique.
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FFP as an alternative to albumin in management of severe OHSS − what an IVF specialist should know? p. 128
Nairuti Sompura, K. Jayakrishnan, B Deepti
Ovarian hyperstimulation syndrome (OHSS) may occur in the luteal phase or in setting of early pregnancy. In severe late-onset OHSS, albumin supplementation may be required to maintain intravascular oncotic pressure, but cases with albumin allergy still lack approved treatment. With this in mind, we discussed here the role of fresh frozen plasma as an albumin substitute in a patient with late-onset OHSS who developed severe albumin allergy. We also evaluated the efficacy and safety of pigtail catheter drainage for the management of ascites complicating severe OHSS.
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