Luteal phase defect (LPD) is a condition with insufficient endogenous progesterone for maintenance of functional secretory endometrium, normal embryo implantation, and growth. In today’s era, there is a lot of complex research with wide diversity with respect to LPD and its treatment. With such diversity and complexity of research data, we hereby did this review to address the pathophysiology of LPD and the role of luteal phase support in assisted reproductive cycles based on available scientific evidence in a simplified manner. An electronic search of Pubmed, Scopus, Embase, and Google Scholar was performed for LPD, luteal phase support, and assisted reproductive technologies. There is no valid diagnostic test for LPD. Prompt identification and treatment of underlying factors is the preferred approach. In assisted reproductive cycles, the luteal phase is usually abnormal and luteal phase support in form of exogenous progesterone with or without estrogen or hCG and GnRH agonists, which enhance endogenous progesterone release have a significant effect on successful reproductive outcomes. The choice of drug is dependent upon the patient’s characteristics and type of ongoing treatment. It should be started on the day of oocyte retrieval or till the day 3 postretrieval and to be continued till a positive pregnancy test at least.

Introduction:This pilot study was done to evaluate the effectiveness of intrauterineinstillation of autologous platelet rich plasma in the treatment of infertile woman with ≥2 IVF failures due to thin endometrium not responding to empirical medical therapies. Design: Prospective interventional study. Material and Methods: Intra uterine instillation of PRP was done in 50 women between 23 to 38 years with suboptimal endometrial receptivity, ≥ 2 IVF failures and HRT cycle cancellations over a course of 9 months. Frozen embryo transfer was done when optimal endometrial thickness and vascularity was achieved. Results: The mean endometrial thickness pre PRP was 5.78mm which increased to 7.20mm post-PRP (P value < 0.001). There was a statistically significant increase in endometrial vascularity. The mean PI uterine artery pre-PRP was 3.18 which decreased to 2.71 post PRP (P-value < 0.001). There was a statistically significant fall in uterine artery RI from 1.04 to 0.86 after PRP therapy. The implantation rate, clinical pregnancy rate were 15.3% & 33.3% respectively. One patient had early clinical pregnancy loss. Cervical ectopic pregnancy was diagnosed in 1 patient. 4 patients had DADC twins. Conclusion: PRP is a safe, inexpensive and acceptable alternative for endometrial preparation of infertile patients with ≥2 IVF failures due to suboptimal endometrium.

Background: Fertility prediction application is the need to increase the likelihood for early approach at right time in infertility. In this study, we propose to investigate the use of a fertility score predictor (FSP), score system with colour code for easy understanding and calculated by using common easily available variables associated with fertility. We applied this score system retrospectively to our own out patients and analysed our infertility management protocols to those patients with outcome. Materials and Methods: A total of 100 patients who attended for the infertility treatment at Ssmile Fertility Center in Pune during the period of October 2018 to February 2020 were retrospectively evaluated. The demographic variables were categorised according to their impact on fertility reported by previous studies and each category was assigned to a value to calculate the Fertility score predictor (FSP) with colour code (green, blue, orange, and red green, blue, orange, red, black) for easy understanding and applicability. Results: The association between infertility and colour codes based on FSP was evaluated and the results showed that all analysed variables were significantly associated to the colour code, revealing that a higher number of patients with high FSP presented a healthy lifestyle, regular menstruation, and regular sexual intercourse. Also, it was observed that all patients with high FSP had been diagnosed with unexplained infertility, and the number of patients with other causes of infertility increased as score was lower. Conclusions: The association between FSP and fertility related parameter suggests that the score is suitable for detecting the patients with lower fertility at early stage. The treatment option based on FSP was associated with early detection and appropriate intervention.

Background: The success of IVF depends to a large extent on the number and quality of mature oocytes obtained at the time of oocyte retrieval after controlled ovarian stimulation. This can be done by correctly predicting the ovarian response, which largely depends on ovarian reserve. The objective of present study was to assess accuracy of novel biomarker Ovarian Response Prediction Index (ORPI) based on three parameters patient age, AFC, AMH for prediction of ovarian response, so, we would be able to formulate individualized controlled ovarian stimulation approach to optimize cycle outcome. Methodology: This retrospective analysis was performed at our centre involving 100 patients undergoing IVF cycle between August 2019 and February 2020. We calculated ORPI by the following equation: ORPI = (AMH × AFC)/patient age, which was derived by Oliveira et al. Results: There was significant (p = 0.0001) positive correlation of ORPI with AFC, AMH, oocyte, MII oocyte and Embryo (gr1+2). ROC curve analysis showed that at ORPI cut off >0.18 (AUC 0.94) has sensitivity and specificity of 95.7% and 85.7%, respectively, for prediction of ≥4 oocyte recovery, and at cut off >2 (AUC 0.91) has sensitivity and specificity 75% and 85.2%, respectively, for prediction of ≥15 oocyte recovery. This study has demonstrated that for collection of ≥4 MII oocytes, ORPI at cut off >0.50 (AUC 0.86) has sensitivity and specificity of 74.1% and 78.9%, respectively. For probability of collection of >6 good quality embryos, we found ORPI cut off >0.75 with sensitivity and specificity of 72.7% and 64.2%, respectively. Conclusion: This study demonstrated that ORPI, which is simple 3 variable index, has shown excellent ability to predict low and excessive ovarian response and can be useful to tailor individualized controlled ovarian stimulation programme and will be beneficial for counselling and prognostication of infertile couple.

Background: The aim of the study was to study the comparison of the efficacy of letrozole versus clomiphene citrate (CC) for ovulation induction in infertile women with polycystic ovary syndrome (PCOS) in Indian population. Methods: This prospective trial included 92 infertile women with PCOS. Letrozole dose of 2.5 mg/day (n = 47) or a CC dose of 100 mg/day (n = 45) was given from day 3 to day 7 of the menstrual cycle. Follicular monitoring was started from day 7 and done until the mean diameter of the largest follicle reached 18 mm, then, 5000 IU of human chorionic gonadotropin (HCG) was given. Intrauterine insemination was done in two sittings, 24 and 48 hours after HCG. Statistical testing was conducted with SPSS 17.0. Results: The clinical profile of patients belonging to both groups were comparable. The number of follicles ≥18 mm on the day of HCG was 1.11 ± 0.43 for the letrozole group and 2.53 ± 1.10 for the CC group (P<0.001). Endometrial thickness on the day of HCG administration (mm) was higher in the letrozole group than the CC group (P<0.001). Ovulation rate was higher in the letrozole group (P = 0.047). Urine pregnancy test (UPT) positive patients were 40.42% in the letrozole group and 20% in the CC group (P = 0.033). Clinical pregnancy rates were slightly higher in the letrozole group. Higher twin pregnancy (P = 0.025) and miscarriage rates were noted in the CC group (P = 0.033). Conclusion: Letrozole appears to be superior to CC for ovulation induction in infertile PCOS patients.

Objective: The aim of the study was to evaluate efficacy of hyaluronan-rich medium on implantation and clinical pregnancy rates in vitrified-warmed blastocyst transfers in recurrent implantation failure patients. Methods: This was a randomized controlled study conducted at Akanksha IVF Centre, New Delhi. One hundred patients with history of previous two or more implantation failures, with at least one implantation failure at the present center, were included in the study. Patients were randomly divided into two groups: study group (n = 37) had embryos transferred into 20 μL of EmbryoGlue for 10 minutes prior to transfer inside uterine cavity. In the control group (n = 31), embryos were transferred to the conventional blastocyst culture medium. Statistical analysis was performed using Statistics Package for Social Sciences. Results: The patient’s mean age, causes of infertility, serum anti-Müllerian hormone level, embryo quality and the number of transferred embryos were comparable between the study and control groups. The clinical pregnancy rate in study group was higher than control group (40.5% vs 25.8%). However, the difference was not statistically significant (P = 0.58). There was no statistically significant improvement in implantation rate (44% vs 34.1%; P = 0.32), miscarriage rate (6.6% vs 12.5%; P = 0.27) and multiple pregnancy rate (13.3% vs 12.5%; P = 0.9). Conclusion: The use of EmbryoGlue in transfer medium in the blastocyst transfer in vitrified-warmed cycles does not have any significant effect on the implantation and pregnancy rates in patients with previous implantation failure.

Introduction: The declining trend of male reproductive health in recent times has raised concern among investigators and the contribution of environmental toxicants to this public health disorder has not been sufficiently evaluated in our setting. Objective: To evaluate the seminal plasma levels of lead (Pb), cadmium (Cd), zinc (Zn), and serum testosterone of nonoccupationally exposed infertile males. Materials and Methods: A total of 70 infertile males investigated for infertility and 50 men of proven fertility were evaluated. The seminal plasma Pb, Cd, and Zn levels were determined by atomic absorption spectrophotometer (Buck Scientific Model VGP-210, Germany), while the serum testosterone was assayed by Enzyme-linked immunosorbent assay (ELISA) technique using reagent supplied by Diagnostic Products Monobind Inc. Lake Forest, CA 92630, USA). Semen analyses were performed using standard techniques as recommended by the World Health Organization. The results were compared between infertile and fertile groups using unpaired Students t test. Results: Mean seminal plasma Pb, Cd, and Cd/Zn ratio were significantly higher (P<0.001) in infertile males than controls. Cd/Zn ratio (r = −0.242; P<0.04) correlated negatively (P<0.001) with serum testosterone. Mean serum Zn level was significantly lower (P<0.001) in infertile men than controls, but the difference in the level of serum testosterone was not significant (P<0.415). Conclusion: Evaluation of seminal plasma Cd, Pb, Zn, and Cd/Zn ratio may be considered in a comprehensive investigation of the infertile men while informed risk modeling to preventing exposure to toxic metals may help to mitigate their health consequences.

Introduction: There is a paucity of data evaluating role of endometrial blood flow in frozen thawed embryo transfer cycles (FET cycles) in hormone replacement treatment (HRT) cycles. Objective: To compare pregnancy outcomes in women undergoing ultrasound for endometrial morphology alone to those with endometrial morphology with blood flows in frozen embryo transfer cycles. Patients: Patients aged 23 to 38 years undergoing first two frozen thawed single blastocyst embryo transfer cycles. From August 2019 to January 2020, 163 patients undergoing hormone replacement frozen embryo transfer cycles were enrolled in the study. Patients were divided in two groups. Patients in group A (n = 92) had ultrasonographic evaluation of endometrial thickness and morphology and in group B (n = 71) patients underwent ultrasound for endometrial thickness, morphology along with Doppler blood flow studies. Outcome measures: Primary outcome was clinical pregnancy rate. Secondary outcome measures were pregnancy loss rate, ongoing pregnancy rate, and ectopic pregnancy rate. Results: Clinical pregnancy rate in group A and group B was 54.34% and 47.88%. Clinical pregnancy rate was similar between both the groups (P = 0.779). Ongoing pregnancy rate in group A and B was 48.91% and 40.84%, respectively. Pregnancy loss rate (7–13 wks) was 5.4% and 7.04% in group A and group B, respectively. There was no significant difference in ongoing pregnancy rate and pregnancy loss rate between both the groups (P = 0.756). Conclusion: Additional measurement of doppler studies do not help in improving implantation and thus seems unnecessary in improving pregnancy rates and reducing pregnancy loss rates in FET cycles.

Objective: To study the effect of intrauterine administration of human chorionic gonadotropin (hCG) before embryo transfer (ET) on biochemical pregnancy rate, implantation rate, and clinical pregnancy rate in in vitro fertilization/intracytoplasmic sperm injection cycles. Design: Prospective and interventional randomized comparative study. Setting: Origyn Fertility & IVF, 4th floor, HB Twin towers, Netaji Subhash Place, Above Max Hospital Pitampura, New Delhi. Patients: All patients aged 23 to 38 years undergoing fresh or frozen ET or planned for in vitro fertilization/intracytoplasmic sperm injection cycle are included in the study. Intervention: From August 2019 to March 2020, 80 patients were included in the study who were divided into two subgroups viz group “A” (Case group) and group “B” (control group). Group “A” patients were given 500 IU of hCG intrauterine 7 min prior to ET and in group “B” patients, the embryo was transferred directly. Outcome measure: Biochemical pregnancy rate, clinical pregnancy rate, and implantation rate. Results: Clinical pregnancy rate was 52.5% in the case group and 45% in the control group. Biochemical pregnancy rate was 57.5% in the case group and 52.5% in the control group. Mean implantation rate was 30.41 ± 36.57 in the case group and 24.57 ± 30.42 in the control group. Conclusion: The intrauterine instillation of 500 IU of hCG 7 min before ET did not show any significant difference in clinical pregnancy rate, biochemical pregnancy rate, and implantation rate. However, as this study was performed on a small group, its reliability in clinical practice needs further studies on a larger study group.

Aim: To assess the role of growth hormone in improving endometrial response and clinical outcome. Materials and Methods: A prospective randomised study was conducted with 50 patients who were treated with FET cycles at Ridge IVF, Delhi, between August 2019 and January 2020. Patients were classified into two groups: group A administered simultaneous GH along with hormone-replacement therapy (HRT), for endometrial preparation; while group B received HRT alone. GH four IU subcutaneously was started on the day of HRT (day two/three) and continued till the endometrium reached a thickness of 8 mm. Statistical analysis: Statistical testing was conducted with the statistical software SPSS 20.0. Continuous variables are presented as mean±SD. Categorical variables are expressed as frequencies and percentages. Categorical data was compared using Chi-square test or Fisher’s exact test as appropriate. Results: Patients in group A had a significantly higher endometrial thickness (8.86±1.06 mm) as compared to group B (8.34±1.16 mm) (P value=0.028). However, patients in group A i.e those given GH, had a lower impedance to blood flow as shown by a lower pulsatility index (1.68±0.12 vs 1.92±0.13) (P value=0.028), resistance index (0.73±0.06 vs 0.86±.02) (P value=0.053), and a lower peak systolic velocity/end diastolic velocity of the uterine arcuate artery (2.68±.13 vs 2.93±0.11) (P value=0.066). The clinical pregnancy rate was comparatively more in group A compared to group B (56% vs 48%) (P value=0.588). Conclusion: Growth hormone when given along with HRT can improve FET results by enhancing endometrial perfusion.

Background: To study the impact of blood and mucus on embryo transfer (ET) catheter tip and in vitro fertilisation (IVF) outcome. Aims: To compare the implantation rate and clinical pregnancy rate of blood and mucus on ET catheter tip. Study setting: Ajanta Hospital and IVF Centre, Lucknow, Uttar Pradesh. Study design: Prospective observational comparative study. Study period: August 2019 to March 2020. Material and methods: In this prospective observational comparative study, 60 patients undergoing IVF-ET were included in the study. Patients were observed for the presence of blood or mucus on the ET catheter tip. The tip of the ET inner catheter was examined under the microscope for the presence of blood or mucus. Statistical analysis: Statistical analysis was performed by the SPSS program of Windows, version 17.0 (SPSS, Chicago, Illinois). Continuous variables being presented as mean ± SD. Normally distributed continuous variables were compared by unpaired t test, whereas the Mann-Whitney U test used for not normally distributed variables. Categorical variables are analyzed by chi square test or Fisher test. P < 0.05 was taken as statistically significant.Results: By this study, it is observed that the implantation rate for mucus group was 66%, whereas for blood group is 20.6% (P value < 0.001). It is observed that the clinical pregnancy rate for mucus group was 66.7%, whereas for blood group was 29.2% (P value = 0.004). Conclusion: A successful ET needs to be smooth, easy to transfer, and have an atraumatic path through cervix and slow transfer of embryos in the endometrium for good implantation rate. This study showed that when blood was present on the ET catheter, there was decreased clinical pregnancy rate and implantation rate, whereas implantation rate (IR) and clinical pregnancy rate (CPR) were unaffected when mucus was present on catheter

Aim: To evaluate knowledge, attitude, and practices (KAP) regarding fertility preservation among various doctors involved in treatment and care of cancer patients and identify the potential barriers for the discussion of fertility preservation with patients. Settings and design: A survey-based cross-sectional study conducted in a tertiary ART centre in Northern India (Jindal IVF & Sant memorial nursing home, Chandigarh). Materials and methods: The study involved Gynecologists, Infertility specialists, Radiotherapists, General Surgeons and Oncologists from multiple institutions. The survey included a questionnaire consisting of 20 items. The study was closed after receipt of the first 201 responses. The responses to questions were analysed by the standard statistical method using SPSS- 22. Results: The knowledge among respondents from all specialties regarding impact of cancer treatment on fertility was very high. The rates of knowledge regarding various fertility preservation (FP) options were variable, least knowledge regarding the transposition of ovaries/gonads, testicular tissue cryopreservation, fertility-sparing chemotherapy. There were variations in clinician’s attitude and practice regarding various fertility issues of the patient and fertility preservation based on the specialty of clinicians. Nearly three-fourth discuss various FP options but only one-third provide written information on the same. The referral practice for FP was variable and was influenced by many factors. The factors considered most important for barriers to fertility preservation are Socioeconomic status/cost and affordability issues, 75.1% (patient factor), prognosis, type of cancer and type of treatment 60.2%, (clinician’s consideration). Conclusion: To improvise utilization of fertility preservation services, the deficit in clinician’s knowledge should be circumvented by providing them with basic, advanced, and up to date information particularly among primary contact clinicians of cancer patients. The referral pathways should be defined and made clear.

There is a conflicting evidence that prior hysteroscopy in IVF treatment is beneficial in terms of successful pregnancy rate and subsequent live birth rate. So a study was planned to compare 2D TVS & 3D USG in detecting uterine anomalies in infertile patients & to know whether prior hysteroscopy has any effect on Clinical Pregnancy and Abortion rate. A sample size of 90 was selected and further randomized into 3 groups. Patients were randomized over 6-month time. All patients underwent same baseline investigations. In group 1 subjects, 2D TVS was done to detect uterine anomalies, in group 2 3D USG was performed and group 3 subjects underwent gold standard diagnostic hysteroscopy. Subjects in group 1 & 2 who tested positive for uterine anomalies were confirmed with diagnostic hysteroscopy and subsequently excluded from the study. Those subjects who had false positive results in group 1 & 2 were included in group 3 for Frozen Embryo transfer. This procedure was done till each of the 3 groups had 30 subjects. Furthermore, subjects in group 1 & 2 who tested negative for uterine anomalies, underwent IVF but did not conceive further underwent diagnostic hysteroscopy to confirm the diagnosis as a part of calculating Sensitivity and Specificity of 2D TVS and 3D USG. A total of 160 patients were accessed and finally 90 were included in the study. There was no significant difference in baseline demographic characteristics, type of infertility, duration of infertility, hormonal profile & mean antral follicle count and size. The Sn, Sp, PPV for 2D TVS & 3D USG was found to be 66.6%, 90%, 75% & 90.9%, 95% and 90.9% respectively. There was no difference in CPR and miscarriage rate in patients who conceived in each group. The results of the study are in line with the previous studies. Larger scale RCTs need to be conducted to ascertain the exact role of prior hysteroscopy in pregnancy outcome in infertile patients with no uterine anomalies.

Objective: An attempt was made to evaluate the impact of the length of ovarian stimulation on the embryo quality, with recommended strength of gonadotropin doses in women who underwent IVF/ICSI-ET cycles. Setting: Women, who underwent oocyte retrieval and fresh embryo transfer between August 2019 and November 2019, were evaluated. Design: Prospective observational study. Method: Women with primary and secondary infertility were recruited from the OPD. Ovarian stimulation was started with gonadotropins according to our center’s protocol (Antagonist protocol). Oocyte retrieval was performed approximately 36 hours after the hCG administration (trigger) followed by IVF/ICSI. Fertilization analysis was performed approximately 16 to 18 hours postinsemination. After fertilization, embryo scoring was carried out on the day of embryo transfer procedure. The primary outcome was the development of good quality embryos in relation to the days of ovarian stimulation. Statistical Analysis: Data were analyzed by Statistical Package for Social Studies (SPSS) 21.0 software package (IBM Corporation, USA): Chi-square test for categorical variables, nonparametric Kruskal Wallis test, ANOVA test, and Pearson correlation for continuous variables were applied. These tests were applied as appropriate and statistically significant level calculated at P < 0.05. Results: The length of ovarian stimulation has little impact on the quality of embryo and pregnancy outcome. Conclusion: The length of ovarian stimulation has little impact on the quality of embryo and pregnancy outcome. Future studies on large number with proper randomization are invited to be conducted to confirm the finding of present study.

A 25-year-old lady with 3 years of primary infertility was diagnosed with an infantile uterus, premature ovarian failure due to streak gonads, and 46XX gonadal dysgenesis. She has received hormone therapy irregularly since menarche and gets withdrawal bleeding only after taking estrogen and progesterone combination. She also received three cycles of ovulation induction elsewhere. Her transvaginal ultrasonogram (USG) showed uterus that measured 4.1 × 2.3 cms, right ovary measured 1.4 × 0.9 × 1.08 cm and left ovary could not be visualized. She was given hormone replacement therapy to achieve optimal uterine size for a period of 1 year and achieved pregnancy with the second cycle of the donor oocyte program. She developed early onset-gestational hypertension and underwent elective lower segment caesarean section (LSCS) at 37 weeks. At cesarean section, fallopian tubes were normal and ovaries were small in size and streak like. An alive female baby was delivered who weighed 3.5 kg.

The present study presents a case report of a rare anomaly called accessory cavitated uterine mass (ACUM). The patient, 26 years old, had presented with severe dysmenorrhea which was refractory to the medical treatment. The hysteroscopic examination was normal and laparoscopic examination showed a subserosal bulge, present over anterior and lateral fundal region above the attachment of the round ligament. Chromo-pertubation was performed and dye came freely from both the tubes but not from the cavity of this uterine mass. The chocolate-colour material was drained during excision of the mass. The final histopathology report showed myometrial tissue lined by collection of hemosiderin laden macrophages as well as endometrial cuboidal lining and occasional endometrial glands.