Poor responders are real challenges for infertility physicians, as they produce lesser numbers of oocytes after ovulation stimulation. Fertility begins to decline after 30 years of age in women. Hence, in elderly women, diminution of ovarian reserve is a reality. Diminished ovarian reserve (DOR) may be found in young women as well. Ovarian reserve test (ORT) are many, but among them, estimation of follicle-stimulating Hormone (FSH), antral follicle count (AFC) by ultrasound, and estimation of anti-Müllerian Hormone (AMH) are far more standardized. In recent years, one of the androgens called dehydroepiandrosterone (DHEA) has been tried to elevate ovulatory response in DOR patients. DHEA mostly brings the sleeping follicular pool to functional pool and prevents apoptosis of many follicles, thereby, promoting ovulatory response of ovaries with diminished ovarian functions. One such case with premature ovarian failure (POF) has been presented here, who conceived after DHEA treatment. Though escape ovulation can happen in postmenopausal patients, here the lady conceived with DHEA treatment 7 years after achieving premature menopause, during which she suffered from complete secondary amenorrhea.

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Objective: Infertility is a growing concern of the society. In many cases the exact cause of infertility may not be elucidated, whether it is the tubal factor, male factor, uterine factor, or a combination. This adds to the emotional trauma of the couple. Many previous reports have tried to decipher the cause and the best line of management for these cases of unexplained infertility. The choice often lies between a diagnostic approach favoring laparoscopic evaluation and a therapeutic approach favoring the use of assisted reproductive techniques. This paper aims to understand the role of diagnostic hysterolaparoscopy in cases of unexplained infertility, the optimum time to perform it, and its role in changing the future management plan. Design: This was a retrospective study. Patients and Methods: Data of the identified patients were collected from patient case records and they included factors such as age, duration and type of infertility, clinical examination findings, and gynecological ultrasound. Previous treatment history included details of ovulation stimulation, intrauterine insemination (IUI), and other treatment. Intraoperative findings such as presence of peritubal adhesions, endometriosis, tubal pathology, perihepatic adhesions, and hysteroscopic findings were recorded. Results: Our study shows that performing diagnostic hysterolaparoscopy in cases of unexplained infertility is of advantage, especially in patients who have had two or more failed IUI in the past. Conclusion: Performing diagnostic hysterolaparoscopy prior to ovulation induction/IUI has not shown any significant advantage.

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Background: Gonadotrophin treatment to achieve pregnancy in infertile individuals with polycystic ovarian syndrome (PCOS) who are resistant to ovulation induction drugs is costly, time consuming and associated with hyperstimulation and multiple pregnancy. Aim: The aim was to determine the pregnancy rate after laparoscopic ovarian drilling (LOD) in infertile PCOS cases resistant to oral ovulation-inducing drugs. Setting and Design: The setting was a tertiary care center without assisted reproductive techniques (ART) facilities catering to patients with general gynecological problems from all socioeconomic strata. This was a prospective observational study involving women resistant to oral ovulation induction drugs. Period of Study: The period of the study was from 2008 to 2012. Materials and Methods: Forty-eight infertile PCOS cases who did not achieve pregnancy after three or more cycles of clomiphene citrate (CC)/CC and metformin combination and letrozole. LOD was carried out by electrical diathermy. Results: The overall pregnancy rate was 66%. Thirteen percent conceived in the same cycle, 11% in the second cycle, and 6% in the third cycle. Spontaneous abortion occurred in 10% and the live birth rate was 90%. Conclusion : Ovarian drilling may be considered as a good option for oral drug-resistant PCOS cases, as 66% achieved pregnancy with this procedure.

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Title of the article: Ideal value of serum anti-Mullerian hormone as a predictor of ovarian reserve and outcome in assisted reproductive technology. Aims: To evaluate serum AMH as a marker of ovarian reserve and reproductive outcome. Settings and Design: Division of Reproductive Medicine, Kasturba Medical College, Manipal University, Manipal, Karnataka, India. Methods and Material: A prospective two year analysis of 84 women undergoing ART with AMH, FSH and AFC measurements was analysed on day 2 of the cycle. The study group was Group I - <0.7, Group II - 0.7 - 3.5, Group III - >3.5 ng/ml. Outcome measures such as the mature oocytes, quality embryos and pregnancy rates were compared between these groups. Statistical analysis used: Non parametric test (Kruskal Wallis), Exact test and ROC curves was used. Results: AMH levels correlated best with age (P = 0.012), antral follicles (P = 0.001), follicles retrieved (P = 0.002) and oocytes obtained (P = 0.041). The number of mature embryos were higher in Group II & III than Group I (P = 0.312). AMH levels were significantly lower in canceled cycles than completed cycles (P = 0.010). The occurrence of OHSS was higher (61%) in Group III and 10% in in Group II (P = 0.001). Conclusions: AMH value of 0.7-3.5 was better than FSH in prediction of number of oocytes. Both FSH and AMH were not good predictors of pregnancy.

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Introduction: Infertility is a global problem with a wide range of sociocultural, emotional, physical, and financial problems. This study aims to identify couples, with an unfulfilled desire for a child, who require psychological support. Materials and Methods: In this study, a total of 158 couples were selected who filled up the questionnaire. The questionnaire comprised 19 questions, 15 in the psychological evaluation test (PET) to detect emotional reactions to the infertility-related stressors and four close-ended questions to find out the couple's attitudes toward childbearing and their future. The data were statistically analyzed by Mann-Whitney U test and Fischer's exact test, with the level of significance at 5%. Results: The mean age of the men was 35.2 ± 3.5 years, while that of the women was 28.4 ± 2.8 years. Male infertility was diagnosed in 28 couples, female infertility in 47, both male and female infertility in 12, and the remaining 71 couples were either not diagnosed or had unexplained infertility. The mean years of married life was 5.6 ± 3.2 years. Of all the couples, 148 were diagnosed with primary infertility and 10 had secondary infertility. The mean positron emission tomography (PET) score for women and men of 28.3 ± 8.4 and 25.6 ± 7.2, respectively, was not statistically significant. Conclusion: Both women and men give great importance to the inability to bear a child; they were supportive of their spouse, but social stimuli provoked their stress. Women were more emotional and sensitive when personal feelings were considered. PET score >30 required additional psychological support to cope with normal life.

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Aim: The aim of this study is to compare the metabolic and endocrinal parameters between obese and nonobese polycystic ovarian syndrome (PCOS) women with normal controls. Materials and Methods: The study was a cross-sectional comparative study. One-hundred PCOS women were randomized into two groups: Group I obese (n = 50) and Group II nonobese (body mass index [BMI] cutoff <23 kg/m ² ). Fifty non-PCOS normal weight women formed the control Group III. Metabolic parameters (lipid profile, blood sugar profile, and serum insulin) and endocrinal parameters (serum luteinizing hormone [LH], follicle-stimulating hormone, and testosterone) were compared between the three groups. Results: Mean age of all the groups was comparable. A significantly higher waist circumference was seen in Group I; however, waist-hip ratio (WHR) was comparable between obese and nonobese PCOS groups. Between Groups I and II, mean fasting blood sugar, mean values of impaired glucose tolerance (IGT), and clinical hyperandrogenism were statistically comparable. Degree of insulin resistance (IR) in Group I versus Group II (44% vs. 36%) and of metabolic syndrome in Group I (20%) versus Group II (8%) was statistically comparable. Degree of hypertension (P = 0.001), IGT (P = 0.001), and dyslipidemia were higher in nonobese PCOS group versus normal group. Mean values of serum LH, serum fasting insulin, and serum testosterone were significantly different in nonobese PCOS women when compared with normal. Prevalence of IR (36% vs. 8%; P < 0.01) and metabolic syndrome was significantly higher in nonobese PCOS than normal controls. Conclusion: PCOS per se has evolved as a risk factor for endocrinal and metabolic derangements irrespective of the BMI status. Prevalence of IR and metabolic syndrome is high in nonobese PCOS as compared to normal controls, risks being as high as that in obese PCOS.

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Despite the tremendous advancements made, absolute uterine factor infertility (absence of the uterus or the presence of a nonfunctional uterus) is one of the few spheres where still there is a lot of scope for research and growth. One option for this group of patients is a uterine transplant. Uterine transplant is a type of an ephemeral/quality of life-enhancing transplant. This article reviews the beginning, research in animals, application in humans, donor and recipient selection, technical details, and finally the ethical aspects of its application in the Indian context.

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Here we present a rare case of complex uterine anomaly with Obstructed Hemivagina and ipsilateral renal agenesis (OHVIRA), also known as the Herlyn-Werner-Wunderlich syndrome (HWWS). A 16-year-old girl presenting with dysmenorrhea underwent ultrasonography, intravenous urogram (IVU), and magnetic resonance imaging (MRI) of kidney, ureter, and bladder (KUB). An abdominopelvic MRI was found to be very effective in reaching appropriate diagnosis with the avoidance of interventions like laparoscopy or laparotomy, which was needed in the past to diagnose this rare anomaly. We also discuss the embryopathogenesis of this anomaly and review the literature.

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A rare case of a 28-year-old female who suffered from a right ovarian ectopic pregnancy conceived by in vitro fertilization (IVF) is illustrated in this paper. She had history of one earlier pregnancy conceived with intrauterine insemination (IUI) that led to right tubal ectopic pregnancy, which was treated conservatively. At subsequent IVF cycle, she presented at 9 weeks of gestation with the compliant of severe pain in lower abdomen and mild vaginal bleeding. Serum β-human chorionic gonadotropin (β-hCG) concentration was 7,843 IU/L. Transvaginal sonography suggested a mass of 4.0 cm × 3.6 cm × 4.9 cm adjacent to the right ovary with cystic area interpreting right ovarian ectopic pregnancy. Prompt decision of laparoscopic management was taken depending upon the status of the patient and the desire to preserve her fertility. The ectopic tissue was aspirated laparoscopically while conserving more than 50% of the ovary. The ovarian pregnancy was also confirmed histologically. Early and accurate diagnosis and prompt management of ovarian ectopic pregnancy can preserve fertility.

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Background: Etiologies behind recurrent pregnancy loss (RPL) in half of the cases remains idiopathic even after an extensive investigation. The role of oxidative stress (OS) has been implicated in the pathogenesis of many human diseases including male fertility, but its role on male partner of RPL couple is limited. Materials and Methods: Semen samples from fifty male partners of the female with the history of three or more idiopathic primary RPL and fifty controls were obtained and analyzed according to the WHO guidelines along with sperm function tests. Functioning of the accessory gland was evaluated selecting one marker for each gland such as citric acid and fructose. OS markers such as reactive oxygen species, total antioxidant capacity, lipid peroxidation, and superoxide dismutase levels were estimated. Statistical analysis was done using independent samples t-test using statistical software SPSS version 14. Results: In RPL group, significantly lower scores were observed for sperm function test than the control group. Fructose and citric acid levels did not show any significant difference between the groups. Among RPL group, 2% and 4.5% of individual have a lower value for fructose and citric acid, respectively. The malondialdehyde concentration and ROS levels were significantly higher in RPL group. While the activity of superoxide dismutase and total antioxidant level was significantly lower in RPL males than in the control group. Conclusion: This study highlights the importance of evaluation of male factors for sperm function tests, OS markers, and accessory gland assessment along with the conventional parameters. This may help for better pregnancy outcome through proper evaluations and management.

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