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Management of Polycystic Ovary Syndrome in India
Sonia Malik, Kuldeep Jain, Pankaj Talwar, Sudha Prasad, Bharti Dhorepatil, Gouri Devi, Ashok Khurana, Vandana Bhatia, Nomita Chandiok, Alka Kriplani, Duru Shah, Geeta Sinha, Jyoti Unni, Madhuri Patil, Meeta Singh, Phagun Shah, Ratnabali Chakraborty, SM Bhattacharya, Siddarth Chatterjee, Sukumar Barik, Rama Vaidya, Subhash Kumar Wangnoo, Ambrish Mithal, Mohd Ashraf Ganie, Binayak Sinha, Jayashree Gopal, Waman Khadilkar, Rahul Nagpal, VK Khanna, Nitin Verma, Ahmed Zaheer, Bindu Sthalekar, Latika Arya, Niti Khunger, Rekha Sheth, Dhiraj Bhatia, Varun Duggal, Anuradha Khadilkar, Beena Joshi
January-June 2014, 1(1):23-43
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Pregnancy in a lady with premature ovarian failure following dehydroepiandrosterone (DHEA) treatment
Siddhartha Chatterjee, Rajib Gon Chowdhury, Sandip Dey, Debidas Ganguly
January-June 2015, 2(1):40-42
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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Genital tuberculosis and infertility
Jai B Sharma, Sona Dharmendra, Shefali Agarwal, Eshani Sharma
January-June 2016, 3(1):6-18
Female genital tuberculosis (TB) is an important cause of significant morbidity, short- and long-term sequelae especially in infertility in which incidence varies from 5 to 15% cases in India. The causative agent is Mycobacterium tuberculosis. The fallopian tubes are mainly involved in 90 to 100% cases, endometrium in 60 to 80% cases, ovaries in 30% cases, and cervix in 15% cases of genital TB. Vagina and vulva TB is rare involving 1 to 2% cases. Diagnosis is made by detection of acid fast bacilli on microscopy or culture on endometrial biopsy or on histopathological detection of epithelioid granuloma on biopsy. Polymerase chain reaction (PCR) may be false positive and alone is not sufficient to make the diagnosis. Laparoscopy and hysteroscopy is the gold standard for the diagnosis of the disease. Treatment is by giving daily therapy of rifampicin (R), isoniazid (H), pyrazinamide (Z), and ethambutol (E) for 2 months followed by rifampicin (R) and isoniazid (H) daily for 4 months. Three weekly dosing throughout therapy (RHZE thrice weekly for 2 months followed by RH thrice weekly for 4 months) can be given as Directly Observed Treatment Short Course. Surgery is rarely required only for drainage of abscesses. Role of in vitro fertilization and embryo transfer is required in women whose fallopian tubes are damaged but endometrium is healthy. Surrogacy or adoption is needed for women whose endometrium is damaged.
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Dysmenorrhea membranacea: A case report and review of the literature
Pragati S Upasham, Swapnil V Sirmukaddam, Anita Sharan
January-June 2014, 1(1):56-57
Dysmenorrhoea membranacea is a rare condition in which there is spontaneous expulsion of the fragments of endometrium in a cylindrical piece retaining the shape of the uterus. Here we present a case of dysmenorrhoea membranacea in 53 year old female patient who was on hormonal therapy for her irregular menstrual history, presented with the history of menorrhagia and passage of clots since one month.. Patient was subjected to D&C , during PV examination there was an expulsion of this endometrial cast. On histopathology it was diagnosed as dysmenorrhoea membranacea. It is an uncommon diagnosis, predominantly occurring in second and third decade of life. We also reviewed the literature associated with this lesion.
  13,685 833 -
Tamoxifen for ovulation induction in infertile PCOS women who did not conceive with 3 or more cycles of clomiphene citrate: A prospective clinical study
Avanthi Gadipudi, Paapa Dasari, Haritha Sagili
January-June 2017, 4(1):22-29
Objectives: To assess the ovulatory, pregnancy rates and side effects of tamoxifen (TMX) in women who are infertile with polycystic ovarian syndrome (PCOS) and who did not conceive with three cycles of clomiphene citrate (CC). Study Design: A prospective interventional study. Population: Seventy-four women who were infertile with PCOS and who did not achieve pregnancy after a minimum of three cycles of CC were included in the study. Materials and Methods: TMX was given orally from Day 2 to Day 6 of the menstrual cycle, with a dose of 40 mg in the 1st cycle and 80 mg in the subsequent two cycles. Transvaginal ultrasound was used for follicular monitoring from Day 10 and on every alternate day till the day of ovulation or till the 20th day of the cycle. Statistical Analysis: Ovulation rates with different doses were compared using McNemar test. Kruskal–Wallis test was used to find out differences in maximum follicular diameter and endometrial thickness (ET) between 3 cycles. Results: The mean maximum follicular diameter was 16 ± 5.2 mm, and the mean ET was 8.9 ± 1.7 mm with an ovulatory rate of 41.90% with 40 mg of TMX. Mean increase in the maximum follicular diameters with 80 mg of TMX was higher when compared with 40 mg (P value − 0.000) of TMX. Increasing the dose of TMX in cycles 2 and 3 resulted in a statistically significant increase in the ovulatory rates; however, it was not so with ET. There were no clinical pregnancies, and minor side effects occurred in 14.1% of the participants. Conclusion: TMX induced ovulation only in 56% of the participants, and optimum ET was achieved in 92.7% of the participants; in addition, there were no pregnancies. Hence, TMX is not a useful ovulation inducing agent for CC failure/CC-resistant PCOS.
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A prospective study to correlate serum progesterone levels and clinical pregnancy outcome in frozen embryo transfer cycles
Rachita Chawla, KU Kunjimoideen
July-December 2019, 6(2):82-88
Methods: Total 100 patients were included in the study and divided into two groups (A and B). Blood levels of p4 were measured when beginning progesterone and on the day of Frozen embryo transfer (FET) in one group and were supplemented if levels were less than 10 ng/mL. No measurement of serum p4 was undertaken in the other group (B). Statistical tests like chi square test and Mann-Whitney test were applied and SPSS version 23 was used. Outcome: Clinical pregnancy outcome. Results: Clinical pregnancy rate was 32.69% in group A vs 24% in the other group which is non-significant. Conclusion: Serum p4 should be between 1.5 and 24 ng/mL on the starting day for a positive result. Level in blood on the day of starting progesterone to obtain a positive clinical pregnancy was 0.21 ng/mL and should not exceed 0.96 ng/mL.
  13,727 372 -
Emerging role of Color Doppler in Infertility Management: A Public Health perspective
Saumya Pandey, Gita Khanna, Aparna Bajpai, Anil Khanna
July-December 2014, 1(2):87-91
Color Doppler is emerging as a valuable diagnostic imaging modality in the field of reproductive medicine, primarily infertility. Reproductive disorders, including infertility and spontaneous abortions/miscarriages, have emerged as major public health problem(s) worldwide. Color Doppler energy imaging is a high throughput technology based on the total integral of energy frequency spectrum. We extracted the most relevant articles (comprehensive reviews and original research articles) for inclusion in our review by performing a comprehensive literature search using the Pubmed (last accessed on 2015 April 28) scientific database. Color Doppler is a high-throughput, sophisticated imaging technique for the assessment of uterine anomalies, intrauterine pathology, tubal patency, polycystic ovaries, ovarian follicular monitoring, endometrial receptivity, failed and/or ectopic pregnancy, male infertility, and uterine, endometrial, and ovarian vascularity. Assessments of the uteroovarian pulsatility indices (PIs), resistance indices (RIs), and endometrial color signals are important determinants of in vitro fertilization (IVF) cycles and pregnancy rates. With our clinical/scientific research experience in the field of reproductive medicine, we strongly believe that an overall public health model needs to be designed in managing infertility patients; therefore, major issues such as cost-effectiveness and technical artifacts should be addressed so as to achieve an accurate clinical diagnosis, successful IVF outcome/pregnancy, and overall patient satisfaction in a clinical research setting. Simple, safe, efficient, and affordable diagnostic modalities should be incorporated at infertility clinics coupled with well-designed patient counseling sessions and community-based public health awareness campaigns conducted so as to reduce the morbidity and mortality rates associated with reproductive disorders.
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Pregnancy after DHEA-S for low ovarian reserve due to laparoscopic ovarian drilling
Paapa Dasari, Ashraf M Ali
July-December 2018, 5(2):68-71
A 32-year-old married for three years, who had taken treatment for primary infertility, approached for assisted reproductive techniques (ART) after the failure of 10 cycles of ovulation induction with clomiphene citrate (CC) and laparoscopic ovarian drilling (LOD) two years ago. She was evaluated and found to have anti-Mullerian hormone (AMH) of 0.63 ng/ml and antral follicle count (AFC) of four and was treated with dehydroepiandrosterone sulphate (DHEA-S) for three months. Her AMH increased to 1.2 ng/ml and AFC to seven and she underwent three cycles of ovulation induction and intrauterine insemination (IUI) which was unsuccessful. She conceived naturally after the fourth cycle of ovulation induction with gonadotropins without cycle monitoring. Her Pregnancy was supported with progesterone until 36 weeks, and she underwent elective lower segment Caesarean section (LSCS) for mid-pelvic contraction at 38 weeks of pregnancy. The Caesarean section inspection of the ovaries showed bilateral charring and a few tubo-tubal adhesions. Her postoperative period was normal and mother and baby were discharged on the fifth postnatal day.
  11,671 323 -
Spontaneous conception following anti-tubercular treatment for sub-fertile women with multiple imaging markers suggesting genital tuberculosis
Nikita Naredi, Pankaj Talwar, Nagaraj Narayan, Seema Rai, Shakti Vardhan, Subrat Panda
January-June 2014, 1(1):44-49
Background: Female genital tuberculosis (FGTB) primarily an asymptomatic disease is one of the most important causes of female infertility in developing countries. Damage to the pelvic organs after genital tuberculosis (GTB) is a well recognized entity .It is thus prudent to diagnose and treat GTB as early as possible to prevent or at least to minimize the damage to the genital organs. Although diagnosis of GTB has been a challenge, its detection and treatment cannot be based on single test and multiple markers must be utilised with the clinical background and early treatment instituted. Objective: The present study was aimed to diagnose or predict GTB based primarily on imaging modalities in the form of hysterosalpingography, pelvic ultrasound and supported by the basic laboratory investigations like Mantoux test, Erythrocyte Sedimentation rate (ESR) . Once the diagnosis or prediction of GTB was made, an early institution of anti tubercular therapy was done and patients were followed up to observe the spontaneous pregnancy rate. Material And Methods: This was a prospective study wherein the patients underwent complete evaluation for infertility including a hysterosalpingograhy and pelvic ultrasonography. The patients were considered to be positive for genital tuberculosis if three or more of the following were found on evaluation: raised ESR ( ≥ 20mm/first hour), Mantoux test positive ( induration ≥ 10 mm), HSG picture or Ultrasonological picture suggestive of GTB. Observation: It was seen that out of the 400 women who were included; 265 women (Group A) were adjudged to have genital tuberculosis as per our study protocol and thus were started on ATT whereas 135 (group B) were not put on antitubercular therapy. Within this duration (during or after completion of ATT), 157(59.2%) conceived spontaneously in group A, on the other hand only 27(20%) women conceived spontaneously in group B. This difference was found to be statistically significant (P Value<0.0001). Conclusion: Although Genital tuberculosis poses a great diagnostic challenge because of its varied presentations, diverse imaging pictures, and myriads of tests with its own limitations, it is advisable not to resort to all of them. Tests which are simple, feasible, specific and sensitive, and facilitates early diagnosis should be carried out. Institution of anti-tubercular treatment should be done in early disease, thus enhancing the chance of pregnancy and preventing irreversible damage to the genital organs.
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How safe is your IVF program?
Kuldeep Jain
July-December 2014, 1(2):63-66
  7,374 4,023 -
Successful in vitro fertilization pregnancy in a case of unicornuate uterus with diminished ovarian reserve: A case report
Shikha Jain, Kanad D Nayar, Deepak K Jain
July-December 2016, 3(2):98-101
The occurrence of Mullerian anomalies with concomitant gonadal abnormalities is very rare. Very limited number of case reports are published in the literature, and the exact incidence is not known. In this report, we present a case of unicornuate uterus with non-communicating rudimentary horn along with absence of adnexa on one side and smaller ovary on other side, leading to diminished ovarian reserve. The patient conceived with in vitro fertilization (IVF) with oocyte donation and delivered a healthy child at 38th week of gestation. Establishing an accurate diagnosis and management by IVF followed by adequate supervision of resulting pregnancy may lead to successful obstetric outcome in women with unicornuate uterus with diminished ovarian reserve.
  10,793 265 -
A comparison of microdose flare versus antagonist protocol in poor responders chosen according to the Bologna criteria
Neena Malhotra, Latika Chawla, Reeta Mahey, Anupama Bahadur, Ashok K Bhatt, Alka Kriplani
July-December 2017, 4(2):81-86
Background: Uncertainty exists in deciding the optimal stimulation protocol in poor responders undergoing in-vitro fertilization (IVF). Our study aims to compare microdose flare and antagonist protocols in the management of patients considered to be poor responders, chosen according to Bologna criteria. Materials and Methods: In a prospective observational study, 66 poor responders as per the Bologna criteria were recruited to undergo IVF-ICSI cycles using either microdose flare protocol (Group I; n = 28) or the flexible antagonist (Group II; n = 38). Pregnancy rate per cycle was taken as the primary outcome. Total days of stimulation, total dose of gonadotropins, estradiol (E2) and progesterone levels on the day of human chorionic gonadotropin (hCG) trigger, cycle cancellation rate, total oocytes retrieved, total Metaphase II (MII) oocytes, number of embryos formed, number of Grade I embryos, fertilization and cleavage failure, total number of cycles that did not reach embryo transfer were taken as secondary outcome measures. Results: There was no significant difference in the pregnancy rates between the two groups. The microdose flare group (Group I) had higher levels of E2 on the day of hCG trigger (P = 0.03) and more number of MII oocytes (P = 0.04). Conclusion: Patients stimulated with the microdose flare protocol had significantly more E2 levels with the recovery of more MII oocytes, but this did not transform to higher pregnancy rates. A large multicentered randomized trial would be required to draw definite conclusion to achieve significant difference between the cycle cancellation and pregnancy rates between these two protocols for poor responders.
  10,086 448 -
Good clinical practice recommendations on management of infertility in patients from India with polycystic ovary syndrome
Sonia Malik, Sohani Verma, Kuldeep Jain, Pankaj Talwar, Bharati Dhorepatil, Gouri Devi, Umesh Jindal, Sudha Prasad, Kanad Dev Nayar, Neena Malhotra, Neeta Singh, Geeta Radhakrishnan, Rashmi Sharma, Leena Wadhwa, Nomita Chandhiok, Gita Khanna, Sushma Sinha, Pondicherry Marudachalam Gopinath
July-December 2015, 2(2):107-132
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Association of body mass index (BMI) and sub-fertility among young women in Karachi, Pakistan
Mubashir Zafar
January-June 2019, 6(1):23-28
Objective: The aim of the study is to determine the association of body mass index (BMI) with sub-fertility among young women in Karachi Pakistan. Methods: It is a case control study in which 284 participants were selected through simple random sampling technique and 142 divided into cases and control group. Cases were nulliparous women who were not able to conceive after 24 months of unprotected intercourse and controls were primigravida women. Validated questionnaire was given to patients, height and weight was measured and BMI was calculated. Odds ratio (OR) was calculated with logistic regression. Results: Mean age of the study participants were (25.3 years standard deviation ± 2.5). After adjustment of the covariates, women with high BMI (BMI 30 and above) were more than four times {OR 4.20 (95% confidence interval, CI, 1.59–10.14)} and women with BMI 25 to 29.9 were more than one times sub-fertile {OR 1.19 (CI 0.45–3.13)} compared to normal (BMI 20.0–22.4). The women with less frequency of intercourse (1–2 times/week) were more than three times {OR 3.73 (CI 1.75–7.94)} were sub-fertile. Conclusion: There is need for inventions to control BMI which increase fertility level among women. Nutritional modification requires to counter infertility because obese women require higher doses of medication and produce fewer follicles.
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Stem cells—The new agents in infertility treatment: The light at the end of the tunnel?
Gita Radhakrishnan
July-December 2017, 4(2):70-73
  8,489 678 1
IUI in hypogonadotropic hypogonadism: Do not give up
Seema Rai, Nagaraja Narayana, Prashant Sharma, Pankaj Talwar
July-December 2014, 1(2):112-113
Ovulation is dependent on the presence of a functioning hypothalamic-pituitary-ovarian (HPO) axis. Estimates of chronic anovulation rates range from 6-15% of women during the reproductive years.Potential causes of anovulation are PCOS, hyperprolactinemia,thyroid dysfunction, stress etc. Idiopathic hypogonadotropichypogonadism (IHH) is rare cause of anovulation. Idiopathic hypogonadotropichypogonadism (IHH) is a collection of genetic mutations that result in delay of puberty, infertility, and low gonadotropins.Women with IHH have hypoestrogenism, amenorrhea, and low gonadotropin levels. Ovulation induction is the method for treating anovulatory infertility. For patients with hypogonadotrophichypogonadism, the treatment involves administration of both FSH and LH, while HCG is injected for follicle rupture. Such patients need high dosage and longer duration of stimulation than other patients.
  8,557 545 -
In Vitro Maturation
Jayant G Mehta
January-June 2014, 1(1):7-15
In vitro maturation (IVM) of the human oocytes has recently found an important niche among assisted reproductive techniques (ART). Even though the ovarian stimulation protocols continue to evolve and last for few days, they are still not patient-friendly. The development of several follicles is associated with a high risk of ovarian hyperstimulation syndrome (OHSS), leading to hospitalization that can be fatal. Natural IVF cycles, mild stimulation with low dose gonadotrophins and IVM of human oocytes ready for fertilisation now offer an alternative to the traditional IVF treatment. Infertile women with polycystic ovaries or polycystic ovarian syndrome (PCOS) form the main category of patients who would benefit from IVM. However, concern exists that IVM may interfere at the epigenetic level and in particular with genomic imprinting. For normal embryonic development, timely acquisition of correct imprinting patterns in oocytes and maintenance of genomic imprinting after fertilisation is required. It is therefore necessary that patients undergoing IVM be offered preimplantation genetics screening (PGS) prior to embryo transfers. This review considers our current understanding of in-vitro maturation of human oocytes and its importance in clinical applications.
  7,992 887 -
Maternal and neonatal outcome of surviving twin after single fetal demise at 25 weeks: A rare case report
Mohan L Swarankar, Usha Shekhawat, Manisha Choudhary, Vinu Choudhary
January-June 2017, 4(1):30-34
Single fetal demise in twin pregnancy in late second or third trimester is a complex clinical situation and the management may face a dilemma. This is a rare case report of continuing pregnancy for 9 weeks in an intrauterine insemination (IUI) conceived dichorionic diamniotic twin pregnancy with intrauterine fetal demise of one twin at 25 weeks of gestation. A gravida 2 abortion 1 presented to Jaipur fertility centre (Department of Reproductive Medicine & Medical Genetics, MGUMST) with unexplained infertility of 3 years. She conceived with IUI at first attempt. The routine antenatal care scan at 25 weeks revealed 25 weeks 3 days single live fetus and second fetus 21 weeks with absent fetal heart pulsation and features of hydrops. The patient was hospitalized for conservative management. Regular follow-up was performed with daily fetal movement count, weekly coagulation profile, and ultrasound for fetal well-being. Inj. betamethasone was given for lung maturation at 32 weeks of gestation. She underwent caesarean section at 34 completed weeks for the preterm premature rupture of the membrane, the outcome being first fetus 2.2 kg female with Apgar score 7/10 and second macerated female fetus of 840 g. Postoperative period was uneventful for both mother and newborn. The baby was on regular check-up under a neonatologist. Her growth and neurological development was optimum according to her age group as seen on the long-term follow-up for 1 year.
  8,384 421 -
Morphological assessment of embryo quality during assisted reproduction: A systematic review
Athanasios Papathanasiou, Bayan Osmani, Pek Joo Teoh, Abha Maheshwari
July-December 2014, 1(2):67-80
Background: Various parameters of embryo morphology have been routinely used to select the embryo/s with maximum implantation potential during in vitro fertilization (IVF). Hence, there is a dilemma in clinical practice as to which morphological scoring system/test to use. We performed a systemic review to determine the predictive power as well as the clinical and cost-effectiveness of existing morphological tests of embryo quality described in an IVF setting. Materials and Methods: The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines for systematic review were followed. A mixed-method analysis was performed. Qualitative and quantitative techniques were used to synthesize the final results. A narrative summary approach was used for initial data exploration and description, followed by the pooling of data, where appropriate, using Meta-DiSc software. Receiver operating characteristic (ROC) curves were plotted wherever appropriate, and the area under the curve (AUROC) was determined. Results: Day 3, day 5, and early cleavage (EC) all had similar discriminatory value for predicting implantation (AUC 0.66, 067, and 0.63 respectively). There was no evidence of improvement in pregnancy rates due to routinely doing EC. No studies were identified that determined the cost-effectiveness of any of the tests. Conclusions: All tests have low accuracy. They lack the discriminatory power to identify an embryo that will/will not lead to implantation. Appropriately designed studies are required to assess the predictive value and the clinical and cost-effectiveness of novel embryo scoring technologies.
  6,962 1,695 2
The impact of acupuncture on IVF success rates: A randomised controlled trial
K. Gillerman, A. Kulkarni, A. Shah, A. Gudi, Roy Homburg
July-December 2018, 5(2):48-54
Background: Clinical trials to assess the benefits of acupuncture on in vitro fertilisation (IVF) treatment have differed in study design, protocol, outcome measures and commercial bias. This heterogeneity has precluded any firm conclusion regarding the efficacy, or otherwise, of acupuncture in this field. To address this, 15 international acupuncturists with experience in treating women during IVF participated in Delphi questionnaires and reached a consensus protocol to be used in future research. We were among the first to adopt this newly agreed standard protocol. The aim of this study was to address whether the agreed acupuncture consensus protocol is beneficial for IVF outcomes and may be offered to women undergoing IVF. Methods: An randomised controlled trial, in which 157 women were randomised to receive either acupuncture treatment three times in the treatment cycle in addition to our standard IVF protocol (n = 79) or no acupuncture treatment (n = 78) in their first or second IVF cycle. They were between 23 and 43 years with body mass index below 30. The study group (n = 79) received acupuncture based on the Delphi consensus protocol, between days 6 and 8 of ovarian stimulation, and twice on the day of embryo transfer, before and after transfer. The IVF practitioner was blinded to the randomisation. The primary end point was live birth. Results: Fifteen out of 79 women in the intervention group withdrew from the study compared to 9/78 women from the control group (P < 0.001). A per-protocol analysis revealed that the rate of live births (27/64, 42% vs. 11/69, 15.94%, P = 0.001) and positive pregnancy tests (34/64, 53% vs. 19/69, 27.53%, P = 0.013) were significantly higher in the acupuncture group compared with the control group. Conclusion: The results of this study imply that acupuncture may be offered as a possible method of improving IVF outcome. This study followed a widely approved consensus protocol hoping to settle disagreement in the literature and resolve previous disparity. Trial Registration: ClinicalTrials NCT02683967.
  7,830 665 3
Tracking the implantation window: Synchronizing endometrial preparedness for implantation with stage of blastocyst to be transferred in antagonist IVF cycles involving single blastocyst transfers
Bindu N Chimote, Natchandra M Chimote
January-June 2018, 5(1):27-32
Introduction The day of menstrual period is usually not taken into account during embryo transfer in IVF cycles. Aim We sought to track the relevance of ‘implantation window’ by contemplating a correlation between stage of blastocyst transferred and endometrial preparedness for implantation with respect to day of menstrual period in antagonist in vitro fertilization (IVF) cycles. Design, Materials and Methods This study involved retrospective analysis of 443 cycles in women undergoing antagonist treatment protocol followed by oocyte-retrieval approximately between days 12 and 16 (rarely on days 17 and 18 in case of long follicular phase) of their menstrual period. All cycles involved day 5/6 single blastocyst-transfer (sBT) of top (AA) or good (AB/BA) quality blastocysts of various stages. Slightly modified Gardner’s system for blastocyst-stage grading was followed. Inner cell mass, trophectoderm, were graded as A, B, C as per Gardner’s system. Clinical pregnancy rate (CPR) and live birth rate (LBR) were main outcome measures. Results Overall CPR = 26.64% (118/443), whereas LBR was 21.67% (96/443). CPR was influenced by transfer of various stages (1–6) of the blastocysts on different days of menstrual period (days 17–24, covering the implantation window). Our results indicate that as day of menstrual period advances during the window period, higher stage blastocyst-transfer enhances the odds of a live birth. Conclusion Synchrony between stage of blastocyst transferred and the endometrial preparedness for implantation with respect to day of menstrual cycle has a definitive influence on LBR in IVF cycles. Asynchrony and out of phase BT may lead to missing out the implantation window and unnecessarily hamper CPR/LBR.
  8,089 376 -
Findings in diagnostic laparoscopy in patients with unexplained infertility
Shilpa Bhandari, Aparna Singh, Pallavi Agrawal, Ishita Ganguli
January-June 2015, 2(1):29-33
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.
  7,601 561 -
Laparoscopic ovarian drilling for infertile PCOS women who are resistant to oral ovulation-inducing drugs
Papa Dasari
January-June 2015, 2(1):15-18
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.
  7,467 511 1
Comparison of the efficacy of letrozole and low-dose gonadotropin combination with clomiphene and low-dose gonadotropin combination as a controlled ovarian stimulation regime prior to intrauterine insemination in patients with unexplained infertility
Kiran Chaudhary, Vanita Suri, Lakhbir Kaur Dhaliwal, Shalini Gainder
July-December 2014, 1(2):98-103
Objective: To evaluate and compare the effects of letrozole and low-dose gonadotropin combination with clomiphene citrate (CC) and low-dose gonadotropin combination prior to intrauterine insemination (IUI) in patients with unexplained infertility. Design: Prospective, randomized, clinical study. Setting: Academic tertiary institute. Patient(s): A total of 94 patients in the age group of 21-37 years with unexplained infertility were randomized using computer-generated random number table to receive follicle-stimulating hormone (FSH) injection and human menopausal gonadotropin (hMG) injection, along with either letrozole or CC. Intervention(s): All the patients received 150 IU of purified urinary FSH on day 2 of the cycle and from day 3 to day 7 of the cycle 5.0 mg/d of letrozole or 100 mg/d of CC were administered; this was followed by administration of 150 IU of hMG on day 9. Ovulation was triggered with human chorionic gonadotropin (hCG) injection (5,000 IU) when the dominant follicle(s) reached 18 mm in diameter. A single IUI was performed 36 h later. The luteal phase was supplemented with micronized progesterone vaginally. Main Outcome Measure(s): Pregnancy rates and the incidence of multiple pregnancies were our primary outcome. The secondary outcome included the number of dominant follicles, grade of perifollicular blood flow, endometrial thickness, endometrial blood flow pattern, side effects, and complications. Result(s): There were no differences in demographic characteristics between the two groups. Pregnancy occurred in four out of 47 patients (120 cycles) in the letrozole group (pregnancy rate: 8.5% per patient and 3.3% per cycle) and eight out of 47 patients (121 cycles) (pregnancy rate: 17% per patient and 6.6% per cycle) in the CC group; the differences were not statistically significant. None of the regimes resulted in a multiple gestation gestation. The number of follicles per cycle was significantly higher in the CC + gonadotropin group as compared to the letrozole + gonadotropin group (1.77 ± 0.99 vs. 1.39 ± 0.617, P < 0.001). There was no statistically significant difference in perifollicular blood flow, endometrial thickness, and endometrial blood flow pattern between the two groups. No side effects were observed in either group. There was one case of ectopic gestation in the CC group. Conclusion(s): The use of lower dose of gonadotropins and oral agents together resulted in decreased medication costs, lesser monitoring [ultrasound (USG) visits], and good primary and secondary outcomes. However, more randomized controlled trials are needed to prove the efficacy of one regime over the other.
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Ideal value of serum anti-Mullerian hormone as a predictor of ovarian reserve and outcome in assisted reproductive technology
Pratap Kumar, Subasri Sambandam Ravichandran
January-June 2015, 2(1):24-28
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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