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   Table of Contents - Current issue
January-June 2019
Volume 2 | Issue 1
Page Nos. 1-49

Online since Tuesday, June 25, 2019

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Sexual health of breast cancer survivors p. 1
Nalini Mahajan
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Role of ovarian reserve testing in cancer survivors p. 3
Padma Rekha Jirge
Improved survival in children and young women affected with malignancies bring forth the impact of gonadotoxic chemotherapy and radiotherapy on future fertility. This review looks at the understanding of mechanisms of damage to ovarian follicular pool and the evolution of assessment of ovarian reserve. The search for articles was done through PubMed. The review summarizes the current evidence on the value of ovarian reserve testing in young cancer survivors.
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Breast Cancer and Fertility Part 3: Pregnancy after breast cancer p. 9
Nalini Mahajan, Madhuri Patil
The incidence of breast cancer (BC) in young nulliparous women is on the rise globally. Early diagnosis and improved multimodality treatment have given survivors an opportunity to fulfill their reproductive needs. Concerns of disease recurrence, increased risk of antenatal and neonatal complications, and possibility of cancer inheritance in the baby influence decision making on pregnancy after BC (PAFBC). Fertility itself may be an issue as ovarian reserve is compromised by chemotherapy, and patient may need the help of assisted reproductive technique's. Fortunately, PAFBC treatment does not jeopardize disease outcome. However, the optimal time for conception after completion of treatment needs to be determined. Safety of pregnancy in women with a history of hormone (estrogen and progesterone) receptor positive BC, also remains controversial. Advice on going through with pregnancy should be individualized after evaluating the status of the women, keeping in mind safety of both fetus and the mother. Wishes of the patient need to be respected and the final decision rests with her.
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Fertility preservation surgeries in gynecological malignancies at a tertiary care institute in South India p. 16
Paapa Dasari, Sonal Garg
Background: Fertility preservation surgery is a method to preserve the fertility potential of women without affecting the management of Gynecological cancer. It is important to know the type of malignancies and age group at which these are diagnosed and managed as this differs from centre to centre. Aims and Objectives: The aim was to find out the spectrum of Gynaecological malignancies in young women and to find out the type of malignancies in which Fertility sparing surgery was feasible. Materials and Methods: This is a retrospective analysis of young women (≤ 40 years of age) with Gynaecological malignancies who underwent fertility sparing surgeries from January 2017 to December 2018 in the department of Obstetrics and Gynaecology, JIPMER, Puducherry, South India Results: Out of 558 women with Gynecological malignancies admitted for management, 127 were ≤ 40 years of age. The most common malignancy was Ovarian (58%) followed by Cervix (24%) and Endometrium (14%). In Ovarian carcinoma, surface epithelial tumors were the commonest (62%) followed by Germ cell tumors (31%). Fertility sparing surgery was feasible in all germ cell tumors and only 30 % of surface epithelial tumors as the mean age at presentation was 25 years. In women with carcinoma cervix and carcinoma endometrium the mean age was 37 and 35 years respectively and all of them completed their family. Conclusion: In this retrospective cohort, fertility sparing surgery was needed only in Ovarian malignancies.
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Distribution of anthropometric, clinical, and metabolic profiles of women with polycystic ovary syndrome across the four regions of India p. 20
Jasneet Kaur, Madhuri Patil, Sujata Kar, Padma Rekha Jirge, Nalini Mahajan
Context: Polycystic ovary syndrome (PCOS), one of the most common endocrine disorders encountered in women of reproductive age, is associated with an increased prevalence of metabolic syndrome (MetS). Development of PCOS and its phenotypic expressions is influenced by genetic, ethnic and environmental factors. Due to the vast cultural diversity in our country, differences in the prevalence of MetS may exist across different regions. Aims and Objectives: To study the distribution of anthropometric, clinical, and metabolic profiles of women with PCOS across the four regions of India. Materials and Methods: A multicentric prospective study using data collected from four tertiary Assisted Reproductive Centres across four different regions of India was carried out between January 2017 and December 2017. A total of 651 women were diagnosed with PCOS, with 178 belonging to North, 209 to East, 115 to West and 149 to South India. A comparison of the metabolic and anthropometric profiles of women with PCOS was made across the four different ethnic regions of India. Statistical Analysis: Quantitative variables were compared using the Mann–Whitney test and qualitative variables using the Chi-square test.P < 0.05 was considered statistically significant. Results: North Indian women had the highest mean body mass index (BMI) – 27.53 ± 4.55 kg/m2 and a higher waist circumference (89.93 ± 14.53 cm) compared to women from South and West India (P = 0.0001). The prevalence of MetS (41.98%) and impaired glucose tolerance (IGT) (37.04%) was also highest in North India followed by East India. PCOS women from East India were lean but had the highest waist-to-hip ratio (WHR) 0.9 ± 0.05 (P = 0.0001) and dyslipidemia. Using multivariate logistical regression analysis, age >25 years, BMI >25 kg/m2, and WHR >0.8 had a strong association with MetS. Conclusion: Prevalence of MetS is high among Indian PCOS women, with women from the North and East India having the worst metabolic profiles. IGT is the main driver for MetS.
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Assisted reproductive technology outcome in poor responders classified by patient-oriented strategies encompassing individualized oocyte number stratification p. 27
Madhuri Patil, Milind Patil, Radha Puchalapalli
Aim: This study aims to evaluate the assisted reproductive technology (ART) outcome among various subgroups of poor responders classified by Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number (POSEIDON) criteria. Successful end point of any ART treatment is live birth, which depends on various factors including adequate number of follicles being stimulated, adequate number of oocytes retrieved, and quality of oocytes, which in turn depends on ovarian response. Usually, success rate is low in women who respond poorly to controlled ovarian stimulation. Bologna criteria have been used in the past to identify poor responders. Heterogeneity of subgroups using the Bologna criteria makes it difficult to manage the poor ovarian responder group. Moreover, specific profiles of abnormal ovarian response like hypo and suboptimal and the age-related embryo/blastocyst aneuploidy rate, which could dramatically change the prognosis in women that have the same oocyte yield were not included in Bologna criteria. The main goal of this study was to evaluate the ART outcome among various subgroups of poor responders defined by the POSEIDON stratification. Materials and Methods: In this retrospective cohort study, the clinical and laboratory records of 260 poor responder women undergoing their first ovarian stimulation and fresh embryo transfer cycle were reviewed. Patients were categorized into 4 groups according to the POSEIDON classification. Results: There was no difference in the fertilization and cleavage rate across the groups, but the blastocyst formation rate was higher in younger patients and reached statistical significance (P < 0.001). Implantation rate is significantly high in women <35 years (P < 0.001). Clinical pregnancy rate (CPR) was statistically higher in Group 1b and Group 2b where ovarian reserve was adequate and more than 5 oocytes were retrieved irrespective of the age (P < 0.001). In those with low ovarian reserve, CPR was statistically higher in the women <35 years (P < 0.001). Live birth rate (LBR) is high in Group 1b and Group 2b where more than 5 oocytes were retrieved irrespective of the age (P = 0.029). In patients with low ovarian reserve though the LBR was more in women <35 years it did not reach statistical significance. Conclusions: Poor responders are a heterogeneous group and not homogenous for pregnancy prospects. Apart from oocytes retrieved, age and ovarian reserve will also modulate the chance of pregnancy which is higher in women <35 years and those with adequate ovarian reserve. Poor responders still represent a therapeutic challenge to the clinician, and future studies should explore the most optimal treatment strategy for management of poor responders according to the POSEIDON stratification.
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In vitro activation of ovary p. 35
Nalini Mahajan, Jasneet Kaur, Bithika Bhattacharya, Padmaja Naidu, Shalu Gupta
Primary ovarian insufficiency (POI) affecting 1% of women leads to infertility due to a lack of follicle growth and ovulation, and oocyte donation is the only treatment option. Studies have reported that ovarian cryopreservation, fragmentation, and in vitro activation with drug treatment followed by autotransplantation can result in the successful pregnancy outcomes. Herein, we report a case of POI, in which we performed the procedure of in vitro ovarian activation (OA) and autotransplantation without using drugs to see if it would induce the follicular growth. This is the first case report from India, and it shows that the procedure of OA works and can be tried as an experimental procedure for women with POI who are very keen on trying pregnancy using their own oocytes.
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Role of fertility preservation in young cancer survivors: A case series p. 38
Aishwarya Parthasarathy, Kundavi Shankar
There is still a huge lacunae in the fertility preservation services being offered to young cancer survivors. The future fertility prospects should be discussed before the treatment to decrease the psychological trauma when they are expected to have a long-term survival. There has been growing awareness in India with the establishment of focused societies. The strategies are still experimental worldwide barring a few. Here, we present four cases of fertility preservation in varying scenarios in young cancer survivors who attended the Institute of Reproductive Medicine, Madras Medical Mission, Chennai, Tamil Nadu, India.
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Should we discard cryopreserved embryos with poor post-thaw survival? – Report of a successful pregnancy with <50% blastomere survival p. 41
Surleen Kaur, Snigdha Pathak, Nidhi Sehrawet, Manika Saxena
The objective of the present study is to report a case of successful ongoing pregnancy following transfer of two cleavage-stage day 3 embryos with one-two blastomeres survival. The study was conducted at a private clinical-assisted reproductive technology center. A 31-year-old female with a 3-year history of primary infertility underwent an in vitro fertilization cycle followed by a frozen embryo transfer cycle. The main outcome measure was clinical pregnancy. Ultrasonographic examination at 6 weeks revealed a single gestational sac with positive cardiac activity. Follow-up scans at 10, 12, and 14 weeks of pregnancy showed fetal age parameters corresponding to gestational age and normal value of nuchal translucency. Noninvasive prenatal screening test confirmed a euploid fetal development. Transfer of frozen-thawed embryos with only one–two blastomeres survival resulted in an ongoing pregnancy with euploid fetus development; therefore, we suggest that embryo with <50% post-thaw survival should not be discarded and considered as a viable embryo.
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Why results of endometrial receptivity assay testing should not be discounted in recurrent implantation failure? p. 46
Simrandeep Kaur, Padmaja Naidu
Recurrent implantation failure (RIF) is often encountered in patients undergoing ART leading to severe emotional, financial and physical distress. Thorough investigations should be carried out to ascertain whether there is any underlying cause of the condition. Endometrial receptivity (ER) remains a major stumbling block in IVF success as most available tests for diagnosis lack accuracy and predictive value. Microarray technology allows identification of the transcriptomic signature of the window of implantation, hence the development of an ER assay (ERA) for the diagnosis of an altered ER. ERA evaluates 238 genes expressed during WOI using RNA sequencing. Use of ERA test in patients with RIF has shown that window of implantation (WOI) is displaced in a quarter of these patients and use of a personalized embryo transfer (pET) significantly improves reproductive performance. We report three cases of RIF all of whom had failed IVF cycles despite good quality blastocysts transfer with apparently, no identifiable cause of implantation failure (uterine factores, embryonic, immunological factors ruled out). Two patients though had ERA testing done outside which showed displaced WOI, but however pET was not carried out leading to RIF. Subsequently pET carried out at our centre led to successful implantation and clinical pregnancy in both the patients.
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