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Impact of mid-luteal serum progesterone levels on pregnancy outcome in fresh and frozen embryo transfer cycles in women of Indian ethnicity
Jasneet Kaur, Padmaja Naidu, Rani Kumkum, Nalini Mahajan
January-June 2018, 1(1):30-35
Context: Luteal phase defect has been identified in all assisted reproductive technology cycles, necessitating progesterone supplementation. Aims: The aim of our study was to assess whether mid-luteal serum progesterone (P) levels' impact pregnancy outcome in fresh and frozen embryo transfer (FET) cycles. Settings and Design: A total of 145 women undergoing embryo transfer (ET) were prospectively enrolled and received standard luteal phase support. Methodology: Serum progesterone levels were assessed for all the patients in the mid-luteal phase. Patients were divided into groups based on the type of ET performed. Group A – fresh ET and Group B – FET. These groups were further subdivided based on mid-luteal serum P levels being below (Groups A1/B1) or above 15 ng/mL (Groups A2/B2). Progesterone levels were correlated with the clinical pregnancy outcome. Statistical Analysis Used: Chi-square test was used for qualitative analysis, and student's t-test was used for comparison of means. Results: Patients with mid-luteal serum P levels <15 ng/mL (Group A1) in fresh ET cycles had a statistically significant lower clinical pregnancy rate (CPR) (P = 0.049). In FET cycles, though there was no difference in the CPR, the percentage of biochemical pregnancies was significantly higher in the group with P levels <15 ng/mL (Group B1) (P = 0.024). Conclusions: This study suggests that, in Indian women, mid-luteal serum P levels <15 ng/mL have a negative impact on pregnancy outcome in both fresh (<CPR) and FET (>biochemical pregnancies) cycles. Individualizing luteal phase support by measuring serum progesterone levels might help to enhance pregnancy outcomes.
  7,164 458 -
The use of preimplantation genetic testing for aneuploidy and mitochondrial DNA scoring helps in improving assisted reproductive techniques outcome
Nalini Mahajan, Jasneet Kaur
July-December 2019, 2(2):66-73
Background: Aneuploidy is a leading cause of implantation failure and miscarriage. Preimplantation genetic testing for aneuploidy (PGT-A) with mitoscore enables screening of viable euploid embryos, thereby improving in vitro fertilization (IVF) outcome. Aim of the study: The aim of this study is to determine if the use of PGT-A in patients with valid indications can help improve assisted reproductive techniques outcome. Materials and Methodology: All patients undergoing IVF-PGT-A cycles between April 2016 and March 2018 were included (n = 42) in the study. Patients were compared with a control group consisting of fresh or frozen blastocyst transfers selected by morphology, during the same period (n = 226). Trophectoderm samples were subjected to chromosome analysis and mitoscore assessment using next-generation sequencing. Single-embryo transfer was done according to transfer priority determined by mitoscore. Statistical Analysis: The Chi-square test was used for comparisons between the study groups with respect to percentages. A value of P <0.05 was considered as statistically significant. Results: The indications for PGT-A in our patients were advanced maternal age 33%, followed by recurrent pregnancy loss 25%, recurrent implantation failure 19%, previous history of aneuploidy 16%, and severe male factor 6%. An ongoing pregnancy rate (OPR) of 61% versus 48% (P = 0.0049) was achieved with PGT-A versus controls, respectively. Thirty-two percent of patients did not have any euploid embryos for transfer. Conclusion: Offering PGT-A with mitoscore for valid indications seems to be an impressive tool to increase implantation and OPRs and helps in counseling patients for further course of treatment.
  7,206 379 -
Why results of endometrial receptivity assay testing should not be discounted in recurrent implantation failure?
Simrandeep Kaur, Padmaja Naidu
January-June 2019, 2(1):46-49
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.
  5,708 387 3
Intrauterine autologous platelet-rich plasma therapy to improve implantation rates in patients undergoing frozen embryo transfer: A pilot study
Anju Madhavan, Padmaja Naidu, Kum Kum Rani, Jasneet Kaur, Nalini Mahajan
July-December 2018, 1(2):81-85
Background: Successful implantation is a well-orchestrated event requiring the presence of a healthy embryo, a receptive endometrium, appropriate embryo endometrial cross-talk, and adequate maternal immune protection. Despite advances in assisted reproductive technology, there are insignificant improvements in the implantation and pregnancy rates. Intrauterine infusion of platelet-rich plasma (PRP) might improve implantation rates through its paracrine effects by recruiting growth factors and cytokines that favor decidualization and implantation. Objectives: The objective of the study is to study whether intrauterine PRP improves implantation rates in patients undergoing frozen embryo transfer (FET). Subjects and Methods: In this retrospective study, we collected data of patients who underwent FET in Mother and Child Hospital for 11 months from January 2018 to November 2018. We screened data of 98 patients who had at least one previous failed FET and underwent subsequent FET. The patients were divided into a study and control group. The study group received Intrauterine PRP before FET, while the control group did not. All patients underwent the same hormone replacement therapy regimen for endometrial preparation. Main Outcome Measure: The main outcomes studied were the implantation rates and clinical pregnancy rates (CPR) after embryo transfer. Results: Patient demographics such as mean age, body mass index, and anti-mullerian hormone of both groups were comparable. Overall, the CPR was 42.8% in the control group and 47.6% in the intervention group, and the difference was not statistically significant. Conclusion: Intrauterine PRP does not increase the implantation rates/CPR significantly in patients who have had one previous FET failure.
  5,550 534 6
Ovarian tissue cryopreservation and transplantation using thawed ovarian cortex for fertility preservation
Nao Suzuki
January-June 2018, 1(1):3-8
In the late 1990s, ovarian tissue cryopreservation was first employed clinically to preserve fertility in female children, adolescents, and young adults with cancer in Europe and the United States. In 2004, Donnez reported the first live birth after ovarian tissue cryopreservation and transplantation. Ovarian tissue cryopreservation can be employed when ova cannot be collected by intravaginal procedures, when induction of ovulation is impossible in girls before menarche, and when cancer therapy must be initiated promptly and there is insufficient time to induce ovulation. In patients with some cancers (e.g., ovarian cancer and leukemia), tumor cells can potentially infiltrate the ovaries and could be transferred by transplanting thawed ovarian tissue so ovarian tissue cryopreservation is contraindicated. Recently, live birth has been achieved up to 30% of women undergoing transplantation of cryopreserved and thawed ovarian tissue. If ovarian tissue contains more primordial follicles (as in children/adolescents), the likelihood of live birth after transplantation is higher. Therefore, the patient's age should also be considered. However, even a woman who underwent ovarian tissue cryopreservation in her late 30s has achieved live birth. Since initial clinical application of ovarian tissue cryopreservation and transplantation in 1997, approximately 100 live births have been reported, including 3 in Japan. This article reviews the current status of ovarian tissue cryopreservation and transplantation of thawed ovarian cortex for fertility preservation.
  5,243 617 -
Should we discard cryopreserved embryos with poor post-thaw survival? – Report of a successful pregnancy with <50% blastomere survival
Surleen Kaur, Snigdha Pathak, Nidhi Sehrawet, Manika Saxena
January-June 2019, 2(1):41-45
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.
  5,559 285 -
Psychosocial needs of cancer survivors in fertility preservation: A systematic review
Shayanth Manche Gowda, Harish Thippeswamy, Santosh K Chaturvedi
January-June 2018, 1(1):24-29
Background: There is a rise in the global incidence of cancer however, with the advancement in the available treatment options there is an increased survival rate in patients with cancer. Among cancer survivors, there are varied psychosocial challenges in the context of fertility preservation which are poorly addressed and there are limited studies on psychosocial interventions to address those psychosocial concerns. Methods: This literature review aims to study the psychosocial issues; ethical, moral and legal challenges in the context of fertility preservation in patients with cancer. PubMed and PsychINFO were systematically searched for English-language publications from the earliest available publication date of each database uptill November 2017. Among 144 unique articles concerning oncofertility and psychosocial issues; ethical, moral and legal challenges in fertility preservation in patients with cancer, 18 articles met the inclusion criteria and were included for the study. Results: In the context of fertility preservation in patients with cancer, the most common short term psychosocial concerns are dealing with double jeopardy (cancer and risk of losing fertility), fear about cancer mortality, concerns about sexuality and reproductive capacity, body image and illness related adjustment disorder or depression which all could affect the decision making and quality of life if, left unaddressed. The long term psychosocial concerns are changes in relationship, prolonged grief, internal conflicts regarding disclosing about their illness, uncertainty about fertility and devastation from the confirmed infertility, post cancer treatment regret. The ethical and legal challenges which arises with fertility preservation in cancer patients are poorly addressed by the existent practice codes and guidelines. Conclusions: To the best of the authors' knowledge, little research to date has addressed the psychosocial concerns of the patients with cancer in fertility preservation. Health care providers should take a pro-active step in identification and addressing the psychosocial concerns of the patients and to adapt a collaborative approach by involving mental health professionals. There is a need for guidelines that are culturally sensitive.
  4,968 431 -
Fertility preservation in endometrial carcinoma: Case series of 11 patients
Madhuri Patil, Nalini Mahajan
January-June 2018, 1(1):36-43
Introduction: Endometrial cancer comprises 7.1% of all new cancer cases in females. Carcinoma of the endometrium is one of the long-term complications of polycystic ovarian syndrome (PCOS) due to unopposed estrogen action due to chronic anovulation. The standard treatment involves hysterectomy and bilateral salpingo-oophorectomy, due to its hormonal sensitivity. In endometrial cancer without infiltration to the myometrium and no extrauterine involvement, conservative treatment can be offered to women who wish to preserve fertility. Results: We report 11 cases of endometrial carcinoma either diagnosed during workup for infertility or referred for fertility preservation (FP) before definitive treatment. About 72.7% (7/11) of patients had PCOS, it becomes important for clinicians to suspect and rule out endometrial carcinoma by regular endometrial surveillance which, includes transvaginal ultrasound and/or endometrial biopsy in all PCOS women who have abnormal uterine bleeding, prolonged amenorrhea, unopposed estrogen exposure, and thick endometrium especially on day 3 of the menstrual cycle. About 36.36% (4/11) of our patients were not convinced for FP and were either lost to follow-up or underwent definitive therapy. Thus, it is important that all patients with endometrial carcinoma should be counseled not only by the oncologist but also by a reproductive endocrinologist and a psychosocial counselor, both together and separately. This will enable the patient to make a right choice of the treatment modality. Conclusion: Conservative treatment with progestogen therapy in selected young patients with well-differentiated carcinoma limited to the endometrium helps in preserving fertility. If they fail to conceive in the first attempt of in vitro fertilization, it is mandatory to monitor them for recurrence till a definitive treatment is planned. If definitive treatment is required fertility can be preserved either by oocyte or embryo freezing. Some women with low risk of ovarian involvement can benefit by ovarian tissue cryopreservation.
  4,642 373 -
Breast cancer and fertility: A Review - Part 1
Nalini Mahajan
January-June 2018, 1(1):9-16
Breast cancer (BC) treatment leads to a reduction in reproductive lifespan due to the use of gonadotoxic agents and prolonged hormonal treatment. With an increasing incidence of BC in the young and better survival rates, fertility issues have come into focus. Pregnancy does not appear to have a detrimental effect and may even improve survival rates. Fertility counseling and offering fertility preservation (FP), therefore, is the standard of care. Among the FP procedures, oocyte freezing is preferred as it allows reproductive autonomy. Ovarian stimulation required for oocyte recruitment does not worsen BC prognosis. Reproductive outcome using cryopreserved gametes gives live birth rates similar to nononcological patients though studies are limited in this aspect. Ovarian tissue cryopreservation can be safely offered if neoadjuvant therapy is required. Fertility issues are extremely relevant in BRCA mutation carriers and FP should be offered to them. Co-administration of gonadotropin-releasing hormone agonist with chemotherapy is recommended in patients wishing to preserve ovarian function.
  4,551 462 -
Testicular dysfunction and cancer: The current status
Pankaj Talwar, Sapna Yadav
January-June 2018, 1(1):17-23
Anticancer treatments have increased the survival rates in young cancer patients in the past 15 years due to early detection. These cytotoxic therapies affect spermatogenesis temporarily or permanently because of detrimental effect they have on germ cells. Chemotherapy impairs spermatogenesis depending on the additive dose of the drugs and the combination of the drugs used for the cancer treatment. Alkytlating agents such as Cyclophosphamide has the most detrimental effect on germ cells. Radiation therapy is also associated with the risk of permanent sterility. Cryopreservation of semen and testicular tissue in the postpubertal and adult males before the cancer treatment is the only nonexperimental and efficient method to preserve future male fertility. With the advancements in cryopreservation and assisted reproductive technologies, surviving cancer patients can use their frozen sperms to raise a family.
  4,546 444 -
Comparing the effectiveness of intrauterine infusion of platelet-rich plasma and granulocyte-Colony-stimulating factor in frozen embryo transfer cycles
Priya Selvaraj, Kamala Selvaraj, Hamini Chandrasekar, Lakshaya Sairam
July-December 2019, 2(2):62-65
Aim: The aim of the study was to compare the effectiveness of intrauterine perfusion of platelet-rich plasma (PRP) and granulocyte-colony-stimulating factor (G-CSF) in improving assisted reproductive technology (ART) outcomes in women with thin endometrium and recurrent implantation failure (RIF) undergoing frozen embryo transfer (FET). Materials and Methods: The study was conducted at GG Hospital, Fertility and Women's Speciality Centre, Chennai, India, between March 2016 and September 2019. The study group comprised of 132 demographically identical women with RIF and thin endometrium undergoing FETs. The mean age of the participants in both the groups was 33.18 ± 4.30 and 32.5 ± 5.02, respectively. These women were randomly divided into PRP Group A (n = 56) and G-CSF Group B (n = 76). Both the groups were initiated with the conventional preparation for FET using estradiol valerate and micronized progesterone along with a trigger (10,000 IU of human chrionic gonadotropins (HCG)). Intrauterine PRP and G-CSF were then administered for those patients with thin endometrium (≤0.8 cm) on days 16 and 18, and sequential embryo transfers were performed as day 3 embryos along day 5 blastocyst. Results: The average endometrial thickness before the infusion of PRP and G-CSF was 0.67 ± 0.09 and 0.70 ± 0.08, whereas after the infusion, it improved to 0.78 ± 0.14 and 0.75 ± 0.06, respectively. P value between Groups A and B was 0.0968 and hence statistically not significant, indicating similar improvement by both the methods. P value for implantation rate, clinical pregnancy rate, live birth rate (LBR), and miscarriage rate was 0.182, 0.695, 0.287, and 0.270, respectively. It was found that there is no statistically significant difference in ART outcomes in both the PRP and G-CSF groups. Conclusion: Intrauterine infusion of PRP and G-CSF was beneficial in improving LBR in RIF with thin endometrium, both being statistically comparable. There were no differences to show superior of one over the other.
  4,434 402 -
Breast Cancer and Fertility Part 3: Pregnancy after breast cancer
Nalini Mahajan, Madhuri Patil
January-June 2019, 2(1):9-15
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.
  4,317 447 -
Distribution of anthropometric, clinical, and metabolic profiles of women with polycystic ovary syndrome across the four regions of India
Jasneet Kaur, Madhuri Patil, Sujata Kar, Padma Rekha Jirge, Nalini Mahajan
January-June 2019, 2(1):20-26
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.
  4,300 455 3
Does growth hormone supplementation improve oocyte yield and pregnancy outcome in patients with poor ovarian reserve undergoing in vitro fertilization: A prospective randomized trial
Simrandeep Kaur, Nalini Mahajan
January-June 2018, 1(1):44-50
Context: Poor ovarian reserve (POR) results in poor ovarian response to controlled ovarian stimulation (COS) in in vitro fertilization (IVF) cycles. Despite various strategies, clinical pregnancy rates (PRs) remain low in patients with POR. Aims: This study aims to assess if growth hormone (GH) supplementation in POR patients improves oocyte yield and PR in IVF-intracytoplasmic sperm injection (ICSI) cycles. Settings and Design: Prospective, randomized controlled study. Materials and Methods: Patients with anti-mullerian hormone ≤1.1 (ng/ml) and total antral follicle count ≤6 undergoing IVF-ICSI were enrolled in the study. Gonadotropin (GT) stimulation with GT-releasing hormone antagonist protocol was used for IVF. Patients were randomly divided into two groups: group A (n = 30) received recombinant GH 4 IU from the day of COS till the day of human chorionic gonadotropin trigger. Group B (n = 32) received COS and no GH. Statistical Analysis Used: The unpaired t-test and Mann–Whitney test was used. Categorical variables were analyzed using either the Chi-square test or Fisher's exact test. Results: Total dose of GT injections used were significantly less in GH group (Group A) compared to no GH group (Group B) (3000.89 ± 742.20), P = 0.009). There was no statistically significant difference in number of oocytes retrieved (OR), total days of stimulation, mean estradiol levels on the day of trigger and fertilization rates between the two groups. There was a nonsignificant increase in the clinical PR and chemical PR in the GH group. Conclusions: GH cotreatment with antagonist protocol decreased the amount of GTs required for COS but did not improve the oocytes yield, fertilization or PR significantly in POR patients.
  4,377 330 -
Role of ovarian reserve testing in cancer survivors
Padma Rekha Jirge
January-June 2019, 2(1):3-8
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.
  4,216 392 2
Oocyte embryo and ovarian tissue freezing in endometriosis: Food for thought
Umesh Jindal, Swati Verma
July-December 2019, 2(2):57-61
Fertility preservation by oocyte, embryo, or ovarian tissue in females is an established technique now. In addition to oncology patients, the indications have been extended to other benign diseases such as endometriosis which carry a significant risk of decrease in ovarian reserve due to disease or therapy instituted. Fertility preservation is not without its pros and cons. All young women need to be counseled regarding the decrease in ovarian reserve with endometriosis, age and/or surgery. Fertility preservation options need to be discussed whenever immediate childbearing is not possible or desired.
  4,202 326 -
Comparison of ovarian reserve and response to gonadotropin stimulation in fertile and infertile Indian women based on ovarian reserve markers, anti-Mullerian hormone and antral follicle count
Jasneet Kaur, Nalini Mahajan
July-December 2018, 1(2):74-80
Background: Poor ovarian response to gonadotropin (GT) stimulation during assisted reproductive technology cycles is often encountered in infertile women and is considered to be a cause of their infertility. Poor ovarian response is mostly a result of a low ovarian reserve (OR), implying that there may be an earlier depletion of the oocyte pool in infertile women. Aim of the Study: To evaluate whether infertile Indian women below the age of 35 years have an earlier depletion of their OR and a lower ovarian response to GT in comparison to age-matched fertile controls. Materials and Methodology: A total of 146 women undergoing in vitro fertilization-intracytoplasmic sperm injection at our fertility center between March 2017 and August 2017 were prospectively enrolled in this study. Anti-Mullerian hormone and antral follicle count (AMH and AFC) assessment was done for women enrolled in the study in the early follicular phase. Flexible GnRH antagonist protocol was followed. Age, AMH, AFC, body mass index, and response to ovarian stimulation (OS) were compared between the fertile and infertile groups. We also sought to determine which among these had the best prediction for ovarian response to controlled OS. Statistical Analysis: Chi-square test was used for comparisons between study groups with respect to percentages. P < 0.05 was considered to be statistically significant. Results: When adjusted for the differences in the demographic variables, we found no difference in the AMH (P = 0.298) and AFC (P = 0.302) between the fertile and infertile women. In addition, there was no difference in the ovarian response; the mean number of oocytes retrieved was 15.8 ± 7.5 in the fertile group and 14.3 ± 7.5 in the infertile group (P = 0.510). AMH had the strongest correlation with the number of oocytes retrieved (r = 2.11) in comparison to AFC (r = 0.08) and age (r = −0.45) Conclusion: There is no difference in OR and response in fertile and infertile Indian having similar demographics and basal characteristics.
  4,074 407 -
Fertility preservation for female cancer patients by manipulating ovarian stem cells that survive oncotherapy
Deepa Bhartiya
July-December 2019, 2(2):53-56
Infertility and premature ovarian failure are unwanted side effects of oncotherapy in females; however, a large number of patients survive cancer due to recent advances in their management. One of the available options to restore fertility in cancer survivors is to transplant ovarian cortical tissue slices at orthotopic sites which has resulted in the birth of 130 babies. Spontaneous pregnancies have also been reported after heterotopic transplantation of cortical tissue slices which can only be explained by the presence of stem cells and paracrine support provided by transplanted ovarian slices to the nonfunctional ovary. The ovary harbors two populations of stem cells, including very small embryonic-like stem cells (VSELs) and slightly bigger ovarian stem cells (OSCs) that divide and undergo clonal expansion to form germ cell nests in adult ovary before undergoing neo-oogenesis and primordial follicle assembly. Being relatively quiescent, VSELs survive oncotherapy and can regenerate the nonfunctional ovary. Stem cells niche gets affected by oncotherapy and transplanting autologous bone marrow mesenchymal stem cells (MSCs, which provide paracrine support) have shown to normalize ovarian function in rodents with the birth of healthy pups. Similarly, transplanting of autologous MSCs in human ovary with premature ovarian failure resulted in the birth of a baby. These advances in the field of OSCs need to be put in proper context before considering making transplantation of ovarian cortical tissue at orthotopic sites as method of standard care. Transplanting autologous MSCs is safe, and efficacy to regenerate nonfunctional ovaries needs to be evaluated in clinical settings.
  4,103 328 -
Fertility preservation surgeries in gynecological malignancies at a tertiary care institute in South India
Paapa Dasari, Sonal Garg
January-June 2019, 2(1):16-19
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.
  3,981 379 -
Relevance of fertility preservation in developing nations
Nalini Mahajan
January-June 2018, 1(1):1-2
  3,798 450 -
In vitro activation of ovary
Nalini Mahajan, Jasneet Kaur, Bithika Bhattacharya, Padmaja Naidu, Shalu Gupta
January-June 2019, 2(1):35-37
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.
  3,732 343 3
Outcome of fertility-preserving surgery for ovarian malignancy in young women
M Ali Ashraf, Paapa Dasari
January-June 2018, 1(1):51-54
Ovarian cancer is considered to be one of the most lethal gynecological malignancies. It is estimated that 10% of ovarian cancer cases will be diagnosed in women of reproductive age and >80% would be in advanced stage. Conservative treatment can be carried out for Stage IA, B, C1, C2, C3 (International Federation of Gynecology and Obstetrics) to preserve fertility. However, accurate staging prior to surgery is difficult and some of these women require chemotherapy after fertility-preserving surgery which affects ovarian reserve, and there are a lot of anxieties regarding the aftereffects of chemotherapy on conception. In this article, cases of three young women who underwent conservative surgery for ovarian cancer followed by chemotherapy and subsequent treatment for infertility are presented. These are immature teratoma, juvenile granulosa cell tumor, and dysgerminoma. There was tumor spill in case of immature teratoma and capsule rupture in case of juvenile granulosa cell tumor. All the three women received chemotherapy and could achieve pregnancy after infertility treatment and had normal children. Tumor spill or rupture did not result in adverse outcomes and hence it should not prompt the surgeon to undertake radical procedure in women desirous of pregnancy. Undergoing chemotherapy subsequently did not result in adverse fetal outcome and there was no recurrence of malignancy among these women.
  3,690 303 -
Idiopathic hyperprolactinemia with tumoral prolactin levels
Nadia Belmahi, Houda Salhi, Said Boujraf, Hanan El Ouahabi
July-December 2018, 1(2):107-110
The causes of hyperprolactinemia are varying, from physiological to pharmacological and pathological causes; but some cases are classified as “idiopathic” because of unknown causes. We describe a 29-year-old woman who presented to our department with galactorrhea and secondary amenorrhea. She had no clinical features of hypopituitarism and was not taking any medication. On physical examination, she had bilateral galactorrhea. Prolactin (PRL) level was high, up to 200 ng/ml, and other pituitary and thyroid indices were normal, including testing for macroprolactinemia. Pituitary magnetic resonance imaging was normal; and thoraco-abdominopelvic tomography was performed with no abnormalities detected. Cabergoline was started at the dose 0.5 mg/week. Galactorrhea disappeared, the menstrual cycle had become regular, and PRL level decreased to 26 ng/ml. Should all causes of hyperprolactinemia be ruled out and pituitary imaging revealed as negative, idiopathic hyperprolactinemia is therefore diagnosed. In symptomatic patients, treatment with dopaminergic agonists is indicated.
  3,546 246 -
Resetting the “biological clock”
Nalini Mahajan
July-December 2019, 2(2):51-52
  3,298 345 -
Assisted reproductive technology outcome in poor responders classified by patient-oriented strategies encompassing individualized oocyte number stratification
Madhuri Patil, Milind Patil, Radha Puchalapalli
January-June 2019, 2(1):27-34
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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