Failed ovarian cortex transplant but successful ovulation induction in a cancer survivor with premature ovarian failure: A paradox.

Better diagnostic and treatment modalities for malignancies occurring in childhood and young age have increased the overall survival of the affected young girls and boys, but this has come at a cost of developing premature ovarian failure in girls and azoospermia in boys because of the gonadotoxicity of chemotherapy and radiotherapy. Thus, young girls and women of reproductive age who are at risk of ovarian failure due to cancer treatment must be mandatorily offered fertility preservation in any form such as cryopreservation of mature metaphase II oocytes after ovarian stimulation with gonadotropins and oocyte recovery and cryopreservation of embryos if the young female has a partner. However, these modalities may require the postponement of chemotherapy. Thus, in such instances, cryopreservation of ovarian tissue remains the only option. Herein, we report a case of a nulligravid young female patient who had stage IV Hodgkin's lymphoma and had to be taken up for immediate fertility preservation owing to the advanced stage of the disease. Therefore, cryopreservation of ovarian tissue was performed. The uniqueness of the case is that after remission of the disease was achieved with chemotherapy, transplantation of the ovarian tissue was carried out which was not successful, but the desire for motherhood prompted to carry out an ovulation induction in the remnant native ovary with a severely compromised ovarian reserve, and she conceived.

"Does serum estrogen level have an impact on outcomes in hormonal replacement frozen-warmed embryo transfer cycles?"

AIM: To evaluate the impact of serum estradiol (E2) levels on cycle outcomes in hormone replacement frozen embryo transfer (HR- FET) cycles. MATERIALS AND METHODS: We retrospectively analyzed 509 HR-FET cycles performed from September 2018 to September 2019. Patients were divided into 6 groups based on their E2 values measured a day before progesterone initiation . Group 1: <100 pg/mL, group 2: 100-200 pg/mL, group 3: 200 - 300 pg/mL, group 4: 300-400 pg/mL, group 5: 400-500 pg/mL, group 6: >500 pg/mL. Implantation rate (IR), clinical pregnancy rate (CPR), miscarriage rate (MR), multiple pregnancy rate (MPR) and ectopic pregnancy rates were compared between all groups. RESULTS: IR and CPR were similar between a wide range of E2 values, but when E2 values were more than 500 pg/mL there was a non significant fall in the IR (47.3% vs 48.3% vs 48.6% vs 47.8% vs 48.7% vs 39.6% p = .77) and CPR (63.6% vs 65.1% vs 65.6% vs 65.3% vs 65.6% vs 53.1% p = .692). MR was significantly high when E2 was less than 100 pg/mL (28.5%) and when E2 was more than 500 pg/mL (41.1%) (p = .02). MPR and ectopic pregnancy rates were similar between all the groups. CONCLUSION: Outcomes of FET cycles were similar between a wide range of E2 values (100-500 pg/mL). When E2 levels were less than 100 pg/mL or more than 500 pg/mL there was significant increase in the MR but the numbers in these groups are less and further studies are required to confirm these facts.

A prospective study of oral estrogen versus transdermal estrogen (gel) for hormone replacement frozen embryo transfer cycles.

AIM: This study was done to compare the efficacy of transdermal estrogen (gel) to oral estradiol in hormone replacement frozen embryo transfer cycles (HR- FET). MATERIALS AND METHODS: This was a prospective study conducted between March 2019 and December 2019. We included 294 HR FET cycles: 156 cycles using oral estrogen tablets (oral group) and 138 cycles using transdermal gel (17 beta estradiol 0.06% w/w) (gel group). Primary objective of this study was to compare endometrial thickness (ET) on the day of progesterone start between the two groups. Our secondary objective was to compare implantation rates (IR), clinical pregnancy rates (CPR), miscarriage rates (MR), duration of estrogen administration, estradiol (E2) levels before the start of progesterone, cycle cancellation rates, patient satisfaction score and undesirable side effects between both the groups. RESULTS: There was no significant difference in the ET, IR, CPR, MR and duration of E2 administration and cycle cancellation rates between both the groups. Patient satisfaction score was significantly higher (8.02 ± 1.07 vs 6.96 ± 0.99 p < .01) and side effects were significantly lower (18.1% vs 55.1%, p≤.01), in the gel group compared to the oral group. CONCLUSION: This study concluded that transdermal estrogen (gel) is equally efficacious as oral estrogen in HR FET cycles with transdermal gel having an added benefit of better patient comfort with less side effects and better safety profile.

Comparative Study of Serum Progesterone Levels at the Time of Human Chorionic Gonadotropin Trigger and Ovum PickUp in Predicting Outcome in Fresh in vitro Fertilization Cycles.

BACKGROUND: Studies have shown that premature rise of progesterone in controlled ovarian stimulation (COS) at the time of human chorionic gonadotropin (hCG) trigger is negatively associated with in vitro fertilization (IVF) outcome in fresh IVF cycles. Some authors have failed to demonstrate this. One large single centre retrospective cohort study has compared the pre and post hCG progesterone and observed that the ratio of the rise in progesterone could be a positive predictor. There is paucity of literature on this aspect. AIMS AND OBJECTIVES: To compare the serum progesterone at hCG trigger and ovum pick-up (OPU) with IVF outcome by estimating the respective paired hormone levels. MATERIAL AND METHODS: Serum progesterone levels at hCG trigger and OPU are compared retrospectively in 301 fresh IVF cycles with IVF outcome by long protocols with GnRH agonists for two years. Parametric and nonparametric testing of null hypothesis is performed. P value <0.05 is taken as significant. RESULTS: There is no predictive association of IVF outcome with either progesterone levels. The ratio of rise in progesterone is strongly positively associated with IVF outcome (P < 0.001). However, after adjusting for confounders and modifiers the retrieved number of oocytes are positively associated with IVF outcome (P = 0.044). CONCLUSIONS: The ratio of rise in progesterone is significantly associated with number of oocytes retrieved which in turn is associated with successful IVF outcome in fresh cycles. Ratio of rise in progesterone seems to be therefore an indirect parameter for predicting successful IVF outcome in fresh cycles.

Dermatological Manifestations in Patients Undergoing In Vitro Fertilisation: A Prospective Study.

BACKGROUND: Changing sociodemographic patterns with an increase in the age of childbirth have affected fertility rates worldwide. With advancing reproductive medicine, assisted reproductive techniques (ARTs) are becoming common. While dermatological manifestations in normal pregnancies have been well documented, there is a paucity of data regarding cutaneous manifestations in patients undergoing ART. OBJECTIVES: The objectives of our study were to estimate the incidence and types of dermatological manifestations in patients undergoing in vitro fertilisation (IVF) and to study their associations with age, type of infertility, and outcome of the procedure. METHODS: A prospective cohort of 200 patients undergoing IVF in a tertiary care centre was observed for occurrence of any dermatological manifestations from initiation of the IVF protocol to the outcome of the procedure at 3 weeks after embryo transfer. RESULTS: Dermatological manifestations were seen in 27% of the study group, with urticaria being the most common cutaneous finding seen in 13.5%, followed by acneform eruptions (3%). Twenty-six (96.3%) of patients who manifested with urticaria were on progesterone. No statistically significant association was found between the occurrence of dermatological manifestations and the outcome of IVF, type of infertility, history of ART, and ovum donation in our study. Association between the age of the patient and the outcome of IVF cycle was statistically significant. CONCLUSION: Dermatological manifestations are seen in almost one-quarter of patients undergoing IVF, with progesterone-induced urticaria being the most common. Occurrence of cutaneous manifestations has no significant association with the outcome of IVF.

Calcium gluconate infusion is as effective as the vascular endothelial growth factor antagonist cabergoline for the prevention of ovarian hyperstimulation syndrome.

BACKGROUND: Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic and potentially life-threatening disease process, which may occur in healthy young women undergoing controlled ovarian hyperstimulation for assisted reproduction. As the treatment is largely empirical, prevention forms the mainstay of management. OBJECTIVE: The present study was aimed to evaluate the effectiveness of intravenous (IV) calcium gluconate infusion in comparison to the dopamine agonist cabergoline (Cb2) in preventing OHSS in high risk patients undergoing assisted reproductive technique cycles. MATERIALS AND METHODS: It was a comparative study wherein the 202 high risk patients undergoing in vitro-fertilization over a period of 18 months after meeting the strict inclusion and the exclusion criteria, were randomly divided into two groups (98 subjects in Group I and 104 in Group II). Women in Group I were administered IV calcium gluconate while the remaining 104 received the dopamine agonist Cb2. The 104 patients belonging to Group II were started Cb2 0.5 mg/day from the day of ovulation trigger and continued until the next 8 days while the 98 high risk patients from Group I were infused with 10 ml of 10% calcium gluconate solution in 200 ml physiologic saline within 30 min of ovum pick up and continued thereafter on day 1, day 2 and day 3. RESULTS: The occurrence of OHSS was seen in only nine patients (in the calcium infusion group, when compared with 16 patients (9.2% vs. 15.4%) who were administered Cb2, but it was not statistically significant. However, only one had severe OHSS in Group I, whereas two women were diagnosed as severe OHSS belonging to the Cb2 arm. CONCLUSION: Our results document that calcium infusion can effectively prevent severe OHSS and decreases OHSS occurrence rates when used for high-risk patients, but does not suggest its superiority over Cb2. With comparable success rates, either of them can be employed as a preventive strategy for OHSS.