Effect of trigger day serum luteinising hormone levels on the in-vitro fertilization outcome: an observational study.

OBJECTIVE: Controlled ovarian stimulation leads to profound changes in the endocrine characteristics of the ovarian cycle. Serum luteinising hormone (LH) levels on the day of trigger have been shown to correlate with oocyte quality and pregnancy rate in antagonist cycles. METHODS: This is an observational study of 86 women undergoing an antagonist in-vitro fertilisation cycle. Oocyte maturation trigger used was either Inj. human chorionic gonadotropin or Inj. triptorelin 0.2 mg s/c or a combination of both. Women were categorised into four groups based on serum LH levels on the day of trigger i.e., LH ≤0.5 (n=8), LH=0.6- 1.0 international units (IU)/L (n=12), LH=1.0-1.5 IU/L (n=13), and LH >1.6 IU/L (n=53) and the subgroup analysis was done based on type of trigger used. RESULTS: Mature oocyte (MII) retrieval rate did not show a significant relation with serum LH levels (87%, 89%, 77%, and 76% in groups with LH <0.5, 0.5-1.0, 1.0-1.5, and >1.5 IU/L respectively; P-value=0.243). There was no significant difference in the clinical pregnancy rate either when women were split according to the type of trigger given or according to trigger day LH levels. Women with low LH levels (<0.5 IU/L) required significantly more doses of gonadotropins compared to women with LH levels of 1.0-1.5 IU/L. (3,531+1,133 vs. 2,281+938; P-value=0.01). CONCLUSION: Based on the observation from the current study, there was no significant association of serum LH levels with MII retrieval rate and clinical pregnancy rate. The group with low LH levels required slightly longer days of stimulation.

Cytokines, NK cells and regulatory T cell functions in normal pregnancy and reproductive failures.

PURPOSE OF THE REVIEW: Pregnancy brings about an intricate assortment of dynamic changes, which causes proper connection of genetically discordant maternal and foetal tissues. Uterine NK cells are immune cells populating the endometrium and play a major role in implantation and also regulate placentation. This review mainly aims explore the role of uterine NK cells in implantation and how it is affecting in adverse pregnancy outcomes. RECENT FINDINGS: Though the functions of uterine NK (uNK) cells are not clearly understood, NK cell activity plays a vital role during immunomodulation which is the main step in implantation and sustaining the early pregnancy. Cytokines, cell surface receptors of NK cells and hormones such as progesterone modulate the NK cell activity in turn affect the implantation of the embryo. Altered NK cell activity (number and functionality) would be an important attributing factor in adverse pregnancy outcomes. Furthermore, T regulatory cells and cytokines also modulate the immune responses in the decidua which in turn contributes to successful implantation of embryos. SUMMARY: Immunological responses and interactions in the Foetus-maternal interface is crucial in the successful implantation of allogenic foetus resulting in a healthy pregnancy. NK cells, Treg cells and cytokines play a major role in successful implantation which remains an enigma. Comprehending pregnancy-induced immunological changes at the foetus-maternal interface will allow newer therapeutic strategies to improve pregnancy outcomes.

Comparing Assisted Reproductive Outcomes in Women with Different Polycystic Ovary Syndrome Phenotypes Undergoing Frozen Embryo Transfer.

Background: Patients with polycystic ovarian syndrome (PCOS) have unique characteristics depending on its phenotype. Therefore, prediction of controlled ovarian stimulation (COS) response and assisted reproductive technique (ART) outcome in these becomes challenging. Aims: To assess the outcomes of assisted reproductive technology (ART) in various polycystic ovary syndrome (PCOS) phenotypes and to evaluate the predictive value of anti-Mullerian hormone (AMH) and total testosterone on ART success. Clinical pregnancy rate (CPR) was measured as the primary outcome. Settings and Design: This was a prospective observational study conducted at a tertiary care centre. Materials and Methods: A total of 190 infertile women with PCOS (Rotterdam criteria) were enrolled and were subdivided into four phenotypes. Baseline screening and transvaginal scan were done. All patients underwent COS using antagonist protocol with recombinant follicle-stimulating hormone, and an agonist trigger was given for follicular maturation. One or two blastocysts were transferred in a frozen-thawed embryo transfer cycle. Luteal phase support was given with vaginal progesterone. Statistical Analysis Used: For quantitative variables, we employed the Kruskal-Wallis Test with post hoc Tukey's analysis. For continuous or ordinal variables, the Mann-Whitney U test was utilized. The analysis of categorical data was conducted using the Chi-square (χ2) test with SPSS 21 software. Results: Phenotype A was the most prevalent (37%). CPR was the highest in phenotype D (57.7%), followed by phenotype C (53.06%), A (43%) and B (36%). The mean serum AMH level was the highest in phenotype A (9.7 ± 4.3 ng/dL) and the lowest in phenotype B (5.9 ± 1.8 ng/dL). The mean total testosterone level was 103 ± 15.68 ng/mL in Type A, 109.46 ± 37.08 ng/mL in Type B and 48.52 ± 17.07 ng/ml in Type D. Conclusion: Phenotype D showed higher CPR and lower miscarriage rate compared to other phenotypes (not significant) and was associated with good clinical outcome. No correlation could be established with serum AMH, total testosterone levels and CPR.

Comparing Progesterone Primed Ovarian Stimulation (PPOS) to GnRH Antagonist Protocol in Oocyte Donation Cycles.

Background: Progesterone-primed ovarian stimulation (PPOS) protocol is based on the principle of preventing pre-mature luteinising hormone surge during ovarian stimulation using progesterone. Aims: In this study, we aimed to compare the cost-effectiveness of PPOS over GnRH antagonist cycles in oocyte donor cycles where freeze all is a norm. Settings and Design: It is a prospective cohort study with 130 participants. Materials and Methods: We included all women undergoing oocyte donation using PPOS protocol and antagonist protocol at our centre. Fifty-seven belonged to the PPOS group and were given medroxyprogesterone acetate (MPA) and 73 belonged to the GnRH antagonist group who received cetrorelix. The primary outcome was the number of mature oocyte retrieved at OPU and the cost involved per stimulation cycle. Statistical Analysis Used: For normally distributed observations, we used t-test, and for the variables of non-normal distribution, Mann-Whitney U-test was used. The significance was accepted for P < 0.05. Results: The baseline clinical characteristics of the donors were comparable with a mean age of 25.42 ± 2.90 years, body mass index of 24.00 ± 4.00 kg/m2 and antral follicle count of 18.63 ± 5.23. The duration of stimulation was similar in both the groups as well as the total gonadotropin dose required was not significantly different. The number of mature oocytes retrieved was same in both the groups (10.41 ± 4.04 with antagonist and 10.25 ± 3.23 with PPOS, P = 0.964). There were no reported cases of severe ovarian hyperstimulation syndrome (OHSS) in any of the groups. The incidence of mild-to-moderate OHSS in the antagonist group was 5.4% and in the PPOS group was 3.6%, and the difference was not significant (P = 0.69). The cost per mature oocyte (M2) was significantly higher in the antagonist protocol in comparison to the PPOS protocol (INR 9485.69 ± 5751.11 vs. Rs. 5945.86 ± 2848.59, respectively, P < 0.001). Conclusion: Our study identifies PPOS protocol using MPA to be more cost-effective and patient-friendly than conventional GnRH antagonist protocol in oocyte donor cycles.

Management of peri-ovarian hematoma following oocyte retrieval in a pooling cycle IVF: Case report.

Here we report a case of peri-ovarian hematoma following ovum pick-up in a patient in a pooling cycle IVF (in vitro fertilization). We have attempted to discuss the possible mechanisms for the development of hematoma in such patients, the common clinical presentation, monitoring, and management of these cases. The decision to operate or to manage conservatively forms an important aspect of managing such patients. This case report can help to keep the clinicians alert while managing this subgroup of patients.

Effects of prematuration culture with a phosphodiesterase-3 inhibitor on oocyte morphology and embryo quality in in vitro maturation.

OBJECTIVE: The study assessed the developmental potential of germinal vesicle (GV) oocytes subjected to in vitro maturation (IVM) after prematuration culture with cilostamide (a phosphodiesterase-3 inhibitor) and the impact of cilostamide exposure on the morphology of meiosis II (MII) oocytes and subsequent embryo quality. METHODS: In total, 994 oocytes were collected from 63 patients. Among 307 GV oocytes, 140 oocytes were selected for the experimental group and 130 oocytes for the control group. The denuded GV-stage oocytes were cultured for 6 hours with cilostamide in the experimental group and without cilostamide in the control group. After 6 hours, the oocytes in the experimental group were washed and transferred to fresh IVM medium. The maturational status of the oocytes in both groups was examined at 26, 36, and 48 hours. Fertilization was assessed at 18 hours post-intracytoplasmic sperm injection. Embryo quality was assessed on days 3 and 5. RESULTS: In total, 92.1% of the oocytes remained in the GV stage, while 6.4% converted to the MI stage (p<0.01) after cilostamide exposure. In both groups, more MII oocytes were observed at 36 hours (25.8% vs. 21.5%) than at 26 hours (10.8% vs. 14.6%) and 48 hours (13% vs. 7.9%) (p>0.05). With the advent of cilostamide, blastocyst quality was better in the experimental group than in the control group (p<0.05). CONCLUSION: Cilostamide effectively blocked nuclear maturation and promoted cytoplasmic growth. Prematuration culture with cilostamide enabled synchronization between cytoplasmic and nuclear maturity, resulting in better blastocyst outcomes.

Emotional Impact of Delay in Fertility Treatment due to COVID-19 Pandemic.

BACKGROUND: COVID-19 pandemic is an unprecedented public health emergency. When the pandemic started in our country fertility treatment was suspended for sometimes following national and international guidelines. This has led to delay in fertility treatment for some couples which was emotionally upsetting. METHODOLOGY AND DESIGN: This study was done on the patients enrolled at our various fertility units across India. The survey questionnaire was sent to patients during the month of first May to June 15, 2020, when COVID-19 pandemic was active across the country, and fertility units were just resuming the services back. The questionnaire was distributed to 100 patients who were currently under treatment and their response was recorded. Ethical committee approval was not taken as surveys are exempted from IRB. RESULTS: This survey was undertaken to understand the emotional impact of delay/cancelation in the fertility treatment during the COVID-19 pandemic. The survey revealed that majority (95%) of couples felt cancelation of cycles as upsetting and 16% reporting it to be extremely upsetting. The impact was seen in the form of mood disturbances, anxiety, sleep disturbances, and depressive ideas. Almost half of the couples (49.4%) were desirous to start the fertility treatment immediately. Their knowledge regarding COVID-19 and pregnancy and future child was limited. CONCLUSION: COVID-19 has had impact on every sphere of life. Delay in treatment and cancelation of cycles were emotionally upsetting to majority of couples and they were keen to restart the treatment sooner than later.

Role of Seminal Plasma Proteins in Effective Zygote Formation- A Success Road to Pregnancy.

Seminal plasma proteins contributed by secretions of accessory glands plays a copious role in fertilization. Their role is overlooked for decades and even now, as Artificial Reproduction Techniques (ART) excludes the plasma components in the procedures. Recent evidences suggest the importance of these proteins starting from imparting fertility status to men, fertilization and till successful implantation of the conceptus in the female uterus. Seminal plasma is rich in diverse proteins, but a major part of the seminal plasma is constituted by very lesser number of proteins. This makes isolation and further research on non abundant protein a tough task. With the advent of much advanced proteomic techniques and bio informatics tools, studying the protein component of seminal plasma has become easy and promising. This review is focused on the role of seminal plasma proteins on various walks of fertilization process and thus, the possible exploitation of seminal plasma proteins for understanding the etiology of male related infertility issues. In addition, a compilation of seminal plasma proteins and their functions has been done.

Perifollicular Vascularity in Poor Ovarian Responders in In vitro Fertilization Cycles.

CONTEXT: Poor response is reported in 9%-24% of stimulated cycles. Color Doppler indices of follicular blood flow are correlated with oocyte recovery, fertilization rate, developmental potential of oocyte, and pregnancy rate in in vitro fertilization (IVF) treatment. AIM: The aim of this study is to find out the correlation between perifollicular vascularity with clinical outcomes in poor ovarian responders during IVF cycles. SETTINGS AND DESIGN: A total of 49 poor ovarian responder women undergoing conventional IVF-embryo transfer procedure at a tertiary care hospital between September 2014 and 2015 were included in the study. It was a prospective observational study. SUBJECTS AND METHODS: Patients were recruited on the day of trigger following a transvaginal ultrasound if they developed ≤4 dominant follicles of ≥16 mm diameter. After ovarian stimulation patients who had all follicles with low-grade vascularity were classified as Group A, those with follicles with high-grade vascularity were Group C, and Group B included patients with follicles of both good and poor vascularity. STATISTICAL ANALYSIS USED: Analysis of variance and Chi-square/Fisher's exact test and software, namely SAS 9.2 and SPSS 15, has been used. RESULTS: A total 49 patients were recruited for the study.10 patients were allocated in Group A, 26 patients in Group B and 13 in Group C. Both groups were comparable in terms of age, period of infertility, follicle-stimulating hormone, luteinizing hormone, and gonadotrophin requirement. The number of metaphase II oocytes and good quality oocytes was significantly higher in Group C. Implantation rate, clinical pregnancy rate, multiple pregnancy rate, miscarriage rate, and live birth rate were comparable among all groups. CONCLUSIONS: Perifollicular vascularity has an important role to play in clinical outcomes in poor ovarian responders in IVF cycles.

Cadmium effects on sperm morphology and semenogelin with relates to increased ROS in infertile smokers: An in vitro and in silico approach.

Smoking releases cadmium (Cd), the metal toxicant which causes an imbalance in reactive oxygen species level in seminal plasma. This imbalance is envisaged to impair the sperm DNA morphology and thereby result in male infertility. In order to correlate this association, we performed in vitro and in silico studies and evaluated the influence of reactive oxygen species imbalance on sperm morphology impairments due to smoking. The study included 76 infertile smokers, 72 infertile non-smokers, 68 fertile smokers and 74 fertile non-smokers (control). Semen samples were collected at regular intervals from all the subjects. Semen parameters were examined by computer assisted semen analysis, quantification of metal toxicant by atomic absorption spectrophotometer, assessment of antioxidants through enzymatic and non-enzymatic methods, diagnosis of reactive oxygen species by nitro blue tetrazolium method and Cd influence on sperm protein by in vitro and in silico methods. Our analysis revealed that the levels of cigarette toxicants in semen were high, accompanied by low levels of antioxidants in seminal plasma of infertile smoker subjects. In addition the investigation of Cd treated sperm cells through scanning electronic microscope showed the mid piece damage of spermatozoa. The dispersive X-ray analysis to identify the elemental composition further confirmed the presence of Cd. Finally, the in-silico analysis on semenogelin sequences revealed the D-H-D motif which represents a favourable binding site for Cd coordination. Our findings clearly indicated the influence of Cd on reactive oxygen species leading to impaired sperm morphology leading to male infertility.

Human sperm DNA damage inhibition and antioxidant activity of T. arjuna bark: an in vitro study.

Complimentary or natural antioxidant type of alternative medicine is developed worldwide to treat male infertility. The aim of this study is to the extraction of T. arjuna bark and activity against human sperm DNA damage in asthenoteratospermic smoker's subjects-an in vitro study. All preliminary and antioxidant assays (DPPH, H2O2, and total antioxidant, reducing power activity) were done. T. arjuna bark metal analysis was done with AAS. On the other hand, patients were asked to fill a direct questionnaire about smoking history; 25 infertile smokers were identified as asthenoteratospermic; 34 fertile non-smokers (control) were assessed for semen parameters by CASA, seminal plasma Zinc analysis by AAS, DNA fragmentation by colorimetric method and semen genomic DNA damage inhibition by modified non-enzymatic salting out extraction method. Most of the antioxidants are highly present in the aqueous extract; meanwhile, the major content in this extract is zinc 16 µg/g (Ca = 0.5 µg/g; Se = 2.2 µg/g and Mg = 1.6 µg/g) along with FT-IR peaks which also confirmed the metal presence. The semen parameters in smokers that were noticed are low sperm count and morphological changes. Meanwhile, in the seminal plasma of smokers, zinc and DNA fragmentation results were positively correlated with sperm morphology (p < 0.001). Repaired DNA bands were noticed in the in vitro study of aqueous T. arjuna bark, in smokers' semen. T. arjuna bark will act as cryo protector as well as great zinc supplementary to maintain sperm motility and morphology in smokers.

Correlation of subendometrial-endometrial blood flow assessment by two-dimensional power Doppler with pregnancy outcome in frozen-thawed embryo transfer cycles.

CONTEXT: Various markers have been proposed to evaluate endometrial receptivity, such as molecular markers and sonographic markers. Commonly used sonographic markers include endometrial thickness and pattern. A good endometrial blood flow is considered necessary for improved pregnancy outcome. AIM: The aim of the present study is to evaluate the role of subendometrial endometrial blood flow with two-dimensional-power Doppler (2D-PD) in predicting pregnancy outcome in hormone replacement frozen-thawed embryo transfer (FET) cycles. SETTING AND DESIGN: Prospective, non-randomized observational study. A total of 165 patients undergoing their first FET cycle were evaluated for subendometrial-endometrial blood flow by 2D-PD once the endometrium was ≥7 mm thick. Group A consisted of 127 women showing the presence of subendometrial-endometrial blood flow. Group B comprised of 38 women in whom subendometrial blood flow was absent. Progesterone supplement was added and transfer of 2-3 cleavage stage good quality embryos was done after 3 days. STATISTICAL ANALYSIS: Independent two-tailed t-test and Chi-square test. RESULTS: There was no significant difference in body mass index, endometrial thickness, follicle stimulating hormone, luteinizing hormone levels, number of mature oocytes, semen parameters and the number of good quality embryos in the two groups (P > 0.05). The mean age in Group A was 32.05 years and 33.73 years in Group B, and the difference was statistically significant (P = 0.04). Overall pregnancy rate (PR) was 30.90%. PRs were significantly higher in the presence of subendometrial-endometrial blood flow than in its absence (35.43% vs. 15.78%, P = 0.02). Furthermore, clinical pregnancy rate and implantation rate were significantly higher in Group A when compared to Group B (31.49% and 14.79% vs. 13.15% and 6.52%, P = 0.02 and 0.03, respectively). CONCLUSION: The presence of endometrial blood flow significantly improves cycle outcome in hormone replacement therapy-FET cycles.

Effect of Pre-ovulatory Single Dose GnRH agonist Therapy on IVF Outcome in GnRH Antagonist Cycles; A Prospective Study.

BACKGROUND: The purpose of present study was to evaluate the role of pre-ovulatory GnRH agonist therapy on IVF outcomes in GnRH antagonist cycles. METHODS: In this prospective study we recruited 100 infertile women undergoing IVF cycles with GnRH antagonists. The patients were assigned to two groups: Group A (the study group, n = 42) were assigned for receiving hCG + triptorelin for the final oocyte maturation and group B (the control group, n = 58) were assigned for only hCG. The t-test, chi-square (χ(2)), and Fisher's exact test were used for data analysis. A p < 0.05 was taken as statistically significant. The results are presented by mean± SD, and in percents (%). RESULTS: LH levels significantly (p < 0.001) increased in the study group on the day of oocyte retrieval. All embryological parameters including the number of mature oocytes, fertilization and cleavage rates, number of high quality embryos and number of cases whose embryos were frozen were non-significantly higher in the study group. There were small but non-significant improvements in the clinical pregnancy, ongoing pregnancy, live birth and implantation rates in the study group. CONCLUSION: Administering a single dose of GnRH agonist before oocyte retrieval in antagonist cycles may be helpful in improving the pregnancy rate but the results need to be verified in a larger trials.

Does local endometrial injury in the nontransfer cycle improve the IVF-ET outcome in the subsequent cycle in patients with previous unsuccessful IVF? A randomized controlled pilot study.

BACKGROUND: Management of repeated implantation failure despite transfer of good-quality embryos still remains a dilemma for ART specialists. Scrapping of endometrium in the nontransfer cycle has been shown to improve the pregnancy rate in the subsequent IVF/ET cycle in recent studies. AIM: The objective of this randomized controlled trial (RCT) was to determine whether endometrial injury caused by Pipelle sampling in the nontransfer cycle could improve the probability of pregnancy in the subsequent IVF cycle in patients who had previous failed IVF outcome. SETTING: Tertiary assisted conception center. DESIGN: Randomized controlled study. MATERIALS AND METHODS: 100 eligible patients with previous failed IVF despite transfer of good-quality embryos were randomly allocated to the intervention group and control groups. In the intervention group, Pipelle endometrial sampling was done twice: One in the follicular phase and again in the luteal phase in the cycle preceding the embryo transfer cycle. OUTCOME MEASURE: The primary outcome measure was live birth rate. The secondary outcome measures were implantation and clinical pregnancy rates. RESULTS: The live birth rate was significantly higher in the intervention group compared to control group (22.4% and 9.8% P = 0.04). The clinical pregnancy rate in the intervention group was 32.7%, while that in the control group was 13.7%, which was also statistically significant (P = 0.01). The implantation rate was significantly higher in the intervention group as compared to controls (13.07% vs 7.1% P = 0.04). CONCLUSIONS: Endometrial injury in nontransfer cycle improves the live birth rate, clinical pregnancy and implantation rates in the subsequent IVF-ET cycle in patients with previous unsuccessful IVF cycles.

The degree of serum estradiol decline in early and midluteal phase had no adverse effect on IVF/ICSI outcome.

BACKGROUND: Estradiol levels fall rapidly in the luteal phase of ART cycles. So far, the effect of this estradiol decline on pregnancy outcome has remained controversial. AIM: To study the effect of early and midluteal estradiol decline on pregnancy and miscarriage rate. We also sought to determine whether estradiol fall was related to increased risk of bleeding per vagina in the first trimester among pregnancies which crossed 12 weeks. SETTING: Tertiary Assisted conception center. DESIGN: Retrospective study. MATERIALS AND METHODS: We analyzed data of 360 consecutive patients who underwent IVF-ET/ICSI cycles using one of the three protocols: Midluteal downregulation, short flare, and antagonist protocol. STATISTICAL METHODS: Statistical evaluation was performed with the Student's t test, Chi square, Fischer's exact test, analysis of variance, and Mann-Whitney tests were appropriate using SPSS for Windows, Standard version 11.0. RESULTS: The mean % EL-E2 and % ML-E2 declines were not significantly different in the pregnant and nonpregnant groups when analyzed separately in the three protocols. Also, the degree of midluteal estradiol decline did not correlate with pregnancy outcome. Moreover, the mean % early and midluteal estradiol decline did not differ significantly in patients with preclinical, clinical abortions, and ongoing pregnancy. The estradiol decline was not found to influence the risk of bleeding in the first trimester. CONCLUSIONS: Our results show that the degree of estradiol fall in the luteal phase of ART cycles does not influence pregnancy and first trimester miscarriage rate.