Andon Hestiantoro

Sex differences in the hypothalamus in the different stages of human life

Quite a number of structural and functional sex differences have been reported in the human hypothalamus and adjacent structures that may be related to not only reproduction, sexual orientation and gender identity, but also to the often pronounced sex differences in prevalence of psychiatric and neurological diseases. One of the recent focuses of interest in this respect is the possible beneficial effect of sex hormones on cognition in Alzheimer patients. The immunocytochemical localization of estrogen receptors (ER) alpha, beta and androgen receptors has shown that there are indeed numerous targets for sex hormones in the adult human brain. Observations in the infundibular nucleus have, however, indicated that in this brain area the hyperactivity resulting from a lack of estrogens in the menopause seems to protect females against Alzheimer changes, in contrast to males. It is thus quite possible that estrogen replacement therapy may, in these brain areas, lead to inhibition of neuronal metabolism and thus to the same proportion of Alzheimer changes as are observed in men. Knowledge about the functional sex differences in the brain and the effect of sex hormones on neuronal metabolism may thus provide clues not only for the possible beneficial effects of these hormones (e.g., on cognition or hypertension), but also on possible central side effects of estrogen replacement therapy.

The effect of a fortified milk drink on vitamin D status and bone turnover in post-menopausal women from South East Asia

Calcium and vitamin D are essential for bone growth; milk is an appropriate vehicle to be fortified with calcium, vitamin D and other minerals. The purpose of the current study was to compare the effect of supplementing with a high calcium milk drink with added vitamin D, magnesium and zinc (HCM) versus a placebo drink on serum parathyroid hormone (PTH) and vitamin D status as well as markers of bone formation/resorption in postmenopausal women living in South East Asia (Jakarta, Indonesia and Manila, the Philippines) over a period of 4 months. Calcium intake at baseline was 237 mg (median; 176-316, interquartile range) for Indonesia and 353 mg (median; 222-480, interquartile range) for the Filipino women per day. Fortified milk supplementation reduced the percentage of women that were insufficient in 25 (OH) vitamin D(3) (<50 nmol/L) from 70% to 22% in the Indonesian women and 20% to 0% in the Filipino women. Fortified milk supplementation significantly reduced parathyroid hormone levels (PTH) by week 2 (22% and 11%), C-telopeptide of type I collagen (CTX) by week 2 (34% and 27%), osteocalcin (OC) by week 8 (18% and 25%) and procollagen type I N-propeptide (PINP) by week 8 (15% and 21%), in women from Indonesia and the Philippines, respectively. Thus, the HCM intervention was able to significantly improve vitamin D status, lower PTH levels and reduce bone turnover in two groups of South East Asian women.

Sperm chromatin maturity and integrity correlated to zygote development in ICSI program

ABSTRACT This study aimed to evaluate sperm chromatin maturity and integrity of that injected into good-quality oocytes in an in vitro fertilization-intra cytoplasmic sperm injection (IVF-ICSI) program. A cut-off value of sperm chromatin maturity and integrity was developed as a function of their correlation to the zygote development, i.e., embryo formation and cleavage rate. The study assessed sperm chromatin maturity using aniline blue (AB) staining, whereas toluidine blue (TB) staining was used to assess sperm chromatin integrity. Ejaculates from 59 patients undergoing ICSI and 46 fertile normozoospermic donors for determination of normal values of sperm chromatin status were used in this study. Embryo formation and cleavage rates were observed for the period of 3 days after ICSI. There was a significant difference in the percentage of sperm with mature chromatin between ejaculate from ICSI patients and fertile donor (p=0.020); while there was no significant difference in sperm chromatin integrity of both samples (p=0.120). There was no significant correlation between sperm chromatin maturity and either embryo formation or cleavage rate; as well as sperm chromatin integrity to both parameters of zygote development (p>0.05). Furthermore, we found that the cut-off value of sperm chromatin maturity and integrity of the fertile normozoospermic ejaculates were 87.2% and 80.2%, respectively. Using the cut-offs, we found that low sperm chromatin maturity at the level of <87% correlated significantly with the cleavage rate of the zygote (p=0.022; r=0.371); whereas poor sperm chromatin integrity at the level of <80% correlated with embryo formation (p=0.048; r=0,485). In conclusion, this study showed that poor maturity and integrity of sperm chromatin (AB<87% and TB<80%, respectively), could affect zygote development following ICSI. Abbreviations: AB: aniline blue; CMA3: chromomycin A3; ICSI: intra cytoplasmic sperm injection; IVF: in vitro fertilization; PBS: phosphate buffer saline; SPSS: Statistical Package for Social Science; TB: toluidine blue; WHO: World Health Organization

Indonesian kalkulator of oocytes (IKO): A smart application to determine our biological age

Background: The use of smartphones and its associated application provides new opportunities for physicians. In current situations, there are still few applications are designed in the field of infertility and Assisted Reproductive Technologies (ART). A study conducted on 1616 subjects proved that AMH (Anti-Mullerian Hormone) could be used to predict a woman’s biological age earlier than Follicle-Stimulating Hormone (FSH) and Antral Follicle Count (AFC). In this study, we describe the AMH nomogram that has been developed into a mobile application as “Indonesian Kalculator of Oocytes” (IKO). The software required to create IKO application was the Android 4.0.3 Ice Cream Sandwich and Java Application Development. The hardware specification that needed to develop the IKO apps were a 4.0-inch screen, 512 MB RAM (random-access memory), and CPU (central processing unit) with dual core 1.2 Ghz. The application is built using the Android SDK (Software Development Kit) and Java Application Development. In this app...

BAX/BCL-2 expression in granulosa cells was not altered in patients with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS), a hyperandrogenic disturbance commonly found in women of reproductive age (6%), can disturb normal fertility. The symptoms of PCOS include hyperandrogenism, oligomenorrhea, chronic anovulation, and hyperinsulinemia. Hyperandrogenism causes oocytes to be of poor quality (immature). Meanwhile, granulosa cell apoptosis could also affect oocyte quality. This study aimed to identify differences in the expression of the pro-apoptotic gene BCL-2–associated X (BAX) and anti-apoptotic gene B-cell lymphoma-2 (BCL-2) between patients with PCOS and healthy controls. In this cross-sectional study, 40 respondents (20 women with a confirmed diagnosis of PCOS and 20 controls) were recruited at the Yasmin IVF Clinic of Cipto Mangunkusumo Hospital (Jakarta, Indonesia). These respondents provided informed consent. BAX and BCL-2 levels were assayed using real-time PCR. There were no significant differences in terms of BAX (p = 0.38) or BCL-2 levels (p = 0.223) between the PCOS and control groups. The BAX/BCL-2 ratio was also not significantly different between the groups (p = 0.31). In conclusion, BAX/BCL-2 gene expression did not significantly differ between the patients with PCOS and control subjects. Further studies using larger sample sizes are warranted to confirm these findings.

Study of GDF9 and BMP15 mRNA profiles in granulosa cells to predict oocyte quality in endometriosis patients undergoing in vitro fertilization

Growth differentiation factor-9 (GDF9) and bone morphogenetic 15 (BMP15) are oocyte-secreted factors (OSF) that are proteins and are members of the transforming growth factor β superfamily with roles in folliculogenesis to produce mature oocytes. GDF9 and BMP15 are candidates in the search for selective markers to predict oocyte quality. Women with endometriosis undergoing in vitro fertilization (IVF) usually present with reduced quality of their oocytes. The aim of this study is to examine GDF9 and BMP15 expressions in granulosa cells to evaluate oocyte quality in these patients. We collected 20 granulosa cell samples from patients suffering from endometriosis (test group) along with 12 samples of granulosa cells from those without endometriosis (control group) and measured GDF9 and BMP15 expressions. Absolute quantification real-time PCR was used to quantify gene expression levels, using pre-manufactured oligonucleotides as standards. Our results showed no significance differences in GDF9 or BMP15 expressions between patients with endometriosis and those without it (both p > 0.05). Hence, the expression levels of gdf9 and bmp15 should not be considered when predicting oocyte quality. Further investigations regarding other factors affecting oocyte quality should be conducted to obtain more information.

An evaluation of multimedia and online support groups (OSG) contents and application of information by infertile patients: Mixed method study

Background: The presence of Online Support Groups (OSG) is expected to empower patients with infertility, thus allowing patients to be the focus of healthcare services. This study will evaluate multimedia content, OSG, and utilization of information for decision-making by patients using infertility services. This study is a mixed method study conducted from January – June 2016 at Yasmin IVF Clinic, Dr. Cipto Mangunkusumo General Hospital; and SMART IVF Clinic, Jakarta. The subjects are patients with infertility who sought treatment at the clinics. Data was collected through a structured interview in the form of a questionnaire. Informed consent was obtained from all individual participants included in the study. All procedures that performed in studies were by the ethical standards of the institutional. The result from 72 respondents showed quantitative analysis did not reveal any association between multimedia and OSG information sources with patient knowledge regarding infertility management. However, q...

Genetic and clinical predictors of ovarian response in assisted reproductive technology

Several factors are known to influence ovarian response to rFSH stimulation such as age, antral follicle count (AFC), and basal FSH level, Mutation of allele Ser680Asn in FSHR gene was responsible to ovarian resistance toward exogenous FSH. The aim of this study is to develop a prediction model of ovarian response to COS in IVF. This study was a prospective cohort study. One hundred and thirteen women undergoing their first cycle of IVF in Yasmin IVF Clinic Jakarta were recruited to this study. Clinical datas included were age, BMI, and AFC. Basal FSH and E2 as well as serum AMH was measured from peripheral blood taken at second day of cycle. Bsr-1 enzyme is used to identify the polymorphism in exon 10 position 680 with RFLP technique. Three genotype polymorphism, Asn/Asn (255 bp ribbon), Asn/Ser (97 bp and 158 bp), and Ser/Ser (97 bp, 158 bp, and 255 bp). AFC has the highest predictor for ovarian response with AUC 0.922 (CI 95% 0.833-1.000). AMH also showed high predicting value (AUC 0.843 CI 95% 0.663-1.000). The multivariate analysis revealed combination of AFC, AMH, age, and basal FSH is a good model for ovarian response prediction (AUC=0.97). No significant relation between Asn/Asn, Asn/Ser, or Ser/Ser genotype FSHR polymorphism with ovarian response (p = 0.866) and total dose of rRSH (p = 0.08). This study showed that model combination of AFC, AMH, patients age and basal FSH are very good to predict number of mature oocytes.

Correlation between Follicular Fluid’s Androgen Level and Fertilization Rate in Poor Responder Patients Undergone IVF: A Prospective Cohort Done in Yasmin IVF Clinic, Jakarta, Indonesia

Introduction Androstenedione (A4), testosterone (T), and dehidroepiandrosterone (DHEA) are known to be involved in folliculogenesis and follicular maturity. Lower follicular androgen levels in poor responder due to malfunctioned granulosa and theca cells and decreased inhibin B production will decrease FSH and LH. However, androgenic follicular fluid might also induce follicular atresia, decreased oocytes viability, thus affecting fertilization. The aim of current study is to find the correlation between intra-follicular androgen levels and fertilization rate, specifically in poor responder whom contributed in 84% cancelled cycle. Material and Methods This prospective cohort study was done at Yasmin IVF Clinic, Jakarta, Indonesia, in January 2014-March 2015. Infertile women undergone IVF were asked to participate, grouped into poor responder and other, and the androgen levels in the follicular fluid of each consenting patients were measured. Results From total 62 patients, aged 23-47 years old (37.6±5,068), there were 21 poor responders, whereas the other 41 patients with other indication. In poor responder group, levels of androstenedione, testosterone, and DHEA were 50.8 – 272.3 (103.5 ± 59.9), 383.2 – 1747.9 (1114.4 ± 373.2), 11.3 – 454.8 (151.3 ± 96.8), whereas in other group the androgen levels were 44.3 – 326.8 (95.1 ± 61.2), 414.1 – 1463.7 (976.9 ± 258.4), 44.6 – 265.8 (132.7 ± 61.3) with the correlation with fertilization rate 0.609, 0.095, and 0.361 respectively. Conclusion Correlation between follicular androgen levels and fertilization rate found to be not significantly different. The low number of subjects might cause this result, as well as the presence of bias, e.g.male factor and endometriosis might also affect fertilization. A multi-center study with larger sample size added with thorough analysis is needed to reconfirm current data.

Anti-Müllerian hormone as a predictor of polycystic ovary syndrome treated with clomiphene citrate

Objective This study aimed to determine the threshold of anti-Müllerian hormone (AMH) as predictor of follicular growth failure in polycystic ovary syndrome (PCOS) patients treated with clomiphene citrate (CC). Methods Fifty female subjects with PCOS were recruited and divided into two groups based on successful and unsuccessful follicular growth. Related variables such as age, infertility duration, cigarette smoking, use of Moslem hijab, sunlight exposure, fiber intake, body mass index, waist circumference, AMH level, 25-hydroxy vitamin D level, and growth of dominant follicles were obtained, assessed, and statistically analyzed. Results The AMH levels of patients with successful follicular growth were significantly lower (p=0.001) than those with unsuccessful follicular growth (6.10±3.52 vs. 10.43±4.78 ng/mL). A higher volume of fiber intake was also observed in the successful follicular growth group compared to unsuccessful follicular growth group (p=0.001). Our study found the probability of successful follicle growth was a function of AMH level and the amount of fiber intake, expressed as Y=–2.35+(–0.312×AMH level)+(0.464×fiber intake) (area under the curve, 0.88; 95% confidence interval, 0.79–0.98; p<0.001). Conclusion The optimal threshold of AMH level in predicting the failure of follicle growth in patients with PCOS treated with CC was 8.58 ng/mL.