Firuza R. Parikh

Genital tuberculosis-a major pelvic factor causing infertility in Indian women

OBJECTIVE To study the effect of tuberculosis, a common infectious disease in the Indian subcontinent, on the female pelvic factor and its subsequent effect on female fertility. DESIGN Retrospective case studies. SETTING Department of Infertility Management and Assisted Reproduction, Jaslok Hospital and Research Centre, Bombay, India. PATIENT(S) Three hundred women, between the ages of 25 and 35 years, with tubal factor as a cause of their infertile state. RESULT(S) One hundred seventeen women with a tubal factor were found to have tuberculosis as the cause of tubal blockage. On laparoscopy, 49.5% were found to have simple tubal blockage, 15.3% showed tubo-ovarian masses, and 23.9% had a frozen pelvis. Seventy-five percent complained of menstrual irregularities, thus indicating endometrial involvement; 25.6% of these women underwent an IVF procedure. The pregnancy rate after IVF-ET was 16.6% per transfer. CONCLUSION(S) This study highlights the fact that tuberculosis, a chronic infectious disease, is one of the major etiologic factors of female tubal infertility, especially on the Indian subcontinent.

Specific and Sensitive Immunoassays Detect Multiple Anti-ovarian Antibodies in Women With Infertility

Serum anti-ovarian antibodies (AOAs) have been shown in autoimmune premature ovarian failure and in vitro fertilization-embryo transfer (IVF-ET) cases. The specificity of assays detecting these antibodies has been questioned. Researchers have used several techniques (e.g., ELISA and indirect immunofluorescence). Few have reported on the non-specificity and the type of molecular and cellular targets. We reported earlier on the presence of naturally occurring anti-albumin antibodies as the likely factor for non-specificity. Having developed a novel blocking recipe, we show substantial elimination of this non-specificity. With these standardized tests, we hereby report multiple targets at protein and histological levels. In our study group, 15 of 50 (30%) patients with premature ovarian failure and 13 of 50 (26%) IVF-ET patients showed the presence of AOAs. Western blotting showed a large number of patients making AOAs to a 90-kDa protein, followed by 97- and 120-kDa proteins. Histochemically, it was evident that the sera of these patients predominantly react with the oocyte; other somatic cellular targets are also involved. The specific non-invasive test developed by us was found to be useful because it could carry out a reliable diagnosis of an autoimmune etiology that would be very helpful to select patients in whom immune-modulating therapy could be recommended, which in turn may restore ovarian function and fertility.

Identification and validation of candidate biomarkers involved in human ovarian autoimmunity

Antibodies to multiple ovarian antigens have been proposed as markers of ovarian autoimmunity. The role of ovarian autoantibodies has been widely discussed in the pathophysiology of premature ovarian failure and unexplained infertility, but the autoantigens are yet to be identified. Three immunodominant ovarian autoantigens, α-actinin 4 (αACTN4), heat shock 70 protein 5 (HSPA5) and β-actin (ACTB), have been identified using anti-ovarian antibody-positive sera from women with idiopathic premature ovarian failure (n=50) and women undergoing IVF (n=695), using mass spectrometry. These autoantigens were subsequently validated using Western blot, immunohistochemistry and enzyme-linked immunosorbent assay. These autoantigens are localized to different components of the ovary such as the ooplasm of the oocyte, theca, granulosa, corpus luteum and zona pellucida. All the above antigens were found to be expressed in the ooplasm throughout follicular development. All the autoantigens are expressed specifically in the oocyte except αACTN4. The three autoantigens could contribute to the array of biomarkers to be used for developing specific and sensitive tests for diagnosis of women at risk of premature ovarian failure and IVF failure due to ovarian autoimmunity and could give an insight into the molecular mechanisms involved in the pathophysiology of these conditions.

Computer-assisted semen analysis parameters in men with varicocele: is surgery helpful?

OBJECTIVE To assess sperm characteristics and fertility before and after varicocelectomy using computer-assisted semen analysis (CASA). DESIGN Preoperative and postoperative sperm parameters of infertile men with varicocele were analyzed statistically and the outcome of pregnancy was determined. SETTING Department of Infertility Management and Assisted Reproduction, Jaslok Hospital and Research Centre, Bombay. PATIENTS Semen samples of 49 men with varicocele-related infertility were analyzed using CASA. INTERVENTIONS Sperm parameters of 26 men who underwent varicocelectomy were evaluated 3, 6, and 9 months postoperatively. Conception, occurring either naturally or therapeutically, was recorded. MAIN OUTCOME MEASURES Evaluation of improvement of sperm parameters after surgery. RESULTS Sperm count, motility parameters, curvilinear velocity, straightline velocity, lateral head displacement, and normal morphology were significantly lower in men with varicocele. Postoperatively, there was significant improvement in count, motility, and normal morphology, with a decrease in proportion of acrosome-deficient heads and tapering forms. After varicocelectomy, 46.2% of the men had normal semen parameters, with the overall pregnancy rate being 50%. CONCLUSIONS Computer-assisted semen analysis provides the potential for accurate quantitative evaluation of semen in men with varicocele. Varicocelectomy results in improvement in semen quality with pregnancy rates of 50%.

Can anti-ovarian antibody testing be useful in an IVF-ET clinic?

ObjectiveTo establish importance of anti-ovarian antibodies (AOA) testing in infertile women.DesignA clinical reproductive outcome comparative study between two groups of women undergoing IVF-ET. Group 1 consists of women tested positive for AOA, put on corticosteroid therapy, reverted to AOA negative and then taken up for IVF-ET. Group 2 were seronegative for AOA.SettingMajor urban infertility reference centre and National research institute.Patient(s)Five hundred seventy infertile women enrolled for IVF-ET.Intervention(s)AOA testing, corticosteroid therapy and IVF-ET/ICSI.Main outcome measure(s)Comparable clinical outcome and significance of AOA testing established.ResultsAOA positive serum samples were sent periodically to re-investigate presence of AOA after corticosteroid therapy and women turned AOA negative were taken up for IVF-ET. Of the 70/138 women in group 1 who were treated with corticosteroids and turned seronegative for AOA, 22/70 were poor responders and needed donor oocyte-recipient cycles. Results demonstrated that fertilization and clinical pregnancy rates between both groups are comparable. Nevertheless, it is also observed that there is poor response to stimulation protocol, smaller number of oocytes retrieved and more spontaneous abortions in group 1 women. Hence not all outcomes following the treatment are comparable between the two groups. Usefulness of the test was established in two case studies.ConclusionsAOA testing could be included in the battery of tests investigating and treating infertility.

Epigenetic Regulatory Mechanisms Associated with Infertility

Infertility is a complex human condition and is known to be caused by numerous factors including genetic alterations and abnormalities. Increasing evidence from studies has associated perturbed epigenetic mechanisms with spermatogenesis and infertility. However, there has been no consensus on whether one or a collective of these altered states is responsible for the onset of infertility. Epigenetic alterations involve changes in factors that regulate gene expression without altering the physical sequence of DNA. Understanding these altered epigenetic states at the genomic level along with higher order organisation of chromatin in genes associated with infertility and pericentromeric regions of chromosomes, particularly 9 and Y, could further identify causes of idiopathic infertility. Determining the association between DNA methylation, chromatin state, and noncoding RNAs with the phenotype could further determine what possible mechanisms are involved. This paper reviews certain mechanisms of epigenetic regulation with particular emphasis on their possible role in infertility.

Microdeletion Syndromes Detected by FISH - 73 Positive from 374 Cases

Abstract Fluorescence in situ hybridization (FISH) has facilitated the detection of microdeletions seen in Prader-Willi/Angelman (PW/AS), Williams and DiGeorge syndromes. Out of 374 suspected cases tested at Jaslok Hospital inthe past 5 years, 73 were positive, including 29 cases of Angelman, 16 of Prader-Willi, 24 of Williams and 4 ofDiGeorge syndrome. Male preponderance was seen, mainly in Williams syndrome. The mechanisms causing Prader-Willi and Angelman syndrome include microdeletions, intragenic mutations, uniparental disomy and imprintingdefects, though FISH can only detect microdeletions. Metaphase FISH helped to detect 1 case each with deletion ofthe control (PML) signal and duplication of the critical PW/AS region, which are associated with autism. Onesuspected case of Prader-Willi syndrome had a Robertsonian translocation t(14;15)(q10;q10) which led to a deletionof a major part of the SNRPN region in 10% cells, resulting in low-grade mosaicism. Another FISH-positive case wasdue to a reciprocal translocation t(2;15)(q37;q11), where loss of critical genes at the breakpoint on chromosome 15caused the Prader-Willi phenotype. FISH in a child with an Angelman phenotype showed no microdeletion, thoughTrisomy 15 was seen in 1 metaphase suggesting uniparental disomy due to trisomy rescue. A known polymorphism inthe form of an additional tiny green signal on chromosome 14 was observed in 17 of 284 (6%) cases studied forPrader-Willi/Angelman syndrome. Another inherited polymorphism was seen in 5 cases, where one control signal wasvery small. Prenatal diagnosis was carried out with normal results, in 12 women with a previously affected child.

FLUORESCENCE IN-SITU HYBRIDIZATION (FISH)-A RAPID AND USEFUL TECHNIQUE FOR DIAGNOSIS AND MANAGEMENT IN LEUKEMIA

Abstract Fluorescence in situ hybridization (FISH) is a rapid reliable technique in molecular cytogenetics. It supplements conventional karyotyping by providing additional information in certain cases. A large number of cells are available for quantitative analysis by FISH, as even interphase nuclei can be studied. It helps in detection of minimal residual disease and disease recurrence, as a very small percentage of abnormal cells can also be identified. The FISH probes used in this study were for the detection of the BCR/ABL fusion or t(9;22) in chronic myeloid leukemia (CML), PML/RARA fusion or t(15;17) in acute promyelocytic leukemia (APML) and determination of the XX/XY ratio in sex mismatched bone marrow transplantation. One hundred and fifty eight heparinized bone marrow or leukemic blood samples referred by consultants were analysed using the above mentioned FISH probes. These included samples of patients who underwent bone marrow transplantation. Karyotyping was carried out where indicated. Cases where FISH provided additional information or a different interpretation to karyotype analysis have been described.

PGD by FISH for a Reciprocal Translocation: First Baby from India

A couple with a history of five early miscarriages due to a balanced reciprocal translocation t(6;19) (p22;q13.4) in the wife, was referred for preimplantation genetic diagnosis (PGD) by fluorescence in situ hybridization (FISH). After oocyte retrieval, nine embryos were obtained. One cell from each embryo was biopsied, fixed and subjected to FISH using centromere and subtelomere probes for chromosomes 6 and 19. Five embryos which had unbalanced translocations, were not transferred. A balanced translocation or absence of translocation was seen in three embryos, which were transferred. One embryo had an anucleate cell and subsequently arrested. A pregnancy was achieved in the first intracytoplasmic sperm injection cycle itself and resulted in the birth of a healthy baby. This is the first baby after PGD for a reciprocal translocation in India. In 2010, the team of the authors reported the first successful pregnancy after PGD for a Robertsonian translocation and a normal child was born.

Affordable in vitro fertilization

Individuals often experience the pursuit of a baby through assisted reproductive technology (ART) as emotionally, physically, and financially exhaustive. Despite the birth of over 5 million babies through in vitro fertilization (IVF), restricted accessibility to these procedures due to financial constraints continues to affect many couples. Governmental intervention offers help in a few countries; however, insurance coverage is usually minimal. Efforts to make these procedures cost effective can be driven by medical professionals, government institutions, nongovernmental organizations (NGOs), the pharmaceutical industry, and by the couples themselves. Affordable IVF should translate into both cost effectiveness and efficiency, resulting in the best possible outcome.