Perumal Vanamail

Does endometrial injury enhances implantation in recurrent in-vitro fertilization failures? A prospective randomized control study from tertiary care center

Background: Though Assisted Reproductive Techniques have overcome many fertility disorders, implantation is still considered, the rate-limiting step for the success of IVF. Aim0 : The aim of this study was to evaluate the role of endometrial scratching in improving the implantation rate in patients undergoing IVF-ET cycles. Design: Prospective randomized control trial. Methods and Material: Sixty infertile women with a history of >1 previous failed IVF-ET cycles were randomizedinto two groups of 30 each. The patients in group 1 underwent endometrial scratching once between days 14-21 of menstrual cycle in the cycle prior to embryo transfer (ET), while in group 2scratching were not done. Implantation rate, ongoing pregnancy rate, abortion rate and live birth rate were comparedbetween both groups. Statistical Analysis: Mean values were compared between two groups using Student′s′t′ independent test. Frequency distributions of categorical variables were compared using Chi-Square/ Fisher′s exact test as appropriate. Results: Implantation rate in group 1 was 19.4% whereas in group 2 it was 8.1%. Difference between two groups was statistically significant (P =0.028). The live birth rate was higher in the group 2 compared to group 1, however this difference was not statistically significant (3.3% vs 10%, P =0.612). No significant difference was observed between the two groups regarding the ongoing pregnancy rate (16.7% vs 0.0%; P =0.052), abortion rate (10.0% vs 3.3%, P =0.612) and miscarriage rate (6.7% vs 3.3%, P =0.99). Conclusions: Implantation rate increases significantly after endometrial scratching in patients with previous failed IVF-ET.

Role of dehydroepiandrosterone in improving oocyte and embryo quality in IVF cycles.

The purpose of this study was to evaluate the role of dehydroepiandrosterone (DHEA) on the number and quality of oocytes and embryos in poor responders undergoing IVF cycles. A total of 50 patients with a history of poor ovarian response in the previous cycle(s) were enrolled in a prospective cohort study. They were treated with oral micronized DHEA 25mg three times a day for 4 months. Oocyte and embryo number and quality were recorded before and after treatment. The results were analysed using Students paired t-test. After treatment with DHEA, a significant increase in number of mature follicles was seen in the post treatment period (⩽ 35 years P<0.001; ⩾ 36 years P = 0.002). There were significant increases in numbers of oocytes retrieved, fertilization rates and, consequently, the total number of embryos available. More embryos were vitrified among patients ⩽ 35 years (P<0.001) post treatment, and clinical pregnancy rate in this group was 26.7%. DHEA treatment resulted in a higher number of oocytes retrieved, oocytes fertilized, embryos overall and of grade-I embryos. It can help in increasing pregnancy rate in poor responders. This study was performed to evaluate the role of dehydroepiandrosterone (DHEA) treatment on the number and quality of oocytes and embryos in poor responders undergoing IVF cycles. Fifty patients with a history of poor ovarian response in the previous cycle(s) were enrolled in the study and a prospective cohort study was performed. Patients were prescribed oral micronized DHEA 25mg three times a day for 4 months. Oocytes and embryos in terms of both number and quality were measured before and after treatment. A significant increase in mean number of mature follicles was seen in the post-treatment group. There was a significant increase in the number of oocytes retrieved, fertilization rates and, consequently, in the total number of embryos available after treatment with DHEA. More embryos were vitrified post treatment and the overall pregnancy rate was 20%. DHEA resulted in a significant improvement in the numbers of oocytes retrieved, oocytes fertilized, embryos and grade-I embryos. DHEA can help improve pregnancy rate in poor responders with history of previous failed IVF cycles.

A prospective study on role of dehydroepiandrosterone (DHEA) on improving the ovarian reserve markers in infertile patients with poor ovarian reserve

Abstract Aim: The aim of this study was to evaluate the role of dehydroepiandrosterone (DHEA) supplementation on the ovarian reserve markers in infertile patients who were poor responders in previous in vitro fertilization (IVF) cycles. Study design: A prospective clinical trial was conducted on 30 patients with history of poor response in previous IVF cycles. These patients were treated with DHEA, (Tab Eema-D, Corona Remedies Pvt Ltd., Ahmedabad, Gujurat, India) 25u2009mg thrice a day for four months. Ovarian stimulation was done using the previous protocol. Clinical parameters were measured before and treatment with DHEA. Results were analysed using Student’s “t” paired test. Results: DHEA resulted in a significant increase (pu2009<u20090.05) in the serum Antimullerian hormone in all age groups (35, 36–38 and >38 years). Peak estradiol level on the day of human chorionic gonadotrophin administration also increased significantly (pu2009<u20090.05). A significant decrease (pu2009<u20090.05) was noted in Day 2 follicle-stimulating hormone (FSH) in all age groups. There was no statistically significant difference in the antral follicle count (AFC). Pregnancy rate was 16.7% after treatment. Thus, DHEA has a significant effect in improving the ovarian reserve in poor responders with previously failed IVF cycles. It can help in enhancing clinical pregnancy rate in these patients.

Effect of endometriosis on implantation rates when compared to tubal factor in fresh non donor in vitro fertilization cycles

OBJECTIVE: The objective of the following study is to compare the outcome of in vitro fertilization and embryo transfer (IVF-ET) in women with endometriosis and tubal-factor infertility. DESIGN: Retrospective study. SETTING: Tertiary referral hospital, assisted reproductive technologies unit. MATERIALS AND METHOD: The study group consisted of 78 women diagnosed with advanced stage endometriosis. The control group included 100 women with tubal-factor infertility. These groups were retrospectively analyzed regarding stimulation, fertilization, embryo development, implantation and pregnancy outcome. INTERVENTION (S): Controlled ovarian hyperstimulation and IVF-ET. RESULTS: Lower oocyte yield with lower fertilization rate were found in women with endometriosis compared with tubal-factor control subjects. However, no differences were found in cleavage, implantation and clinical pregnancy rates between the endometriosis and tubal-factor groups. CONCLUSIONS: Our results showed that women with endometriosis have a lower oocyte yield and lower fertilization rate compared with women with tubal-factor infertility. However, once the oocyte is fertilized, it seems that the embryo has a normal chance of implantation, leading to similar pregnancy rates and adequately treated women with endometriosis have equal chances of conception as seen with tubal-factor infertility.

Perinatal survival and procedure-related complications after intrauterine transfusion for red cell alloimmunization.

ObjectivesTo study the perinatal survival and procedure-related (PR)complications after intrauterine transfusions in red cell alloimmunization.MethodsProspective data of 102 women with Rh-alloimmunized pregnancy undergoing intrauterine intravascular transfusion for fetal anemia, from January 2011 to October 2014 were analyzed. Main outcome measures were perinatal survival and procedure-related (PR) complications.ResultsA total of 303 intrauterine transfusions were performed in 102 women. Of 102 fetuses, 22 were hydropic at first transfusion. The mean period of gestation and hematocrit at first transfusion was 26.9xa0±xa03.3xa0weeks (range 19.7–33.8xa0weeks) and 17xa0±xa07.82xa0% (range 5.7–30xa0%), respectively. Average number of transfusions was 2.97 (range 1–7) per patient. Overall survival was 93xa0% and mean period of gestation at delivery was 34.5xa0±xa01.94 (range 28.3–37.4) weeks. Mean hematocrit at delivery was 36.9xa0±xa08.77xa0% (range 10–66xa0%). Fetal death occurred in four cases (3PR), neonatal death occurred in three cases (2PR). Emergency cesarean delivery after transfusion was performed in four pregnancies. The total PR complication rate was 2.97xa0%, resulting in overall PR loss in 1.65xa0% per procedure.ConclusionOur results compare favorably with other studies published in the literature. Intravascular transfusion is a safe procedure improving perinatal survival in fetuses with anemia due to Rh-alloimmunization.

Comparison of gonadotropin-releasing hormone agonist with GnRH antagonist in polycystic ovary syndrome patients undergoing in vitro fertilization cycle: Retrospective analysis from a tertiary center and review of literature

INTRODUCTION: Polycystic ovary syndrome (PCOS) is one of the most common infertility factor for which women are enrolled in in vitro fertilization (IVF) technique. In the recent years, gonadotropin releasing hormone antagonist protocol has emerged as the protocol of choice for controlled ovarian hyperstimulation in these patients. OBJECTIVES: The objective of the present study is to compare conventional long agonist protocol with fixed antagonist protocol in PCOS patients undergoing IVF cycle. MATERIALS AND METHODS: Retrospective analysis of 4 years data of a single center from northern India. Totally 81 patients who had long agonist protocol were compared with 36 patients with similar baseline characteristics who had antagonist protocol. RESULT: Total dose of gonadotropin required was significantly lower (P - 0.004) in the antagonist group. There was no significant difference in pregnancy rate or incidence of ovarian hyperstimulation syndrome between two groups. Cycle cancellation due to arrest of follicular growth was significantly higher in the antagonist group (P - 0.027). CONCLUSION: More randomized control trials and meta-analysis are required before replacing conventional long agonist protocol with antagonist protocol in patients with polycystic ovary syndrome.

Six months versus nine months anti-tuberculous therapy for female genital tuberculosis: a randomized controlled trial

OBJECTIVEnTo compare six months versus nine months anti-tuberculous therapy in patients of female genital tuberculosis.nnnSTUDY DESIGNnIt was a randomized controlled trial in a tertiary referral center teaching institute on 175 women presenting with infertility and found to have female genital tuberculosis on clinical examination and investigations. Group I women (86 women) were given 9 months of intermitted anti-tuberculous therapy under directly observed treatment short course (DOTS) strategy while Group II (89 women) were given 6 months of anti-tuberculous therapy under DOTS. Patients were evaluated for primary end points (complete cure, partial response, no response) and secondary end points (recurrence rate, pregnancy rate) during treatment. All patients were followed up further for one year after completion of therapy to assess recurrence of disease and further pregnancies.nnnRESULTSnBaseline characteristics were similar between two randomized groups. There was no difference in the complete clinical response rate (95.3% vs 97.7%, p=0.441) between 9-months and 6-months groups. Four patients in 9-months group and two patients in 6-months group had recurrence of disease and required category II anti tuberculous therapy (p=0.441). Pregnancy rate during treatment and up to one year follow up was also similar in the two groups (23.2% vs 21.3%, p=0.762). Side effects occurred in 27(31.4%) and 29(32.6%) in 9-months and 6-months of therapy and were similar (p=0.866).nnnCONCLUSIONSnThere was no difference in complete cure rate, recurrent rate and pregnancy rate for either 6-months or 9-months of intermittent directly observed treatment short course anti-tuberculous therapy in female genital tuberculosis.nnnCLINICAL TRIAL REGISTRATIONnThe trial was registered in clinicaltrials.gov with registration no: CTRI/2009/091/001088.

Role of early serum beta human chorionic gonadotropin measurement in predicting multiple pregnancy and pregnancy wastage in an in vitro ET fertilization cycle.

OBJECTIVE: This study was performed to assess the prognostic value of serum beta human chorionic gonadotropin (βhCG), measured on day 14 post embryo transfer (ET) for predicting multiple gestation and pregnancy wastage in women undergoing in vitro fertilization ET (IVF-ET). MATERIALS AND METHODS: This retrospective study was performed between May 2009 and November 2012. Out of the 181 women who conceived, 168 were included and the remaining 13 were excluded as their pregnancy was biochemical. Serum βhCG was measured using a chemiluminescent enzyme immunometric assay. The predictive values of serum βhCG for establishing multiple pregnancy and pregnancy wastages were calculated by receiver operating characteristic (ROC) curve analysis. Median values of serum βhCG and outcome of all pregnancies were compared. RESULTS: Out of the 168 patients who conceived after IVF treatment, 114 (68%) were viable pregnancies (delivered/ongoing). Among the viable pregnancies, 97 (85%) had a successful pregnancy outcome and the remaining 17 patients are ongoing pregnancies. Median values of βhCG (625 IU/L) among viable pregnancies was significantly (P < 0.05) higher than that of nonviable pregnancies (174 IU/L). The median values of βhCG for singleton (502 IU/L), twins (1093 IU/L), and triplets (2160 IU/L) was statistically significant (P < 0.05). Using ROC curve it was predicted that for a value of βhCG at 375 IU/L, the sensitivity of viable pregnancy was 65% and specificity of viable pregnancy was also 65%, with positive and negative predictive values of 65 and 68%, respectively. Similarly for multiple pregnancy and pregnancy wastage the predictive values of βhCG were 808 and 375 IU/L, respectively; while the sensitivity and specificity is more than 65% each. CONCLUSION: βhCG cutoff values determined on day 14 post ET by ROC curve analysis are useful in discriminating between multiple pregnancy and pregnancy losses. The cutoff value might aid in the prognosis, clinical management, and counseling of the IVF patients.

Comparative Study of Laparoscopic Abdominopelvic and Fallopian Tube Findings Before and After Antitubercular Therapy in Female Genital Tuberculosis With Infertility.

STUDY OBJECTIVEnTo study the effect of antitubercular treatment (ATT) on the laparoscopic abdominopelvic and fallopian tube findings in female genital tuberculosis (FGBT).nnnDESIGNnProspective cohort (Canadian Task Force classification II2).nnnSETTINGnTertiary referral center in northern India.nnnPATIENTSnFifty women with infertility and diagnosed with FGTB on laparoscopy, histopathology findings, or endometrial sampling (acid-fast bacilli culture, granuloma on histopathology, positive polymerase chain reaction).nnnINTERVENTIONSnDiagnostic laparoscopy in all women diagnosed with FGTB before and after a 6-month course of ATT (2 months of rifampicin, isoniazid, pyrazinamide, and ethambutol, followed by 4 months of rifampicin and isoniazid). All procedures were performed by the same surgeon between June 2012 and May 2014.nnnMEASUREMENTS AND MAIN RESULTSnThe mean patient age was 28.7 years, mean parity was 0.9, and mean body mass index was 23.6 kg/m(2). Infertility was seen in all 50 women (66% primary infertility, 34% secondary infertility), with a mean duration of 6.06 years. Abnormal laparoscopic findings of FGTB included tubercles in the pelvic peritoneum, fallopian tube, and ovary in 27 women (54%) before ATT and in only 1 (2.04%) woman after ATT (p < .001). Caseous nodules and encysted ascites were seen in 4 women (8%) before ATT, and in no women after ATT (p < .001); however, there was no change from before ATT to after ATT in the rate of pelvic adhesions (42% vs 42.5%) and perihepatic adhesions (56% vs 58%). Laparoscopic findings in fallopian tubes included hydrosalpinx (32%), pyosalpinx (4%), beaded tubes (12%), nonvisualization of tube (20%), and tubal blockage on the right side (56%), left side (50%), and both sides (38%) before ATT. Hydrosalpinx, beaded tubes, and nonvisualized tube were seen in 33.4%, 4.1%, and 20.8% cases, respectively, after ATT; however, free spill increased to 52% on the right side and 50% on left side after ATT.nnnCONCLUSIONnATT improves laparoscopic findings in FGTB with infertility. However, advanced fibrotic lesions (eg, pelvic and perihepatic adhesions, bilateral blocked tubes) do not improve with ATT.

Comparative Proteomic Analysis of Advanced Ovarian Cancer Tissue to Identify Potential Biomarkers of Responders and Nonresponders to First-Line Chemotherapy of Carboplatin and Paclitaxel

Conventional treatment for advanced ovarian cancer is an initial debulking surgery followed by chemotherapy combination of carboplatin and paclitaxel. Despite initial high response, three-fourths of these women experience disease recurrence with a dismal prognosis. Patients with advanced-stage ovarian cancer who underwent cytoreductive surgery were enrolled and tissue samples were collected. Post surgery, these patients were started on chemotherapy and followed up till the end of the cycle. Fluorescence-based differential in-gel expression coupled with mass spectrometric analysis was used for discovery phase of experiments, and real-time polymerase chain reaction, Western blotting, and pathway analysis were performed for expression and functional validation of differentially expressed proteins. While aldehyde reductase, hnRNP, cyclophilin A, heat shock protein-27, and actin are upregulated in responders, prohibitin, enoyl-coA hydratase, peroxiredoxin, and fibrin-β are upregulated in the nonresponders. The expressions of some of these proteins correlated with increased apoptotic activity in responders and decreased apoptotic activity in nonresponders. Therefore, the proteins qualify as potential biomarkers to predict chemotherapy response.