Journal of Human Reproductive Science
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    Table of Contents - Current issue
Coverpage
January-March 2022
Volume 15 | Issue 1
Page Nos. 1-99

Online since Thursday, March 31, 2022

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EDITORIAL  

Editorial commentary p. 1
Padma Rekha Jirge
DOI:10.4103/jhrs.jhrs_42_22  
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REVIEW ARTICLE Top

Potential use of immature oocyte to improve fertility preservation outcome: A narrative review p. 3
Batara Sirait, Ahmad Aulia Jusuf, Budi Wiweko, Nining Handayani, Daniel Abidin Aubry, R Muharam
DOI:10.4103/jhrs.jhrs_112_21  
Fertility preservation through gamete vitrification has become one of the critical strategies to secure a childbearing potential in patients who are diagnosed with cancer or risks of infertility. Preserving the gametes would prevent the deleterious effects of cancer drugs or radiotherapy exposure on the quality of the gametes. Furthermore, in vitro fertilisation of vitrified mature human oocytes has lately demonstrated promising results that are reflected in the increased survival rate of thawed oocytes and the resultant clinical pregnancy rate. However, limitations in the cryopreservation of mature oocytes of cancer patients persist. Ovarian stimulation protocols which comprise administering gonadotrophin-releasing hormones could aggravate cancer or delay essential cancer therapy. Considering such circumstances, vitrification of immature oocytes would become a rational option. While the vitrification procedure of mature oocytes has been established, the vitrification of immature oocytes remains controversial due to a low post-thaw in vitro maturation and fertilisation rate. Apparent cryoinjuries to the immature oocytes post thawing or warming have been observed in both human and animal model oocytes. An alternative strategy was therefore proposed to improve the effectiveness of utilising immature oocytes for fertility preservation by conducting the in vitro oocyte maturation process first before vitrification. This method has prevailed, especially in oncofertility patients. Although the success rate of the clinical outcomes remains low, this approach, in conjugation with proper counselling, might provide oncofertility patients with an opportunity to preserve their reproductive potential.
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ORIGINAL ARTICLES Top

Reproductive toxicity of Carlina gummifera L. incense inhalation in adult male wistar rats p. 12
Hallegue Dorsaf, Moujahed Sabrine, Ben Barka Zaineb, Tebourbi Olfa, Sakly Mohsen, Ben Rhouma Khemais
DOI:10.4103/jhrs.jhrs_149_21  
Background: Burning incense of Carlina gummifera L. is a traditional practice in North African countries for religious or ritual intentions. Aim: The aim of this study was to investigate the effects of smoke incense of this plant on the reproductive function in adult male rats. Setting and Design: This study was conducted in the Integrated Physiology Laboratory. Materials and Methods: Plant roots were collected, dried and finely ground in powder form. Adult Wistar rats were randomly assigned to treated groups exposed daily during 60 min for 15 consecutive days to smoke incense at 2, 4 and 6 g and a control group was subjected to the same conditions in the absence of smoke. Statistical Analysis Used: Statistical analysis was performed using one-way analysis of variance followed by Tukey's multiple comparison as the post hoc test. Results: Exposure to the incense of Carlina gummifera L. seriously affected dose dependently the reproductive function in male rats. It was found that in treated groups, the testicle relative weight decreased, while those of seminal vesicles and prostate increased when compared to the untreated group. Carlina gummifera L. incense inhalation reduced the total number, viability and mobility of epididymis spermatozoa compared to control. Furthermore, incense exposure induced various histological changes in the testes, prostate and seminal vesicles, including in particular a decrease in the number of gametes in the seminiferous tubes, the reduction of prostatic secretions and the macrophagic resorption of the seminal secretions. The effect of Carlina incense on the antioxidant system was evaluated by assaying the two antioxidant enzyme activities catalase and superoxide dismutase as well as thiol group levels in the testicles. Our results showed that fumigation affected these parameters, suggesting that the morphological and functional modifications in the male reproductive system induced by Carlina gummifera L. incense may be related, in part, to the alteration of the oxidative balance in the testicle. Conclusion: Smoke incense of Carlina gummifera L. caused marked reproductive toxicity in adult male rats associated with induced oxidative stress.
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An In vitro study on the protective effect of melatonin on human sperm parameters treated by cadmium p. 21
Sekineh Amirjannaty, Nasrin Ghanami Gashti, Ali Mojtahedi, Asieh Ashouri, Mohammad Hadi Bahadori
DOI:10.4103/jhrs.jhrs_151_21  
Background: Male infertility account for nearly 50% of infertility cases. Cadmium is regarded as a well-known toxic metal for industrial applications; high amounts of cadmium in the human body can result in chronic toxicity. Melatonin as a free radical scavenger has anti-inflammatory, and even anti-cancer and antiapoptotic functions. Aim: In this work, we evaluated the protective effect of melatonin on human sperm parameters treated by cadmium. Study Setting and Design: This was an experimental study carried out from May to December 2019. Materials and Methods: A total of 41 fresh semen samples were collected from fertile men and were divided into 4 groups: (1) control, (2) sperm +25 Nm cd, (3) sperm +25 nM cd +0.1 mM melatonin,(4) sperm +0.1 mM melatonin treated for 60 min. In all groups, semen analysis was performed for motility, viability and DNA fragmentation index (DFI). Statistical Analysis: The groups were compared using the ANOVA test. Results: The group treated with cadmium showed a significant decrease in rapid and slow motility, and survival rate compared with the control group (P < 0.05). However, the degree of DFI and sperm with non-progressive motility in the group treated with cadmium had a significant increase compared to the control (P < 0.05). The use of melatonin significantly improved sperm parameters such as motility, survival rate and decreased sperm DFI with non-progressive motility. Conclusions: The use of melatonin reduces the amount of cadmium damage in human sperm in vitro.
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Lipid accumulation product better predicts metabolic status in lean polycystic ovary syndrome than that by visceral adiposity index p. 27
Hurjahan Banu, Md Shahed Morshed, Tania Sultana, Sukanti Shah, Shazia Afrine, MA Hasanat
DOI:10.4103/jhrs.jhrs_114_21  
Background: Both visceral adiposity index (VAI) and lipid accumulation product (LAP) can be used to assess insulin resistance (IR) and metabolic syndrome (MetS) which are required for management of even lean polycystic ovary syndrome (PCOS) (body mass index [BMI] <23 kg/m2). Aim: This study was aimed to see the magnitude of associations of VAI and LAP with cardiometabolic risk factors including IR and MetS in lean PCOS. Study Setting and Design: This cross-sectional study was done amongst 62 newly detected lean PCOS patients and 58 age- and BMI-matched healthy controls. Materials and Methods: PCOS was diagnosed according to the Revised 2003 Rotterdam Consensus criteria. Along with relevant clinical data, fasting blood was taken to measure glucose, insulin and lipid profile by glucose oxidase, chemiluminescent microparticle immunoassay and by glycerol phosphate dehydrogenase-peroxidase method, respectively. IR was calculated by homeostasis model of IR (HOMA-IR). VAI and LAP were calculated from BMI, waist circumference, triglyceride and high-density lipoprotein cholesterol by using sex-specific formulae. Statistical Analysis Used: Linear and binary regression analyses and receiver operating characteristics curve (ROC) analyses were done as appropriate. Results: Only LAP had predictive associations with age, systolic and diastolic blood pressure and total and low-density lipoprotein cholesterol. Both VAI and LAP had predictive associations with history of subfertility and MetS. LAP had moderate discriminating index for IR with cut-off of HOMA-IR of 2.3. Both VAI and LAP had excellent discriminating index for MetS in lean PCOS patients. Conclusions: LAP had more associations with cardiometabolic risks than VAI and was a moderate discriminator of IR in lean PCOS.
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Correlation of serum homocysteine levels and hyperinsulinaemia with body mass index in polycystic ovarian syndrome p. 34
Rashmi Bhushan, Parul Sinha
DOI:10.4103/jhrs.jhrs_147_21  
Background: Polycystic ovary syndrome (PCOS) is one of the most common endocrinopathies affecting women in reproductive age group. The interrelationship of serum homocysteine, homoeostatic assessment of insulin resistance (HOMA-IR) and body mass index amongst overweight, obese and non-obese PCOS patients is not fully established. Aims: We aimed to study the correlation of serum homocysteine levels and hyperinsulinaemia with body mass index (BMI) in PCOS patients. Study Setting and Design: This was a case–control study in which 35 women with PCOS and 35 non-PCOS women acting as controls were enrolled. Materials and Methods: Cases were identified by Rotterdam's criteria. (IR) indices, HOMA determination and serum homocysteine levels were determined and their correlation with BMI was studied. Statistical Analysis Used: Student's t-test and analysis of variance test were used for statistical analysis. The Pearson correlation coefficient was then used to estimate the correlation. Results: On overall evaluation, a significant positive correlation of fasting insulin, HOMA-IR and serum homocysteine) was observed (P < 0.05), however, on evaluating the correlation of these markers independently in cases and controls, only fasting insulin and HOMA-IR showed a significant correlation. In a multivariate model where PCOS was considered a dependent variable with age, fasting glucose, HOMA-IR, serum homocysteine and body mass index as the independent variables, only serum homocysteine levels were found to be significantly associated with the dependent variable (odds ratio = 1.172; 95% confidence interval = 1.032–1.330). Conclusion: PCOS women had significantly higher mean fasting glucose, fasting insulin, HOMA-IR and homocysteine levels as compared to non-PCOS controls. Mean HOMA-IR, homocysteine and fasting insulin levels showed a significant incremental trend with increasing BMI category in overall evaluation as well as in cases and controls independently.
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Prevalence of polycystic ovarian syndrome, phenotypes and their ovulation response to sequential letrozole dose escalation among infertile women at a tertiary care centre in Southern India p. 42
Abha Khurana, MV Swamy, Sujoy Mitra, Sangisapu Srinivas, N Nagaraja
DOI:10.4103/jhrs.jhrs_141_21  
Background: Women with polycystic ovarian syndrome (PCOS) often have anovulatory infertility requiring ovulation induction with letrozole. Aims: This study aimed to determine the prevalence and phenotypic categorisation of infertile PCOS women and to assess ovulatory response and pregnancy rates of PCOS phenotypes with sequential letrozole dose escalation. Study Setting and Design: This was a prospective observational study. Materials and Methods: One hundred seventy-five infertile PCOS women were enrolled. One hundred fifty-six women received ovulation induction as per the protocol with sequential letrozole dose escalation in each subsequent cycle (2.5 mg, 5 mg and 7.5 mg). Responses were assessed by ovulation and/or pregnancy. Statistical Analysis Used: Descriptive statistics were elaborated by means, medians, frequencies and percentages. Group comparisons and linear correlation between two continuous variables were done using appropriate statistical tests. Results: Eighty-seven (49.7%) women were Phenotype A; 11 (6.3%) were Phenotype B; 20 (11.4%) were Phenotype C and 57 (32.6%) were Phenotype D in our study. After excluding the lost to follow up participants in each induction cycle, 33.3% (2.5 mg dose); 62.8% (5 mg dose) and 78.9% (7.5 mg dose) women responded to letrozole. A significant increase in ovulation to escalating letrozole doses was noted (Phenotype A: 35.1% to 2.5 mg, 53.7% to 5 mg and 72.7% to 7.5 mg; Phenotype B: 30% to 2.5 mg and 80% to 5 mg; Phenotype C: 35.3% to 2.5 mg and 87.5% to 5 mg and Phenotype D: 30.8% to 2.5 mg, 65.6% to 5 mg and 87.5% to 7.5 mg). Fifty-six of 156 (35.9%) infertile PCOS women achieved pregnancy; increase in pregnancy rates with escalated doses of letrozole was noted. Conclusion: All PCOS phenotypes show a similar response to escalating doses of letrozole. The role of phenotypic sub-categorisation for variable response to letrozole as an ovulation-inducing agent is uncertain.
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The İmpact of gonadotropin type on controlled ovarian stimulation and İntrauterine İnsemination cycle outcomes p. 51
Ozge Senem Yucel Cicek, Merve Demir
DOI:10.4103/jhrs.jhrs_177_21  
Background: Intrauterine insemination (IUI) combined with controlled ovarian stimulation (COS) results in higher pregnancy rates. However, there is still no consensus on the optimal COS protocol. Aims: In the present study, we aimed to analyse the effects of COS protocols with different gonadotropin types on IUI outcomes. Study Setting and Design: This was a retrospective cohort study conducted at the infertility clinic of a University hospital, including 237 COS + IUI cycles. Materials and Methods: Eligible cycles were divided into three groups according to the type of gonadotropin used for COS; cycles with recombinant follicle-stimulating hormone (rFSH) (group 1, n = 36), highly purified FSH (HP-FSH) (group 2, n = 178) and highly purified menotropin (HP-hMG) (group 3, n = 23). Clinical pregnancy rate (CPR) and live birth rate (LBR) per cycle were compared between groups. Statistical Analysis Used: The Mann–Whitney U test and Kruskal–Wallis test were used to compare numerical variables. Dunn test was used for multiple comparisons. Results: The duration of stimulation and total gonadotropin dose were similar between the three groups (P > 0.05). The CPR was 16.7% in rFSH group, 9.6% in HP-FSH group and 13.0% in HP-hMG group. The LBR was 16.7% in rFSH group, 8.4% in HP-FSH group and 13.0% in HP-hMG group. Both CPR and LBR were comparable in all three groups (P > 0.05). Conclusions: Ovarian stimulation with rFSH, HP-FSH and HP-hMG show similar COS characteristics. Furthermore, these three gonadotropin protocols for COS + IUI yielded comparable CPR and LBR. These findings suggest that all three gonadotropin types (rFSH, HP-FSH, HP-hMG) are similarly effective in COS + IUI cycles.
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Does Follicle-Stimulating hormone receptor polymorphism status affect In vitro fertilization-intracytoplasmic sperm injection results and live birth rate? A retrospective study p. 58
Burak Bayraktar, Ebru Sahin Gulec, Yasar Bekir Kutbay, Can Kose, Esra Bahar Gur, Ahmet Demir
DOI:10.4103/jhrs.jhrs_165_21  
Background: Follicle-stimulating hormone (FSH) plays a key role in fertility and shows its effect through the FSH receptor (FSHR), which is localized in cells. Aims: The aim of this study was to examine pregnancy outcomes and responses to controlled ovarian stimulation according to FSHR polymorphism types. Study Setting and Design: The study was retrospective, and included patients who applied to the University of Health Sciences Tepecik Training and Research Hospital in vitro fertilization (IVF) Unit during 2018 and 2019. Materials and Methods: Patients who underwent IVF-intracytoplasmic sperm injection and at the same time studied FSHR gene polymorphism in the genetic unit of our hospital were included in the study. Statistical Analysis: The Kruskal–Wallis test was used for multiple comparisons of continuous variables. The Chi-square test was used for categorical variables between groups. Results: A total of 143 patients who met our criteria were included in the study. 14% (n = 20) of the patients are also homozygous natural (Asn/Asn) type; 44.7% (n = 64) of the heterozygous mutant (Asn/Ser) type; 41.3% (n = 59) of them were homozygous mutant (Ser/Ser) type. There was no statistically significant difference between the groups in terms of pregnancy rate per started cycle, ongoing pregnancy per started cycle, ongoing pregnancy per embryo transfer and live birth per embryo transfer. A significant difference was observed between peak E2 and peak progesterone levels between Asn/Ser and Ser/Ser groups, and the levels of these hormones were lower in the Ser/Ser group (P = 0.018 and P = 0.016, respectively). Ovarian responses were classified as poor (≤3 oocytes), normal (4-20 oocytes) and hyperresponse (≥20 oocytes) according to the oocyte count. Accordingly, the number of patients with poor response was higher in the Ser/Ser group (P = 0.011). Conclusions: Ser/Ser polymorphism is characterised by a poor ovarian response. Despite this, polymorphisms in the FSHR gene do not seem to affect the results of pregnancy per started cycle, ongoing pregnancy per started cycle, ongoing pregnancy per embryo transfer and live birth per embryo transfer.
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Role of female age in regulating the effect of sperm DNA fragmentation on the live birth rates in intracytoplasmic sperm injection cycles with own and donor oocytes p. 64
Deepthi Repalle, KV Saritha, Shilpa Bhandari, Megha Chittora, Jitendra Choudhary
DOI:10.4103/jhrs.jhrs_150_21  
Background: Sperm DNA integrity assessment has been progressively used as an unfettered measure of sperm as it proffers more prognostic and diagnostic information than routine semen analysis. The contentious effect of sperm DNA fragmentation (SDF) on clinical outcomes can be attributed to female factors such as age, oocyte quality and ovarian reserve. Aims: The study is mainly aimed to know the influence of SDF on the live birth rates in intracytoplasmic sperm injection (ICSI) cycles with own and donor oocytes. Second, to know the role of female age in regulating the effect of SDF on the live birth rates in ICSI cycles with own and donor oocytes. Setting and Design: A prospective cohort study was done at our tertiary care centre attached to the reproductive medicine unit in medical college. Materials and Methods: The study included 356 patients who underwent first ICSI cycles either with own or donor-oocytes along with day 5 fresh embryo transfers only. The main outcome measures were live birth rates and miscarriage rates. Statistical Analysis Used: Chi-squared test was used to compare the categorical variables between the groups. The receiver operating characteristic curve was developed to correlate the female age with the live birth rate. Results: A significant decrease in the live birth rates (42.85% vs. 26.15%, P = 0.023) and an increase in the miscarriage rates (12.30% vs. 34.61%, P = 0.013) were observed in the high-SDF group ICSI cycles of own-oocyte patients. However, there was no significant difference in the live birth rates and miscarriage rates in the low- and high-SDF groups of donor oocyte ICSI cycle patients (P > 0.05). The own-oocyte ICSI cycle patients were further stratified based on the female age. In the female age group ≤30 years there was no significant difference in the live birth and miscarriage rates (P > 0.05) similar to donor oocyte ICSI cycles. Whereas, there was a significant difference in the live birth rates in the females of age >30 years (13.79% vs. 34.37%, P = 0.040). Conclusion: In conclusion, high-SDF has a negative influence on the live birth rates and a positive influence on the miscarriage rates in patients with own-oocyte ICSI cycles. A similar influence was not observed in patients with donor-oocyte ICSI cycles and in young female patients (age ≤30 years) with own-oocyte ICSI cycles.
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Positive correlation of oestradiol level on trigger day with the secretion level of endometrial kisspeptin and leukaemia Inhibitory Factor in the Mid-Luteal Stimulated Cycle p. 72
Arie Adrianus Polim, Nusratuddin Abdullah, Mochammad Hatta, Rosdiana Natzir, Soegiharto Soebijanto, Caroline Hutomo, Aryando Pradana, Reino Rambei
DOI:10.4103/jhrs.jhrs_120_21  
Background: Kisspeptin plays a role in the oestradiol negative-feedback regulation of GnRH as well as gonadotropin. In addition, kisspeptin has been postulated to induce the production of an important cytokine called leukaemia inhibitory factor (LIF). Aims: This study aims to investigate the correlation between varying oestradiol levels measured on trigger day of the ovarian stimulation and the mRNA expression level of endometrial kisspeptin and LIF. Study Setting and Design: Prospective cross-sectional study took place in Morula IVF Jakarta clinic. Materials and Methods: A total of 43 infertile couples underwent an in-vitro fertilization (IVF) program. Subjects were grouped based on oestradiol levels as follows: group A ([≧ 3000 pg/mL, n = 15], group B [2000–2999 pg/mL, n = 14], group C [<2000 pg/mL, n = 14]). Statistical Analysis Used: ANOVA test was utilised to compare the expression of kisspeptin and LIF among study groups while Pearson correlation was used to identify the correlation between variables. Results: A significantly higher mRNA expression of both Kisspeptin and LIF was found in group A than in groups B and C (P < 0.001). The mRNA expression of kisspeptin and LIF correlated positively with the oestradiol level (r = 0.638, P < 0.001 and r = 0.634, P < 0.001, respectively). Moreover, a strong association between Kisspeptin and LIF expression was also detected (r = 0.700, P < 0.001). Conclusions: mRNA expression of kisspeptin and LIF was significantly different according to the oestradiol levels in the study groups. Increased oestradiol level was shown to elevate the expression of endometrial kisspeptin and LIF in women undergoing the IVF programme.
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The correlation of chronological age and micro ribonucleic acid-135b expression in spent culture media of In vitro fertilisation patient p. 78
Tiara Berliana Azzahra, Ririn Rahmala Febri, Pritta Ameilia Iffanolida, Kresna Mutia, Budi Wiweko
DOI:10.4103/jhrs.jhrs_122_21  
Background: The lack of accuracy in embryo viability assessment methods still remains a challenge to increase the in vitro fertilisation (IVF) success rate. The chronological age and micro ribonucleic acid (RNA)-135b influence the quality of the embryo since microRNA-135b expresses stably in the spent culture media. Therefore, microRNA-135b has the potential to become a non-invasive biomarker of IVF embryo quality. Aims: (1) The aim of this study is to determine the chronological age and microRNA-135b expression distribution of IVF patients. (2) to determine the correlation between chronological age and microRNA-135b expression in spent culture media of IVF patients. Study Setting and Design: An observational study was conducted in Yasmin IVF clinic. Materials and Methods: The chronological age data were collected from the medical records and 31 spent culture media samples from 11 IVF patients were taken on day 5 of embryo culture. We also collected the basal media sample as the control group. The microRNA-135b expression was analysed using quantitative real-time polymerase chain reaction (qPCR) analysis. Statistical Analysis Used: The data analysis was performed using IBM SPSS Statistics 25. Results: The chronological age and microRNA-135b expression were distributed abnormally. There was a significant positive correlation with moderate statistical power between chronological age and microRNA-135b expression in spent culture media. MicroRNA-135b expression increased 4.9-fold in spent culture media than basal media of IVF. Conclusions: The increase of chronological age is followed by the rise of microRNA-135b expression in spent culture media of IVF patients. The microRNA-135b is a potential biomarker to predict IVF embryo quality.
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Mitochondrial DNA levels in trophectodermal cells show no association with blastocyst development and pregnancy outcomes Highly accessed article p. 82
G Ritu, Geetha Veerasigamani, Mohammed C Ashraf, Sankalp Singh, Saniya Laheri, Stacy Colaco, Deepak Modi
DOI:10.4103/jhrs.jhrs_103_21  
Background: In patients undergoing assisted reproduction, levels of mitochondrial DNA (mtDNA) in the trophectodermal cells of the developing blastocyst are suggested to be associated with its ability to implant. However, discrepancies exist regarding the use of mtDNA levels as a reliable biomarker to predict outcomes of assisted reproduction. Aims: The aim of the study is to explore the association of trophectodermal mtDNA levels to determine blastocyst quality, implantation potential of blastocyst and clinical outcomes in couples who have undergone pre-implantation genetic testing for aneuploidy (PGT-A). Study Setting: Private fertility centre. Study Design: Retrospective analysis. Materials and Methods: We analysed mtDNA levels in the trophectodermal cells of 287 blastocysts from 61 couples undergoing PGT-A. The levels of mtDNA were estimated by next-generation sequencing method. mtDNA levels were correlated with maternal age, blastocyst morphology, ploidy status, implantation rates, miscarriage rate and live birth rate. Statistical Analysis Used: Linear regression and one-way ANOVA with Tukey's all column comparison test. Results: The trophectodermal mtDNA levels did not correlate with maternal age. There were no significant differences in their levels in grade 1 and grade 2 blastocysts. No significant differences were seen between mtDNA levels of implanted and non-implanted blastocysts or those blastocysts that resulted in miscarriage or live birth. However, significantly lower amounts of mtDNA were seen in euploid blastocysts as compared to that in aneuploid blastocysts. Conclusion: mtDNA levels in the trophectodermal cells of the blastocyst do not associate with blastocyst quality (grade 1 and grade 2), implantation potential and clinical outcomes but can differentiate between aneuploid and euploid blastocysts. Our study does not support the use of trophectodermal mtDNA levels as a biomarker for blastocyst quality and predictor of clinical outcomes.
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Transvaginal ultrasound-guided methotrexate instillation for failed medical management of ectopic pregnancies in subfertile women p. 90
Nikita Naredi, Sumeet Ranjan Tripathy, Rajesh Sharma
DOI:10.4103/jhrs.jhrs_1_22  
Background: Ectopic pregnancy (EP) defined as extrauterine implantation of the embryo can be managed medically or surgically. Medical management entails systemic administration of the antineoplastic drug methotrexate (MTX) which, if not successful, surgical management is resorted to. However, we carried out this study wherein the failed medical management cases were given intra-gestational sac MTX instead of surgery. Aim: The aim of this study was to assess the efficacy of intra-gestational MTX administration as a treatment modality for failed medical management of ectopic pregnancies. Study Setting and Design: It was a prospective interventional study carried out at the Reproductive Medicine Centre of a tertiary care hospital. Materials and Methods: It was a prospective interventional study wherein 12 patients of EP with failed medical management (as per established criteria) were administered intra-gestational MTX with follicle aspiration needle under transvaginal sonography guidance. Statistical Analysis Used: Data were collected in Microsoft Excel. Numerical continuous variables were expressed as mean ± standard deviation. Categorical variables were expressed as count/percentage. Results: All the patients responded to the local administration of MTX, with none requiring rescue surgery. In addition, no one had any complication of the local instillation. However, one patient required an additional dose of MTX. Conclusion: Intra-gestational MTX administration is a viable non-surgical modality for treatment of ectopic pregnancies even in cases of failed medical management with an added benefit of tubal preservation.
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LETTER TO EDITOR Top

Age-Specific distribution of serum anti- Müllerian hormone and antral follicle count in indian infertile women p. 96
Mahmood Dhahir Al-Mendalawi
DOI:10.4103/jhrs.jhrs_2_22  
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AUTHORíS REPLY Top

Age-Specific distribution of serum anti- Müllerian hormone and antral follicle count in Indian infertile women p. 97
Devika Gunasheela
DOI:10.4103/jhrs.jhrs_37_22  
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LETTER TO EDITOR Top

46XX testicular disorder of sex development p. 98
Aasim N Maldar, Phulrenu H Chauhan
DOI:10.4103/jhrs.jhrs_19_22  
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46, XX testicular disorder of sex development: A case report p. 99
Krishnachaitanya Mantravadi
DOI:10.4103/jhrs.jhrs_34_22  
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