Journal of Human Reproductive Science
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    Table of Contents - Current issue
Coverpage
July-September 2021
Volume 14 | Issue 3
Page Nos. 215-326

Online since Tuesday, September 28, 2021

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EDITORIAL  

Editorial Commentary p. 215
Padma Rekha Jirge
DOI:10.4103/jhrs.jhrs_140_21  
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REVIEW ARTICLE Top

Genetics of male infertility – Present and future: A narrative review Highly accessed article p. 217
Digumarthi V S Sudhakar, Rupin Shah, Rahul K Gajbhiye
DOI:10.4103/jhrs.jhrs_115_21  
Infertility affects 8%–12% of couples worldwide with a male factor contributing to nearly 50% of couples either as a primary or contributing cause. Several genetic factors that include single-gene and multiple-gene defects associated with male infertility were reported in the past two decades. However, the etiology remains ambiguous in a majority of infertile men (~40%). The objective of this narrative review is to provide an update on the genetic factors associated with idiopathic male infertility and male reproductive system abnormalities identified in the last two decades. We performed a thorough literature search in online databases from January 2000 to July 2021. We observed a total of 13 genes associated with nonobstructive azoospermia due to maturation/meiotic arrest. Several studies that reported novel genes associated with multiple morphological abnormalities of the sperm flagella are also discussed in this review. ADGRG2, PANK2, SCNN1B, and CA12 genes are observed in non-CFTR-related vas aplasia. The genomic analysis should be quickly implemented in clinical practice as the detection of gene abnormalities in different male infertility phenotypes will facilitate genetic counseling.
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ORIGINAL ARTICLES Top

Association of serum leptin with anthropometric indices of obesity, blood lipids, steroidal hormones, and insulin resistance in polycystic ovarian syndrome p. 228
Manjulata Kumawat, Priyanka Choudhary, Sameer Aggarwal
DOI:10.4103/jhrs.jhrs_35_21  
Background: Polycystic ovarian syndrome (PCOS) is a major form of anovulatory infertility in women. It is often associated with obesity and insulin resistance (IR), both of which are linked to leptin and its receptors. Aim: The aim of this study was to evaluate the interrelationship between serum leptin level with anthropometric indices of obesity, lipid profile, IR, and with circulating steroidal hormones in PCOS women. Settings and Design: An observational case–control study was conducted in a medical college and hospital setting. Methods: Ninety diagnosed cases of PCOS along with ninety age-matched normal women were enrolled. Serum insulin, lipid profile, steroidal hormones, and serum leptin were estimated. IR was calculated using the Homeostatic Model Assessment-IR. Anthropometric measurements were also taken of each study participant. Statistical Analysis: Descriptive statistics along with independent sample t-test and Pearson (r) correlation coefficients were used. Results: Women with PCOS had high mean value of waist circumference (P = 0.00), hip circumference (P = 0.00), and hormonal levels than the control group (luteinizing hormone [LH] [P = 0.00], testosterone [P = 0.00], LH/follicle-stimulating hormone ratio [P = 0.00], leptin [P = 0.00], and IR [P = 0.00]). Serum insulin levels (P = 0.02), IR (P = 0.01), body mass index (BMI) (P = 0.03), and fasting blood sugar (P = 0.01) had a positive correlation with leptin. Insulin (P = 0.01), IR (P = 0.02), fasting blood sugar (P = 0.001), and leptin (P = 0.00) were more in the obese control group. Conclusion: Serum leptin level is raised in PCOS patients, and it is correlated positively with BMI, fasting blood sugar, insulin metabolism, and IR.
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Visceral adiposity index and lipid accumulation product as diagnostic markers of metabolic syndrome in South Indians with polycystic ovary syndrome p. 234
Zeinab Naghshband, Lakshmi Kumar, Sonia Mandappa, Ashitha S Niranjana Murthy, Suttur S Malini
DOI:10.4103/jhrs.jhrs_12_21  
Background: Cardiovascular disease (CVD) is one of the debilitating consequences of polycystic ovary syndrome (PCOS). Early diagnosis of metabolic syndrome (MetS) with a simple but accurate method can reduce the risk of progression to CVD in PCOS. Aims: This study aimed to determine the accuracy of various anthropometric indices and lipid accumulation product (LAP), in assessing the risk of MetS in PCOS. Settings and Design: This is a cross-sectional study including 150 PCOS women and 100 control subjects. Materials and Methods: Anthropometric parameters were measured and calculated. Lipid profile, fasting plasma glucose (FPG), and insulin were estimated. MetS was detected according to the International Diabetes Federation criteria. Statistical Analysis: Logistic regression and receiver operating characteristic curve analysis were applied to determine the potential association of anthropometric indices such as body mass index, waist circumference (WC), waist-to-hip ratio, waist-to-height ratio, conicity index (CI), visceral adiposity index (VAI), abdominal volume index (AVI), body adiposity index (BAI), and a body shape index (ABSI) and LAP with MetS. Results: In our study of PCOS women of the south Indian population, the prevalence of MetS was 59.3%, which was higher than other populations and the cutoff values of VAI and LAP were 6.05 and 53, respectively. VAI showed the strongest association with MetS, followed by diastolic blood pressure BP, FPG, and LAP. Conclusions: We recommend VAI and LAP as new indices for MetS diagnosis. As these indices exhibit population specificity, it is imperative that independent cutoffs are determined for every demographic population.
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Does the serum vitamin D status and its possible effect on serum anti-müllerian hormone levels predict fertility in premenopausal women? p. 244
Oyinkansola Islamiyat Lawal
DOI:10.4103/jhrs.jhrs_234_20  
Context: Evidence suggests that serum Vitamin D level influences female reproduction. However, clinical studies have reported conflicting evidence on the effect of serum Vitamin D levels on serum Anti-Müllerian hormone (AMH), with little evidence in African women. Aim: The study aimed to compare the relationship between serum Vitamin D and serum AMH among infertile and fertile women. Settings and Design: This comparative cross-sectional study analyzed data from 170 premenopausal women; 81 infertile, and 89 fertile women attending a Nigerian tertiary hospital between March and June 2019. Materials and Methods: Serum AMH and 25-hydroxyvitamin D (25(OH) Vitamin D) concentrations were analysed using enzyme-linked immunosorbent assay. Statistical Analysis: Statistical analysis was done using SPSS version 25 for windows. Categorical variables were summarized in frequencies and proportions while continuous variables were summarized in means ± standard deviation and median (interquartile range). The association was explored using linear regression. The level of significance was set at 0.05. Results: The prevalence of Vitamin D deficiency (<20 ng/ml) in infertile women and fertile women was 16% and 18%, respectively. There was no difference in serum Vitamin D levels between infertile and fertile women in this study after controlling for age and body mass index (BMI) (P = 0.186). There was no association between serum 25(OH) Vitamin D and serum AMH in infertile (B = 0.002; P = 0.474) and fertile women (B = ‒0.002; P = 0.522) after adjusting for age and BMI. Conclusion: Infertile and fertile women had similar serum Vitamin D levels and there was no relationship between serum Vitamin D and serum AMH in both infertile and fertile women.
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Evaluation of role of transabdominal and transvaginal ultrasound in diagnosis of female genital tuberculosis p. 250
Jai Bhagwan Sharma, Ashok Khurana, Smriti Hari, Urvashi Singh, Ritu Yadav, Sona Dharmendra
DOI:10.4103/jhrs.jhrs_161_20  
Background: Female genital tuberculosis (FGTB) is a common problem in developing countries causing significant morbidity, especially infertility. Radiological imaging, especially ultrasound, can help in diagnosis of FGTB with tubo-ovarian masses. Aims: The present study was performed to evaluate the role of ultrasound in diagnosis of FGTB and to see various findings of FGTB on ultrasound. Study Setting and Design: It was a prospective cross-sectional study over 4-year period between August 2015 and August 2019 in a tertiary referral center. Subjects and Methods: One hundred and seventy-five patients of infertility diagnosed to have FGTB on composite reference standard (CRS) of positive acid-fast bacilli on microscopy or culture of endometrial biopsy, positive polymerase chain reaction, positive GeneXpert, epithelioid granuloma on histology of endometrial biopsy, or definite or probable finding of FGTB on laparoscopy were subjected to transvaginal ultrasound by an experienced sonographer for various findings of FGTB. Statistical Analysis: Data analysis was carried out using STATA software 12.0. Comparison of categorical values was tested using Chi-square Fisher's exact test, with P < 0.05 being taken as significant. Results: Mean age, body mass index, parity, and duration of infertility were 28.9 years, 22.9 kg/m2, 0.26, and 6.06 years, respectively. Menstrual dysfunction was common (44%). Diagnosis of FGTB was made by CRS. Ultrasound was normal in 112 (64%) cases and was abnormal in 63 (36%) cases. Various ultrasound findings were ovarian cyst (23.42%), tubo-ovarian masses (15.42%), unilateral or bilateral hydrosalpinx (13.71%), pyosalpinx (0.57%), adhesion (1.14%), adnexal fixity (6.28%), thin endometrium (24.57%), endometrial fluid (12.57%), endometrial calcification (1.7%), endometrial synechiae (4.57%), cornual synechiae (2.28%), impaired endometrial vascularity (21.71%), ascites (6.85%), and peritoneal or omental thickening (1.75%). Conclusion: Carefully performed ultrasound is a useful modality in diagnosis of FGTB, especially in adnexal masses.
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Association of semen bacteriological profile with infertility:– A cross-sectional study in a tertiary care center p. 260
Madhuvanti Karthikeyan, NS Kubera, Rakesh Singh
DOI:10.4103/jhrs.jhrs_49_21  
Context: Infections are an important cause of male infertility. The specific effects of infections on various semen parameters remain unexplored, especially within the Indian subcontinent. Aim: The aim of the study was to determine the bacteriologic profile of semen, and its effect on semen parameters, with particular emphasis given to Ureaplasma urealyticum and Mycoplasma hominis tested by semen polymerase chain reaction (PCR). Study Setting and Design: The research was a cross-sectionl analaytical study conducted in a tertiary care center in South India from March 2018 to November 2019, on 48 male partners of couples presenting with infertility. Methodology: After obtaining informed consent from the study participants, semen collection was done. The sample was subjected to standard semen analysis according to the WHO 2010 Manual, followed by bacteriological testing using routine culture methods. In addition, real-time PCR was done to test for U. urealyticum and M. hominis. Statistical Analysis: Demographic data, semen analysis parameters, bacteriological culture findings, and real-time PCR results were compared and analyzed using the software IBM® SPSS 19.0. Results: A significant difference in viscosity of semen, which was higher in the samples that were positive for real-time PCR of M. hominis, was found. Other than this, no other parameter had a statistically significant difference between culture or real-time PCR positive samples and negative samples. Conclusion: Our study, though limited by a small sample size, highlights the role played by seminal infections in the context of male infertility. Larger scale prospective studies in this area would be invaluable in deciding the management plans of male factor infertility.
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To compare the effect of GnRH agonist versus human chorionic gonadotropin (HCG) trigger on clinical pregnancy rate in intrauterine insemination cycle p. 267
Rashmi Sharma, Imlesh Meena
DOI:10.4103/jhrs.JHRS_100_20  
Context: Gonadotropin-releasing hormone (GnRH) agonist trigger mimics the natural surge more closely with both luteinizing hormone (LH) and follicle-stimulating hormone surge. The present study attempts to find whether this apparent physiological advantage translates into the better pregnancy rate. Aims: To compare the effect of GnRH agonist versus human chorionic gonadotropin (hCG) trigger on the clinical pregnancy rate (CPR) in infertile women undergoing intrauterine insemination (IUI) with oral ovulogens. Settings and Design: Retrospective analysis at a tertiary care in vitro fertilization center. Materials and Methods: The records of 280 infertile women, who underwent IUI with oral ovulogens were analyzed. Women who received 0.2 mg triptorelin (GnRH agonist (GnRHa)) as trigger were categorised in Group A (n = 129) and those who received 10,000 IU urinary hCG in Group B (n = 151). The outcome in terms of CPR was studied. Statistical Analysis Used: The quantitative variables were compared using the independent t-test/Mann–Whitney test. The qualitative variables were compared using the Chi-square test. P < 0.05 was considered statistically significant. Results: There was a trend toward better CPR in Group A (21/129 – 16.28%) than in Group B (16/151 – 10.60%), although the difference was not found to be statistically significant (P – 0.162). Conclusions: There was a trend toward better CPR with the use of GnRH agonist trigger in IUI cycles with oral ovulogens in comparison to hCG trigger, although the difference was not found to be statistically significant. Further randomized controlled trials are needed to confirm these findings.
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Short ejaculatory abstinence in normozoospermic men is associated with higher clinical pregnancy rates in sub-fertile couples undergoing intra-cytoplasmic sperm injection in assisted reproductive technology: A retrospective analysis of 1691 cycles p. 273
Sweta Gupta, Vikram J Singh, Ashish Fauzdar, Kamta Prasad, Ajay Srivastava, Kamlesh Sharma
DOI:10.4103/jhrs.jhrs_235_20  
Background: The current WHO abstinence recommendations are ideal only for clinical diagnosis, as in recent years a negative correlation of abstinence duration with good embryo development and clinical pregnancy rate has been seen. Aim: The aim of the study was to evaluate the impact of variation in abstinence period on fertilization, embryo development potential, pregnancy, and miscarriage rate in sub-fertile couples undergoing assisted reproductive technology (ART) treatment. Setting and Design: A prospective analysis was conducted at a tertiary (level 3) infertility care clinic. Materials and Methods: The study included analysis of 1691 cycles for the patient undergoing ART procedures between September 2017 and August 2019. The influence of ejaculatory abstinence (EA) was investigated based on variation in abstinence length with four groups: Group I – 1 day; Group II – 2–5 days; Group III – 6–7 days; and Group IV – EA length of ≥8 days. Statistical Analysis: Analysis of variance and Chi-square test were used to calculate P value. Results: In our primary outcome, we have seen a strong positive correlation of abstinence duration with semen volume, total sperm count, total motile count, and difference between each group was significant. Secondary outcomes showed a significantly higher implantation rate, biochemical pregnancy rate was observed in Group I (1 day) per embryo transfer as compared to longer abstinence groups. This resulted in significantly higher clinical pregnancy rates in Group I 30.0% vs. 25.4% in comparison to longer abstinence groups. Conclusions: Our study has shown duration of abstinence is negatively correlated with positive β-human chorionic gonadotropin rate, clinical pregnancy rate, and implantation rate. Lower miscarriage rate was also observed with shorter abstinence duration.
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Evaluating the contribution of oocyte, sperm, and uterus in determining the outcome of intracytoplasmic sperm injection – A retrospective observational comparative study on intracytoplasmic sperm injection using own oocytes and donor oocytes p. 281
Deepeka Thangamani Shanthi, Parasuram Gopinath, Karthika D Kumar, Ramesh Parameswara Iyer, Revathi Kesavaramanujam, Gopinathan Kannoly Karunakaran
DOI:10.4103/jhrs.jhrs_20_21  
Context: Several studies have assessed the contribution of oocyte, sperm, and endometrium on the outcome of intracytoplasmic sperm injection (ICSI) separately. This study assesses the relative contribution of oocyte, sperm, and uterus in achieving clinical pregnancy (CP) through ICSI by comparing own and third-party ICSI cycles. Aim: The aim of the study is to evaluate and compare the strength of contribution of oocyte, sperm, and uterus in achieving CP through ICSI. Settings and Design: This retrospective observational study of ICSI cycles for 20 months including 1000 embryo transfers (ETs). Methodology: Subjects were divided into two groups, Group 1 – ICSI with own oocytes (550 ETs) and Group 2 – ICSI with donor oocytes (450 ETs). Both the groups had 3 subgroups – a (husband sperm, transferred to self), b (donor sperm, transferred to self), c (husband sperm, transferred to a gestational surrogate). CP rate (CPR) as a major outcome was studied in the groups and subgroups. Statistical Analysis: CPR was compared between various subgroups using Z-test and Chi-square of significance of difference between proportions. A P < 0.05 was taken as the level of statistical significance. Results: CPR in subgroup 1a < 35 years, 1a ≥35 years, and 2a was 42.98%, 26.21%, and 40.92%, respectively (P = 0.001). CPR was compared between 2a and 2c (40.92%, 56.5%, P = 0.044) and between 2a and 2b (40.92%, 42.11%, P = 0.866). Implantation rate was highest in Group 2c (34.88%) compared to other subgroups. Conclusion: The higher CPR in women <35 years undergoing ICSI with own oocytes than older women and a comparable CPR as that of recipients of donor oocytes suggests that age thereby oocyte quality is the strongest determining factor in achieving clinical pregnancy. Among oocyte recipients, higher CPR in surrogate uterus than patient uterus suggests that uterus/endometrium plays a considerable role, and comparable CPR between ICSI using husband sperm and donor sperm indicates that sperm quality might not play a major role in achieving CP.
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An artificial intelligence-based algorithm for predicting pregnancy success using static images captured by optical light microscopy during intracytoplasmic sperm injection p. 288
Jared Geller, Ineabelle Collazo, Raghav Pai, Nicholas Hendon, Soum D Lokeshwar, Himanshu Arora, Manuel Molina, Ranjith Ramasamy
DOI:10.4103/jhrs.jhrs_53_21  
Context (Background): Analysis of embryos for in vitro fertilization (IVF) involves manual grading of human embryos through light microscopy. Recent research shows that artificial intelligence techniques applied to time lapse embryo images can successfully ascertain embryo quality. However, laboratories often capture static images and cannot apply this research in a real-world setting. Further, current models do not predict the outcome of pregnancy. Aims: To create and assess a convolutional neural network to predict embryo quality using static images from a limited dataset. We considered two classification problems: predicting whether an embryo will lead to a pregnancy or not and predicting the outcome of that pregnancy. Settings and Design: We utilized transfer learning techniques using a pretrained Inception V1 network. All models were built using the Tensorflow software package. Methods: We utilized a total of 361 randomly sampled static images collected from four South Florida IVF clinics. Data were collected between 2016 and 2019. Statistical Analysis Used: We utilized deep-learning techniques, including data augmentation to reduce model variance and transfer learning to bolster our limited dataset. We used a standard train/validation/test dataset split to avoid model overfitting. Results: Our algorithm achieved 0.657 area under the curve for predicting pregnancy versus nonpregnancy. However, our model was unable to meaningfully predict whether a pregnancy led a to live birth. Conclusions: Despite the limited dataset that achieved somewhat of a lower accuracy than conventional embryo selection, this is the first study that has successfully made IVF predictions from static images alone. Future availability of more data may allow for prospective validation and further generalisability of results.
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Seasonal influence on assisted reproductive technology outcomes: A retrospective analysis of 1409 cycles p. 293
Amandeep Singh, Treasa Joseph, Reka Karuppusami, Aleyamma Thayparmbil Kunjummen, Mohan Shashikant Kamath, Ann Margaret Mangalaraj
DOI:10.4103/jhrs.jhrs_39_21  
Background: It is well known that seasonal variations influence natural conception and birth rates variably in different populations. It has been hypothesised that similar seasonal influences may affect treatment outcomes following assisted reproductive technology (ART). However, most studies report conflicting results. Aim: The aim of the study is to elucidate whether seasonality had any impact on the treatment success of the ART program. Study Setting and Design: We conducted a retrospective cohort study at a university-level tertiary care hospital in South India. Materials and Methods: All couples who underwent ART between January 2012 and December 2016 were included in the study. We divided the study population into three groups based on the seasonal differences experienced in our region. The primary outcome was live birth rate (LBR). Statistical Analysis: Univariate and multiple logistic regression models were used to compare outcomes and results reported as odds ratio (OR) and 95% confidence interval (CI). Results: Univariate analysis revealed no significant difference in LBR in monsoon season (174/651, 26.7% vs. 83/319, 26.0%; OR 1.04, 95% CI 0.77,1.41; P = 0.81) as compared to summer. However, LBR was significantly higher in winter season (114/341, 33.4% vs. 83/319, 26.0%; OR 1.43; 95% CI: 1.02, 2.00; P = 0.04). Further, multivariate analysis following adjustment for various confounding factors revealed no significant statistical difference in LBR in monsoon (adjusted odds ratio [aOR], 0.92; 95% CI: 0.66, 1.26; P = 0.59) or winter (aOR 1.32; 95% CI: 0.92, 1.88; P = 0.13) as compared to summer season. Conclusion: The current study found no significant effect of seasonal variation on LBR following ART.
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Pregnancy in older women: Analysis of outcomes in pregnancies from donor oocyte In- vitro fertilization p. 300
James A Osaikhuwuomwan, Michael E Aziken
DOI:10.4103/jhrs.jhrs_209_20  
Background: As the number of older women attempting to conceive through donor oocyte-in vitro fertilization (DO-IVF) rises, their safety in pregnancy needs to be judiciously considered. Aims: This study aims to review the obstetric and perinatal outcomes of pregnancies achieved by DO-IVF. Study Setting and Design: A retrospective study design conducted at a private health facility with services for assisted reproduction and gynecologic endoscopy. Methods: A retrospective comparative study of all pregnancies achieved using DO-IVF and that using Self oocyte In-vitro fertilization (SO-IVF) treatment over a 3 years' period was performed. Statistical Analysis: Comparative analysis of demographic variables, major obstetric, and perinatal complications was done with Chi-square test and Student's t-test as appropriate. Regression analysis was done to determine a significant predictor variable for pregnancy and delivery outcome. The significance level was set at P < 0.05. Results: A total of 343 completed IVF treatment cycles was reviewed; there were 238 DO-IVF and 105 SO-IVF cycles, with clinical pregnancy rate of 41.6% and 37.1%, respectively. The DO-IVF group was significantly older than the SO-IVF group (46.1 years vs. 34.1 years, P < 0.001). Major obstetric complications identified, were hypertensive disorders in pregnancy (23.9%), preterm labor (16.7%), antepartum hemorrhage (11.6%). There was no statistically significant difference between the two groups in terms of obstetric complications and adverse maternal or perinatal outcomes. There were 97 (77.6%) singleton and 28 (22.4%) multiple pregnancies. Pregnancy complications were significantly associated with fetal plurality, P < 0.001. Multiple pregnancy had higher odds of experiencing adverse perinatal 4.96 (1.95–12.58) and maternal 7.16 (2.05–25.03) outcomes compared to singleton pregnancies, P < 0.001. Conclusion: Key obstetric outcomes did not differ between DO or SO IVF achieved pregnancy. Even for older women, satisfactory outcomes can be expected for pregnancies achieved by DO-IVF. It is, however, instructive that for multiple pregnancies, obstetricians should institute appropriate surveillance strategies during pregnancy and delivery period and also to develop institutional capacity for quality neonatal care.
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“When love does not bear a fruit”: Patterns and prevalence of sexual difficulties in infertile men and women as predictors of emotional distress p. 307
Ansha Patel, P. S. V. N. Sharma, Pratap Kumar
DOI:10.4103/jhrs.jhrs_70_21  
Background: Self-identity, sexuality, and subfertility have multidirectional effects on each other. Subfertility is known to alter sexual esteem, threaten identity, body image, sexual attractivness, coital pleasure, and sexual satisfaction. Objective: This study aimed to evaluate sexual difficulties as predictors of infertility-specific stress in patients undergoing fertility treatments and to assess the profile of sexual dysfunctions in participants. Study Setting and Design: This cross-sectional study was conducted in a tertiary hospital setup of a medical college. Methods: Three hundred married men and women diagnosed with infertility participated. The psychological evaluation test, international classification of diseases (10th, CDDG), female sexual functioning index, and international index of erectile functioning were used as measures. Statistical Analysis: Data were analyzed using SPSS (version 15, Chicago, USA). Chi-square test was used for univariate analysis between stress and presence of sexual dysfunctions in men and women. Medians, quartile, and cutoff scores were used to profile the sexual issues in participants. Results: Prevalence of sexual dysfunctions since marriage was higher in women (75%) than men (60%). Ninety-two percent of women and 86% of men experienced emergence of sexual difficulties after the couple started treatments. Conclusions: Sexual dysfunctions appear to be a consistent psychosocial concern for those awaiting conception. These appear to worsen during the treatments. Our findings suggest the need to sensitively approach and explore sexual anamnesis with the couple before recourse to medically assisted reproductive treatments. Psychological interventions for sexual issues in distressed patients before, during, and after treatments such as controlled ovarian hyperstimulation, intrauterine insemination, in vitro fertilization, and intracytoplasmic sperm injection are most needed.
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CASE REPORTS Top

Vaginoscopic incision of oblique vaginal septum in an adolescent girl with OHVIRA syndrome: Simple management of complicated anomaly p. 313
Aruna Nigam, Pragati Aggarwal, Anamika Baghel, Neha Gupta, Sumedha Sharma, Abhinav Jain
DOI:10.4103/jhrs.jhrs_46_21  
OHVIRA syndrome comprises uterine didelphys, obstructed hemivagina, and ipsilateral renal agenesis. It usually presents with pain abdomen and pelvic or vaginal mass with normal menses. Early diagnosis is important to prevent complications in later life. The case of a 12-year-old girl who presented with pain abdomen and progressive dysmenorrhea for the last 6 months (since menarche) is discussed. She was managed successfully with vaginoscopic septal incision with simultaneous preservation of hymenal integrity.
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Robert's uterus-rare cause of intractable dysmenorrhea and chronic pelvic pain p. 317
Aruna Nigam, Namoijam Basanti, Sumedha Sharma, Neha Gupta, Abhinav Jain
DOI:10.4103/jhrs.jhrs_32_21  
Robert's uterus is a rare type of congenital uterine anomaly where septum divides the uterine cavity asymmetrically resulting in the formation of a noncommunicating hemiuterus. Patients may present with recurrent pain, dysmenorrhea, recurrent abortions, and infertility. They are often misdiagnosed as unicornuate uterus with a noncommunicating horn. Thirty-year nulliparous female with history of severe dysmenorrhea since her menarche for which she had been operated thrice with no relief, presented with severe abdominal pain. Magnetic resonance imaging findings were suggestive of possibility of accessory horn with left hematosalpinx and hemorrhagic fluid in pelvis. Intraoperatively, it was found to be thick uterine septum completely dividing the uterine cavity asymmetrically with no communication with cervix indicative of Robert's uterus.
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Severe ovarian hyperstimulation syndrome in a case of nonmutated recurrent genuine empty follicle syndrome p. 321
Sumina Mannur, Talha Jabeen, Mohd Abdul Khader, Ramanachary Namoju, Lendale Sai Shakti Rao
DOI:10.4103/jhrs.jhrs_61_21  
Empty follicle syndrome (EFS) is a rare event in which no oocytes are retrieved from apparently normal growing follicles with normal steroidogenesis despite meticulous follicular aspiration in assisted reproductive technology (ART) cycles. EFS is mainly of two types, genuine EFS and false EFS. Here, we report a case of a 24-year-old woman presenting with primary infertility with normal ovarian reserve and regular menstrual cycles, husband having severe “oligo-astheno-teratozoospermia,” and planned for ART treatment. We could not retrieve any oocytes in successive cycles despite optimum human chorionic gonadotropin (hCG) levels on the day of oocyte retrieval and using different management protocols mentioned until now in the literature. The whole genomic analysis was found to be normal (46, XX). Further, the patient had experienced severe ovarian hyperstimulation syndrome (OHSS) after the second cycle of ovarian stimulation despite no luteal hCG support. We were ineffectual to find the cause of recurrent EFS in this patient and therefore counseled the patient for donor oocytes. This case highlights the difficulty in treating genuine EFS patients and the need for monitoring serum estradiol levels during ovarian stimulation to prevent another serious complication of OHSS.
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LETTER TO EDITOR Top

Do basal luteinizing hormone and luteinizing hormone/follicle-stimulating hormone ratio have significance in prognosticating the outcome of In vitro fertilization cycles in polycystic ovary syndrome? p. 325
Pathum Sookaromdee, Viroj Wiwanitkit
DOI:10.4103/jhrs.jhrs_87_21  
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AUTHORS’ REPLY Top

Do basal luteinizing hormone and luteinizing hormone/follicle-stimulating hormone ratio have significance in prognosticating the outcome of In vitro Fertilization cycles in polycystic ovary syndrome? p. 326
Singh Neeta, Mishra Neha, Dogra Yogita
DOI:10.4103/jhrs.jhrs_105_21  
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