Journal of Human Reproductive Science
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    Table of Contents - Current issue
October-December 2022
Volume 15 | Issue 4
Page Nos. 323-404

Online since Friday, December 30, 2022

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Editorial Commentary p. 323
Padma Rekha Jirge
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Premature progesterone elevation in in vitro fertilisation cycles – current perspectives p. 325
Sumana Gurunath
The impact of premature elevation of progesterone (PPE) on the day of the trigger on pregnancy outcome in in vitro fertilisation (IVF) cycles has been a matter of contention and debate for decades. Research over the last 30 years has indicated that PPE >1.5 ng/ml is associated with declining live birth rates following fresh embryo transfer. Freeze-only approach has become a universal solution to overcome the issue of PPE. However, the topic is still mired with controversy. Few studies have not shown a negative impact on pregnancy rates. The impact of PPE on embryological parameters such as oocyte and embryo quality and ploidy is still very controversial. An important contentious issue is the choice of the threshold P value above which it is considered abnormal and a freeze-all strategy would be cost-effective. Currently, though a cutoff of >1.5 ng/ml is widely used, practices are not uniform and varying thresholds from 0.4 to 3 ng/ml are utilised. This review addresses the current understanding of PPE in IVF and the above controversies. The incidence, aetiology and source of progesterone rise, impact on endometrial receptivity, oocyte and embryo quality, impact on live birth and cumulative live birth and impact on frozen embryo transfer and donor oocyte cycles are discussed. Current controversies regarding the optimal threshold, assay performance and future directions are addressed.
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Glutamine supplementation attenuates bisphenol a-induced testicular toxicity in rats p. 337
Ben E Ehigiator, Elias Adikwu, Zellijo N Igweze
Background: The induction of testicular toxicity by bisphenol A (BPA) may involve oxidative stress. Glutamine (Gln) is a rate limiter for the synthesis of glutathione (GSH), which inhibits oxidative stress. Aim: This study assessed the potential of BPA to preserve testicular structure and function in BPA-treated albino rats. Study Settings and Design: Thirty-two adult male albino rats (210–250 g) were randomly allocated to 4 (A-D) of 8 rats per group with the approval of the Research Ethics Committee. Materials and Methods: Groups B-D were orally treated with Gln (20 mg/kg body weight), BPA (50 mg/kg body weight) and Gln (20 mg/kg body weight) + BPA (50 mg/kg body weight) daily for 65 days, respectively. Group A (control) was orally treated with normal saline (0.2 mL) daily for 65 days. At the termination of treatment, the rats were weighed and anaesthetized blood samples were collected and evaluated for gonadal hormones. The testes were weighed and evaluated for sperm parameters, oxidative stress markers and histology. Statistical Analysis Used: The data were analysed using one-way analysis of variance and Bonferroni post hoc test. Results: BPA caused a significant (P < 0.001) decrease in testis and body weights, sperm count, volume, motility and normal morphology when compared to the control. BPA significantly (P < 0.001) decreased serum testosterone, follicle-stimulating hormone, luteinising hormone, testicular catalase, superoxide dismutase, GSH and GSH peroxidase levels relative to control. Significantly (P < 0.001) increased serum prolactin, estradiol and testicular malondialdehyde levels occurred in BPA-treated rats relative to control. The testes of BPA-treated rats showed sloughing and coalescence of germ cells. However, Gln supplementation prevents BPA-induced testicular toxicity. Gln supplementation restored testis histology. Conclusion: Based on the observation in this study, Gln seems effective against BPA-induced testicular toxicity.
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Effect of high dose gonadotropin stimulation on follicular atresia through light chain 3B and voltage dependent anion channel 2 p. 343
Mahmut Kemal Ozbilgin, Mustafa Öztatlıcı, Meltem Üçöz
Background: Follicle development takes place under the control of hormonal and environmental stimuli. It suggested that to improve in vitro fertilisation outcomes in poor responders increasing gonadotropin doses be used. Excessive gonadotropin leads to atresia and impairs follicular development, but the molecular mechanisms of follicular atresia remain largely unknown. Recently, it was suggested that autophagy may be an alternative mechanism involved in follicle depletion. Aims: In this study, we aimed to clarify the role of autophagic markers such as light chain (LC) 3B and voltage dependent anion channel 2 (VDAC2) in follicular atresia using the high dose gonadotropin stimulation. Settings and Design: The female 24 BALB/c mice were employed in the present study under the Committee for the Purpose of Control and Supervision of Experiments on Animals guidelines with ethical clearance from the institutional ethical committee. These mice were categorised into four groups, with six rats in each as control and test animals. Materials and Methods: Group 1 (control): no action will be taken. Group 2 (sham): only saline will be applied. Group 3: low-dose gonadotropin Pregnant mare's serum gonadotropin (PMSG) + human chorionic gonadotropin (HCG) will be applied. Group 4: high-dose gonadotropin + HCG will be applied. The animals were sacrificed 48 h after the last injection. For all group samples, both protein and mRNAs of the LC3B and VDAC2 were examined by immunohistochemical and reverse transcription-polymerase chain reaction techniques. Statistical Analysis Used: All variables were analysed using GraphPad Prism 8. Kruskal–Wallis t-test and Mann–Whitney U test were used to compare immunohistochemical results; in addition to this, parametric one-way ANOVA test and Shapiro–Wilk test were applied for quantitative polymerase chain reaction statistics. Results: An increased number of atretic follicles were observed in the high-dose gonadotropin + HCG group. LC3B immunoreactivity of the atretic secondary follicles in the high-dose group is higher than in other groups. The expression of VDAC2 protein in the secondary and Graafian follicles and also VDAC2 mRNA in the ovary were more highly expressed in the control and sham groups. The decrease in VDAC2 mRNA level and immunohistochemical expression was remarkable in the low-dose and high-dose follicle-stimulating hormone groups compared to the control and sham groups. Conclusion: In this study, the increased LC3B and decreased VDAC2 expression, which are autophagy markers, were observed in both the gonadotropins groups, so we suggested that high doses of gonadotropins may cause ovarian atresia.
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Male idiopathic hypogonadotropic hypogonadism: Serum insulin-like growth factor-1 and oestradiol levels p. 351
Nastaran Salehisedeh, Amir Parhizkar, Parichehreh Yaghmaei, Marjan Sabbaghian
Background: Idiopathic hypogonadotropic hypogonadism (IHH) is a form of male infertility caused by a congenital defect in the secretion or action of gonadotropin-releasing hormone from the hypothalamus. Oestradiol emerged as the main sex steroid in the regulation of the hypothalamic–pituitary–testicular axis, reproductive function and growth hormone/insulin-like growth factor-1 (GH/IGF-1) axis in men. Moreover, GH/IGF-1 axis has been suggested to play a role in IHH. Aims: This study evaluated serum IGF-1 in IHH men and controls. Furthermore, we evaluated the association between serum total oestradiol (TE2) and IGF-1 levels in patients and controls. Parameters including age, body mass index and fertility history were analysed. Settings and Design: This prospective study was conducted at the Royan institute. Materials and Methods: In 20 men with IHH and 20 controls, serum IGF-1 levels were estimated using chemiluminescence immunoassay and serum E2 levels were assessed by means of the electrochemiluminescence method. Statistical Analysis Used: Kolmogorov-Smirnov test, parametric t-test or the Mann-Whitney and the Pearson correlation coefficient were performed. SPSS version 22 was used for the analysis of data. Results: There was a significant decrease in serum IGF-1 levels in IHH patients compared with controls (145.1 ± 8.9 ng/ml vs. 229.6 ± 7.3 ng/ml P < 0.001, respectively). Furthermore, a significant decrease was observed in TE2 levels in IHH male patients (12.3 ± 2.5 pg/ml) compared with controls (31.9 ± 5.3 pg/ml P < 0.001). A positive correlation was observed between serum IGF-1 and TE2 levels in the total number of participants, suggesting that E2 deficiency in IHH cases can explain the lower levels of serum IGF-1. Conclusions: These findings suggest that the reduction in IGF-1 levels may be associated with the influence of E2 on the GH/IGF-1 axis, and may confirm the role of the GH/IGF-1 axis in IHH. Further investigations will be required to determine the exact mechanisms by which E2 and IGF-1 affect the reproductive neuroendocrine function.
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Does coronavirus disease-19 infection affect ovarian reserve in infertile women? A retrospective study p. 357
Serkan Kahyaoglu, Muzeyyen Gulnur Ozaksit, Inci Kahyaoglu, Ahmet Arif Filiz, Meryem Kuru Pekcan, Ece Atalay, Ozlem Moraloglu Tekin
Background: Previous studies have revealed menstrual changes following coronavirus disease-19 (COVID-19) disease. The potential impact of COVID-19 on female reproductive organs, ovary in particular, has not been investigated thoroughly. Aims: The aim of this study was to evaluate changes in serum levels of follicle-stimulating hormone (FSH), luteinising hormone (LH) and oestradiol (E2) following COVID-19 disease as a surrogate for the detection of ovarian vulnerability to SARS-CoV-2 infection. Settings and Design: In this retrospective study, hospital records of unexplained infertile women between 21 and 40 years old who have attended our institution's reproductive medicine unit for evaluation and/or treatment of infertility have been evaluated. Materials and Methods: Menstrual cycle day 2–5 serum follicle-stimulating hormone, luteinising hormone and E2 levels of 28 infertile women have been studied both before and after the COVID-19 disease to evaluate ovarian reserve before the ovulation induction treatment cycle. Statistical Analysis Used: The demographic characteristics and hormonal results of these 28 unexplained infertile women have been compared. The Shapiro–Wilk test has been used to evaluate the normal distribution of variables. Comparison of ovarian reserve markers which were established before and after COVID-19 infection has been performed using paired samples t-test. Results: All patients except one have shown mild COVID-19 symptoms and their infection courses have resulted in uneventful recovery. Serum FSH, LH and E2 levels of 24 (85%) and serum anti-Müllerian hormone (AMH) levels of 4 (15%) patients have been evaluated before and after COVID-19 disease is statistically similar. Conclusion: COVID-19 disease or inflammatory response of the infection itself does not seem to affect pituitary gonadotropins and ovarian hormones in infertile women based on menstrual cycle day 2–5 serum FSH, LH, E2 and AMH levels. Further studies including higher patient numbers are urgently needed to clarify the potential effects of COVID-19 disease on the gonadal function of women.
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Hysterosalpingography observations in female genital tuberculosis with infertility p. 362
Jai Bhagwan Sharma, Supriya Kumari, Parul Jaiswal, Sona Dharmendra, Smriti Hari, Urvashi B Singh
Background: Hysterosalpingography (HSG) is radiographic evaluation of uterine cavity and tubal patency. Aims: The aim of this study was to evaluate the safety and utilisation of HSG in female genital tuberculosis (FGTB) with infertility. Settings and Design: The study was conducted in a tertiary referral centre of North India. Materials and Methods: It was a prospective study on 87 cases of FGTB with infertility. Diagnosis of FGTB was made by composite reference standard using the presence of acid-fast bacilli on microscopy/culture or positive GeneXpert, positive polymerase chain reaction or epithelioid granuloma on endometrial biopsy or definitive or probable findings on laparoscopy or hysteroscopy. Statistical Analysis Used: Suitable statistical methods were used with STATA software version 12.0. Results: HSG findings were normal in 49 (56.32%) cases. There were filling defects in 14 (16.09%), short and shrunken cavity in 4 (4.49%), intrauterine synechiae in 14 (16.09%), T-shaped cavity in 3 (3.44%) and deformed uterine cavity in 5 (5.74%) cases. Fallopian tube findings were hydrosalpinx in 12 (13.79%) and 11 (12.64%) cases, beading of tube in 4 (4.59%) and 2 (2.29%) cases, pipestem appearance in 2 (2.29%) cases each and Maltese cross appearance in 3 (3.44%) and 2 (2.29%) cases, respectively. Tubal blockage was seen in 69 (79.31%) and 67 (77.01%) cases being cornual block in 28 (32.18%) and 26 (29.88%) cases, mid-tubal block in 16 (18.39%) and 15 (17.24%) cases, multiple blocks in 10 (11.49%) and 12 (13.79%) cases and fimbrial block in 15 (17.24%) and 14 (16.09%) cases. None of the cases had flare-up of the disease after HSG in the current study. Conclusion: HSG is a useful modality in FGTB with infertility.
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The impact of high circulating anti-müllerian hormone on endometrial thickness and outcome of assisted reproductive technology in women with polycystic ovarian syndrome: A cohort study p. 370
Ahmed Aboelfadle Mohamed, Tarek K Al-Hussaini, Reda S Hussein, Karim S Abdallah, Saad A Amer
Background: Elevated circulating anti-Müllerian hormone (AMH) in women with the polycystic ovarian syndrome (PCOS) has been found to have a detrimental effect on endometrial function. This may adversely affect the outcome of in vitro fertilisation (IVF) in PCOS women. Aims: To investigate the impact of high serum AMH concentrations on endometrial thickness (ET) and the outcome of IVF in women with PCOS. Settings and Design: This retrospective cohort study included all PCOS women who underwent fresh IVF\intracytoplasmic sperm injection cycles between January 2016 and December 2021 in one major IVF centre. Materials and Methods: PCOS diagnosis was based on Rotterdam criteria, and participants were identified from centre database. All women received antagonist protocol. Primary outcomes were trigger-day ET and live birth rate (LBR). Circulating AMH was correlated with ET and ovarian response. Statistical Analysis Used: AMH levels were compared between women with and without live birth. ET and LBRs were compared between women with AMH <7.0 ng/ml versus those with AMH ≥7.0 ng/ml. Results: The study included 102 PCOS women, of which six were excluded due to poor response (n = 4), hyperresponse (n = 1) or fertilisation failure (n = 1). Of the remaining 96 women, 42 (43.8%) achieved a live birth. There was no statistically significant (P > 0.05) correlation between AMH and ET. Mean ± standard deviation AMH concentration was not significantly (P > 0.05) different between women with live birth (6.5 ± 3.4 ng/ml) and those without (6.5 ± 2.4 ng/ml). High AMH positively correlated with the number of oocytes retrieved, metaphase II oocytes and embryos (P = 0.003, 0.006 and 0.006, respectively). There was no statistically significant (P > 0.05) difference in ET or LBR between women with AMH <7.0 ng/ml (n = 72; ET, 10.7 ± 1.8 mm; LBR, 45.8% [33/72] versus those with AMH ≥7.0 ng/ml (n = 24; ET, 10.8 ± 1.7 mm; LBR, 37.5% [9/24]). Conclusions: High circulating AMH in PCOS women does not seem to negatively affect ET or LBRs during assisted reproductive technology.
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Assessment of the impact induced by different incubation time, storage time, storage medium and thawing methods on sperm DNA fragmentation assay: A before–after study p. 377
Marjan Sabbaghian, Hani Hosseinifar, Alemeh Rafaee, Mohammad Ali Sadighi Gilani
Background: The sperm DNA fragmentation has been considered an important index in the field of male infertility. Aims: Our study aims to evaluate the impact of different factors, including incubation time, storage time, storage medium and method of thawing, on DNA fragmentation of semen samples. Settings and Design: This study was designed as a before–after study in five experiments. Materials and Methods: Experiment 1 was conducted to assess the effect of storage time in liquid nitrogen on 15 semen samples. In experiment 2, DNA fragmentation was performed on 10 semen samples with different incubation times before freezing. In experiments 3, 4, two different storage media and thawing methods were applied respectively in two separate groups, each containing 30 samples and the DNA fragmentation index (DFI) was measured using the sperm chromatin structure assay method. Statistical Analysis: Data were analysed using Stata version 11. Results: There was a significant increase in sperm DNA fragmentation of samples stored in liquid nitrogen for 1 month. This increase occurred in the first 2 weeks. Furthermore, our results showed a significant increase in the DFI after 120 min of incubation at room temperature (RT) and also thawing in RT separately. Conclusion: It is better to use fresh samples to measure DNA fragmentation up to 2 h after ejaculation to achieve more accurate results. Furthermore, if sperm freezing is inevitable, the use of a water bath (37°C) to thaw will be the most appropriate option, as it can lead to less DNA damage.
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Two-six hours is the optimal timing of intracytoplasmic sperm injection after oocyte pickup: Single-centre 10 years cohort study p. 382
Neeta Singh, Neena Malhotra, Reeta Mahey, Garima Patel, Monika Saini
Background: Optimal incubation period for oocyte competence remains contentious despite intracytoplasmic sperm injection(ICSI) being in practice for 34 years. Dilemma exists as the current literature favors both early and delayed denudation with equivocal results. With ever-rising demand for the procedure this conundrum continues to plague the clinical outcomes. Aims: This study attempts to provide a consensus regarding optimal time duration required for incubating the oocytes after oocyte pickup(OPU) and time to perform ICSI. Settings and Design: A retrospective study in a tertiary centre. Materials and Methods: A retrospective 10-year cohort study including 726 ICSI cycles was conducted in a single tertiary care infertility centre. All cycles comprised at least one metaphase-II oocyte injected with one good quality sperm followed by fresh embryo transfer. The cohort was broadly divided into two groups: (a) Group 1: OPU-ICSI <4 hours(n=466) and (b) Group 2: OPU-ICSI>4 hours(n=260). Statistical Analysis Used: The fertilization(FR) and clinical pregnancy rates(CPR) were compared using the Pearson Chi-square test. The OPU-ICSI interval were subdivided into one-hourly intervals and CPR was compared after adjustment for multiple comparisons by holm method. Results: The FR and CPR were similar between Group 1 and Group 2(p>0.05). Comparing CPR for each one-hourly OPU-ICSI interval revealed no significant clinical difference (p>0.05) amongst one another, however, the CPR was maximum for 2-3 hours as the OPU-ICSI interval. Conclusion: With no significant clinical difference amongst various temporal groups, this study advocates and reinstates 2-6 hours as the optimal timing for ICSI after the OPU. This will also translate into better time management for both embryologists and clinicians and help them prioritise the laboratory workflow.
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Does testicular sperm alter reproductive and perinatal outcomes in assisted reproductive technology cycles? 10 years' experience in an Indian clinic Highly accessed article p. 388
Krishna Chaitanya Mantravadi, Durga Gedela Rao, Y Rupa Sree
Background: Intra-Cytoplasmic Sperm Injection (ICSI) has revolutionized the reproductive outcomes for couples with male factor infertility. Especially in azoospermic men, use of ICSI with surgically retrieved testicular sperm has helped them have their own biological child. However, considering the immature nature of testicular sperm safety of testicular sperm has been debated. Aims: To compare reproductive outcomes, neonatal outcomes and the incidence of congenital malformations in children born after intracytoplasmic sperm injection (ICSI), using different sperm origins. Settings and Design: This is a retrospective study in which a total of 989 participants were enrolled. Study group (Testicular Sperm Aspiration (TESA) ICSI group) had 552 couples with female partners aged ≤37 and had self gamete cycles. ICSI cycles with ejaculated sperm (EJS) acted as the control group. Materials and Methods: All male patients underwent surgical sperm retrieval and all the women underwent controlled ovarian stimulation and transvaginal oocyte retrieval and Ovum Pick Up (OPU) as per the standard operating procedures of the clinic. Frozen embryo transfer with two good-grade blastocysts, which had shown 100% survival, were transferred in subsequent cycles. Statistical Analysis Used: The Student's t-test was performed for age distribution; odds ratio was performed to find the confounding factors. Results: Embryonic and reproductive outcomes were comparable and not statistically significant in the study and control groups. Incidence of congenital anomalies was observed in singleton live births and twin live births in both the TESA-ICSI group and the EJS-ICSI group, but the difference was not statistically significant. Conclusions: Our study revealed that congenital malformations in children born out of ICSI using testicular sperm and EJS were similar; no difference was observed in miscarriages between the testicular sperm-ICSI and EJS-ICSI group. Our data suggests that surgical sperm retrieval in couples with male factor infertility does not alter their reproductive outcome.
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Failure to detect viral ribonucleic acid in follicular fluid of a severe acute respiratory syndrome coronavirus 2-infected female – A report from the indian subcontinent p. 396
Dhir Pooja Bhayana, Kumar Anuj Raja, Jhingan Chitra, Bansal Sonu
Till today, we are still not clear about the impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on reproductive tissues and its vertical transmission through the gametes and embryos. There are few case reports that aim to detect the presence or absence of SARS-CoV-2 viral ribonucleic acid (RNA) in the follicular fluid of the infected females. We hereby present the case report of a 33-year-old woman who was undergoing intracytoplasmic sperm injection with testicular sperm aspiration and was found to be positive for SARS-CoV-2 infection. The follicular fluid analysis failed to detect the presence of viral RNA in the sample. Ours is the first case report from India trying to detect the viral RNA from the follicular fluid of a female with SARS-CoV-2 positive status.
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Coexistence of ectopic tubal pregnancy with serous tubal intraepithelial carcinoma: A rare case report with review of literature p. 399
Shirish Sahebrao Chandanwale, Yesha Parimalbhai Lad, Padmakar Rajabhau Bardapurkar, Archana Chirag Buch
Serous tubal intraepithelial carcinoma is a precursor lesion for high-grade pelvic serous carcinoma. The incidence is 0.6%–6% in tubectomy specimens of women who are BRCA-1,2 positive or have a strong family history of breast or ovarian cancer. STIC in women who do not have BRCA-1,2 mutations or concomitant high-grade serous carcinoma is exceedingly rare. Ectopic tubal gestation coexisting with serous tubal intraepithelial carcinoma is very rarely reported. These lesions pose considerable difficulty in the diagnosis. A combination of histology and immunohistochemical expression p53 and ki67 substantially improves the reproducibility of the diagnosis. Diagnosing these lesions will help identify potential at risk patients and their families for carcinoma. Adequate prolonged follow-up for incidental serous tubal intraepithelial carcinoma is the mainstay. We report one such case of a 31-year-old female who was operated for the right tubal gestation and found to have serous tubal intraepithelial carcinoma.
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Does choosing microfluidics for sperm sorting offer an advantage to improve clinical pregnancies in donor egg recipients? p. 402
Vishan Dev Singh Jamwal
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Does choosing microfluidics for sperm sorting offer an advantage to improve clinical pregnancies in donor egg recipients? p. 403
Sapna Srinivas, Suhasini Donthi, Anupama Deenadayal, Aarti Deenadayal Tolani, Mamata Deendayal
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Reviewers, 2022 p. 404

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