Many couples present fertility problems at their reproductive age, and although in the last years, the efficiency of assisted reproduction techniques has increased, these are still far from being 100% effective. A key issue in this field is the proper assessment of germ cells, embryos and endometrium quality, in order to determine the actual likelihood to succeed. Currently available analysis is mainly based on morphological features of oocytes, sperm and embryos and although these strategies have improved the results, there is an urgent need of new diagnostic and therapeutic tools. The emergence of the - OMICS technologies (epigenomics, genomics, transcriptomics, proteomics and metabolomics) permitted the improvement on the knowledge in this field, by providing with a huge amount of information regarding the biological processes involved in reproductive success, thereby getting a broader view of complex biological systems with a relatively low cost and effort.

Background : There is substantial evidence that adult stem cell populations exist in human endometrium, and hence it is suggested that either endogenous endometrial stem/progenitor cells can be activated or bone marrow derived stem cells can be transplanted in the uterine cavity for endometrial regeneration in Asherman's syndrome (AS). Aims and Objectives : The objective was to evaluate the role of sub-endometrial autologous stem cell implantation in women with refractory AS in attaining menstruation and fertility. Setting : Tertiary care referral center. DESIGN: Prospective case series. Materials and Methods : Six cases of refractory AS with failed standard treatment option of hysteroscopic adhesiolysis in the past were included. Mononuclear stem cells (MNCs) were implanted in sub-endometrial zone followed by exogenous oral estrogen therapy. Endometrial thickness (ET) was assessed at 3, 6, and 9 months. RESULTS: Descriptive statistics and statistical analysis of study variables was carried out using STATA version 9.0. The mean MNC count was 103.3 × 106 (±20.45) with mean CD34+ count being 203,642 (±269,274). Mean of ET (mm) at 3 months (4.05 ± 1.40), 6 months (5.46 ± 1.36) and 9 months (5.48 ± 1.14) were significantly (P < 0.05) increased from pretreatment level (1.38 ± 0.39). Five out of six patients resumed menstruation. Conclusion : The autologous stem cell implantation leads to endometrial regeneration reflected by restoration of menstruation in five out of six cases. Autologous stem cell implantation is a promising novel cell based therapy for refractory AS.

Aims : The current study was to assess the protective role of resveratrol in cypermethrin-induced reproductive toxicity in male Wistar rats. Materials and Methods : Rats were exposed to cypermethrin (3.83 mg/kg bw) for 14 days. Pre- and post-treatment of resveratrol (20 mg/kg bw for 14 days) was given to cypermethrin exposed rats. At the end of the experiment, rats were sacrificed, testis and epididymis were removed, sperm characteristics, sex hormones, and various biochemical parameters were studied. Results : Cypermethrin exposure resulted in a significant decrease in weight of testis and epididymis, testicular sperm head counts, sperm motility and live sperm counts and increase in sperm abnormalities. Serum testosterone (T), follicle stimulating hormone (FSH), luteinizing hormone (LH), reduced glutathione (GSH), catalase (CAT), superoxide dismutase (SOD), glutathione S-transferase (GST), glutathione reductase (GR), glutathione peroxidase (GPx) and total protein (TP) content were decreased and lipid peroxidation (LPO) level was increased on cypermethrin exposure. Pre- and post-treatment of resveratrol increased sperm head counts, sperm motility, live sperm counts, T, FSH, LH, GSH, CAT, SOD, GST, GR, GPx and TP contents and decreased LPO. Treatment with resveratrol alone has improved sperm parameters and testicular antioxidant defence system. Conclusion : The study concluded that resveratrol ameliorated cypermethrin-induced testicular damage by reducing oxidative stress and by enhancing the level of sex hormones.

Context : The primary outcome is to remove the worry of getting immature oocytes with early administration of human chorionic gonadotropin (hCG). Aim : The aim was to find out the association between the day of hCG administration and follicular response in relation to the number and maturity of oocytes, and fertilization rate in assisted reproduction to avoid weekend oocyte recovery (OR). Settings and Design : Retrospective study was carried out in the university infertility clinic. Materials and Method : Controlled ovarian hyperstimulation (COH) in 94 patients undergoing assisted reproductive technology (2010-2011) with recombinant follicle stimulating hormone and timely gonadotropin-releasing hormone antagonist were analyzed regarding day of hCG from day 8-11. Oocyte maturity and fertilization was analyzed and correlated with the day of hCG administration. STATISTICAL ANALYSIS: Kruskal-Wallis test. Results : The average number of >18 mm follicles observed from day 8-11 of hCG administration was not statistically different. However, the OR rate (54.2%), number of mature oocytes (92.5%), and fertilization rate (78.5%) was maximum in the patients where hCG was administered on day 8 of COH. Conclusions : The day of hCG administration between 8 and 11 does not affect the OR rate significantly although the number of oocytes recovered on day 8 are marginally higher compared with day 9-11. Hence, it is possible to safely avoid weekend oocyte retrieval, by delaying or advancing hCG administration without compromising the outcome.

Context : Cancer survival has improved significantly and maintaining fertility is both a major concern and an important factor for the quality of life in cancer patients. Aims : To explore differences in oocyte stimulation for fertility preservation (FP) patients based on cancer diagnosis. Settings and Deign : Between 2005 and 2011, 109 patients elected to pursue FP at a single institution. Materials and Method : In vitro fertilization (IVF) outcome variables between four cancer diagnostic groups (breast, gynecologic, lymphoma/leukemia and other) and age-matched male factor or tubal factor infertility IVF control group were compared. Statistical Analysis : ANOVA and Chi-square analyses were employed to compare variables between the groups that were normally distributed. Kruskal-Wallis with subsequent Mann-Whitney U-test were used for data that were not normally distributed. Results : Women with gynecologic malignancies were significantly older than the women in the other three groups, but tended to have a better ovarian response. Women with hematologic malignancies were most likely to have been exposed to chemotherapy and had the longest stimulations with a similar number of oocytes retrieved. The age-matched IVF controls had higher peak estradiol levels, number of oocytes obtained, and fertilization rates when compared to cancer patients with or without a history of prior chemotherapy. Conclusions : Factors including age, type of cancer and chemotherapy exposure, can influence response to ovarian stimulation. Discussing these findings with patients presenting for FP may aid in setting realistic treatment expectations.

Objectives : The overwhelming numbers of twins following assisted reproductive technology (ART) are dichorionic twins, but monochorionic twins account for around 0.9% of post ART pregnancies. The data for post ART-monochorionic pregnancy outcomes are scarce due to the rarity of this condition. Hence, we evaluated the obstetric outcomes of monochorionic and dichorionic pregnancies conceived on ART. Settings : University teaching hospital. Study Design : A case-control study of monochorionic diamniotic (MCDA) and dichorionic diamniotic (DCDA) pregnancies conceived following ART treatment. Charts of all women who conceived following ART from 2008 to 2013 were screened. Among them, the monochorionic twins diagnosed in the first trimester were included and their obstetric outcome was followed-up. For comparison, an equal number of dichorionic twin pregnancies from age and body mass index matched mothers was selected. Results : The baseline clinical characteristics were similar between the two groups. MCDA group had a higher miscarriage rate (50%) than the DCDA group (10%), with three seconds trimester miscarriages in the MCDA group. The live birth rates were lower in the MCDA versus DCDA group (40% vs. 90%). Among triplet pregnancies with a monochorionic component, the live birth rate was only 25%. Conclusions : Monochorionic pregnancies following ART have poorer obstetric outcomes when compared to dichorionic pregnancies. For monochorionic pregnancies following ART, intensive antenatal surveillance at a tertiary level obstetric and neonatal center may help optimize the outcome.

Background : The damage to ovarian reserve inflicted by surgery for endometriosis represents a major concern in the balance between reproductive benefits and risks. Aim : To evaluate the ovarian reserve in sub fertile women after laparoscopic endometriotic cystectomy. Settings and Design : Prospective study, done in Department of Obstetrics and Gynecology, tertiary care hospital between August 2010-2012. Materials and Method : Laparoscopic cystectomy performed by stripping technique for endometriotic cysts. Endometriosis was staged according to revised American Society of Reproductive Medicine classification (rASRM). Ovarian reserve assessed by comparing FSH and LH levels, measurement of residual ovarian volume, antral follicle counts and stromal blood flow on second day of menses pre and postoperatively. Cyst wall was evaluated histologically to note the presence of normal ovarian tissue in resected tissue. STATISTICAL ANALYSIS: SPSS for Windows version 16.0 (SPSS Inc., Chicago, IL) was used for statistical calculations. Wilcoxon signed test and Pearson Chi - Square test were applied. Significance level was P < 0.05. Results : Incidence of minimal, mild, moderate, and severe endometriosis was 4.1%, 21.9%, 28.7%, 45.3% respectively. Ovarian reserve was assessed both by ultrasound and biochemical parameters on day 2 of menses; pre and post-operatively. Preoperative and post-operative values; FSH (7.24 ± 1.21, 7.23 ± 1.51 m IU/ml), LH levels (6.37 ± 1.8, 6.6 ± 2.3 m IU/ml), residual ovarian volume (8.5 cm ³ ± 5.3, 7.4 cm ³ ± 5.8), antral follicle count(3.3 ± 1.9, 4.1 ± 1.5) and stromal blood flow (6.8 cm/sec ± 4.57, 7.1 cm/sec ± 3.55) were statistically not significant. Loss of follicle was seen in 27.2% cyst walls on histopathological examination while 72.73% had no loss. Conclusion : Laparoscopic cystectomy when performed for endometriotic cysts with accurate surgical technique leads to no significant ovarian tissue removal.

Context : Various markers have been proposed to evaluate endometrial receptivity, such as molecular markers and sonographic markers. Commonly used sonographic markers include endometrial thickness and pattern. A good endometrial blood flow is considered necessary for improved pregnancy outcome. Aim : The aim of the present study is to evaluate the role of subendometrial endometrial blood flow with two-dimensional-power Doppler (2D-PD) in predicting pregnancy outcome in hormone replacement frozen-thawed embryo transfer (FET) cycles. Setting and Design : Prospective, non-randomized observational study. A total of 165 patients undergoing their first FET cycle were evaluated for subendometrial-endometrial blood flow by 2D-PD once the endometrium was ≥7 mm thick. Group A consisted of 127 women showing the presence of subendometrial-endometrial blood flow. Group B comprised of 38 women in whom subendometrial blood flow was absent. Progesterone supplement was added and transfer of 2-3 cleavage stage good quality embryos was done after 3 days. Statistical Analysis : Independent two-tailed t-test and Chi-square test. Results : There was no significant difference in body mass index, endometrial thickness, follicle stimulating hormone, luteinizing hormone levels, number of mature oocytes, semen parameters and the number of good quality embryos in the two groups (P > 0.05). The mean age in Group A was 32.05 years and 33.73 years in Group B, and the difference was statistically significant (P = 0.04). Overall pregnancy rate (PR) was 30.90%. PRs were significantly higher in the presence of subendometrial-endometrial blood flow than in its absence (35.43% vs. 15.78%, P = 0.02). Furthermore, clinical pregnancy rate and implantation rate were significantly higher in Group A when compared to Group B (31.49% and 14.79% vs. 13.15% and 6.52%, P = 0.02 and 0.03, respectively). Conclusion : The presence of endometrial blood flow significantly improves cycle outcome in hormone replacement therapy-FET cycles.

Aim : The aim of the following study is to find out the prevalence of abnormal spermatozoa and associated functional parameters in clinical semen samples of sub-fertile males with the tobacco chewing habit. Settings and Design : Retrospective study was conducted at infertility unit of a tertiary health care center, in a period of 3 years. Materials and Method : Semen of 642 males were analyzed; of them 194 men (30.2%) were tobacco chewers and they were grouped according to their intensity of chewing (<10 and ≥ 10 packets/day). Counts, motility, vitality, and morphology of sperms were analyzed. Results : In tobacco chewers, 66% of subjects were oligozoospermic, 85% asthenozoospermic and 28% teratozoospermic. Sperm counts (odds ratio [OR] =2.2; 95% confidence interval [CI]: 1.5-3.09), motility (OR = 3.2; 95% CI: 2.05-4.9), and normal morphology (OR = 8.4; 95% CI: 4.9-14.6) were significantly affected (P = 0.001) in tobacco chewers than the non-chewing group. Further, in comparison to the intensity of tobacco chewing, patients with the intensive practice of using ≥10 packets/day had a significant effect on sperm morphology (P = 0.003, OR = 2.7; 95% CI = 1.41-5.08) only. Structural defects in head (P = 0.001) and cytoplasmic residues (P = 0.001) were found to be positively correlated with the intensive chewing, but no significant changes were found in anomalies in mid-piece and tail. Conclusion : The adverse impact of tobacco chewing on semen parameters was evident even with mild chewers, but with the intensive chewing practice, phenotypes of sperms, mainly defects in the head and cytoplasmic residue were severely affected.

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.

We present a patient with complete androgen insensitivity syndrome (CAIS) diagnosed with a serous papillary cystadenofibroma. A 41-year-old married female with a mass in the left inguinal region and a history of primary amenorrhea. A bulging mass of 13.7 cm × 8 cm × 12.4 cm in the left inguinal region extending from the hip joint to the level of labia majus, and a 3.2 cm × 2.8 cm mass in her right inguinal region were found by ultrasonography and magnetic resonance imaging. We performed bilateral gonadectomy. The pathology showed testicular tissue in the right inguinal mass and a serous papillary cystadenofibroma in the left one. CAIS is an infrequent clinical entity, occurrence of serous papillary cystadenofibroma is even rarer in this syndrome serous cystadenofibroma should come to mind in patients with a huge inguinal mass. Gonadectomy should be performed right after puberty to prevent the risk of malignancy development in the testes.

A 30 year old woman presented 12 days after embryo transfer with lower abdominal pain and orange vaginal discharge. She was diagnosed to have pyometra. A conservative management with drainage of the pyometra was followed by an uneventful pregnancy and term delivery. Conservative management in a case of pregnancy with pyometra needs close supervision to ensure maternal and fetal well being.