Recurrent miscarriages are postimplantation failures in natural conception; they are also termed as habitual abortions or recurrent pregnancy losses. Recurrent pregnancy loss is disheartening to the couple and to the treating clinician. There has been a wide range of research from aetiology to management of recurrent pregnancy loss. It is one of the most debated topic among clinicians and academics. The ideal management is unanswered. This review is aimed to produce an evidence-based guidance on clinical management of recurrent miscarriage. The review is structured to be clinically relevant. We have searched electronic databases (PubMed and Embase) using different key words. We have combined the searches and arranged them with the hierarchy of evidences. We have critically appraised the evidence to produce a concise answer for clinical practice. We have graded the evidence from level I to V on which these recommendations are based.

Pituitary stimulation with pulsatile gonadotropin-releasing hormone (GnRH) analogs induces both follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Pituitary gonadotropin secretions are blocked upon desensitization when a continuous GnRH stimulus is provided by means of an agonist or when the pituitary receptors are occupied with a competitive antagonist. GnRH antagonists were not available originally; therefore, prolonged daily injections of agonist with its desensitizing effect were used. Today, single- and multiple-dose injectable antagonists are also available to block the LH surge and thus to cause desensitization. This review provides an overview of the use of GnRH analogs which is potent therapeutic agents that are considerably useful in a variety of clinical indications from the past to the future with some limitations. These indications include management of endometriosis, uterine leiomyomas, hirsutism, dysfunctional uterine bleeding, premenstrual syndrome, assisted reproduction, and some hormone-dependent tumours, other than ovulation induction.

Objective: To evaluate the role of dehydroepiandrosterone (DHEA) supplementation in women with poor ovarian response (POR) undergoing in vitro fertilization (IVF). Design: Prospective case-control study. Setting: Private tertiary fertility clinic. MATERIALS AND Methods: 31 infertile women with POR diagnosed as per the Bologna criteria. Interventions: DHEA supplementation for 2 months and a subsequent IVF cycle, after two previous IVF cycles with POR. Main Outcome Measure(S): Dose and duration of gonadotropin therapy, oocyte yield, embryo number and quality, pregnancy and live birth rate. Results: No difference was seen in gonadotropin requirement before and after DHEA supplementation. There was a significant increase in total and metaphase II oocytes (5.9 ± 0.68 vs. 2.73 ± 0.24; 4.45 ± 0.47 vs. 2.09 ± 0.26), fertilization (3.65 ± 0.49 vs. 2.00 ± 0.27), Grade I embryos (1.52 ± 0.25 vs. 0.55 ± 0.18), pregnancy rate (30% vs. 9.1%) and live birth rate (25% vs 0%) in those who completed the cycle, following DHEA supplementation. Conclusions: Dehydroepiandrosterone supplementation results in an improvement in oocyte yield, embryo quality, and live birth rate in a group of women with POR having undergone at least two previous failures due to POR.

Background: Many reconstructive surgical procedures have been described for vaginal agenesis. Almost all of them are surgically challenging, multi-staged, time consuming or leave permanent scars on abdomen or skin retrieval sites. Aim: A new simple technique using laparoscopic peritoneal pull-through in creation of neo vagina has been described. Material and Methods: Total of thirty six patients with congenital absence of vagina (MRKH syndrome) were treated with laparoscopic peritoneal pull through technique of Dr. Mhatre between 2003 till 2012. The author has described 3 different techniques of peritoneal vaginoplasty. Results: This technique has given excellent results over a period of one to seven years of follow-up. The peritoneal lining changes to stratified squamous epithelium resembling normal vagina and having acidic Ph. Conclusion: Apart from giving excellent normal vaginal function, as the ovary became accessible per vaginum three patients underwent ovum retrieval and pregnancy using surrogate mother, thus making this a fertility enhancing procedure.

Context: Various components of follicular fluid are suggested as biochemical predictors of oocyte quality. Previous studies of follicular steroid hormone levels have shown disparate results when related with fertilization outcomes. Aim: The objective of the study was to relate the levels of steroid hormones of each individual follicle with oocyte maturation, fertilization results, embryo quality, and pregnancy rates. Settings and Design: Prospective cohort study in a university hospital. Methods: In 31 patients, who underwent intracytoplasmic sperm injection, it was performed an ultrasound guided aspiration of follicular fluid of the first two mature follicles from each ovary. Follicular levels of estradiol, progesterone, testosterone, and dehydroepiandrosterone sulfate were measured by chemiluminescent immunoassay. Statistical Analysis: Generalized estimating equation model. Results: In follicular fluids with mature oocyte presence, in normal as well as in failed fertilization, there was a positive correlation between follicular testosterone and progesterone (r = 0.794, P = 0.0001 and r = 0.829, P = 0.0001). Progesterone levels were higher in cases of normal fertilization compared to failed fertilization (P = 0.003). B quality embryos came from oocytes immersed in follicular fluids with higher estradiol values and higher estradiol/progesterone and estradiol/testosterone ratios than those of C quality (P = 0.01; P = 0.0009; P = 0.001). Estradiol levels were higher in patients who achieved pregnancy (P = 0.02). Conclusion: The analysis of follicular hormone composition could be considered as an additional tool in oocyte selection.

Objective: To evaluate the efficacy of blastocyst transfer in comparison with cleavage stage transfer. Study Design: A randomized, prospective study was conducted in Infertility clinic, Department of Obstetrics and Gynecology, Mahatma Gandhi Hospital, Jaipur on 300 patients aged 25-40 years undergoing in-vitro fertilization (IVF)/intra-cytoplasmic sperm injection (ICSI) cycle from May 2010-April 2011. When three or more Grade-I embryos were observed on day 2 of culture, patients were divided randomly into two study groups, cleavage stage transfer and blastocyst transfer group having 150 patients each. Primary outcomes evaluated were, Clinical pregnancy rate and Implantation rate. The results were analyzed using proportions, standard deviation and Chi-square test. Results: Both the groups were similar for age, indication and number of embryos transferred. Clinical pregnancies after blastocyst transfer were significantly higher 66 (44.0%) compared to cleavage stage embryo transfer 44 (29.33%) (P < 0.01).Implantation rate for blastocyst transfer group was also significantly higher (P < 0.001). Conclusion: Blastocyst transfer having higher implantation rate and clinical pregnancy rate lead to reduction in multiple pregnancies.

Context: Plasminogen activator inhibitor-1 (PAI-1) has been inversely correlated to proteolytic extracellular-matrix degradation exerted by urokinase-type (u-PA) and tissue-type plasminogen activators (t-PA). Any pathological disturbance in PAI-1 levels may lead to several pregnancy complications. Aims: To assess the influence of periodicity in serum PAI-1 levels on embryo implantation and clinical pregnancy outcome in IVF cycles Settings and Design: Prospective study of 120 IVF cycles at private infertility centre. Material and Methods: Endometrial response (ER) assessment by measuring Endometrial thickness (cm) and echopattern (grade). Serum PAI-1(ng/ml) measurement by ELISA method on day of hCG, day of ET and days 7 and 14 of ET. Main outcome measure was clinical pregnancy. Statistical Analysis: Student "t" test, ANOVA, Post-test for linear trend, Pearson Correlation. Results: PAI-1 levels declined from dhCG to dET (318.8 ± 36.1 to 176.1 ± 28.4) whereas they increased steadily from dET to d7 to d14ET (176.1 ± 28.4 to 285.2 ± 30.4 to 353.5 ± 150.4;P = 0.0004) in pregnant group (n = 31). Conversely, dhCG to dET levels increased in both nonpregnant (n = 75; 173.8 ± 18.3 to 280.8 ± 26.1) and biochemical pregnancy BCP (n = 14; 172.7 ± 31.1 to 216 ± 30.1) groups. The rising pattern from dET to d7 to d14ET was not observed in non-pregnant and BCP groups. ER thickness and grade shared significant correlation with serum PAI-1 on dET (Pearson r: ER = 0.28, Grade = 0.29) and d7ET (Pearson r: ER = 0.40, Grade = 0.23). Conclusions: Periodicity in serum PAI-1 levels offers a robust prognostic factor for predicting clinical pregnancy outcome. The dhCG to dET PAI-1 transition is a decisive factor for either transferring embryos in same/ongoing cycle or cryopreserving them and postponing ET to subsequent natural cycle.

Aim: The aim of this study was to analyze human seminal plasma proteins in association with male fertility status using the proteomic mass spectrometry technology Surface-Enhanced Laser Desorption Ionization Time-of-Flight (SELDI-TOF-MS). Materials and Methods: Semen analysis was performed using conventional methods. Protein profiles of the seminal plasma were obtained by SELDI-TOF mass spectrometry over a strong anion exchanger, ProteinChip^® Q10 array. Results and Conclusion: We found statistically significant differences in motility and sperm count between fertile and infertile men. In addition, we observed ten seminal proteins that are significantly up-regulated in the infertile group. In conclusion, comparison of seminal plasma proteome in fertile and infertile men provides new aspects in the physiology of male fertility and might help in identifying novel markers of male infertility.

Background: Sperm DNA integrity is considered an important parameter to assess seminal fluid quality and can be used as a predictive test of potential fertility. Amongst the various tests to determine sperm DNA integrity, one is the Acridine Orange test. Recent studies have demonstrated the importance of p53 in maintaining sperm DNA integrity. The aim of this study was to assess if a p53 ELISA assay could be a new indicator of DNA damage in human spermatozoa. Materials and Methods: 103 human semen samples were evaluated using both Acridine Orange test and p53 ELISA and results were compared. Results: A clear correlation between the values measured by two methods was obtained. Conclusions: If this hypothesis will be confirmed by further studies, the p53 ELISA assay could become a new and more precise indicator of DNA damage in human spermatozoa.

Pregnancy in patients with pan-hypopituitarism following surgery of pituitary adenoma is rare and considered high risk. Hormonal dysfunction in these patients involves more than one axis (gonadotrophic, thyroidal, and adrenal). However, advance in infertility treatment have led to the increased pregnancy rate in hypopituitarism women. We present a case of nonfunctioning pituitary macroadenoma, who after pituitary surgery (hypophysectomy) developed hypopituitarism followed by multiple tuberculoma brain with hydrocephalus with arachnoiditis. She conceived spontaneously after 9 years of pituitary surgery and carried her pregnancy to the term. Elective caesarean section was done at 38 weeks and both infant and mother are well. The case highlights the rarity of the phenomenon and the safe outcome of the pregnancy with proper replacement.

Complete Androgen insensitivity syndrome is a disorder of hormone resistance characterized by a female phenotype in an individual with an XY karyotype. The pathogenesis of CAIS involves a defective androgen receptor gene located on X-chromosome at Xq11-12and end organ insensitivity to androgens, although androgen concentrations are appropriate for the age of the patient. There are three major types of androgen insensitivity syndrome: Complete androgen insensitivity syndrome, minimal androgen insensitivity syndrome, and partial androgen insensitivity syndrome. Management of androgen insensitivity syndrome includes multidisciplinary approach and involves gonedectomy to avoid gonadal tumors in later life. Hormone replacement therapy (HRT) and psychological support are required in long-term basis.

31-year-old woman presented with secondary infertility, a history of previous miscarriage and two ectopic pregnancies. Salpingectomy had been performed for the left ruptured tubal pregnancy whereas the right unruptured tubal pregnancy was managed medically. In-vitro fertilization (IVF) was advised to treat tubal factor infertility of 2 years duration. The patient developed fever and cough on day-10 of ovarian stimulation. Complete blood count and peripheral smear with marked leukocytosis were suggestive of acute leukemia. After obtaining the patient's informed consent, 18 oocytes were retrieved. Following intra cytoplasmic sperm injection, 14 eggs were fertilized, and the resulting embryos were cryopreserved. On a referral to a hemato-oncologist, a bone marrow biopsy was performed, which confirmed acute promyelocytic leukemia (APL). Literature review suggests this to be the first case of APL reported during the course of ovulation stimulation for IVF.