International Journal of Fertility & Sterility
Year:2014 | Volume:8 | Issue:3|Papers Count:18

Clinical trials, systematic reviews and guidelines compare beneficial and non-beneficial outcomes following interventions. Often, however, various studies on a particular topic do not address the same outcomes, making it difficult to draw clinically useful conclusions when a group of studies is looked at as a whole (1). This problem was recently thrown into sharp focus by a systematic review of interventions for preterm birth prevention, which found that among 103 randomised trials, no fewer than 72 different outcomes were reported (2).

The luteal phase of all stimulated in vitro fertilization/intra-cytoplasmic sperm injection (IVF/ICSI) cycles is disrupted, which makes luteal phase support (LPS) mandatory. The cause of the disruption is thought to be the multifollicular development achieved during ovarian stimulation which results in supraphysiological concentrations of steroids secreted by a high number of corpora lutea during the early luteal phase. This will directly inhibit luteinizing hormone (LH) secretion by the pituitary via negative feedback at the level of the hypothalamic-pituitary axis, leading to a luteal phase defect. With the introduction of the gonadotropin-releasing hormone (GnRH) antagonist protocol, it became feasible to trigger final oocyte maturation and ovulation with a single bolus of GnRH agonist (GnRHa) as an alternative to human chorionic gonadotropin (hCG). GnRHa triggering presents several advantages, including the reduction in or even elimination of ovarian hyperstimulation syndrome. Despite the potential advantages of GnRHa triggering, previous randomized controlled trials reported a poor clinical outcome with high rates of early pregnancy losses, despite supplementation with a standard LPS in the form of progesterone and estradiol. Following these disappointing results, several studies now report a luteal phase rescue after modifications of the LPS, resulting in a reproductive outcome comparable to that seen after hCG triggering. We herein review luteal phase differences between the natural cycles, hCG trigger and GnRHa trigger and present the most recent data on handling the luteal phase after GnRHa triggering.

Background: To assess the efficacy of luteal phase support (LPS) using intravaginal progesterone (P) on pregnancy rate in Iranian women with polycystic ovarian syndrome (PCOS) who used a combination for ovulation induction consisting of letrozole or clomiphene citrate (CC) and human menopausal gonadotropin (HMG).Materials and Methods: This was a randomized clinical trial undertaken in a fertility clinic in Kashan, Isfahan Province, Iran. A total of 198 patients completed treatment and follow up. Base on chosen ovulation induction programs, they were divided into two following group: i. CC group (n=98) used a combination consisting of CC (100 mg×5 day) and HMG (150 IU×5 day) and ii. letrozole group (n=100) used a combination consisting of letrozole (5 mg×5 day) and HMG (150 IU×5 day). After human chorionic gonadotropin (hCG) administration (5000 IU), the patients (n=122) who randomly received intravaginal P (Cyclogest, 400 mg daily) were included in LPS group, while the rest (n=123) were included in non-P cycles group. The outcome was the comparison of chemical pregnancy rate between the groups.Results: Our findings showed that LPS was associated with a 10% higher pregnancy rate than in non-P cycles, although this difference did not reach statistical significant (p=0.08). LPS improved pregnancy rate in both CC (4%) and letrozole (6%) groups. In addition, patients who used letrozole for ovulation induction along with intravaginal P showed higher pregnancy rates than CC group.Conclusion: Administration of vaginal P for LPS may improve the pregnancy rate in women with PCOS using letrozole or CC in combination with HMG for ovulation induction (Registration Number: IRCT201206072967N4).

Background: One of the most important factors affecting success rates in assisted reproductive techniques (ART) besides the number of oocytes retrieved and high quality embryos derived from them is the technical aspects of embryo transfer. It seems that pretreatement with uterine relaxants can be helpful in preventing unpleasant cramps which can have an adverse effect on ART outcome. In this respect, some drugs such as prostaglandin inhibitors or sedatives have been evaluated but not confirmed yet remain controversial. This study was performed in order to assess the effect of administrating Piroxicam prior to embryo transfer on pregnancy rates in ART cycles.Materials and Methods: This pilot study was performed from August 2010 through December 2011 on 50 infertile women in ART cycles. Recombinant follicle stimulating hormones (rFSH) with a long gonadotropin releasing hormone (GnRH) analogue protocol were used for controlled ovarian hyperstimulation. The subjects were randomly allocated into two groups of 25 patients after obtaining written consent. Group A received a 10 mg Piroxicam capsule 30 minutes before embryo transfer and group B was the control group with no treatment. Data were analyzed by Chi-square and analysis of variance (ANOVA).Results: Pregnancy rate was 34% (n=17) totally, with 32% (n=8) in group A and 36% (n=9) in group B (p=0.75). Uterine cramps were experienced by 4 women (16%) in group B, while none were reported by women in group A (p=0.037).Conclusion: It seems that Piroxicam administration 30 minutes prior to embryo transfer cannot increase pregnancy rates, but can prevent or reduce uterine cramps after the procedure.

Background: Embryo transfer (ET) is one of the most important steps in assisted reproductive technology (ART) cycles and affected by many factors namely the depth of embryo deposition in uterus. In this study, the outcomes of intracytoplasmic sperm injection (ICSI) cycles after blind embryo transfer and embryo transfer based on previously measured uterine length using vaginal ultrasound were compared.Materials and Methods: This prospective randomised clinical trial included one hundred and forty non-donor fresh embryo transfers during January 2010 to June 2011. In group I, ET was performed using conventional (blind) method at 5-6cm from the external os, and in group II, ET was done at a depth of 1-1.5 cm from the uterine fundus based on previously measured uterine length using vaginal sonography. Appropriate statistical analysis was performed using Student’s t test and Chi-square or Fisher’s exact test. The software that we used was PASW statistics version 18. A p value<0.05 was considered statistically significant.Results: Chemical pregnancy rate was 28.7% in group I and 42.1% in group II, while the difference was not statistically significant (p=0.105). Clinical pregnancy, ongoing pregnancy and implantation rates for group I were 21.2%, 17.7%, and 12.8%, while for group II were 33.9%, 33.9%, and 22.1, respectively. In group I and group II, abortion rates were 34.7% and 0%, respectively, indicating a statistically significant difference (p<0.005). No ectopic pregnancy occurred in two groups.Conclusion: The use of uterine length measurement during treatment cycle in order to place embryos at depth of 1-1.5cm from fundus significantly increases clinical and ongoing pregnancy and implantation rates, while leads to a decrease in abortion rate.

Background: To examine whether pregnancy rate (PR) of intrauterine insemination (IUI) is related to certain demographic factors, such as age and body mass index (BMI), along with number of IUI cycles performed, a set of infertile Saudi women.Materials and Methods: During this prospective study (a 24-month period), 301 Saudi women with infertility underwent IUI in our infertility clinic. We investigated whether PR is correlated with patient age and BMI, and the number of IUI trials, in order to determine if they could be used as prognosticators of pregnancy success.Results: The highest PR was 14.89% for ages 19-25 and the lowest PR was 4.16% for ages 41-45, indicating no statistically significant difference among PR in all age groups (p value of 0.225). Also, in terms of BMI, the highest PR was 13.04% for BMI³35 and the lowest was 7.84% for BMI of<25 to 18.5, indicating no significant difference among different BMI groups (p value of 0.788). One-cycle treatment, as expected, was more successful (PR=12.84%) than 2-cycle treatment (PR=5.75%), however, 3-5-cycles treatment still showed encouraging results (PR=17.24%); but the difference did not reach statistical significance (p value=0.167).Conclusion: PR after IUI treatment remained approximately 10% from 19 to 40 years of age and declined after 40. Although no significant difference was observed among different age groups, earlier treatment is still recommended. There was a positive but not statistically significant correlation between PR and patient’s BMI indicating that BMI is not a determining factor. There was also no correlation between PR and number of IUI trials. Patients can thus try as many times as they want before moving on to in vitro fertilization (IVF) treatment.

Background: The aim of this study was to assess the occurrence of polycystic ovary syndrome (PCOS) and its association with body composition among students in University of Sharjah (UOS).Materials and Methods: This cross-sectional study included a total sample size of 50 female students registering in undergraduate programs at the University of Sharjah using convenience sampling technique. A pretested interview schedule was administered to elicit information pertaining to personal background and medical history related to PCOS. A diagnostic ultrasound scan was performed for determining PCOS along with a body composition analysis using bioelectrical impedance analysis (BIA) technology.Results: Twenty percent (10 out of 50 participants) were diagnosed with PCOS, of whom only 4 individuals were previously diagnosed with PCOS and aware of their conditions, while the reports showed 16% with oligomenorrhea, 4% with polymenorrhea, and none with amenorrhea. A positive family history was indicated as reported by 22% of the total participants. Significant difference between the body weights of participants having PCOS (66.7 kg) and those without it (58.8 kg) were noted (p=0.043, t=2.084). On the other hand, the body composition related variables including waist-hip ratio (WHR), fat-free mass (FFM), percent body fat (PBF) and visceral fat area (VFA) were relatively higher in participants having PCOS than those without it. However, there was no statistical significance of differences. Comparatively, the participants with PCOS had lower bone mineral density (BMD) than those without it, whereas the difference was statistically non-significant.Conclusion: The occurrence of PCOS in the present study is consistent with the global prevalence. Comparatively, the body composition of PCOS females is different from the normal females. Further studies are required in the Middle East region on larger sample sizes and broader aspects of health including lifestyle and dietary components to understand these differences.

Background: Since time of menopause is influenced by a variety of racial, environmental, and physiological factors, determining age at natural menopause and its main indicators seems to be necessary. The present study attempted to determine average age at menopause and its main predictors among Iranian women.Materials and Methods: This descriptive-analytic study was carried out on 400 post-menopausal women aged 43 to 65 years attending the health centers in Hamadan, Hamadan Province, Iran, during 2013. Due to potential effects of oral contraceptive pills (OCP) on age of menopause, we considered two groups of women with and without OCP use using cluster sampling method. Data were collected through individual interviews at the health centers.Results: The findings showed significant univariate relationships between age at menopause with some baseline variables including mother’s age at menopause (p<0.001), mother and spouse with high educational level (p<0.001), passive cigarette smoking (p<0.001), weekly physical activity (p<0.001), and high family income (p<001). Adversely, smoking was associated with early menopause.Conclusion: The postmenopausal women doing intense weekly physical activity, having mothers with late menopause, having higher monthly income, and experiencing later-age pregnancy are likely to reach menopause later than their contemporaries, while smokers have an early menopause.

Background: This study aimed to assess sexual functioning among women with polycystic ovary syndrome (PCOS) in Iran.Materials and Methods: A cross-sectional study was conducted to ascertain factors related to sexual functioning in 300 PCOS patients attending to the private practice centers in Kashan, Isfahan Province, Iran, from May to October 2012. The Female Sexual Function Index (FSFI) was used to measure sexual functioning. Moreover, the socio-demographic details and clinical information of PCOS including obesity, hirsutism, acne, menstrual cycle disturbances, infertility and endocrine profile were recorded for each patient.Results: Overall the prevalence of female sexual dysfunction (FSD) was 16.6%. In particular patients indicated poorer sexual functioning for the desire (48.3%) and the arousal (44.7%) subscales. Multiple logistic regression analysis suggested patients with lower educational level (OR: 2.94; 95% CI: 1.46-5.92) and irregular menstrual status (OR: 4.61; 95% CI: 1.93-11) were more likely to report sexual dysfunction.Conclusion: The findings suggest that desire and arousal were the most prevalent sexual disorders reported in this patient population. In addition, findings suggested that women with limited or no formal education and a history of menstrual irregularities were the most likely to report female sexual dysfunction. Further investigations are needed to examine female sexual functioning among women with PCOS, to educate their health care providers, and to develop therapeutic interventions.

Background: Marital instability is affected by many factors. In Iran, socio-cultural and political limitations are obstacles for sexuality-related studies; therefore, insufficient information is available in this area. In the present research, we investigated the relationship between marital instability and sexual satisfaction among Iranian women.Materials and Methods: A case-control study was carried out to investigate women applying for divorce in comparison with our controls during 2011 to 2012 in Isfahan, Iran. Data gathering was done using a questionnaire including two parts: socio-demographic information and factors influencing sexual satisfaction. Larson Inventory of Sexual Satisfaction for determining sexual satisfaction was used to determine sexual satisfaction.Results: Divorce rate is significantly related to sexual satisfaction (p=0.009). There were also significant relationships between sexual satisfaction and the following variables: age, economic status, amount of income, duration of marriage, number of children, housing, alcohol/drug abuse by spouse, being beaten by spouse, compulsory marriage, second marriage of spouse, and being happy with current partner.Conclusion: Sexual satisfaction plays an important role in marital stability of Iranian women. Thus, development of practical strategies in order to provide cultural intervention is needed to improve Iranian couples’ awareness of their sexual relationship. Indeed, trainings in communication skills through sexual encounters are essential.

Background: There are various treatment options for infertility, and new techniques are also being developed as it is an important healthcare problem affecting approximately 15-20% of married couples. The purpose of this study was to evaluate the level of information of fertile and infertile Turkish women on oocyte donation in order to understand their awareness of the legal, ethical, social and religious issues regarding this technique and to compare these two groups in terms of these variables.Materials and Methods: This cross-sectional study included infertile women being treated at the assisted reproductive technologies (ART) program of a university hospital and women who had presented at the gynecology outpatients department of the same university for routine check-ups and who had no previous history of infertility. After consulting with specialists in the field and searching the related literature, a data collection form having 22 questions for infertile women and 18 questions for fertile women was prepared.Results: The women were asked whether they would use the oocytes of another woman if necessary. The results showed that 67.6% of the fertile women said they would never want to use this method, while 63.9% of the infertile women stated they may accept to use this method under certain conditions (two distinct answers appeared in the answers, some women stated they would prefer donated oocytes from close relatives, while others stated they would prefer oocytes from total strangers), such as from a close relative or from someone they do not know at all.Conclusion: Infertile women mentioned that they could use illegal routes if necessary to have a child at much higher rates than stated by fertile women. This shows that desire to have a child is a strong source of motivation in Turkey.

Background: To the general public, the Internet is an acceptable method of obtaining information. It also plays an important role in guiding patients and solving their problems. We investigated the clinical characteristics of an Internet website to provide guidelines and tips for consultation.Materials and Methods: In this retrospective observational study, we analyzed the use of a free public Internet perinatal consultation website provided by the Ministry of Health and Welfare of Korea. We evaluated 2, 254 Internet perinatal consultations and assessments of prenatal and obstetrics from August 2006 to December 2009. We evaluated the patients’ questions based on Williams’ textbook categories and their clinical characteristics.Results: The mean age of patients seeking consultation was 33.9±13.2 years, and parity was 1.2±0.5. The most commonly asked questions were about drug safety during pregnancy (20.4%), and questions regarding prenatal care (18.7%) and labor pain (15.4%) were the second and third most commonly asked questions, respectively.Conclusion: The Internet can provide good information to patients. Thus, guidelines regarding pregnancy-related questions and answers should be created. Obstetricians could use our data to identify question tendencies.

Background: Studies conducted on infertile women in the literature investigated some features such as depression, anxiety, loneliness, and social support. However, there has been no study examining the relationship between levels of perceived social support and depression in infertile women. Considering this deficiency, the study was conducted to determine the relationship between perceived social support and depression in infertile women. The purpose of this study is to determine the relationship between perceived social support and depression in infertile women.Materials and Methods: This descriptive and sectional study was conducted between 16 April and 31 October 2012 in in vitro fertilisation (IVF) Centre of Firat University Research Hospital. Sampling formula was used in cases when the number of elements in the population was not known to calculate minimum sample size required to be included in the study. A total of 238 women who applied to the relevant centre between the specified dates constituted the sample group of the study. A Questionnaire Form, Beck Depression Inventory (BDI) and the Multidimensional Scale of Perceived Social Support (MSPSS) were used to collect the data. A pilot study was carried out on nine infertile women. As a result of the pilot study, we formed the final version of the Questionnaire Form. The data of these nine women were not involved in the research. The data obtained from the study was assessed using Statistical Package for the Social Sciences (SPSS; SPSS Inc., Chicago, IL, USA) version 15.0. Percentage distribution, mean, t test, one-way analysis of variance (One-Way ANOVA), and Pearson correlation analysis were used to evaluate the data.Results: The women’s total mean score on the BDI was 12.55±8.07. Scores obtained by women on the MSPSS was 15.75±8.53 for the subscale of friend, 21.52±8.20 for the subscale of family, and 15.62±8.45 for the subscale of significant others. The women’s total MSPSS score was 52.89±21.75.Conclusion: A significant, negative relationship was found between total BDI score with subscale and total mean scores of MSPSS (r=-0.596, p<0.01). Symptoms of depression decreased as the women’s perceived social support increased.

Background: This study examined the causal model of relation between marital relationship status, happiness, and mental health in infertile individuals.Materials and Methods: In this descriptive study, 155 subjects (men: 52 and women: 78), who had been visited in one of the infertility Centers, voluntarily participated in a self-evaluation. Golombok Rust Inventory of Marital Status, oxford Happiness Questionnaire, and General Health Questionnaire were used as instruments of the study. Data was analyzed by SPSS17 and Amos 5 software using descriptive statistics, independent sample t test, and path analysis.Results: Disregarding the gender factor, marital relationship status was directly related to happiness (p<0.05) and happiness was directly related to mental health, (p<0.05). Also, indirect relation between marital relationship status and mental health was significant (p<0.05). These results were confirmed in women participants but in men participants only the direct relation between happiness and mental health was significant (p<0.05).Conclusion: Based on goodness of model fit in fitness indexes, happiness had a mediator role in relation between marital relationship status and mental health in infertile individuals disregarding the gender factor. Also, considering the gender factor, only in infertile women, marital relationship status can directly and indirectly affect happiness and mental health.

Background: The objective of the study was to investigate the effects of in vitro zinc sulphate additive to semen extender on sperm parameters (progressive motility, viability, membrane integrity and DNA stability) after cryopreservation. Materials and Methods: In this Prospective longitudinal laboratory study, semen samples of 5 buffalo bulls of 3-5 years old were collected at 5 different occasions from Iran, Urmia during summer and autumn 2011, 25 samples were used in each treatment. Sperm progressive motility, viability and abnormal morphology were measured before and at 0.5 (T0), 1(T1) and 2(T2) hours after diluting semen(1:10 v/v) in Tris-citric acid based extender (without egg yolk and glycerol) at 37˚C containing none (control group), 0.072, 0.144, 0.288, 0.576 and 1.152 mg/L zinc sulphate to investigate dose and time effects. Next, a Tris-citric acid-egg yolk-glycerol extender (20% egg yolk and 7% glycerol) containing the same amount of zinc sulphate was prepared, diluted semen (1:10 v/v) was cooled and kept into a refrigerated chamber (4˚C) for 4 hours to equilibrate. Sperm progressive motility, viability, abnormal morphology, membrane integrity and DNA damage were estimated.The equilibrated semen was loaded in 0.5 ml French straws and frozen in liquid nitrogen. Later, the frozen semen was thawed and the same parameters as well as total antioxidant capacity (TAC) of the frozen-thawed semen were etermined.Results: The results showed that zinc sulphate additive at the rate of 0.288 mg/L gave a higher protection of sperm progressive motility (53.7±1.8% vs. 40.5±1.7%), viability (70.8±1.8% vs. 60.1±1.5%), membrane integrity (67.3±1.6% vs. 56.6±1.7%), DNA stability (10.1±0.47% vs. 11.8±0.33% damaged DNA) through the process of dilution, equilibration and freeze-thawing and caused a higher TAC level (81±3.3% vs. 63±3.2 μmol/L) after freez-thawing compared to the control group. Adding 0.576 and 1.152 mg/L zinc sulphate, however, was deleterious to the sperm and significantly reduced the studied sperm parameters.Conclusion: Adding 0.288 mg/L zinc sulphate to the extender, compared to the control group, gives a better sperm preservation upon freezing processes which in turn, may results in higher semen fertility. But, addition of higher zinc sulphate concentrations (0.576 and 1.152 mg/L) are detrimental to buffalo spermatozoa.

Background: RFamide-related peptide-3 (RFRP-3) and kisspeptin (KiSS-1) are known to respectively inhibit and stimulate gonadotropin releasing hormone (GnRH) and luteinizing hormone (LH) secretion in rat. The aim of the present study was to evaluate the relative mRNA expression of RFRP-3 and KiSS-1 in the hypothalamus of pregnant rats. Materials and Methods: In a randomized controlled experimental study, the exact pregnancy day of 18 Sprague-Dawley rats were confirmed using the vaginal smear method and were equally assigned to three groups of days 7, 14 and 21 of pregnancy. Four nonpregnant female rats were ovariectomized and assigned as the control group. All rats were decapitated, and the dorsomedial hypothalamic nucleus (DMH) and the arcuate nucleus (ARC) for detection of KiSS-1 mRNA were separated from their hypothalamus to detect RFRP-3 and KiSS-1 mRNA respectively. Then, their relative expressions were compared between control and pregnant groups using real-time polymerase chain reaction (PCR).Results: The relative expression of RFRP-3 mRNA in DMH did not change significantly during pregnancy (p>0.01). However, the relative expression of KiSS-1 mRNA in ARC was at its highest in day 7 of pregnancy and decreased until day 21 of pregnancy (p<0.01).Conclusion: Decrease in GnRH and LH secretion during the pregnancy of rat may be controlled by constant expression of RFRP-3 mRNA and reduced expression of KiSS-1 mRNA in hypothalamus.

Severe pelvic infections following ultrasound-guided transvaginal oocyte retrieval (TVOR) are rare but challenging. Ovarian abscess formation is one of the consequences and management of such cases as highly debated in pregnant patients. In this case report, an early fetal loss following laparoscopic management of ovarian abscess is described and possible etiologies are discussed.

Placenta percreta is a rare complication potentially fatal to fetus and the mother. We present here a 41-year-old female patient who underwent curettage for incomplete abortion at 6th week of pregnancy. She had persistent vaginal bleeding for 2 months after the curettage, for which she was treated with hysterectomy. Preoperative ultrasonography and magnetic resonance imaging (MRI) made the diagnosis of placenta percreta. Postoperative pathological examination confirmed this diagnosis.