Diagnostic and management dilemmas of pregnancies at the utero-tubal junction: A case series and management algorithm.

OBJECTIVE: A pregnancy at the utero-tubal junction is a rare type of ectopic pregnancy and is associated with high maternal morbidity if it remains undetected. In the present study we discuss four cases of ectopic pregnancies at the utero-tubal junction which caused diagnostic and management dilemmas. METHODS: Four cases of early pregnancies with the gestational sac (G-sac) implanted near the utero-tubal junction are described. In case 1 this was suspected after a failed attempt at dilatation and curettage at our hospital, cases 2 and 3 presented with amenorrhea and pain abdomen and case 4 was diagnosed on first pregnancy documentation scan after frozen embryo transfer. RESULTS: As initial two-dimensional (2D) transvaginal scan (TVS) failed to diagnose the exact location of the G-sac, three-dimensional (3D) TVS helped to localize the exact location of pregnancy and subsequent individualized management. Case 1 had a partial intramural ectopic pregnancy managed by laparotomy and removal of the ectopic sac. The second and third cases were eccentric uterine pregnancies. The fourth was an interstitial ectopic pregnancy managed by a laparoscopic loop and stitch technique. CONCLUSION: This case series describes the role of 3D TVS for the evaluation of pregnancies implanted at the utero-tubal junction and individual management of eccentric intrauterine, interstitial ectopic and intramural ectopic pregnancies. A diagnostic algorithm for such types of cases and management options is discussed.

Prevalence of FSH-R Asn680Ser and Ala307Thr receptor polymorphism and their correlation with ART outcomes among infertile Indian-Asian women-a prospective cohort study.

The present prospective cohort study evaluated the prevalence of FSH-R receptor Asn680Ser and Ala307Thr among infertile Indian women and the correlation of these polymorphisms with ART outcomes. Total 804 infertile and 209 fertile controls were enrolled for FSH-R analysis. Correlation of different genotypes with ovarian reserve markers, IVF parameters, and cumulative live birth rates (CLBR) was done among women undergoing IVF. In fertile controls, at 680 position GG (Ser/Ser) was the most common genotype; but among infertile women, all the genotypes were equally distributed. There was no significant difference in ovarian response parameters, oocyte yield, and CLBR among the three genotype groups. Empty follicle syndrome (EFS) was highest in women with AA or AG type at both positions. On categorisation of unexpected poor responders according to POSEIDON stratification; GG genotype at both positions had the lowest risk ratio of low-oocyte yield in ART cycles, but these differences were not statistically significant. This is the largest study from Indian ethnicity showing GG (Ser/Ser) genotype is most common among fertile women. The effect of FSH-R genotypes is very marginal on IVF parameters and is not reflected in CLBR. More prospective data may be required on the correlation of these genotypes with genuine EFS, thus stratifying the next cycles with self or donor oocytes. Routine genetic testing of FSH-R polymorphism should not be done except in a research setting. As both 680 and 307 positions are in linkage disequilibrium, only 680 position analysis may be done in a research setting.

Utility of Visceral Adiposity Index and Lipid Accumulation Products to Define Metabolically-Unhealthy Polycystic Ovary Syndrome in Asian Indian Women - A Cross Sectional Study.

Background: Polycystic ovary syndrome (PCOS) women are at risk of developing diabetes, cardiovascular disease and metabolic syndrome (MetS) due to insulin resistance (IR) and hyperandrogenism (HA). Both visceral adiposity index (VAI) and lipid accumulation product (LAP) are simple outpatient department-based metric tools that have been introduced to screen PCOS women who are metabolically unhealthy and are at risk of development of MetS. Aims: The aim of the study was to evaluate VAI and LAP in women with PCOS and to correlate them with metabolic and endocrine markers. The study also assessed these parameters amongst different PCOS phenotypes and determined their usefulness to define metabolically healthy PCOS (MH-PCOS) and metabolically unhealthy PCOS (MU-PCOS). Settings and Design: The design of the study was a cross-sectional study. Materials and Methods: Two hundred PCOS women were included in the study, and all the clinical, anthropometric, hormonal, biochemical and metabolic markers were assessed. The cohort was divided into MH-PCOS and MU-PCOS by the modified National Cholesterol Education Programme criteria. VAI and LAP were calculated and correlated with clinical, endocrine and metabolic parameters. Statistical Analysis Used: Univariate and multivariate logistic regression analysis was used to study the independent role of VAI and LAP to predict MetS. Adjusted and unadjusted odds ratios were calculated. Receiver-operating characteristic (ROC) analysis was done to define cut-offs in Asian Indian women. Results: VAI and LAP had good ability to correctly discriminate MU-PCOS from MH-PCOS (area under the curve [AUC] [95% confidence interval (CI)]: 0.89 [0.82-0.95]) and (AUC [95% CI [0.81-0.92] =0.86) using ROC, respectively. The sensitivity of VAI and LAP corresponding to the optimal cut-off of ≥2.76 and ≥48.06 (Youden) was 84.09% and 79.55%, respectively. Similarly, the specificity of VAI and LAP was 85.26% and 79.49%, respectively. VAI has a positive predictive value of 61.7% (95% CI [23.7%-40.3%]) and a negative predictive value of 95% (95% CI [88%-99.1%]). LAP has a positive predictive value of 53% (95% CI [40.3%-65.4%]) and a negative predictive value of 93.3% (95% CI [87.6%-96.9%]). PCOS women having VAI ≥ 2.76 had 19.3 times ([95% CI: 6.50-57.70]) more chance of developing MetS. PCOS women having LAP (≥48.06) have 3.7 times ([95% CI: 1.35-10.60]) more odds. There was no difference between ROC curves of VAI and LAP (P = 0.32). Conclusion: VAI cut-off ≥ 2.76 and LAP with a cut-off of ≥ 48.06 may be used as markers for predicting MetS amongst PCOS women.

Comparison of Cumulative Live Birth Rate (CLBR) According to Patient Oriented Strategies Encompassing Individualized Oocyte Number (POSEIDON) Stratification Among Low Prognosis Women Undergoing IVF-ICSI Cycles.

Background: The purpose of the current study was to evaluate patient-oriented strategies encompassing individualized oocyte number (POSEIDON) criteria, validate stratification of low prognosis women, and prognosticate their reproductive potential in terms of cumulative live birth rate (CLBR) in Indian women. Methods: Out of 4048 women who underwent IVF/ICSI, 3287 women met the criteria for final evaluation of CLBR. They criteria were divided into (a) group 1a as cases with <4 oocytes retrieved and 1b with 4-9 oocytes retrieved; (b) group 2a as cases with <4 oocytes retrieved and 2b with 4-9 oocytes retrieved; (c) group 3 (<35 years, AMH <1.2 ng/ml, AFC <5); and (d) group 4 (≥35 years, AMH <1.2 ng/ml, AFC <5). Non-POSEIDON group was sub-divided into normo-responders (10-20 oocytes) and hyper-responder (>20 oocytes). Results: Overall CLBR was two-fold lower in POSEIDON group as compared to non-POSEIDON group (p<0.001). For every one-year increase in the age, the odds of CLBR decreased by 4% (OR 0.96, CI 0.93-0.99) in POSEIDON group and by 5% (OR 0.95, CI 0.92-0.98) in non-POSEIDON group. For every unit increase in number of oocytes retrieved, the odds of CLBR increased by 1.22 times (OR1.22, CI 1.16-1.28) in POSEIDON group and by 1.08 times (OR 1.08, CI 1.05-1.11) in non-POSEIDON group. Among POSEIDON groups, the highest values in CLBR belonged to group 1b followed by 3, 2b, 4, 1a, and 2a. Conclusion: POSEIDON stratification of low-prognosis women undergoing IVF may be considered valid to prognosticate and counsel women undergoing IVF. Prospective studies will strengthen its validity among different ethnic populations.

Robert's Uterus versus Juvenile Cystic Adenomyoma - Diagnostic and Therapeutic Challenges - Case Report and Review of Literature.

This case report highlights the diagnostic dilemma and therapeutic challenges encountered while managing adolescent girls with progressive dysmenorrhoea and management of Robert's uterus. Two girls aged 20 years and 13 years presented with severe progressive dysmenorrhoea. In the first case, laparoscopy revealed juvenile cystic adenomyoma (JCA) of 3 cm × 3 cm on the left side anteroinferior to the round ligament. Laparoscopic resection of the lesion was done, and histopathology revealed features of adenomyosis. In the second case, there was a globular enlargement of the right half of the uterine body with round ligament and adnexa attached to the lesion (Robert's uterus). In view of severe symptoms, complete resection of the lesion and partial resection of hemi-uterus was done, followed by myometrial defect closure. Both cases were initially diagnosed as JCA, and the final diagnosis was made on laparoscopy. Both girls had complete symptomatic relief from the next menstrual cycle and have been under follow-up for 24 months and 18 months, respectively. Due to the rarity of conditions, Robert's uterus and JCA are usually misdiagnosed with each other or with other Mullerian anomalies such as a non-communicating unicornuate uterus. Radiologists and clinicians should be aware of these different pathologies causing similar symptoms. Understanding the pathology, early diagnosis, timely referral and correct surgical procedure are emphasised to improve reproductive outcomes.

Serum Anti-Mullerian Hormone (AMH) Levels Among Different PCOS Phenotypes and Its Correlation with Clinical, Endocrine, and Metabolic Markers of PCOS.

Anti-Mullerian hormone (AMH) is one of the direct indicators of follicular pool but no standard cutoff has been defined for diagnosis of polycystic ovary syndrome (PCOS). The present study evaluated the serum AMH levels among different PCOS phenotypes and correlated the AMH levels with clinical, hormonal, and metabolic parameters among Indian PCOS women. Mean serum AMH was 12.39 ± 5.3ng/mL in PCOS cohort and 3.83 ± 1.5 ng/mL in non-PCOS cohort (P < 0.01). Out of 608 PCOS women, 273 (44.9%) women belonged to phenotype A, 230 (37.8%) women were phenotype D. Phenotypes C and B were 12.17% and 5.10% respectively. Among those with the highest AMH group (AMH>20ng/ml; 8.05%), majority belonged to phenotype A. Menstrual cycle length, serum testosterone, fasting total cholesterol levels, and follicle number per ovary had positive correlation with serum anti-Mullerian levels (P < 0.05). AMH cutoff for the diagnosis of PCOS was calculated as ≥ 6.06 ng/mL on ROC analysis with sensitivity and specificity of 91.45% and 90.71% respectively. The study shows high serum AMH levels in PCOS are associated with worse clinical, endocrinological, and metabolic parameters. These levels may be used to counsel patients regarding treatment response, help in individualized management and prediction of reproductive and long-term metabolic outcomes.

An unusual association of type II Mayer-Rokitansky-Kuster-Hauser syndrome, turner mosaic syndrome and tubo-ovarian inguinal hernia- case report and review of literature.

BACKGROUND: Herniation of ovaries and Mullerian structures into inguinal canal is usually reported in infants and is rare among adults. We are presenting a rare case of Mullerian agenesis and Turner mosaic syndrome with tubo-ovarian inguinal hernia. CASE PRESENTATION: A 17-year-old girl presented with complaints of primary amenorrhea, phenotypical features of Turner syndrome with left inguinal hernia and severe hypertension. Baseline hormonal analysis was normal. Karyotype revealed Turner mosaic with 46XX (85%); 45XO (15%). MRI showed Mullerian agenesis with normally located right ovary in pelvis and left ovary prolapsed through deep inguinal ring into the canal of Nuck. Anti-hypertensives were started and patient optimized for surgery. Laparoscopic hernia repair and repositioning of left ovary into the pelvis was done. Patient had uneventful post-operative course and was discharged in stable condition on anti-hypertensive medication. Future reproductive issues and need of passive vaginal dilatation or vaginoplasty before marriage were explained to the patient and family. CONCLUSION: This is the first ever reported case with unusual association of atypical MRKH, Turner mosaic syndrome and tubo-ovarian hernia into the inguinal canal. The case emphasizes the need and importance of complete work up of these atypical cases as patients may have more than one cause of primary amenorrhea and complete evaluation is must before any medical or surgical intervention.

Psychological impact of suspension/postponement of fertility treatments on infertile women waiting during COVID pandemic.

OBJECTIVE: To assess the psychological impact of suspension/postponement of various fertility treatments on infertile women during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: This was a cross-sectional study conducted as an online survey among infertile women consulting either through teleconsultation or physical consultation at a fertility clinic of a tertiary care referral unit. A validated questionnaire was given as a WhatsApp link to the women who were consulting for the resumption of services. Questions asked were based on their socio-demographic parameters, fertility treatment at the time of suspension, anxiety (self-reported) and stress (perceived stress scale-4, PSS-4) due to delay in treatment, psychosocial effect of pandemic, and wishes regarding the resumption of fertility services. RESULTS: Of 430 patients who received the questionnaire, 250 completed the survey (response rate: 58%). The mean age of participants was 29.26±4.18 years and the majority (70.4%) had lower socioeconomic status. The average PSS-4 score was 7.8±0.71, and the prevalence of self-reported anxiety was 72%. Those who suffered migration during the pandemic had significantly higher PSS-4 scores, and increasing age was associated with increased self-reported anxiety due to the suspension of fertility services. The top three priorities reported were infertility and treatment delay (48.4%), job loss (19.2%), and the risk of contracting COVID-19 infection (16%). The degree of spousal support was significantly correlated with lower PSS-4 scores (r=-0.30, P<0.01). On multivariate logistic analysis, duration of infertility, delay in treatment due to suspension of services, and fear of COVID-19 infection were significant predictors of stress and anxiety. CONCLUSION: This study emphasizes the need to investigate psychosocial health and to provide psychological support to this vulnerable population in addition to triaging fertility treatments in a phased manner.