Seminal biomarkers and their correlations to semen parameters in subfertile men.

Research question: To assess the levels of seminal biomarkers fructose, zinc and citrate and their correlations to semen parameters in infertile men. Design: 200 infertile male participants undergoing fertility assessment at Singapore General Hospital (SGH), Singapore were recruited prospectively, from June 2020 to August 2021. Their semen samples were assessed for seminal parameters, biomarker levels of fructose, citrate and zinc, leukocyte concentrations and aerobic cultures. They were also assessed for their smoking habits. Results: Sperm concentrations were negatively correlated to seminal fructose levels, r = -0.262, P < 0.001. Progressive motility were positively correlated to seminal citrate levels, r = 0.181, P = 0.014. Sperm morphology and total motile sperm count (TMSC) were positively correlated to seminal zinc and citrate levels, P < 0.05. Zinc and citrate levels were significantly reduced in teratozoospermia, asthenoteratozoospermia and oligoasthenoteratozoospermia groups compared to normozoospermia, P < 0.05. The presence of infection was associated with elevated leukocyte concentrations, lower sperm concentration (12.5 vs 55.8 million/mL, P = 0.024) and fructose levels (35.5 vs 49.2 µmol/ejaculate). Heavy smokers compared to light smokers, had lower sperm concentrations (35.3 vs 49.4 million/mL), TMSC (30.9 vs 47.5 million) and zinc levels (4.9 vs 6.7 µmol/ejaculate) and significantly lower citrate levels (52.6 vs 79.2 µmol/ejaculate, P = 0.029). Conclusions: Higher zinc and citrate levels correlated with better progressive motility, sperm morphology and TMSC. Smoking negatively impacted zinc and citrate levels, thereby affecting sperm quality. In conclusion, the inclusion of biomarkers in basic male work-up assessment would assist in identifying common deficiencies and aid in adequate replacement therapy.

The Intrauterine Bigatti Shaver System: An Alternative Option for Focal Retained Products of Conception.

The management of retained products of conception (RPOC) may be medical or surgical. Surgical options include blind curettage, ultrasound guided curettage, or curettage under direct vision via hysteroscopy. The definitive management of patients presenting with retained products of conception will depend on several factors: severity of bleeding, presence of hemodynamic instability or infection, and patient preference. Optimal management of retained products of conception should result in complete evacuation of the uterine cavity while minimizing endometrial trauma. This is of utmost importance in patients with reproductive desires. We report patients with RPOC managed via hysteroscopic removal using the Bigatti Morcellator. Both patients had complete evacuation of the visualized RPOC. The purpose of this paper is to present this approach as an effective management option particularly in patients with a history of subfertility and failed blind curettage.

Embryo transfer day does not affect the initial maternal serum ß-hCG levels: A retrospective cohort study.

The aim of this study is to compare the serum ß-hCG values post transfer of a cleavage stage embryo versus a blastocyst stage embryo at equal time intervals post oocyte retrieval (OR) in clinically pregnant patients, and to ascertain a ß-hCG value to predict pregnancy outcomes. This is a retrospective cohort study of 560 women with clinical pregnancy who underwent an embryo transfer performed at either the cleavage stage or the blastocyst stage of embryo development between January 2003 and June 2014 at the Center for Assisted Reproduction (CARE), Singapore General Hospital. The serum ß-hCG level was measured on day 17 post OR. The ß-hCG values were not significantly different in the cleavage stage versus the blastocyst stage embryos (mean±SD: 387±486IU/L D3 vs. 352±268IU/L D5, p=0.96, median value 297 in both groups). Our study suggests that the initial maternal serum ß-hCG values were not affected by the day of transfer of the embryos since assessing the ß-hCG at equivalent points after transfer should not lead to a significant difference assuming the progress and development of the embryos occurred as expected.

Hysterosalpingo-foam sonography: patient selection and perspectives.

We present an overview of the common types of tubal patency tests, with a focus on hysterosalpingo-foam sonography (HyFoSy). Current evidence suggests that HyFoSy is an accurate alternative to X-ray hysterosalpingography (HSG) for outpatient tubal evaluation in women who are at low risk for tubal disease. It may be superior to saline hysterosalpingo-contrast sonography (HyCoSy) in excluding tubal occlusion. A hyperechogenic medium may enhance contrast visualization and enable clearer delineation of tubal anatomy. This may enhance confidence in the diagnosis of tubal patency, reduce false occlusion results, and improve the diagnostic yield of the test. It would be reasonable to deduce that HyFoSy would have similar performance characteristics as HyCoSy with other positive contrast agents. The available evidence supports the accuracy of HyFoSy compared to other forms of tubal investigation. We suggest a decision-making pathway based on the most current professional recommendations and available evidence. However, in this article, we do not provide a definitive exposition of the methods used for investigating tubal patency. Rather, we explore the contexts in which the various investigations are most and least suitable, and identify their strengths and limitations. Finally, we also discuss challenges encountered when performing tubal contrast sonography in clinical practice, including the problem of false occlusion results.

Live birth rates and safety profile using dydrogesterone for luteal phase support in assisted reproductive techniques.

INTRODUCTION: Assisted reproductive techniques (ARTs) result in a deficient luteal phase, requiring the administration of intramuscular, intravaginal or oral exogenous progesterone. Dydrogesterone, an oral retroprogesterone with good bioavailability, has been used in assisted reproductive cycles with outcomes that are comparable to those of vaginal or intramuscular progesterone. However, there are limited reviews on its use for luteal phase support in ARTs, in terms of pregnancy outcomes and associated fetal anomalies. This study aimed to review the live birth rates and associated fetal anomalies of women who were given dydrogesterone for luteal phase support in assisted reproductive cycles at a tertiary hospital in Singapore. METHODS: This retrospective descriptive study included 1,050 women who underwent in vitro fertilisation/intracytoplasmic sperm injection at the Centre for Assisted Reproduction of Singapore General Hospital between 2000 and 2011. The women were given dydrogesterone for luteal phase support. The main outcome measures were rates of pregnancy, live birth, miscarriage and fetal anomalies. RESULTS: The pregnancy and live birth rates were 34.7% and 27.7%, respectively. Among those who achieved pregnancy, 17.0% miscarried, 0.8% had ectopic pregnancies and 0.3% had molar pregnancies. Fetal anomalies were detected in 1.9% of pregnancies, all of which were terminated by choice. CONCLUSION: Since the outcomes of dydrogesterone are comparable to those of intramuscular and vaginal progesterone, it is a reasonable option to provide luteal phase support for women who are uncomfortable with injections or vaginal insertions. Randomised controlled studies are needed to determine the optimal dosage of dydrogesterone for luteal phase support in ARTs.

A comparison of hysterosalpingo-foam sonography (HyFoSy) and hysterosalpingo-contrast sonography with saline medium (HyCoSy) in the assessment of tubal patency.

OBJECTIVE: A randomized controlled selective cross-over trial was performed to compare the diagnostic yield and efficacy of ExEm foam (HyFoSy) with saline medium (HyCoSy) as a contrast agent for hysterosalping-contrast sonography in subfertile patients. STUDY DESIGN: 40 patients were randomized into HyCoSy with saline medium and HyFoSy with ExEm foam. Tubal patency were assessed according to pre-determined objective criteria that classified tubes based on degree of certainty in tubal patency. Selective cross-over testing with the other medium was performed in patients who had at least one possibly occluded or unexaminable tube on the initial test. RESULTS: 80 tubes were evaluated. On initial testing, the proportion of tubes that were classified as patent was higher with HyFoSy compared to HyCoSy (70.0% vs 40.0%, p=0.01). A higher proportion of patients in the HyCoSy group required crossover testing [80.0% (16/20) vs 45.0% (9/20), p=0.02]. On cross-over testing, 41.7% (10/24) of possibly occluded or unexaminable tubes in the HyCoSy group were re-classified as patent when examined with Ex-Em foam, compared to 8.3% (1/12) of possibly occluded or unexaminable tubes in the HyFoSy group (p=0.03). CONCLUSION: ExEm foam medium (HyFoSy) might improve the diagnostic yield and efficacy over saline medium (HyCoSy) for hysterosalpingsonography.

Use of In Vitro Fertilisation Prediction Model in an Asian Population-Experience in Singapore.

INTRODUCTION: This retrospective study was conducted to perform an external validation of the in vitro fertilisation (IVF) predict model developed by Scott Nelson et al in an Asian population. MATERIALS AND METHODS: All IVF cycles registered in the study centre from January 2005 to December 2010 were included. Observed and predicted values of at least 1 live birth per cycle were compared by discrimination, calibration. Hosmer-Lemeshow test was used to assess the goodness-of-fit of the model calibration and Brier score was used to assess overall model performance. RESULTS: Among 634 IVF cycles, rate of at least 1 live birth was 30.6%. Causes of infertility were unexplained in 35.5% cases. Fifty-seven percent of women came for their first IVF treatment. First IVF cycle showed significantly higher success in comparison to subsequent cycles. The odds ratio of successful live birth was worse in women with endometriosis. Observed outcome was found to be more than the prediction of the model. The area under the curve (AUC) in this study was found to be 0.65 that was close to that of Nelson model (0.6335) done in internal validation. Brier score (average prediction error) of model was 0.2. Chi square goodness-of-fit test indicated that there was difference between the predicted and observed value (x² =18.28, df = 8, P = 0.019). Overall statistical findings indicated that the accuracy of the prediction model fitted poorly with the study population. CONCLUSION: Ovarian reserve, treatment centre and racial effect on predictability cannot be excluded. So it is important to make a good prediction model by considering the additional factors before using the model widely.

Is semen polymorphonuclear leucocytes count a good predictor of male genital tract infection?

INTRODUCTION: This study aims to evaluate whether an increased polymorphonuclear leucocyte (PMN) count in semen is a good predictor of male genital tract infection, which is detected by semen culture. METHODS: A retrospective cross-sectional study examining the semen of 388 men was conducted at the in vitro fertilisation centre of a tertiary hospital. We compared the culture results of 109 men with increased semen PMN count against those of 279 men with normal semen PMN count. RESULTS: There was no significant difference in the percentage of positive cultures between men with increased PMN count in their semen and those without PMN count elevation (original sensitivity 20.8%, specificity 70.3%; p = 0.1289). The overall percentage of positive semen cultures among all 388 patients was 18.6%. CONCLUSION: Based on the positive cultures of significant organisms in the semen of our cohort, an increased semen PMN count is not a good predictor of genital tract infection in men.

Azoospermia and paternal autosomal ring chromosomes: case report and literature review.

Two men of the same family presented with ring chromosome 22 and azoospermia. The literature on all autosomal ring chromosomes and semen abnormalities was reviewed. Autosomal ring chromosomes were often associated with a low sperm count. This is probably as a result of gamete instability at meiosis due to the ring chromosome which leads to an increased breakdown. In addition, ring chromosomes transmitted from the parents may manifest quite differently in the progeny. Prior to treating these patients with assisted reproduction, appropriate counselling should be offered, in view of the varying phenotypic manifestations of ring chromosomes in the resulting progeny, and prenatal diagnosis or preimplantation diagnosis must be considered.