GnRH agonist trigger and ovarian hyperstimulation syndrome: relook at 'freeze-all strategy'.

A case is reported of early onset ovarian hyperstimulation syndrome (OHSS) after gonadotrophin-releasing hormone agonist (GnRHa) trigger for final oocyte maturation in a GnRH antagonist protocol. The use of GnRHa in place of HCG as a trigger for final oocyte maturation in an antagonist IVF cycle has been proposed as a method for preventing OHSS in predicted high-responders. This approach, however, did not prevent the occurrence of OHSS in our case despite a freeze-all strategy. To the best of our knowledge, this is a possible index case of severe OHSS with GnRHa trigger for oocyte maturation without any luteal HCG rescue for a high responder, despite IVF cycle segmentation.

Social oocyte freezing: a survey among Singaporean female medical students.

AIM: Social oocyte freezing has gained increasing interest worldwide. We conducted a cross-sectional survey on 129 female medical students in Singapore to assess their mindset and attitudes toward fertility and social oocyte freezing. METHODS: An anonymous online survey was conducted among female medical students in Singapore. The desired sample size was 100 participants. Their awareness of the existence of social oocyte freezing was first assessed. An information leaflet was provided subsequently, followed by a more detailed questionnaire. The questions focused on their awareness of age-related fertility decline and their intentions for social oocyte freezing if made available. RESULTS: One hundred and twenty-nine female students participated in the electronic survey, of whom 36.4% had heard of social oocyte freezing. Of these, 70% had personally considered taking up this option. However, after reading the information leaflet, only 48.9% would still consider this option. Of the total, 89.9% considered themselves too old for pregnancy after the age of 35 years, 37.2% would delay family planning for their career, 45.7% would consider social oocyte freezing to postpone family planning for their career, 46.5% would consider oocyte freezing if they had no suitable partners yet, 50.4% may consider freezing their eggs after the age of 30 years and 71.3% may be more amenable to oocyte freezing if government subsidy is available. CONCLUSION: We hypothesize that social oocyte freezing may be a viable option for single young women who wish to delay child-bearing for 'reproductive insurance', so long as this is done with appropriate informed consent with non-directive counseling.

CD26/DPPIV down-regulation in endometrial stromal cell migration in endometriosis.

OBJECTIVE: To test the hypothesis that endometrial stromal cells (ESCs) in endometriosis exhibit increased cell motility under hypoxia. DESIGN: Prospective case-control study. SETTING: University research laboratory. PATIENT(S): Women with endometriosis (n = 18) or benign gynecological disease (n=19). INTERVENTION(S): Eutopic ESCs were cultured under normoxia (20% O2) or hypoxia (6.5% O2), and migration and invasion capacity assayed, with pathway-focused polymerase chain reaction (PCR) array and ELISAs performed. CD26/dipeptidyl peptidase IV (DPPIV) expression was determined by flow cytometric analysis and enzymatic activity assay. The ESCs supplemented with Diprotin A (CD26 inhibitor), stromal cell-derived factor-1α, or AMD3100 (C-X-C motif receptor 4; CXCR4 blocker) were assayed for their migratory potential. MAIN OUTCOME MEASURE(S): Endometrial stromal cell migration and invasion under hypoxia. RESULT(S): Endometriotic ESCs showed significantly higher migration and invasion through collagen gels under hypoxia compared with nonendometriotic ESCs. The PCR array revealed down-regulation of the migration inhibitor CD26/DPPIV and up-regulation of angiogenic factors (vascular endothelial growth factor A, C-X-C motif Ligand 6; CXCL6) in endometriotic ESCs under hypoxia. The CD26/DPPIV surface expression and activity as well as angiogenic protein secretions suggested that the molecular mechanisms underlying aberrant migratory and angiogenic behavior in endometriotic ESCs. A combinatorial treatment with diprotin A and stromal cell-derived factor-1α effectively enhanced migration and invasion preferentially in endometriotic ESCs cultured hypoxically. CONCLUSION(S): Loss of CD26/DPPIV under hypoxia and the subsequent increase in migratory and angiogenic factors may favor conditions for lesion development in endometriosis.

Academy of Medicine-Ministry of Health Clinical Practice Guidelines: assessment and management of infertility at primary healthcare level.

The Academy of Medicine (AMS) and Ministry of Health (MOH) have developed the clinical practice guidelines on Assessment and Management of Infertility at Primary Healthcare Level to provide doctors and patients in Singapore with evidence-based treatment for infertility. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the AMS-MOH clinical practice guidelines on Assessment and Management of Infertility at Primary Healthcare Level, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical/2013/cpgmed_infertility.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.