Primary Uterine Alveolar Soft Part Sarcoma in a Postmenopausal Woman: Histopathologic and Immunohistochemical Characteristics of a Rare Case.

BACKGROUND: Primary uterine alveolar soft part sarcoma (ASPS) is a rare, indolent mesenchymal malignancy with less than 40 patients documented in the literature. CASE: We report an example of ASPS in a 61-year-old postmenopausal woman. Macroscopically, the uterus showed multiple nodular masses. Microscopic examination revealed tumor arranged in nests and alveolar pattern. The tumor cells were moderately to markedly pleomorphic, epithelioid to polygonal, with eccentrically placed nuclei, vesicular chromatin, prominent macro-nucleoli, and moderate to abundant eosinophilic cytoplasm. PAS-positive and diastase-resistant intracytoplasmic crystals were also seen in some tumor cells. On immunohistochemistry, the tumor cells showed diffuse positivity for vimentin and nuclear positivity for TFE3, a surrogate marker for ASPS. These were negative for SMA, desmin, CD10, h-caldesmon, cyclin D1, EMA, Melan A, and CD34. SMARCB1 expression was retained. Based on the histopathology and IHC, a final diagnosis of uterine ASPS was rendered. CONCLUSIONS: Knowledge of the characteristic histopathologic and immunohistochemical features can help accurately diagnose such rare tumors. Knowledge of the characteristic histopathologic and immunohistochemical features can help accurately diagnose such rare sarcoma in an uncommon site with an unusual age.

Stable isotope labeling as a promising tool for rapid drug susceptibility testing in Neisseria gonorrhoeae.

The world is heading towards an era of intractable and impending untreatable N. gonorrhoeae, thereby underlining the significance of rapid and accurate prediction of drug resistance as an indispensable need of the hour. In the present study, we optimized and evaluated a stable isotope labeling-based approach using the MALDI-TOF MS (Matrix-Assisted Laser Desorption/Ionization-Time of Flight Mass Spectrometry) for rapid and reliable detection of ciprofloxacin and azithromycin resistance in N. gonorrhoeae. All the isolates were cultured under three varied condition setups viz. medium supplemented with normal lysine, heavy lysine (isotope), and heavy lysine along with the antibiotics (ciprofloxacin/azithromycin), respectively. After incubation, spectra were acquired using the MALDI-TOF MS which were further screened for unique patterns (media-specific spectra) to differentiate drug-susceptible and resistant isolates. The results of the stable isotope labeling assay were comparable to the results of phenotypic methods used for susceptibility testing.

Validation of Grobman's graphical nomogram for prediction of vaginal delivery in Indian women with previous caesarean section.

Purpose: To validate Grobman's nomogram for prediction of trial of labour after caesarean section (TOLAC) success in the Indian population. Methods: A prospective observational study of women with previous lower segment caesarean sections (LSCS) who were admitted for TOLAC between January 2019 and June 2020 at a tertiary care hospital We compared the Grobman's predicted VBAC success probability to the observed VBAC rate in the study population and devised a receiver-operator characteristics (ROC) curve for the nomogram. Results: Among the 124 women with prior LSCS who chose TOLAC and were included in the study, 68 (54.8%) had a successful VBAC and 56 (45.2%) had a failed TOLAC. The mean Grobman's predicted success probability for the cohort was 76.7%, significantly higher in VBAC women versus CS women (80.6% vs. 72.1%; p 0.001). The VBAC rate was 69.1% with a predicted probability of > 75% and only 42.9% with a probability of 50%. Women in the > 75% probability group had a nearly similar observed and predicted VBAC rate (69.1% vs. 86.3%; p = 0.002), and a greater number of women in the 50% probability group had successful VBAC than predicted (42.9% vs. 39.5%; p = 0.018). The area under the ROC curve for the study was 0.703 (95% CI 0.609-0.797; p 0.001). Grobman's nomogram had a sensitivity of 57.35%, a specificity of 82.14%, a positive predictive value (PPV) of 79.59%, and a negative predictive value (NPV) of 61.33% at a predicted probability cut-off of 82.5%. Conclusions: Women who had a higher Grobman's predicted probability had greater VBAC success rates than those with low predicted probability scores. The prediction ability of the nomogram was highly accurate at higher predicted probabilities, and even at lower predicted probabilities, women did have good odds of delivering vaginally.

Efficacy of a Proprietary Fenugreek Seed Extract (Trigonella foenum-graecum, Furocyst®) in Women with Polycystic Ovary Syndrome (PCOS): a Randomized, Double-Blind, Placebo-Controlled Study.

INTRODUCTION: Polycystic ovary syndrome (PCOS) is characterized by hyperandrogenemia, a quite common heterogenous endocrine/hormonal disorder, and accompanied by elevated androgen level, menstrual irregularity, and hirsutism. The consequences include infertility or miscarriage. It is a challenging problem to the physicians. In a one-arm, non-randomized preliminary investigation in fifty premenopausal women, we demonstrated the efficacy of Furocyst®, a patented, standardized Trigonella foenum-graecum extract, in ameliorating the symptoms of PCOS over a period of 90 consecutive days. OBJECTIVE: In the present study, a double-blind, two-arm, single-center, randomized, comparative study was conducted to assess the efficacy of Furocyst® (2 capsules of 500 mg/day) in 208 pre-menopausal women diagnosed with PCOS. METHODS: Ethical committee approval was obtained. A total of 208 subjects (placebo = 95; Furocyst® = 113; age:18-45 years, BMI < 42 kg/m2) completed the investigation. The comparative efficacy of placebo and Furocyst® was assessed on the number of cysts, ovarian volume, hirsutism, LH:FSH ratio, titer of TSH, SHBG, prolactin and free testosterone. Key clinical parameters such as fasting blood glucose levels, HOMA Index, cholesterol, LDL, and triglyceride levels, as well as total blood chemistry were also investigated. RESULTS: Furocyst® supplementation significantly reduced the number of cysts, ovarian volume, and hirsutism levels, as well as normalized the menstrual cycle in Furocyst®-treated subjects as compared to placebo group. Furocyst® significantly reduced luteinizing hormone (LH) and follicle stimulating hormone (FSH) levels, and thyroid stimulating hormone (TSH) levels, and reduced the prolactin and SHBG levels. Furocyst® significantly reduced the fasting blood glucose levels, HOMA Index, cholesterol, LDL, and triglyceride levels as compared to the placebo group, while the free testosterone levels were significantly decreased in the Furocyst® group. CONCLUSION: The studies collectively demonstrated the efficacy of Furocyst® as a safe, natural phytochemical-based formulation to alleviate the symptoms of PCOS. No significant adverse events were observed.

Prenatal diagnosis for hemophilia A (intron 22 inversion) reveals a rare association with Klinefelter syndrome with diagnostic difficulties in molecular interpretation.

Hemophilia A is an X-linked recessive disorder caused by genetic abnormalities in the F8 . Klinefelter syndrome is sex chromosome aneuploidy caused by nondisjunction during meiosis in the germ cells or mitotic cell divisions in the early embryonic cells. We here report an intriguing case of a prenatal diagnosis where a rare association of hemophilia A and Klinefelter syndrome was found in a fetus. This case highlights the diagnostic difficulty where the inverse-PCR for intron 22 inversion defect leading to hemophilia A did not amplify. Indirect molecular testing was done using multiallelic extragenic variable number tandem repeat (VNTR) DXS52 (St14) and polymorphic markers. The interpretation was further complicated by the presence of Klinefelter syndrome. This case highlights the challenges faced when such rare combinations are found during prenatal diagnosis.

A randomized controlled trial to compare antibiotic prophylaxis in elective gynecological surgeries: Single dose of cefazolin versus single dose of cefazolin and tinidazole.

Objectives: To evaluate if addition of an anti-anaerobic agent to standard drug-cefazolin for antimicrobial prophylaxis would further decrease postoperative infectious morbidity or not. This is relevant as most of the infections in gynecological surgeries are anaerobic but cefazolin does not protect against anaerobes. Materials and Methods: The study design was a parallel randomized controlled trial. Two hundred patients undergoing benign gynecological surgeries were divided into two groups of 100 each. Group A received 2 g cefazolin 30-60 min before incision and Group B received 2 g cefazolin 30-60 min and 1.6 g tinidazole 60-120 min before incision. The patients were followed for any infectious morbidity for 1 month postoperatively. The analysis was done separately for abdominal, laparoscopic, and vaginal surgeries. The analysis was also done for surgeries according to the wound category, i.e. clean and clean-contaminated. Results: The two groups were comparable for age and body mass index (BMI). The two groups were comparable for the factors affecting infectious morbidity such as duration of surgery, blood loss, blood transfusions, duration of hospital stay, and need for additional antibiotics. The postoperative infectious morbidity was analyzed in terms of fever, surgical site infection (SSI), and urinary tract infection (UTI). No patient in vaginal and laparoscopic groups suffered from infectious morbidity. In abdominal surgeries group, postoperative fever occurred in 6/74 (8.1%) and 11/74 patients (14.8%) in Groups A and B, respectively (P = 0.38). SSI occurred in 1/74 (1.3%) and 2/74 (2.7%) patients in Groups A and B, respectively (P = 1.0). UTI occurred in 5/74 patients (6.7%) and 2/74 patients (2.7%) in Groups A and B, respectively (P = 0.44). The data were also analyzed for infectious morbidity for clean and clean-contaminated wound categories, and the results were nonsignificant between both groups for each type of wound category (P > 0.05). Conclusion: Cefazolin alone is a sufficient antibiotic prophylaxis for benign gynecological procedures.

Immunohistochemical evaluation of infiltrating immune cells in endometrial biopsy of female genital tuberculosis.

BACKGROUND: Female Genital Tuberculosis (FGTB) causes infertility in a large number of females in developing countries. Presence of granuloma on histopathological examination of endometrial samples is diagnostic of FGTB. But immunohistochemical evaluation of endometrial aspirates has not been explored before. AIM: To evaluate the immunohistochemical delineation of immune cells in FGTB. METHODS: 1515 infertile women from 20 to 35 years were enrolled and underwent endometrial aspiration (EA), which was subjected to microbiological and histopathological examination along with PCR. Patients positive for conventional tests like granulomas, acid fast bacilli, mycobacterial culture on LJ medium or liquid (MGIT) culture were started on antitubercular therapy. Conventional test negative but PCR positive patients were posted for laparoscopy. Immunohistochemistry (IHC) for LCA, CD68, CD3, CD4, CD8, CD 20, CD138, IFN gamma and IL10 were evaluated. RESULT: 38/1515 (2.5%) subjects tested positive for conventional methods. PCR-TB was positive in 615/1515 samples (40.59%). On IHC, the number of CD45 (LCA) positive immune cells (p = 0.03) and IFN gamma (p = 0.002) and IL10 expression (p = 0.012) at 1 + level were higher in the PCR positive samples. Laparoscopy done in 418/463 patients and 89/418 (21.3%) showed definitive findings of tuberculosis. CD3, CD4, CD8, CD20, CD68 and CD138 showed no correlation with PCR and laparoscopy. CONCLUSION: Increased IFN gamma and IL 10 expressing immune cells in PCR positive EA suggests subclinical early changes, and can be useful as a research tool but have no role in diagnosing FGTB.

The Management of Scar Ectopic: A Single-Center Experience.

PURPOSE: This study aimed to highlight the clinical features, diagnosis, and different modalities of the treatment of cesarean scar pregnancy (CSP). METHODS:  This study was done in the tertiary referral hospital of India for one year. A total of 11 cases were enrolled prospectively. In each case, the diagnostic ultrasonography and measurement of baseline beta-human chorionic gonadotropin (ß-HCG) levels were done. The treatment was given based on the hemodynamic status of the patient and desire for future fertility. Various treatment modalities used were medical, surgical, or interventional digital subtraction angiography to control hemorrhage. Also, in some cases, ultrasound-guided methotrexate was injected into the scar ectopic. Medically treated cases were followed up until their ß-HCG levels became normal. RESULTS: Out of 11 patients, six had a history of two cesarean sections in the past, four patients had a history of one cesarean section and one patient with a previous three low segments cesarean section (LSCS). Seven out of 11 patients underwent medical management with either methotrexate with potassium chloride (KCl) or methotrexate alone. The success of the medical management was monitored by serial ß- HCG values. The mean time for the resolution of these 10 patients was 86.7 ± 53.6 days. Three patients underwent emergency uterine artery embolization due to uncontrolled bleeding and one patient required laparotomy. CONCLUSION: CSP is a life-threatening condition that can be diagnosed with the help of transvaginal ultrasonography. The treatment, however, depends on the hemodynamic status of the patient and desire for future fertility. Well-defined diagnostic criteria coupled with structured management and follow-up protocol can help in treating this challenging form of ectopic pregnancy.

Sonographic Optic Nerve Sheath Diameter Following Seizure Prophylaxis in Pre-Eclamptic Parturients With Severe Features: A Prospective, Observational Study.

OBJECTIVES: Neurological manifestations, including raised intracranial pressures, are a hallmark of worsening pre-eclampsia. Invasive methods for measuring intracranial pressure, though a gold standard, are not always a viable option. Maternal ocular sonography is a promising bedside tool, which serves as a noninvasive, cost-effective means for measuring optic nerve sheath diameter (ONSD), a surrogate marker of raised intracranial pressures. We studied the ultrasonographically measured ONSD in severely pre-eclamptic women, and the effect of magnesium sulfate therapy on its values. METHODS: Thirty severely pre-eclamptic women at ≥28 weeks gestation were included. We recorded baseline ONSD values, serum magnesium levels, neurological symptoms, vitals, and repeated them at 4 and 12 hours following magnesium sulfate therapy, and then at 24 hours postpartum. An ONSD value >5.8 mm was suggestive of raised intracranial pressure. Primary outcome measure was to evaluate changes in ultrasonographically measured ONSD following seizure prophylaxis with magnesium sulfate. RESULTS: Women, 73.3%, had baseline ONSD >5.8 mm, with mean diameter being significantly high (6.02 ± 0.77 mm). There was a statistically nonsignificant decline in mean ONSD values at 4 and 12 hours, as well as at 24 hours postpartum. Patients with neurological symptoms declined significantly (from 70 to 10%; p value <.001) following magnesium sulfate therapy. CONCLUSIONS: Majority of severely pre-eclamptic parturients had high ONSD value suggestive of raised intracranial pressures, which persisted in the postpartum period and was unaffected by magnesium sulfate therapy. Ultrasound can thus serve as a point-of-care, cost-effective, easily available bedside tool for indirectly measuring intracranial pressures in this high-risk population.

Female Dhat syndrome in primary care setting.

AIM: The study aimed to evaluate the females presenting with the complaint of nonpathological vaginal discharge to a general gynecology outpatient service in a rural community clinic from the perspective of female Dhat syndrome. METHODOLOGY: Sixty-nine females considered to have nonpathological vaginal discharge after detailed gynecological evaluation, including required investigations, attending a rural community clinic were assessed for their belief about the vaginal discharge. The study subjects were also evaluated on the proposed criteria of female Dhat syndrome by using a semi-structured interview. RESULTS: The mean age of onset of vaginal discharge was 36.1 (standard deviation - 8.5) years. Most of the females considered the loss of vaginal fluid as loss of a vital fluid from the body. Consumption of warm foods and drinks (75.8%) was the most common reason reported for vaginal discharge followed by eating unbalanced food/inappropriate food (73.5%). A majorty of the subjects considered vaginal discharge responsible for bodily weakness (87.0%), backache (71.0%) and stomache (66.7%). About two-third of the participants considered the taking energizing medications like vitamins/tonics/tablets and treatment from a gynecologist the treatment for vaginal discharge. CONCLUSIONS: Significant proportion of females with non-pathological vaginal discharge have a belief that they are losing a vital fluid of the body. The subject attributes their symptoms to factors such as consumption of warm foods and drinks, and eating unbalanced food/inappropriate food. Accordingly, assessment and management of women with Dhat syndrome require addressing these important issues.

Prevalence and Pregnancy Outcome of Mullerian Anomalies in Infertile Women: A Retrospective Study.

BACKGROUND: Uterine anomalies arise if there is agenesis of one or two mullerian ducts, or absence of fusion or reabsorption of the septum between these ducts. The process may be partial or total and affect one or multiple parts of the tract. AIMS: This study was done to assess the distribution of various types of mullerian anomalies in infertile women, their classification based on ESHRE and AFS, associated anomalies, types of diagnostic modalities used, surgical interventions done(if any), various types of infertility treatment used and their outcomes. SETTING AND DESIGN: A retrospective analysis in a tertiary level hospital. MATERIALS AND METHODS: This was a retrospective study in which the women found to have mullerian anomalies were recruited from infertility clinic from July 2019 to March 2020. They were classified according to ESHRE and AFS criteria and their records were analyzed after taking various factors like age, ovarian reserve, duration of infertility, treatment given , associated ovarian and tubal factors and pregnancy outcomes. STATISTICAL ANALYSIS: Analysis was performed in Excel. RESULTS: There were 30 women with mullerian anomalies. Unicornuate uterus was most common anomaly. Four women required septoplasty in view of septate uterus. Five women had associated renal anomalies in form of shrunken kidney and ectopic kidney. Most of these women were considered for controlled ovarian stimulation followed by intrauterine insemination. In our study 16.6% women had successful pregnancy outcome. CONCLUSION: Mullerian anomalies continue to attract infertility specialist as they pose challenge in making clear diagnosis and its management as obstetrics outcomes are excellent after septum resection in women with septate uterus and conservative management in women with other anomalies. Proper work up of infertility and its management varies from case to case and associated factors like endometriosis, male factor, polycystic ovarian syndrome etc.

A study to compare maternal and perinatal outcome in early vs. late onset preeclampsia.

OBJECTIVE: The risk factors, clinical trends, and maternal and fetal health of early- and late-onset preeclampsia have not been adequately studied. We examined the effects of early- and late-onset preeclampsia on maternal and perinatal outcomes as well as the known risk factors of preeclampsia. METHODS: One hundred and fifty women with preeclampsia were consecutively enrolled in each group. Those who developed preeclampsia before 34 weeks of gestation were identified as having early-onset preeclampsia, while those who developed at 34 weeks or later were identified as having late-onset preeclampsia. Maternal and perinatal outcomes were compared between groups. RESULTS: Compared with the late-onset group, the early-onset group had higher rates of abruptio placentae (16% vs. 7.3%; P=0.019), but there was no intergroup difference in the composite maternal outcomes. A significantly higher number of women with early-onset preeclampsia developed severe features during the disease course, and most required treatment with antihypertensive drugs. Late-onset preeclampsia was more prevalent among primigravid mothers. Babies born to mothers with early-onset preeclampsia had a significantly higher rate of adverse outcomes. CONCLUSION: These study findings indicate that women with early-onset preeclampsia had more adverse outcome than those with late-onset preeclampsia, but the difference was not statistically significant. There were more babies with adverse perinatal outcomes in the early-than late-onset group.

To study the changes in maternal hemodynamics with intravenous labetalol or nifedipine in acute severe hypertension.

OBJECTIVE: To study the maternal hemodynamic changes in acute severe hypertension after treatment with intravenous labetalol or oral nifedipine using color doppler ultrasound. STUDY DESIGN: We evaluated thirty pregnant women with gestational age between 28 and 40 weeks in acute severe hypertension (more than or equal to 160/105 mmHg) which were randomly allocated to receive either intravenous labetalol or oral nifedipine until blood pressure was lowered to less than or equal to 140/90 mmHg. Doppler vascular indices namely pulsatility index, resistance index, S/D ratio of bilateral uterine arteries and maternal renal artery were measured baseline at the time of acute severe hypertension and repeated after control of blood pressure, to assess the changes in maternal hemodynamics if any with labetalol or nifedipine. RESULTS: When evaluating right uterine artery Doppler parameters, a trend to increase in PI and RI was observed in those who received labetalol and nifedipine however the difference was not statistically significant. Whereas, while evaluating left uterine artery indices a trend to decrease PI was seen in nifedipine group but the difference was not statistically significant. On intergroup comparison there was no any significant change in any of uterine artery as well as renal artery indices in either group. CONCLUSION: The use of labetalol and nifedipine were not related to any significant changes in maternal Doppler, which is reassuring about the safety of these drugs when treating acute severe hypertension in pregnancy.

Wound complication among different skin closure techniques in the emergency cesarean section: a randomized control trial.

OBJECTIVE: Cesarean section is the most commonly performed obstetrical surgical procedure; however, there are no standard guidelines on appropriate skin closure techniques and materials. Only few comparative studies have been conducted on different skin closure techniques, and they have shown conflicting results. Therefore, we compared different skin closure techniques during emergency cesarean section to identify the best technique with minimal wound complication rates. METHODS: Patients were randomized into 3 groups (group A, n=100; group B, n=102; and group C, n=98). In group A, the skin was closed using staples; in group B, via the subcuticular technique using monocryl 3-0; and in group C, using mattress suture nylon (2-0). The primary outcome was a composite of wound complications, including infection, seroma, gaping, and need for resuturing and antibiotic administration. The secondary outcome included closure time, pain perception, patient satisfaction, and cost. Analyses were performed in accordance with the intention-to-treat principle. RESULTS: The composite wound complication rate in the entire cohort was 16.6% (n=50); the complication rate was significantly higher in group A than in the other groups. Infection was the most common wound complication observed in the entire study group (86%) and was significantly higher in group A than in groups B and C (P≤0.001). CONCLUSION: The use of staples for cesarean section skin closure is associated with an increased risk of wound complications and prolonged hospital stay postoperative visits.

Role of Immunohistochemistry to Distinguish Grade 3 Endometrioid Carcinoma and Uterine Serous Carcinoma.

AIM: The categorization of endometrial carcinomas into endometrioid and serous categories has prognostic implications but many-a-times, it is difficult to categorize based solely on morphology. The present study was conducted to determine an appropriate immunohistochemical panel to distinguish grade 3 endometrioid carcinoma from serous carcinoma. EXPERIMENTAL DESIGN: This study was a retrospective and a prospective study including 63 cases of endometrial carcinoma diagnosed on morphology as either grade 3 endometrioid (n=29) or serous endometrial carcinomas (n=34). Immunohistochemistry (IHC) was performed using tissue microarrays for 8 immunomarkers on 60 cases. RESULTS: The mean age of presentation was not significantly different for both types of carcinomas and the most common presentation was postmenopausal bleeding (93% of the total cases, P=0.66). Obesity (P=0.038), lymph nodal involvement (P=0.044), and stage at presentation (P=0.042) were found to be significantly different among the 2 types of carcinomas. Estrogen and progesterone receptor (ER, PR) positivity was more common (47.6% and 28.2%, respectively) in endometrioid carcinomas as compared with serous. Mutation type (diffuse or null) p53 staining was a powerful predictor of serous carcinomas. IMP3 and p16 were found to be positive in most cases of serous carcinoma (64.1% and 79.5%, respectively). Vimentin and ß-catenin were found to be of limited utility. On the basis of IHC, 21 cases could be categorized as grade 3 endometrioid carcinomas and 39 as type 2 carcinomas (serous and clear cell carcinoma). CONCLUSIONS: The most appropriate IHC panel to differentiate endometrioid and serous endometrial carcinomas includes ER, PR, IMP3, p53, and p16.

Comparison of Clinical, Metabolic, Hormonal, and Ultrasound Parameters among the Clomiphene Citrate-Resistant and Clomiphene Citrate-Sensitive Polycystic Ovary Syndrome Women.

OBJECTIVE: The objective of the study is to compare the clinical, metabolic, hormonal, and ultrasound parameters among the clomiphene citrate (CC)-sensitive and CC-resistant polycystic ovary syndrome (PCOS) women. MATERIALS AND METHODS: This was a prospective observational study. SETTING: The study was conducted at the infertility outpatient department in a government hospital. SAMPLE SIZE: A total of 164 women with PCOS-related infertility were included. INTERVENTION: Incremental dose of CC from 50 mg/day to 100 mg/day to 150 mg/day over three cycles was given. RESPONSE: Ovulation was the outcome. Those who failed to ovulate with 150 mg CC were CC resistant. RESULTS: Of the total 164 PCOS women, 88 (53.7%) were CC resistant and 76 (46.3%) were CC sensitive. Of the 76 PCOS women who ovulated, maximum, i.e., 37 (22.6%) women ovulated with 100 mg CC. The most common diagnostic feature of PCOS in this study was hyperandrogenism (96.3%). CC-resistant PCOS women had significantly higher weight, waist circumference, waist-hip ratio, and body mass index (BMI). Significantly longer menstrual cycles and hyperandrogenism were significantly more common in CC-resistant group. CC-resistant group had a significantly higher ovarian reserve (ovarian volume, antral follicle count, and anti-Müllerian hormone values). Baseline luteinizing hormone (LH) values and LH-follicle stimulating hormone ratio were significantly higher in the CC-resistant group. CONCLUSION: Clomiphene-resistant PCOS women have significantly higher hyperandrogenism, longer cycles, more deranged metabolic profile, higher BMI, and ovarian reserve. These differences should be kept in mind while deciding the ovulation induction protocol.