Luteal Phase Stimulation in the Same Cycle Is an Effective Strategy to Rescue POSEIDON Poor Responders with No Embryos after the First Follicular Stimulation.

Background: Poor responders may benefit from recruiting a 'second wave' of antral follicles within the same cycle. This concept forms the basis of double stimulation which has been named as 'DuoStim'. This protocol involves ovarian stimulation in both follicular and luteal phases with egg retrieval in each phase, respectively, to increase the number of oocytes and embryos in one menstrual cycle. This can be considered a potentially valuable option for women with poor ovarian reserve/response to maximise the number of oocytes retrieved in a single ovarian cycle in the shortest possible time. Aims: The aim of this study was to evaluate the efficacy of the DuoStim protocol in women classified as POSEIDON poor responders undergoing in vitro fertilization by comparing the embryological outcomes between the follicular and luteal phase stimulations in the same menstrual cycle. Settings and Design: This was a retrospective cohort study of 131 patients who enrolled to undergo DuoStim cycles from January 2021 to Sept. 2022, at a IVF center in a tertiary care hospital. Materials and Methods: The follicular phase stimulation used a standard antagonist protocol for the first oocyte retrieval. Thereafter, the luteal phase stimulation was started 3 days after the first retrieval, with the same dose of gonadotropin along with a daily 10 mg medroxyprogesterone acetate tablet, followed by a second oocyte retrieval. Blastocysts produced in both the phases were subsequently vitrified. Statistical Analysis Used: The paired t-test was used for comparing means and 95% confidence intervals (CIs) for different parameters. McNemar's test was used to compare paired proportions. The analysis was conducted using R statistical environment 4.2. Results: The mean number of oocytes retrieved and the mean number of utilizable blastocysts frozen per stimulation cycle were found to be significantly higher in the luteal phase as compared to the follicular phase (5.71 ± 3.95 vs. 4.87 ± 2.79, P = 0.02, and 1.43 ± 1.22 vs. 0.95 ± 1, P = 0.001, respectively). However, the mean fertilization rate and the mean blastocyst utilization rate were found to be similar between both the phases. The length of stimulation was found to be approximately 3 days longer in the luteal phase (12.63 ± 2.43 vs. 9.75 ± 1.85, P = 0.001). Overall, the odds of obtaining a usable blastocyst in the luteal phase was found to be significantly higher than in the paired follicular phase (73.9% vs. 57.7%, P = 0.012, odds ratio: 2.286 [95% CI: 1.186-4.636]). Also importantly, the luteal phase stimulation was able to rescue 68% (32/47) of patients where no blastocysts were formed in the follicular phase. Conclusion: Our data demonstrate that in women with poor reserve, the addition of luteal stimulation could increase the chances of achieving a pregnancy by significantly increasing the number of eggs and transferable embryos per menstrual cycle compared to follicular stimulation alone. Furthermore, luteal phase stimulation in the same cycle proved to be an effective strategy to rescue POSEIDON poor responders with no embryos after the first stimulation.

Low serum progesterone on day of transfer adversely impacts ongoing pregnancy rates in hormonally prepared single blastocyst frozen embryo transfer cycles.

OBJECTIVE: To evaluate if serum progesterone (P) levels on the day of transfer influence ongoing pregnancy rate (OPR) in hormonally prepared single blastocyst frozen embryo transfer (FET) cycles? STUDY DESIGN: Single center prospective cohort study conducted between June 2021 and August 2022 analyzed 217 single good quality blastocyst FET cycles hormonally prepared with oral estradiol valerate and micronized vaginal progesterone 400 mg twice daily. RESULTS: Mean serum P on the day of embryo transfer (ET) was 9.76 ± 5.19 ng/ml. Receiver operator curve (ROC) showed a significant predictive value of serum P levels on the day of ET for OPR, with an area under curve (AUC) (95 %CI) = 0.58 (0.49-0.66). Optimal serum P threshold for OPR was 7.7 ng/ml (Sensitivity 76.8%, Specificity 43.7%). 35.9% patients had serum P below this threshold. BMI was significantly higher (26.8 ± 3.7 vs 25.6 ± 4.3; p = 0.048) in patients with serum P < 7.7 ng/ml vs ≥ 7.7 ng/ml. OPR was significantly lower (24.4% vs 45.3%; p = 0.002) and clinical miscarriage rates significantly higher (37.9% vs 19.2%; p = 0.042) if serum P < 7.72 ng/ml vs ≥ 7.7 ng/ml. CONCLUSION: This study found that serum P level on the day of transfer in hormonally prepared FET cycles was a significant predictor of OPR.

Spontaneous early pregnancy with very low levels of progesterone during controlled ovarian stimulation-A case report.

One of the most widely accepted axioms of reproductive biology is that pregnancy requires the sole support of progesterone, without which pregnancy cannot be established or maintained. We report a rare case of ongoing third trimester pregnancy in a 41-year-old woman, where early gestational period was maintained despite extremely low progesterone levels of <1 ng/ml, and was discovered during controlled ovarian hyperstimulation (COS) for in vitro fertilization (IVF). She was started on ovarian stimulation (OS) with gonadotrophins after a withdrawal bleed during lactational amenorrhea. Baseline investigations on day 2 of the menstruation confirmed low serum estradiol and progesterone levels (<1 ng/ml). After 5 days of stimulation, on ultrasound scan, a sac-like structure was seen in the uterine cavity. Beta hCG levels were measured and confirmed the presence of early pregnancy despite progesterone levels below 1 ng/ml. COS was stopped, and progesterone support was started. Subsequent scan confirmed live intrauterine pregnancy and the fetus is currently growing uneventfully at 31 weeks of gestation (at the time of writing this report).

Uterin artery embolisation: a rescuer in cervical ectopic pregnancy.

Cervical ectopic pregnancy is an extremely rare form of ectopic pregnancy with potential risk of massive bleeding and associated morbidity. Managing this condition is challenging for clinicians due to the serious risk to patient and dilemma faced in deciding the appropriate management plan. This case report describes the role of uterine artery embolisation in managing a case of cervical ectopic pregnancy with heavy bleeding per vaginum post methotrexate treatment with falling beta human chorionic gonadotropin (HCG) levels. It highlights the unpredictable nature of this condition and need for prompt intervention in an emergency situation.

Natural cycle versus hormone replacement cycle for transferring vitrified-warmed embryos in eumenorrhoeic women. A retrospective cohort study.

OBJECTIVE: To compare pregnancy, miscarriage and live birth rates and cycle monitoring parameters between Natural Cycle (NC-FET) and Hormone replacement cycle (HRC-FET) in eumenorrhoeic women undergoing vitrified-warmed autologous embryo transfer. STUDY DESIGN: Single-centre retrospective cohort study analyzed 173 NC-FET and 507 HRC-FET cycles with transfer of day2/3/5/6 embryos. Natural cycle monitoring occurred with serial ultrasound with the first day of the scan determined by the shortest cycle frequency. Serum progesterone was ordered when ultrasound was ambiguous in ascertaining ovulation. For HRC-FET oral estradiol valerate was used in fixed or escalating doses with maximum daily dose of 12 mg. Transdermal estradiol gel was added when desired endometrial thickness was not achieved. Vaginal progesterone was introduced with Endometrial thickness(ET)> = 7 mm. Embryos were transferred after stage-appropriate progesterone exposure. Luteal support was given with vaginal progesterone in NC-FET and vaginal and oral progesterone in HRC-FET. Primary outcome was live-birth-rate. Secondary outcomes were ET, length-of-estrogenic-phase, numbers-of-ultrasounds&hormone-monitoring, pregnancy&miscarriage rate. The odds ratio for live-birth was adjusted for age, embryo number, previous-live-births, previous-losses, past-negative-ET-cycles, IVF-indication and embryo-developmental-stage. Quantitative variables were compared using unpaired-t-test and qualitative variables with chi-square test. Two tailed p-value < 0.05 was considered significant. Binary logistic regression was used to calculate adjusted odds for live-births. RESULTS: The two cohorts were comparable in age, infertility-duration, previous-live-births, previous-losses, past-negative-ET-cycles, IVF-indication and embryo-developmental-stage. Length-of-estrogenic-phase was significantly shorter for NC-FET than HRC-FET 14.32 ± 2.83vs.18.18 ± 4.48; p = 0.0001) as was mean ultrasound-monitoring-scans (2.73 ± 0.95vs. 3.3 ± 1.04; p = 0.0001). Mean-endometrial-thickness (8.75 ± 1.83vs. 8.5 ± 1.25; p = 0.25) and mean-hormonal-tests (1.75 ± 1.28 vs. 1.88 ± 0.69; p = 0.09) did not differ significantly between NC-FET vs HRC-FET. Significantly higher live births took place in NC-FET vs. HRC-FET (87/173 = 50.3%vs.204/507 = 40.2%;p = 0.026). No significant difference was found in pregnancy rate (66.5% vs. 58%; p = 0.058) or in the pregnancy loss rate (24.3%vs30.6%; p = 0.23). The odds ratio for live-births adjusted for relevant variables was 1.48 (1.03-2.13) in NC-FET compared to HRC-FET. CONCLUSIONS: NC-FET is a superior method of endometrial preparation compared to HRC-FET in eumenorrhoeic women since it has a shorter estrogenic phase, reduces patient visits to the hospital and improves live birth rates. Future adequately powered studies should look at antenatal and perinatal outcomes, patient satisfaction rates and cost-effectiveness in the two endometrial preparation regimes.

A Multicenter, Randomized, Equivalence Trial of a New Recombinant Human Chorionic Gonadotropin Preparation versus Ovitrelle® for Ovulation in Women Undergoing Intrauterine Insemination Following Ovarian Stimulation.

CONTEXT: A new indigenous recombinant human chorionic gonadotropin (r-hCG) has been developed in India with a comparable pharmacological profile to that of Ovitrelle® (Merck Serono). AIMS: This study aims to compare the efficacy and safety of the new r-hCG with that of Ovitrelle for induction of ovulation in women undergoing intrauterine insemination (IUI). SETTINGS AND DESIGN: Randomized (2:1), multicenter, open-label, equivalence clinical trial conducted in India. SUBJECTS AND METHODS: A total of 217 women, aged 20-37 years, undergoing IUI were administered the new r-hCG (test) 250 mcg or Ovitrelle 250 mcg (comparator) after ovarian stimulation with gonadotropins. The ovulation rate was compared as the primary outcome. In addition, pregnancy rates, incidence of adverse events (AEs), and development of immunogenicity were assessed. Statistical Analysis Used: The ovulation and pregnancy rates were compared using Chi-squared test with statistical significance at P < 0.05. RESULTS: With 144 women in the test group and 73 in the comparator group, the ovulation rate (85.4% vs. 78.1%; P = 0.17) and pregnancy rate (serum ß hCG test) (11.8% vs. 12.3%; P = 0.91) were similar in both groups. A total of 15 AEs were reported (11 in the test r-hCG group and 4 in the comparator group) in 11 women; none of these were serious, and all were judged to be unrelated to the study drug. No subject developed immunogenic reaction to the test drug. CONCLUSIONS: The new preparation of r-hCG was equivalent to the conventional preparation of r-HCG in the induction of ovulation in patients undergoing IUI.

A Multicenter Phase IV Study to Investigate the Immunogenicity of Recombinant Human Follicle-Stimulating Hormone and Its Impact on Clinical Outcomes in Females Undergoing Controlled Ovarian Stimulation.

CONTEXT: Therapeutic proteins can cause immune responses, which may have clinical implications. AIMS: The aim of the study was to assess the immunogenicity of recombinant human follicle-stimulating hormone (r-hFSH), when used for controlled ovarian stimulation (COS). SETTINGS AND DESIGN: Prospective, multicenter study conducted at reproductive medicine clinics in India and Vietnam. MATERIALS AND METHODS: A total of 285 women, aged 20-40 years, undergoing 354 COS cycles for either intrauterine insemination (IUI) or in vitro fertilization (IVF) were studied. The primary outcome measure was the incidence of development of anti-drug antibodies (ADA) and their neutralization potential. Other outcome measures were follicle development, dose and duration of r-hFSH, positive serum pregnancy test, clinical pregnancy, cycle cancellation, and adverse events (AEs). STATISTICAL ANALYSIS USED: A sample size of 250 was planned. Descriptive statistics are presented. RESULTS: Four patients tested positive for ADA after r-hFSH administration at different time points; all of them tested negative, subsequently. None were found to have neutralization potential. The mean dose and duration of r-hFSH were 816 IU and 8.1 days in IUI and 2183 IU and 9.5 days in IVF, respectively. The serum and clinical pregnancy rates were 12.4% and 11.6% in IUI and 32.7% and 29.9% in IVF cycles, respectively. Seven AEs were reported, including two cases of ovarian hyperstimulation syndrome; two AEs were judged to be serious. CONCLUSIONS: The tested r-hFSH has very low immunogenic potential and did not lead to the development of neutralizing antibodies. The overall efficacy and safety of the drug were in-line with existing literature data, and no specific clinical impact of immunogenicity could be identified.

Relationship Between Morphology, Euploidy and Implantation Potential of Cleavage and Blastocyst Stage Embryos.

AIM: The aim of this study was to investigate the relationship between the morphology, euploidy and implantation rate of cleavage stage and blastocyst stage embryos. SETTING: Institution-based, tertiary care in-vitro fertilization centre. STUDY DESIGN: This study included a retrospective data analysis of 306 embryos: 154 cleavage stage embryos and 152 blastocysts that underwent biopsy on day 3 and day 5/6, respectively, which were subsequently screened for aneuploidy by array comparative genomic hybridization analysis. MATERIALS AND METHODS: Both cleavage stage and blastocyst stage embryos were categorized according to their morphology into the following three groups: good, average and poor. In addition, blastocysts were categorized into day 5 and day 6 embryos on the basis of their developmental rate. RESULTS: The euploidy rate was found to be significantly higher for blastocysts with good morphology as compared to those with poor morphology, with 73.2, 50 and 40.5% euploid embryos in the good, average and poor morphology groups, respectively (P = 0.001). No significant association was found between day 3 embryo morphology and euploidy rates with 40.6, 29.3 and 25.8% euploid embryos in the three groups, respectively (P = 0.254). The implantation rates, as per morphology, for the transferred euploid cleavage stage and blastocyst stage embryos were 43.8, 37.5 and 0% (P = 0.354) and 51.7, 71.4 and 66.7% (P = 0.562) in the good, average and poor morphology groups, respectively. The euploidy rate for day 5 blastocysts was significantly higher (70% vs. 34.1%, P < 0.001) than that of day 6 blastocysts, but the implantation rate was similar in both the groups (58.8 and 50%, respectively). The miscarriage rates for the euploid cleavage stage and the blastocysts stage embryos were 18.2 and 8.3% (P = 0.575), respectively. CONCLUSION: Blastocyst morphology and the rate of development were found to be significantly associated with euploidy, whereas cleavage stage morphology was not. The implantation rates of the good quality, euploid cleavage stage embryos were higher than that of the poor quality embryos. The implantation rates were similar for all transferred euploid blastocysts, irrespective of their morphology or the rate of development.

Impact of gonadotropin-releasing hormone antagonist addition on pregnancy rates in gonadotropin-stimulated intrauterine insemination cycles.

OBJECTIVES: The objective of the study is to evaluate the efficacy of gonadotropin-releasing hormone (GnRH) antagonist in improving clinical pregnancy rate in gonadotropin-stimulated intrauterine insemination (IUI) cycles in patients of unexplained infertility. STUDY DESIGN: This was a prospective, randomized case-controlled study. SETTINGS: The study was conducted in the infertility clinic of a tertiary care center. MATERIALS AND METHODS: Four hundred twenty-seven women undergoing IUI following controlled ovarian stimulation with gonadotropins (recombinant follicle-stimulating hormone [r-FSH] 75 IU/day) were randomly divided into two groups. Women in Group I received GnRH antagonist (Cetrorelix 0.25 mg/day) in a multiple dose flexible protocol. Women in Group II received r-FSH alone. Ovulatory trigger was given with human chorionic gonadotropin 5000 IU when dominant follicle was ≥18 mm. IUI was performed within 44-48 h. Both groups received similar luteal phase support. Primary outcome measure was clinical pregnancy rate. The trial was powered to detect an absolute increase in clinical pregnancy rate by 13% from an assumed 20% clinical pregnancy rate in the control group, with an alpha error level of 0.05 and a beta error level of 0.20. RESULTS: Clinical pregnancy rate in Groups I and II was 27.6% (n = 56) and 26.5% (n = 54), respectively (P=0.800). Ongoing pregnancy and multiple pregnancy rates were likewise similar between the groups. CONCLUSIONS: Addition of GnRH antagonist to gonadotropin-stimulated IUI cycles results in no significant difference in clinical pregnancy rate.

Determining the Optimal Duration of Progesterone Supplementation prior to Transfer of Cryopreserved Embryos and Its Impact on Implantation and Pregnancy Rates: A Pilot Study.

Objective. To determine the optimal duration of progesterone supplementation prior to transfer of cryopreserved embryos and its impact on implantation and pregnancy rates. Study Design. Prospective randomised study. Materials and Methods. In an IVF unit of a tertiary centre, sixty-six patients undergoing cryopreserved embryo transfer cycles were included. Endometrial preparation was done with estradiol valerate. Once it reached a minimum of 7 mm, patients were allocated randomly into group I (n = 39) and group II (n = 27). Injectable progesterone 100 mg daily was then started for 3 and 4 days, respectively. This was followed by transfer of at least one thawed cleavage stage day 2 embryo of good quality. Groups I and II were compared in terms of clinical pregnancy and implantation rates. Results. In group I (3-day progesterone) and group II (4-day progesterone) the pregnancy rates were 41.02% (16/39) and 18.51% (5/27), respectively. On the other hand, the implantation rates were 16.82% (18/107) and 7.69% (6/78), respectively. The difference was statistically significant (p values 0.0172 and 0.0386, resp.). Conclusion. Progesterone supplementation for three days before the transfer of cleavage stage (day 2) cryopreserved embryos has significantly higher pregnancy and implantation rates, as compared to four-day supplementation.

Preimplantation genetic screening for all 24 chromosomes by microarray comparative genomic hybridization significantly increases implantation rates and clinical pregnancy rates in patients undergoing in vitro fertilization with poor prognosis.

CONTEXT: A majority of human embryos produced in vitro are aneuploid, especially in couples undergoing in vitro fertilization (IVF) with poor prognosis. Preimplantation genetic screening (PGS) for all 24 chromosomes has the potential to select the most euploid embryos for transfer in such cases. AIM: To study the efficacy of PGS for all 24 chromosomes by microarray comparative genomic hybridization (array CGH) in Indian couples undergoing IVF cycles with poor prognosis. SETTINGS AND DESIGN: A retrospective, case-control study was undertaken in an institution-based tertiary care IVF center to compare the clinical outcomes of twenty patients, who underwent 21 PGS cycles with poor prognosis, with 128 non-PGS patients in the control group, with the same inclusion criterion as for the PGS group. MATERIALS AND METHODS: Single cells were obtained by laser-assisted embryo biopsy from day 3 embryos and subsequently analyzed by array CGH for all 24 chromosomes. Once the array CGH results were available on the morning of day 5, only chromosomally normal embryos that had progressed to blastocyst stage were transferred. RESULTS: The implantation rate and clinical pregnancy rate (PR) per transfer were found to be significantly higher in the PGS group than in the control group (63.2% vs. 26.2%, P = 0.001 and 73.3% vs. 36.7%, P = 0.006, respectively), while the multiple PRs sharply declined from 31.9% to 9.1% in the PGS group. CONCLUSIONS: In this pilot study, we have shown that PGS by array CGH can improve the clinical outcome in patients undergoing IVF with poor prognosis.

Effectiveness of paracervical block for pain relief in women undergoing hysterosalpingography.

OBJECTIVES: To evaluate the potential benefit, in terms of pain relief, of the paracervical block with 2% lignocaine in women undergoing hysterosalpingography (HSG). STUDY DESIGN: This study was a prospective randomized controlled study. SETTINGS: This study was conducted in infertility clinic of a tertiary care center. MATERIALS AND METHODS: Four hundred and six patients undergoing HSG as a part of infertility evaluation were included in the study. These women were randomized into two groups: Group I received paracervical block with 2% lignocaine at the time of HSG (n = 53) and Group II (n = 53) served as control. Hyoscine (10 mg) oral tablet was given to all the patients 30 min before the procedure. Pain perception during the procedure was analyzed by the patient between 0 and 10 on a numeric rating scale, immediately after HSG. RESULTS: The baseline demographic characteristics of participants in two groups were similar. Mean pain score immediately after HSG in the study group and control group was 4.84 ± 2.56 and 5.21 ± 1.89, respectively (P = 0.21). CONCLUSIONS: There is no benefit of paracervical block with 2% lignocaine, in terms of pain relief, in women undergoing HSG.

Clomiphene based ovarian stimulation in a commercial donor program.

OBJECTIVE: This study was conducted to compare an extended clomiphene-based ovarian stimulation regimen with the conventional antagonist protocol in donor-recipient cycles. MATERIALS AND METHODS: A total of 170 (N) donors were stimulated between January 2013 and December 2013. Conventional antagonist protocol (group I) was employed in (n1 = 31) cycles, and clomiphene was used in (n2 = 139) donor cycles (group II). 50 mg clomiphene was given simultaneously with gonadotropins from day 2 of the cycle until the day of trigger. The analysis was performed retrospectively for oocytes retrieved, fertilization rates, cycle cancelation, blastocyst formation, and pregnancy rates. The dosages, cost, and terminal E2 (estradiol) were also compared between the two groups. RESULTS: The donor age groups were comparable in both the groups. There were no unsuccessful egg retrievals with clomiphene. The pregnancy rate (positive beta human chorionic gonadotropin) was significantly higher in the clomiphene group (odds ratio: 2.453; P = 0.02). Similarly, fertilization rate was significantly higher in the clomiphene group (59.5/50.5, P = 0.04). Eggs retrieved were similar in both groups, but the terminal E2 was significantly higher in the clomiphene group (P = 0.001). Average gonadotropin used was also significantly lower in clomiphene group (P < 0.001). CONCLUSION: Clomiphene can effectively prevent luteinizing hormone surge and limit the dose of gonadotropins thus bringing down the costs and its negative impact on the endometrium and oocyte quality.

Prevalence of metabolic syndrome in relation to body mass index and polycystic ovarian syndrome in Indian women.

OBJECTIVE: To study the prevalence of metabolic syndrome (MBS) in Indian women and to see how does it correlate to body mass index (BMI) and polycystic ovarian syndrome (PCOS) in this population. STUDY DESIGN: Prospective cross-sectional observational study. SETTING: Infertility clinic of a tertiary center. MATERIALS AND METHODS: Two hundred women, 120 with PCOs and 80 age-matched controls were enrolled. The prevalence of MBS was studied in the women with and without and was co related to BMI by further subgrouping as team (BMI <23 kg/m3) and obese (BMI >23 kg/m2). The sample size was: team controls-40, obese controls-40, team PCOS-80. Each subject underwent a physical examination and laboratory evaluation for the diagnosis of MBS, which was defined according to the guidelines of National Cholesterol Education Program Adult Treatment Pamel (NCEP ATP III) 2005. INTERVENTION: None. MAIN OUTCOME MEASURES: Subjects with and without PCOs were compared with each other for the prevalence of MBS, and similarly team subjects were compared with obese subjects. Receiver operator characteristic (ROC) curves were obtained for both the PCOS and non PCOS population separately, co-relating the prevalence of MBS with BMI. These ROC curves were used to establish the cut off values of BMI, which could best predict the risk of MBS. RESULTS: The prevalence of MBS was significantly higher in the women with PCOS, as compared to age-matched controls. Similarly, when BMI was considered, MBS was more prevalent in overweight subjects than in lean subjects with or without PCOS. In subgroup analysis, the presence of PCOS had a lesser impact on the prevalence of MBS as compared to non-PCOS controls with higher BMI. The relative risk of MBS increased as follows: lean controls-1, lean PCOS-2.66, obese controls-5.33, and obese PCOS-6.5. The most appropriate cut-off level of BMI for predicting the risk of MBS in Indian women without PCOS seems to be 23 kg/m(2), whereas, with PCOS, it was 22.5 kg/m(2). CONCLUSION: MBS is more prevalent in women with PCOS. However, obesity is an independent and stronger risk factor for developing MBS. To reduce the risk of MBS and its related long-term health consequences, lifestyle modification is advisable above BMI of 23 kg/m(2) in the normal population and 22.5 kg/m(2) in women with PCOS.

Worldwide survey of IVF practices: trigger, retrieval and embryo transfer techniques.

PURPOSE: To identify common and varying practice patterns used by in vitro fertilization (IVF) providers from a broadly distributed, worldwide survey. Specific information regarding clinical IVF practices involving the oocyte maturation triggering, oocyte retrieval and embryo transfer was elicited. METHODS: This is an internet-based questionnaire study of IVF practices throughout the world. We used 26 multiple choice questions regarding common clinical practices. The data reported are weighted based on the number of IVF cycles performed at the specific IVF center, represented by a single respondent. RESULTS: Surveys were completed from 359 centers in 71 countries throughout the world. The most common practice patterns (defined as ≥75 % of IVF cycles) identified included: use of human chorionic gonadotropin (hCG) for trigger with an antagonist protocol, no routine patient monitoring from hCG trigger to oocyte retrieval, timing oocyte retrieval 34-37 h following oocyte maturing trigger, use of a single lumen retrieval needle, no routine tests following oocyte retrieval prior to patient discharge and use of ultrasound assistance with embryo transfer. CONCLUSIONS: This is the largest and most diversely represented survey of specific IVF practices addressing oocyte maturation triggers, oocyte retrieval and embryo transfers. Several uniform practice patterns were identified that can be correlated with evidence-based medicine; however, we identified multiple variable practice patterns which is likely the result of the absence of definitive evidence to guide IVF practitioners. The results of this survey allow IVF providers to compare their specific practice patterns with those of a global diverse population of IVF providers.

Hyperprolactinemia.

Prolactin (PRL) is an anterior pituitary hormone which has its principle physiological action in initiation and maintenance of lactation. In human reproduction, pathological hyperprolactinemia most commonly presents as an ovulatory disorder and is often associated with secondary amenorrhea or oligomenorrhea. Galactorrhea, a typical symptom of hyperprolactinemia, occurs in less than half the cases. Out of the causes of hyperprolactinemia, pituitary tumors may be responsible for almost 50% of cases and need to be investigated especially in the absence of history of drug induced hyperprolactinemia. In women with hyperprolactinemic amenorrhea one important consequence of estrogen deficiency is osteoporosis, which deserves specific therapeutic consideration. Problem in diagnosing and treating hyperprolactinemia is the occurrence of the 'big big molecule of prolactin' that is biologically inactive (called macroprolactinemia), but detected by the same radioimmunoassay as the biologically active prolactin. This may explain many cases of very high prolactin levels sometimes found in normally ovulating women and do not require any treatment. Dopamine agonist is the mainstay of treatment. However, presence of a pituitary macroadenoma may require surgical or radiological management.

A prospective randomized study to evaluate the effect of hyaluronic acid sperm selection on the intracytoplasmic sperm injection outcome of patients with unexplained infertility having normal semen parameters.

PURPOSE: Sperm quality plays an important role in determining embryo development and intracytoplasmic sperm injection (ICSI) outcome. Selection of competent sperm based on its ability to bind to hyaluronic acid (HA) has been suggested as one of the methods to assess sperm quality. The aim of the present study was to examine whether injection of HA bound sperm helps in improving outcome in patients undergoing ICSI with unexplained infertility having normal semen parameters. METHODS: Patients with unexplained infertility having normal semen parameters in accordance with WHO 2010 criterion, undergoing their first IVF-ICSI cycle were enrolled during the course of the study.156 patients were prospectively randomized after oocyte retrieval and were assigned to either the ICSI group, where sperm selection for injection was based on visual assessment, or the PICSI group, where sperm were selected based on their ability to bind to HA. Only fresh embryo transfers were included in the analysis. RESULTS: There was no difference in the fertilization rates, number of top quality embryos and clinical pregnancy rates between the ICSI and PICSI groups (65.7 % vs 64.7 %; 45.8 % vs 43.6 % and 35 % vs 35.2 % respectively). However, a higher pregnancy loss rate was observed in the ICSI group (25 % vs 12 %; P = 0.227) as compared to the PICSI group, but the difference was not statistically significant. Implantation rates were 22.03 % and 18.84 % in the PICSI and ICSI groups respectively. There were 22 (31 %) live births in the PICSI group and 21(26.3 %) live births in the ICSI group. CONCLUSIONS: Patients with unexplained infertility having normal semen parameters may constitute a patient group which does not benefit from this sperm selection method. A larger study may be necessary to establish a relationship between PICSI and pregnancy loss rate in patients undergoing IVF with unexplained infertility.

Anti-mullerian hormone cut-off values for predicting poor ovarian response to exogenous ovarian stimulation in in-vitro fertilization.

OBJECTIVES: (a) To establish the cut-off levels for anti-Mullerian hormone (AMH) in a population of Indian women that would determine poor response. (b) To determine which among the three ie.,: age, follicle stimulating hormone (FSH), or AMH, is the better determinant of ovarian reserve. STUDY DESIGN: Prospective observational study. SETTING: In vitro fertilization (IVF) unit of a tertiary hospital. MATERIALS AND METHODS: The inclusion criterion was all women who presented to the center for in-vitro fertilization/Intracytoplasmic sperm injection (IVF/ICSI). The exclusion criteria were age >45 years, major medical illnesses precluding IVF or pregnancy, FSH more than 20 IU/L, and failure to obtain consent. The interventions including baseline pelvic scan, day 2/3 FSH, luteinizing hormone (LH), estradiol estimations, and AMH measurement on any random day of cycle were done. Subjects underwent IVF according to long agonist or antagonist protocol regimen. Oocyte recovery was correlated with studied variables. The primary outcome measure was the number of oocytes aspirated (OCR). Three categories of ovarian response were defined: poor response, OCR ≤ 3; average response, OCR between 4 and 15; hyperresponse, OCR > 15. RESULTS: Of the 198 patients enrolled, poor, average, and hyperresponse were observed in 23%, 63%, and 14% respectively. Correlation coefficient for AMH with ovarian response was r = 0.591. Area under the curve (AUCs) for poor response for AMH, subject's age, and FSH were 0.768, 0.624, and 0.635, respectively. The discriminatory level of AMH for prediction of absolute poor response was 2 pmoL/l, with 98% specificity and 20% sensitivity. CONCLUSIONS: AMH fares better than age and FSH in predicting the overall ovarian response and poor response, though it cannot be the absolute predictor of non-responder status. A level of 2 pmol/l is discriminatory for poor response.