International Journal Of Fertility and Sterility
Volume:8 Issue: 2, Jul-Sep 2014

Although intracytoplasmic sperm injection (ICSI) allows proper fertilization in most cases of male sub fertility, it is one of the most unphysiological techniques in assisted reproductive technologies (ART). Thus, over the last decade, researchers have tried to improve sperm observation with higher-resolution microscopy techniques such as the intracytoplasmic morphologically selected sperm injection (IMSI) technique. In order to identify literatures for this review, the PubMed database was searched from 2000 onwards using the terms IMSI, motile sperm organelle morphology examination (MSOME) and sperm vacuole. Approximately 10 years after the introduction of the MSOME and IMSI procedures, several questions related to the prevalence, origin, location, and clinical consequences of sperm vacuoles have not yet been clarified. It seems that IMSI as a routine application is not state of the art and the only confirmed indications for IMSI are recurrent implantation failure following ICSI and severe male factor.

MicroRNAs (miRNAs) are small non-coding single stranded RNA molecules that are physiologically produced in eukaryotic cells to regulate or mostly down-regulategenes by pairing with their complementary base-sequence in related mRNA molecules in the cytoplasm. It has been reported that other than its function in many physiological cell processes, dysregulation of miRNAs plays a role in the development of many diseases. In this short review, the association between miRNAs and some male reproductive disorders is surveyed. Male factor Infertility is a devastating problem from which a notable percentage of couples suffer. However, the molecular mechanism of many infertility disorders has not been clearly elucidated. Since miRNAs have an important role in numerous biological cell processes and cellular dysfunctions, it is of interest to review the related literature on the role of miRNAs in the male reproductive organs. Aberrant expression of specific miRNAs is associated with certain male reproductive dysfunctions. For this reason, assessment of expression of such miRNAs may serve as a suitable molecular biomarker for diagnosis of those male infertility disorders. The presence of a single nucleotide polymorphism (SNP) at the miRNAs’ binding site in its targeted mRNA has been reported to have an association with idiopathic male infertility. Also, a relation with male infertility has been shown with SNP in the genes of the factors necessary for miRNA biogenesis. Therefore, focusing on the role of miRNAs in male reproductive disorders can further elucidate the molecular mechanisms of male infertility and generate the potential for locating efficient biomarkers and therapeutic agents for these disorders.

Studies have demonstrated the efficacy of metformin (MTF) in reducing insulin resistance and N-acetyl cysteine (NAC) in inhibiting oxidative stress which are involved in the pathogenesis of polycystic ovarian syndrome (PCOS). We aimed to compare the effects of MTF and NAC combination on serum metabolite and hormonal levels during the course of ovulation induction in PCOS individual candidates of intracytoplasmic sperm injection (ICSI). In this prospective randomized clinical trial, placebo controlled pilot study, 80 patients of polycystic ovarian syndrome at the age of 25-35 years were divided into 4 groups (n=20): i. NAC=treated with N-acetyl cysteine (600 mg three times daily), ii. MTF=treated with metformin (500 mg three times daily), iii. MTF+NAC=treated with N-acetyl cysteine plus metformin (the offered doses) and iv. placebo (PLA). A total number of 20 patients (6 from MTF group, 4 from NAC group, 6 from MTF+NAC group and 4 from PLA group) were dropped of the study. The drugs were administrated from day 3 of menses of previous cycle until ovum pick-up. Serum levels of luteinizing hormone (LH), total testosterone, cholesterol and triglyceride, insulin and leptin significantly reduced in the MTF and NAC groups compared to the placebo (p<0.01). But levels of LH, total testosterone, cholesterol and triglyceride had no significant reduction in the MTF+NAC groups compared to the placebo. The serum levels of malonyldialdehyde (MDA), insulin and leptin reduced significantly after treatment in the MTF+NAC group compared to the placebo (p<0.05). Considering the adverse effect of combination therapy, we proposed the conadministration might have no beneficial effect for PCOS patient during course of ovulation induction of ICSI (Registration Number: IRCT201204159476N1).

Small intrauterine lesions such as septum, adhesion, polyp, and submucous myoma may be of greater significance in causing implantation failure, poor reproductive performance and abnormal uterine bleeding. We studied effectiveness of therapeutic intervention through operative hysteroscopy in improvement of pregnancy outcome and cessation of abnormal uterine bleeding (AUB) in women with pregnancy and fertility problems. This prospective cohort study was performed between 2003- 2009 on 65 patients with primary or secondary infertility, recurrent abortion and structural uterine lesions reported in sonography or hysterosalpingography. After hysteroscopic metroplasty, myomectomy, adhesiolysis and polypectomy under laparoscopic guide, we evaluated reproductive outcome, early and late complications, one year after surgery. Among all patients with recurrent abortion, 6 patients (75%) complete their pregnancy successfully. Our results showed that pregnancy rate after metroplasty was 58%. Reproductive outcome was poor after myomectomy and adhesiolysis. Abnormal uterine bleeding was improved in 62% of patients. Structural uterine lesions has been assumed to cause infertility, while several studies have shown very poor reproductive performance with high miscarriage and low term delivery rates when malformation is not treated. We show improvement in conceptional outcome and in patient’s chief complaints after hysteroscopy surgery of these anomalies.

The objective of this retrospective cohort study was to evaluate whether the length of pituitary blockage with gonadotrophin-releasing hormone (GnRH) antagonists or the stimulation period influence intracytoplasmic sperm injection (ICSI) outcomes in patients older than 36 years of age. In this retrospective study, a total of 138 couples with maternal age >36 years undergoing ICSI with an antagonist protocol were included. The influences of stimulation and suppression length on the response to ovarian stimulation and ICSI outcomes were investigated. Receiver operating characteristic curve (ROC) analysis was performed to assess the predictive value of the stimulation period for achievement of implantation and pregnancy. The gonadotrophin stimulation length negatively influenced the implantation rate (RC: -4.200; p=0.023). The area under ROC curve (AUC) could distinguish between women with positive and negative implantation (AUC: 0.611; CI: 0.546-0.673) and pregnancy (AUC: 0.593; CI: 0.528-0.656). The threshold value demonstrated a high negative predictive value on likelihood of implantation (p=0.0032, 90% sensitivity) and pregnancy (p=0.0147, 87.1% sensitivity) when patients underwent more than 10 days of stimulation. The stimulation period negatively influences the implantation rate in women older than 36 years. A stimulation interval greater than 10 days is associated with a negative predictive value for the chance of implantation and pregnancy.

The association between blood types and ovarian reserve is investigated in this study. As an index of ovarian reserve, women with a follicle stimulating hormone (FSH) level of ≥10 mIU/ml in the early follicular phase were designated as having diminished ovarian reserve. In this prospective study, early follicular phase serum FSH and estradiol levels and blood types were evaluated in 500 patients who were admitted to the Infertility Department of Ministry of Health Etlik Zübeyde Hanım Women’s Health Training and Research Hospital between January 2012 and June 2012. Women with serum FSH level <10 mIU/ml formed group I, and women with serum FSH ≥10 mIU/ml formed group II. The prevalence of blood types in each group and their association with ovarian reserve were analyzed. Out of 500 patients, 438 women were in group I, while 62 women were in group II. There was no statistically significant difference among the two groups in terms of blood group proportions (p=0.69), this did not change after age adjustment (p 0.77). The presence of A antigen (in A and AB blood type) (p=0.91), the blood type O (p 0.70), and the blood type B (p=0.51) were not statistically related to ovarian reserve after age adjustment. There was also no statistically significant correlation between rhesus factor and ovarian reserve after age adjustment (p=0.83). The only factor that affected ovarian reserve was age of patients (p=0.006). Blood groups do not constitute a risk or protective factor for ovarian reserve. Therefore, blood groups do not have any predictive value in evaluating ovarian reserve.

Although the risk factors of ectopic pregnancy have been determined in previous studies, the main risk factors of ectopic pregnancy are different in various countries due to different cultural and social characteristics. Determination of main risk factors of ectopic pregnancy leads to a rapid diagnosis and an improvement in strategies for its prevention. The purpose of this study was to determine the main risk factors of ectopic pregnancy in a sample of Iranian women. We designed a case-control study to include 150 cases and 300controls and to compare them by the following factors: socio-demographic characteristics, contraceptive methods, prior tubal surgery, tubal pathology, prior ectopic pregnancy, prior caesarean section, prior abortion, prior infertility, and prior abdominal/pelvic surgery. The case and control groups were significantly similar in term of education and parity. There was an association between ectopic pregnancy and age which was disappeared after controlling for the main risk factors (adjusted OR=2.45, 95% CI: 0.86-6.97). There was no statistically significant relation between ectopic pregnancy and prior tubal surgery, tubal pathology, prior abortion, prior infertility, assisted reproductive technology, and oral contraceptive method (p>0.05). However, there was a significant association between prior ectopic pregnancy, prior tubal ligation, use of intrauterine device, and prior abdominal/pelvic surgery with ectopic pregnancy (p<0.05). The risk of ectopic pregnancy increased with the use of intrauterine device and tubal ligation, whereas decreased with use of oral contraception. This study identified prior ectopic pregnancy, prior tubal ligation, use of intrauterine device, and prior pelvic/abdominal surgery as the main risk factors for ectopic pregnancy in a sample of Iranian women. Our findings can be useful for early diagnosis of ectopic pregnancy and for improvement in strategies of its prevention through medical therapy instead of unnecessarily surgical treatment.

To determine the correlates and the prevalence of infertility in a group of women. This cross-sectional study was carried out on 570 subjects aged 18-49 years in a town of western Turkey between July and August 2012. Women who have inability to become pregnant despite regular sexual intercourse during the last year were considered to be infertile. UCLA Loneliness Scale was used to assess the severity of loneliness. The data were analyzed by Kruskal-Wallis, Mann Whitney U and Chi-square tests. The mean age of the participants was 35.48 ± 8.39 years. The frequency of the infertility in our study was 12.8% (n=73). The prevalence of infertility was higher in those with a history of gynecological disease or gynecologic surgery and in those with menstrual irregularity (p<0.05; for each). The mean score on the UCLA Loneliness Scale was 32.16 ± 9.49 (from 20 to 70). In this study, no difference was found between the level of loneliness and who is responsible for infertility among infertile/fertile women (p≥0.05). Level of loneliness among the women with primary infertility was higher compared to the women with secondary infertility (p<0.05). The prevalence of infertility among the women was relatively high. It was concluded that prospective studies are needed in order to expose the relationship between the infertility and the level of loneliness in women.

Maternal subclinical hypothyroidism during pregnancy is associated with various adverse outcomes. Recent consensus guidelines advocate universal thyroid function screening during pregnancy. There are no data from Iran about the prevalence of thyroid hypofunction in pregnancy. This study aims to find the prevalence of thyroid dysfunction. In this descriptive cross sectional study, thyrotropin (TSH) was measured in 3158 pregnant women irrespective of gestational age from October 2008-March 2012. If TSH was more than 2.5 mIU/L in the first trimester or more than 3 mIU/L in the second or third trimester, free T4 was measured to diagnose subclinical / overt hypothyroidism. If serum free T4 was in the normal range (0.7-1.8 ng/dl) the diagnosis was subclinical hypothyroidism and if below the normal range, overt hypothyroidism was diagnosed. A total of 3158 pregnant women were evaluated. One hundred forty seven of them were diagnosed as hypothyroidism. Subclinical hypothyroidism and overt hypothyroidism were present in 131 (89.1%) and 16 (10.9%) women respectively. Prevalence of subclinical hypothyroidism was 4.15%. Most of the subclinical and overt hypothyroidism cases were diagnosed in the first trimester. It appears logical to check TSH during pregnancy due to the observed prevalence of subclinical hypothyroidism.

Childbearing for the first time is a unique experience. Quality of life is an important indicator in health studies. This study aimed to assess the quality of life of women who were conceived by ARTs and had successful childbirth for the first time and to compare it with quality of life in women who become pregnant naturally and similarly had successful childbirth for the first time. This was a cross sectional comparative study. The accessible sample was recruited from patients attending an infertility clinic and two obstetric and gynecology clinics in Tehran, Iran, during March 2010 to March 2011. In all 276 patients were approached. Of these, 162 women (76 women in natural conception group and 86 women in assisted reproduction technologies group) who met the inclusion criteria were entered into the study. Quality of life was assessed using the 36-item Short Form Health Survey (SF-36). Women completed the questionnaire at two time points: i. last trimester and ii. first month after delivery. Comparison was made between two groups using Mann-Whitney U test and paired samples t test. Comparing the SF-36 scores between women in natural conception group and ARTs group before childbirth, it was found that natural group had better condition on physical functioning, role limitation due to physical problems, bodily pain and social functioning, while the ARTs group reported better status on general health, vitality, role limitation due to emotional problems, and mental health. However, after childbirth, the ARTs group reported a better condition almost on all measures, except for physical functioning. Comparing differences in obtained scores between two groups before and after childbirth, the results showed that improvements in health related quality of life measures for the ARTs group were greater in all measures, expect for general health. The findings from this study suggest that health-related quality of life was improved in women who became a mother for the first time by either method. Comparing to women who became mother by natural conception, women who received ARTs showed better quality of life from this first successful experience.

This study evaluated the impact of body mass index (BMI), total calorie intake and physical activity (PA) as energy expenditure related factors on oxidative stress (OS) in follicular fluid (FF). This prospective study conducted on 219 infertile women. We evaluated patients’ BMI, total calorie intake and PA in their assisted reproduction treatment cycles. Malondialdehyde (MDA) and total antioxidant capacity (TAC) in pooled FF at oocyte retrieval were additionally assessed. There was no relation between OS biomarkers to total calorie intake and PA. The TAC levels in FF adjusted for age, duration of infertility, etiology of infertility, number of used gonadotrophin and PA showed a positive relation to BMI (p=0.001). The number of used gonadotrophin and PA had a negative relation to duration of infertility (p=0.03) and anovulation disorder as an etiology of infertility. The MDA level in FF had a positive association with anovulation disorder as the etiology of infertility (p=0.02). MDA in FF was unaffected by BMI. Increasing age, BMI and PA do not affect OS in FF. In women with longtime infertility and those with anovulation disorder as an etiology of infertility, decreased potent antioxidant defense in the follicular microenvironment may contribute to ovarian function. Therefore antioxidant supplements may be beneficial for these groups of women.

Poor ovarian response (POR) to gonadotropin stimulation has led to a significant decline in success rate of fertility treatment. The immune system may play an important role in pathophysiology of POR by dysfunctions of cytokines and the growth factor network, and the presence of ovarian auto-antibodies. The aim of this study is to investigate the expression of toll-like receptors (TLR) 1, 2, 4, 5, 6 and cyclooxygenase (COX) 2 genes in follicular cells and concentration of interleukin (IL)-6, IL-8 and macrophage migration inhibitory factor (MIF), as major parts of innate immunity, in follicular fluid (FF) obtained from POR women in comparison with normal women. In this case-control study, 20 infertile POR patients and 20 normal women took part in this study and underwent controlled ovarian stimulation. The FF was obtained from the largest follicle (>18 mm). The FF was centrifuged and cellular pellet was then used for evaluation of expression of TLRs and COX2 genes by real-time PCR. FF was used for quantitative analysis for IL-6, IL-8 and MIF by enzyme-linked immunosorbent assay (ELISA). TLR1, 2, 4, 5, 6 and COX2 gene expression were significantly higher in POR (p<0.05). Concentration of IL-6, IL-8 and MIF proteins was significantly increased in POR compared with normal women (p<0.05). These findings support the hypothesis that the immune system may be involved in pathophysiology of POR through TLRs.

The prevalence of hyperprolactinemia following administration of conventional antipsychotic drugs requires further investigation. The current study is designed to evaluate the effect of sulpiride (SPD)-induced hyperprolactinemia on alterations to ovarian follicular growth, gonadotropins, and ovarian hormones and to analyze the extent of potential problems in mammary glands. A total of 40 albino Wistar rats were divided into four groups: control (no treatment), control-sham (0.3 ml olive oil), low dose SPD (20 mg/kg) and high dose SPD (40 mg/kg). All compounds were intraperitoneally (IP) administered for a period of 28 days. After 28 days, we dissected the rats’ ovarian tissues, uterine horns and mammary glands which were sent for histological analyses. We counted the numbers of normal, atretic follicles and corpora lutea (CL). Serum levels of prolactin (PRL), estradiol, progesterone, follicle stimulating hormone (FSH) and luteinizing hormone (LH) were evaluated. SPD-administered animals showed sporadic follicular atresia in different sizes associated with higher numbers of CL on the ovaries. The mammary glands exhibited features of galactorrhea. There was remarkable (p<0.05) elevation in SPD-administered animals’ uterine horn endometrium, myometrium and perimetrium thicknesses. The serum levels of PRL and progesterone significantly (p<0.05) increased, while the serum concentration of estradiol, LH and FSH notably (p<0.05) decreased according to the SPD administered dose. No histological and biological changes occurred in control-sham animals. SPD-induced animals had unsuccessful attempts at mating and decreased pregnancy rates. The present findings suggest that SPD-induced disturbances depend on PRL level. In addition, an increased PRL level is largely dependent on the administered doses of SPD.

Ketamine, an injectable anesthetic in human and animal medicine, is also a recreational drug used by young adults. The aim of this study is to evaluate the effects of ketamine on membrane integrity, DNA fragmentation and sperm parameters in humans. This prospective study was conducted on 40 males with normal semen samples over one month (August 2012). Subjects were randomly allocated to four groups (Control and case I, II and III) whose semen samples were adjusted to different concentrations of ketamine (1, 3, 5 μL) for one hour. Sperm analysis was performed for routine parameters, motility and morphology. Evaluation of membrane integrity and DNA fragmentation was done by eosin-Y staining and the sperm chromatin dispersion (SCD) test, respectively. The results were analyzed by ANOVA and Tukey’s tests. P≤0.05 was considered statistically significant. Total sperm motility in all case groups were significantly lower compared with the control group. In case group III, progressive motility showed significant difference with case group II. After addition of ketamine, sperm had evidence of coiled tails in all case groups compared to the control group however this observation was not significant. Evaluation of membrane integrity showed the rate of necrospermia increased in all case groups. However, ketamine only significantly affected membrane integrity in case group III. SCD staining showed that in the control group nucleoids with medium halos (63.44 ± 1.2) were significantly different compared to the case groups I (15.44 ± 0.45), II (9.05±1.16) and III (10.55 ± 1.14), respectively. Between case groups, nucleoids with large and medium halos showed significant differences in case groups II and III compared with case group I. Nucleoids with medium halos were significantly different between case groups II and III. Ketamine, through its effect on membrane integrity and DNA fragmentation, decreased sperm viability and caused abnormal sperm parameters in progressive motility.

Kisspeptin and naloxone stimulate the reproductive axis while morphine inhibits its function. We have investigated the effect of central injection of kisspeptin-10 on mean plasma testosterone concentration in morphine or naloxone pretreated rats. In this experimental study, 60 male Wistar rats that were divided into 12 groups (n=5 per group) received saline, kisspeptin (1 nmol, ICV), naloxone (2 mg/kg, subcutaneously), morphine (5 or 10 mg/kg, sc) or co-administrations of kisspeptin, morphine and naloxone at 09:00 - 09:30. In the co-administrated groups, kisspeptin was injected 15 minutes following morphine or naloxone injections. Blood samples were collected 60 minutes following injections via the tail vein. Plasma testosterone concentration was measured by a rat testosterone ELISA kit. Central injection of kisspeptin or subcutaneous injection of naloxone significantly increased the mean plasma testosterone concentration compared to saline while subcutaneous injections of different doses of morphine (5 or 10 mg/kg) significantly decreased testosterone compared to saline. The results revealed that morphine significantly attenuated the testosterone increase after kisspeptin injection compared to kisspeptin while a stimulatory additive effect was observed in the kisspeptin/naloxone group compared to either naloxone or kisspeptin. Morphine and kisspeptin systems may interact with each other to control the hypothalamic-pituitary-gonadal (HPG) axis.

Klinefelter syndrome (KS) is the most common sex chromosomal disorder in men. Most of these patients show the 47,XXY karyotype, whereas approximately 15% of them are mosaics with variable phenotype. A 39-year-old male investigated for primary infertility, was clinically normal with small firm testes and elevated levels of FSH, LH and low level of testosterone. Total azoospermia was confirmed on semen analysis. Testicular histopathology revealed no spermatogenesis and absence of germ cells. Karyotype from whole blood culture showed cells with 47,XXY/46,XX/ 45,X/48,XXXY/ 46,XY mosaicism. The predominant cell line was 47,XXY (83.67%). This was confirmed by fluorescence in situ hybridization (FISH). Also the presence of a small population of cells with the 48,XXXY and 45,X karyotypes was detected by FISH. This case illustrates the utility of FISH as an adjunct to conventional cytogenetics in assess the chromosome copy number in each cell line of a mosaic.