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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.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-ultrasoundshormone-monitoring, pregnancymiscarriage 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.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.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.

Purpose.To improve success of in vitro fertilization (IVF), assisted reproductive technology (ART) experts addressed four questions. What is optimum oocytes number leading to highest live birth rate (LBR)? Are cohort size and embryo quality correlated? Does gonadotropin type affect oocyte yield? Should “freeze-all” policy be adopted in cycles with progesterone >1.5 ng/mL on day of human chorionic gonadotropin (hCG) administration?Methods.Electronic database search included ten studies on which panel gave opinions for improving current practice in controlled ovarian stimulation for ART.Results.Strong association existed between retrieved oocytes number (RON) and LBRs. RON impacted likelihood of ovarian hyperstimulation syndrome (OHSS). Embryo euploidy decreased with age, not with cohort size. Progesterone > 1.5 ng/dL did not impair cycle outcomes in patients with high cohorts and showed disparate results on day of hCG administration.Conclusions.Ovarian stimulation should be designed to retrieve 10–15 oocytes/treatment. Accurate dosage, gonadotropin type, should be selected as per prediction markers of ovarian response. Gonadotropin-releasing hormone (GnRH) antagonist based protocols are advised to avoid OHSS. Cumulative pregnancy rate was most relevant pregnancy endpoint in ART. Cycles with serum progesterone ≥1.5 ng/dL on day of hCG administration should not adopt “freeze-all” policy. Further research is needed due to lack of data availability on progesterone threshold or index.

Asherman’s syndrome is an acquired uterine condition and a less frequent though significant cause of infertility in women. Surgical procedures, especially the ones done on gravid uteri and infections, seem to be the major aetiological factor in its development. It manifests pathologically as a combination of endometrial scarring and intrauterine adhesions and clinically as menstrual dysfunction, infertility and various pregnancy complications. Methods to diagnose adhesions are either non-invasive or invasive, and their sensitivity and specificity are measured against the gold standard of hysteroscopy. Hysteroscopic synechiolysis is the primary method of treatment. Blunt, sharp and energy source linked lyses have all been used to obtain the goal of achieving full uterine capacity. One has to be wary of both immediate and late complications associated with lysis in severe cases. Ancillary methods adopted for prevention of adhesion reformation might be successful in reducing the risk and severity of adhesion reformation, but evidence is lacking on their efficacy in improving reproductive outcomes. Reproductive outcomes are mostly improved after hysteroscopic synechiolysis. Future research should focus on more effective ways to prevent adhesion reformation and on therapies to help regenerate functional endometrium.

The aim of the study was to compare simultaneously started clomiphene citrate (CC) and gonadotropins (Gn) with gonadotropins alone in conventional antagonist regimes with respect to fresh-cycle live births, cumulative live births and cost of ovarian stimulation per started cycle.This was a single-center prospective cohort study conducted over 1 year. Women undergoing autologous in vitro fertilization (IVF) treatment in antagonist protocols and who consented to participate in the study were divided into two cohorts. The CC cohort (n = 86) received 50 mg CC for 5 days and individualized Gn daily until the hCG trigger, both starting from day 2 and antagonist daily from day 8 of menstrual cycle. The Gn-only cohort (n = 349) received individualized Gn from day 2 and the antagonist from day 7 of menstrual cycle. IVF outcomes and cost of stimulation were compared between two cohorts across expected ovarian response categories.The CC cohort used a mean lower dose of Gn (1741.38 ± 604.46 vs 1980.54 ± 686.42; MD = -239.16; 95%CI = -348.03 to -189.24; P = 0.003) over fewer days (8.54 ± 1.86 vs 9.25 ± 1.97; MD =-0.71;95% CI = -1.17 to -0.25; P = 0.0026) to achieve similar retrieved oocytes, (9.19 ± 5.92 vs 9.36 ± 6.96; MD = -0.17; 95%CI -1.77 to + 1.43; P = 0.83), positive bhCG rates (40% vs 29.6%, MD = 10.4%; OR = 1.65, 95%CI = 0.95-2.86; P = 0.078) and live births in fresh cycles (32.31% vs 21.30%; MD = 11.01%; OR = 1.76; 95%CI = 0.97-3.19; P = 0.06) and cumulative live births per initiated cycle (30.23% vs 20.34%; MD = 9.89%; OR = 1.697; 95%CI = 0.99-2.88; P = 0.0501). The dose lowering achieved a 28-40% reduction in the cost of stimulation, which was most noticeable in the hyper-responder category for both hMG cycles, (Rs.11 602.3 ± 3365.9 vs 19615 ± 2677.1; MD = -8012.7; %age reduction: 40.8%; P = 0.0007) and recombinant FSH cycles (Rs. 22 459.6 ± 6255.3 vs 33 022.1 ± 9891.2; MD: -10 562; %age reduction: -32%; P = 0.0001).CC started simultaneously with Gn in antagonist regimes helps lower the cost of stimulation without affecting IVF outcomes.

Introduction: There is a paucity of data evaluating role of endometrial blood flow in frozen thawed embryo transfer cycles (FET cycles) in hormone replacement treatment (HRT) cycles. Objective: To compare pregnancy outcomes in women undergoing ultrasound for endometrial morphology alone to those with endometrial morphology with blood flows in frozen embryo transfer cycles. Patients: Patients aged 23 to 38 years undergoing first two frozen thawed single blastocyst embryo transfer cycles. From August 2019 to January 2020, 163 patients undergoing hormone replacement frozen embryo transfer cycles were enrolled in the study. Patients were divided in two groups. Patients in group A (n = 92) had ultrasonographic evaluation of endometrial thickness and morphology and in group B (n = 71) patients underwent ultrasound for endometrial thickness, morphology along with Doppler blood flow studies. Outcome measures: Primary outcome was clinical pregnancy rate. Secondary outcome measures were pregnancy loss rate, ongoing pregnancy rate, and ectopic pregnancy rate. Results: Clinical pregnancy rate in group A and group B was 54.34% and 47.88%. Clinical pregnancy rate was similar between both the groups (P = 0.779). Ongoing pregnancy rate in group A and B was 48.91% and 40.84%, respectively. Pregnancy loss rate (7–13 wks) was 5.4% and 7.04% in group A and group B, respectively. There was no significant difference in ongoing pregnancy rate and pregnancy loss rate between both the groups (P = 0.756). Conclusion: Additional measurement of doppler studies do not help in improving implantation and thus seems unnecessary in improving pregnancy rates and reducing pregnancy loss rates in FET cycles.

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.

Study question: Oocyte donation is an increasingly popular treatment option for pregnancy and parenthood in women with poor ovarian reserve or advanced age. Indian literature still lacks a formal study focusing on expectations and experiences of oocyte donors. Aim: To assess demography, expectations and experiences of oocyte donors in northern India by an interview-based questionnaire. Material and Methods: This is a prospective cross-sectional study at a tertiary care IVF centre from August 2018 to January 2019. Sample size was 65 oocyte donors found fit and willing for egg donation. Interviews were taken using structured questionnaire at the time of registration and after successful oocyte retrieval. Results: Mean age of donors was 25 years. Most of the donors were housewives (70%) and rest were in a private job. Only 29% of donors were educated above tenth standard. Almost all the donors (96%) were commercial donors introduced by paid agents or friends. Most of the donors had very poor understanding of details of the oocyte retrieval procedure. Only 36% of donors felt that compensation given is adequate, rest expected a higher compensation. Average compensation given to donors was INR 15,000–25,000, which was 5000–10,000 less than their expectations. All donors were satisfied with the procedure and did not feel exploited or anxious or depressed but few complained of discomfort experienced in visits and minimal complications like pain, nausea, and fever. None of the donors developed signs/symptoms of OHSS. Average number of oocytes retrieved per donor was 17. Mean dose of gonadotropins required per donor was 1495 IU. Conclusion: Our findings show that the oocyte donation has an overall good acceptance and satisfaction among the donors. However there is a need to impart more detailed information to donors in order to prevent their possible exploitation.

Introduction: There are limited studies in literature regarding the effect of body mass index (BMI) on clinical pregnancy rate following frozen-thawed embryo transfers. Objective: We aim to study the independent effect of BMI on clinical pregnancy rate in single blastocyst frozen-embryo transfer cycle in Asian women. Material and methods: It is a prospective observational study involving 167 women who underwent single, good quality frozen-blastocyst transfer following a uniform protocol. Stimulation was done by hormone replacement therapy in all cycles. The study population was divided into various cohorts as per the BMI classification for Asian adult population (normal: 18.5–22.9, pre-obese: 23–24.9, obese I: 25–29.9, obese II: ≥30). Results: The positive β-HCG rate was 48.93% in normal BMI women, 55.31% in pre-obese, 50% in obese I, and 38.4% in obese II BMI groups. The clinical pregnancy rate was 36.17% in normal BMI women, 48.93% in pre-obese, 45% in obese I, and 30.07% in obese II BMI groups. The difference between various BMI subgroups as regards to positive β-HCG as well as clinical pregnancy is not statistically significant. Women with BMI ≥ 30 had numerically low clinical pregnancy rate, in comparison to those with lower BMI sub-groups. However, this difference was not statistically significant. Conclusion: This study concludes that BMI did not affect clinical pregnancy rate among women following a uniform protocol, single good quality frozen blastocyst transfer in Asian women. The increased difficulty during transfer for women with higher BMI suggests that body habitus may be responsible for difficult transfers, although this may not translate into a worse clinical pregnancy rate. A study with larger sample size may be needed to confirm these findings.