The Onco Fertility Journal

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Though the application of advanced assisted reproductive technologies, such as in vitro fertilization and intracytoplasmic sperm injection (ICSI), circumvents many factors resulting in infertility, it still has its challenges. Among the various reasons, total fertilization failure attributed to oocyte activation deficiency (OAD) is a recognized cause. The application of assisted oocyte activation (AOA) during ICSI has been reported to overcome this issue and improve outcomes. The objective of this review article is to provide an overview of the currently available data regarding oocyte activation, identify areas for further research, and draw conclusions. Many diagnostic methods are developed to diagnose OAD, and thus, it helps to streamline its application. Similarly, many methods of activation are studied, but there is no proposed standardization in techniques, which indicates this area of expertise needs more research for broad application. Hence, AOA cannot be universally applied, as it is not beneficial in all cases of suspected OAD, which eventually points to the need that consensus guidance in clinical practice for the use of AOA should be available to guide clinicians. Importantly, a couple should be well informed about the advantages and risks associated with AOA-ICSI before application.

Endometriosis is being widely diagnosed in women of reproductive age. There often arises a situation which compromises the fecundity of those women with moderate-to-severe endometriosis as it affects the ovarian tissue, lowers ovarian response to stimulation, and may also lead to premature ovarian failure. In order to treat the condition for shifting the living experience of the patients to a better edge, various treatments are being offered. However, surgical interventions are associated with lower ovarian reserve. In endometriosis patients without a male partner, oocyte vitrification can play a vital role. The same can be a choice when there are unforeseen events of azoospermia. The success of oocyte vitrification is dependent on outcome of appropriate treatment protocols followed by technical expertise. This qualitative review has been performed to understand the paradigm of managing the disease and also the role of oocyte vitrification in an endometriosis cohort. An electronic literature search was performed in PubMed/Medline and Google Scholar search engines to retrieve 51 articles that comprised of original articles, short reports, review articles, meta-analysis, and case studies published so far in the relevant field. The search terms used were oocyte vitrification, fertility preservation, endometriosis, endometrioma, infertility, ovarian reserve, and moderate to severe endometriosis. Articles of languages other than English were excluded.

Background: Various methods have been used for the treatment and management of repeated implantation failures (RIFs). One approach that has recently been considered for the treatment of RIF is intrauterine infusion of platelet-rich plasma (PRP). Objective: In the present study, the effect of intrauterine injection of PRP on pregnancy outcome was investigated in women with RIFs. Study Design: This study was performed on 17 patients with RIF history. The number of embryos (5-day blastocyst) transferred in each patient was 1 or 2. An aliquot of 12 mL of venous blood was taken from the patient. After two centrifugal stages, 0.5–1 mL of PRP was obtained. PRP was injected into the womb cavity. Results: The implantation and clinical pregnancy were confirmed in 35.3% (n = 6) of the patients. One patient had a miscarriage in the second month of pregnancy. Live birth rate was 29.4% (n = 5). Conclusion: This study showed the effectiveness of intrauterine infusion of PRP in patients with RIFs.

Aim: Endometrial preparation with exogenous estrogen is a common practice in frozen embryo transfer (FET) cycles. The aim of this study was to compare the clinical outcome of oral estradiol valerate versus transdermal estrogen (17-β estradiol) gel in FET cycles. Materials and Methods: A prospective pilot study was carried out at a tertiary fertility clinic after Ethics Committee approval from January 2018 to December 2018. It included 103 infertile women who underwent FET cycles. Either oral estradiol valerate or transdermal 17-beta estradiol was used for endometrial preparation. Combination was used in case of breakthrough bleeding or if optimal endometrial thickness was not achieved. Baseline demographic parameters and details of the stimulation protocol and embryogenesis in fresh cycle were noted. In the FET cycle, the patient was seen on day 2 of menstrual cycle, where baseline ultrasound (USG), estradiol, and progesterone levels were done. If normal, the patients were given either oral or dermal preparation. The patient was seen again on day 9 for endometrial thickness and if required again after 2 days till endometrial thickness was 9 mm. If optimal endometrial thickness was not achieved or there was breakthrough bleeding, combination of both oral and dermal preparation was used. Once the endometrial thickness was 9 mm or more, progesterone was started, and ET was done on day 5. On the day of progesterone initiation, endometrial thickness, endometrial volume by 3D, and Doppler indices [pulsatility index (PI), resistance index (RI), peak systolic velocity (PSV)] were noted. The primary outcome of the study was clinical pregnancy rate (CPR) and live birth rate (LBR). Results: There was no statistical difference in any of the demographic parameters in groups A and B. In group C, the pregnant patients were younger with higher body mass index and follicle-stimulating hormone and lower anti-Mullerian hormone and antral follicle count when compared with those who did not conceive. Demographics of the fresh cycle did not show any significant difference in dose and duration of stimulation, fertilization, cleavage, and blastulation rate in group A. In group B, the fertilization rate was significantly higher in the pregnant group (0.001), whereas the other parameters were similar. In group C, the pregnant group required more dose and days of stimulation and had lower oocytes retrieved but had a higher blastulation rate. In the hormone replacement therapy (HRT) cycle, there was no difference in the mean duration of HRT in groups A and B but was significantly higher in group C when compared with group A. The CPR with oral estradiol valerate, transdermal gel, and combination therapy was 34.85%, 35%, and 52.94%, respectively. The LBR with oral estradiol valerate, transdermal gel, and combination therapy was 25.76%, 30%, and 47.06%, respectively. Though the CPR and LBR were higher in group C, it did not reach statistical significance and this could be due to small sample size. There was no difference in the abortion rate (oral 7.58%, gel 5%, combination 5.88%) between the three groups. The implantation rate (oral 26%, gel 25.8%, combination 29.03%) in the three groups was also similar. There was also no statistical difference in the endometrial thickness, volume, and blood flow between the three groups. The cut-off values for Doppler indices for a positive pregnancy were as follows: Group A—PSV: >8.7, RI: <0.99, PI: >1.54; Group B—PSV: >5, RI: <0.72, PI: >2.1; Group C—PSV: >5.6, RI: <0.64, PI: >1.29. Conclusion: Both the oral estradiol valerate and transdermal 17-beta estradiol were equally effective for optimal outcome in an FET cycle in HRT. Those not responding to single preparation may benefit from combination therapy. Transdermal 17-beta estradiol gel may be of use in those patients who have breakthrough bleeding with oral preparation which may be due to hepatic bypass effect.

Ovarian cancer is one of the most lethal gynecological malignancies. It is estimated that 10% of ovarian cancer cases will be diagnosed in women of reproductive age and >80% would be in advanced stage. Conservative treatment can be carried out for Stage IA, B, C1, C2, C3 (International Federation of Gynecology and Obstetrics) to preserve fertility. Evidence-based data from the descriptive series suggest that in selected cases, the preservation of the uterus and at least one part of the ovary does not lead to a high risk of relapse. Here, we present the case report of a patient who underwent bilateral salpingo-oophorectomy for early stage ovarian cancer and borderline tumor, conceived through in vitro fertilization, with successful pregnancy outcome.

In this case vignette, we highlight that embryo cryopreservation may not be an automatic choice for fertility preservation in married females but that oocyte cryopreservation also has a place. A 32-year-old married woman with breast cancer, who was initially proceeding for embryo cryopreservation to preserve her fertility before starting cancer treatment, eventually had oocyte preservation because her spouse declined to donate sperm. We discuss the need for detailed and continuous counseling.

The incidence of pregnancy-associated cancer is on the rise. A 36-year-old lady married for three years underwent IVF for mild male factor infertility following the failure of conception with six cycles of ovulation induction and three cycles of IUI. She conceived spontaneously two months after the frozen embryo transfer cycle. She was diagnosed to have breast cancer at 32 weeks of pregnancy. Her records did not show findings of breast examination during the antenatal visits. She was advised to take chemotherapy, but she refused because of the fear of effects on the fetus and underwent LSCS at 35 weeks. An alive female baby with a weight of 2.5 kg was born. Postoperatively, she was managed with neoadjuvant chemotherapy and was referred for mastectomy. Counseling for chemotherapy should involve treating obstetrician in addition to the oncologists.

Online since 7^th August, 2017.