International Journal of Fertility and Sterility

171-175

Authors: Rahil Jannatifar; Kazem Parivar; Nasim Hayati Roodbari; Mohammad Hossein Nasr-Esfahani

Background: One of the important factor associated with male infertility is high production of reactive oxygen species (ROS). The main function of Nuclear factor erythroid 2-related factor 2 (NRF2) is to activate the cellular antioxidant response by inducing the transcription of a wide array of genes that can combat the harmful effects of factors such as oxidative stress. The purpose of this study was to evaluate the effect of N-acetyl-L-cysteine (NAC), as an antioxidant drug, on NRF2 Gene Expression in Asthenoteratozoospermia Men. Materials and Methods: In this randomized, blinded clinical trial study, included 50 infertile men with asthenoteratozoospermia, who received NAC (600 mg, three times daily). Sperm parameters analyzed according to the world health organization (WHO; 2010). Sperm DNA fragmentation, relative NRF2 expression, and seminal plasma level of antioxidant enzymes were measured by TUNEL assay, reverse transcription polymerase chain reaction (RT-PCR) and ELISA test, respectively. Results: After NAC treatment, findings showed a significant increase in sperm concentration and motility compared to pre-treatment status, whereas the percentage of abnormal morphology and DNA fragmentation was significantly decreased (P<0.05). A significant improvement in expression of NRF2 gene and antioxidant enzyme levels were observed compared to pre-treatment by NAC (P<0.05). Significant correlations were observed between NRF2 mRNA expression level, specific sperm parameters and level of antioxidant enzymes (P<0.05). Conclusion: The results demonstrated that NAC oral supplementation protected against oxidative stress by enhancing NRF2 expression. This could improve semen parameters quality parameters in asthenoteratozoospermia men (Registration number: IRCT20170830035998N4).

185-192

Authors: Masha Shirani; Praveen Saneei; Mehran Nouri; Mohamadreza Maracy; Homayoun Abbasi; Gholamreza Askari

Background: This cross-sectional study pointed to assess the relationship between major dietary patterns and dietary diversity score with semen parameters, in infertile Iranian males. Materials and Methods: In this cross-sectional study, 260 infertile men (18-55 years old) who met the inclusion criteria, entered the study. Four Semen parameters, namely sperm concentration (SC), total sperm movement (TSM), normal sperm morphology (NSM) and sperm volume were considered according to spermogram. A 168-item food frequency questionnaire (FFQ) was used to collect dietary intakes and calculate dietary diversity score. Factor analysis was used to extract dietary patterns. Results: The following four factors were extracted: “traditional pattern”, “prudent pattern”, “vegetable-based pattern” and “mixed pattern”. After adjusting potential confounders, those in the highest quartile of the traditional pattern had 83% less odds for abnormal concentration, compared with the first quartile (OR=0.17, 95% CI: 0.04-00.73); however, subjects in the highest quartile of this pattern had 2.69 fold higher odds for abnormal sperm volume as compared with those of the first quartile (95%Cl: 1.06-6.82). Men in the second quartile of prudent pattern had 4.36 higher odds of an abnormal sperm volume in comparison to the reference category (95%CI: 1.75-10.86), after considering potential confounders. With regard to mixed pattern, men in the second, third and fourth quartile of this pattern had respectively 85 (5%Cl: 0.03-0.76,), 86 (95%Cl: 0.02-0.75) and 83 % (95%Cl: 0.034-0.9) less odds of abnormal concentration, compared with the first quartile. Additionally, no significant association was found between dietary diversity score and sperm quality parameters. Conclusion: Higher intake of the traditional diet was linked to lower abnormal semen concentration and poorer sperm volume. Also, the mixed diet was associated with reduced prevalence of abnormal semen concentration.

201-208

Authors: Fatemeh Pashizeh; Reza Mansouri; Fatemeh Davari-Tanha; Reyhaneh Hosseini; Zahra Asgari; Hamideh Aghaei; Farangis Najafi Arbastan; Samira Rajaei

Background: Endometriosis is a chronic inflammatory disorder with known immune disturbances. The aim of this study was to compare the frequency of different CD4+ T cells [T helper (Th)1, Th2, Th17 and regulatory T cells (Tregs)] in peripheral blood (PB) and peritoneal fluid (PF) of patients that have early and advanced stages of endometriosis with a control group. Materials and Methods: In this case control study, PB and PF samples were collected from women aged 24-40 years who underwent laparoscopy procedures. The frequency of CD4+ T subsets were analysed by flow cytometry and compared between three study groups; early endometriosis (stage I, II), advanced endometriosis (stage III, IV) and control (no endometriosis). T cell numbers were compared between the PB and PF in each of the aforementioned groups. Results: No statistically significant difference was found between the study groups regarding the numbers of Th1, Th2 and Th17 cells in PB. The PF of patients with advanced endometriosis had increased numbers of Th17 cells compared to the control group (P=0.003), with P values of 0.059 and 0.045 in both menstrual phases. Increased numbers of Th2 cells in PF from early compared to advanced stages of endometriosis were detected exclusively in the luteal phase (P=0.035). The control group had increased numbers of Treg and Th2 cells in the PF compared to PB (both, P value=0.046). However, in the early stages of endometriosis there were more Th2, Th17 and Treg cells in the PF compared to PB (P values: 0.005, 0.047 and 0.013, respectively), while the number of Th17 cells was higher in the PF compared with PB in the advanced stages of endometriosis (P= 0.013). Conclusion: There were increased numbers of Th17 cells in the PF of patients with advanced stages of endometriosis, which could be related to the severity of this disease.

213-217

Authors: Pinar Gulsen Coban; Ayla Sargin Oruc; Meryem Kuru Pekcan; Hasan Inal; Necati Hancerliogullari; Nafiye Yilmaz

Background: We investigated the impact of the choice of catheter type and tenaculum use on pregnancy related outcomes in intrauterine insemination (IUI) treatments. Materials and Methods: A total of 338 consecutive IUI cycles were assessed in this retrospective study. Participants were divided according to the insemination technique - soft catheter (group 1; n=175), firm catheter (group 2; n=100), or tenaculum (group 3; n=63). Clinical, laboratory, semen parameters and pregnancy related outcomes were compared. Results: Demographic characteristics and laboratory parameters were similar between the groups (P>0.05). The clinical pregnancy rate (CPR) was significantly higher in the firm catheter (19%, 19/100) and tenaculum (31.7%, 20/63) groups compared to the soft catheter group (5.1%, 9/175, P<0.001). There were no significant differences between the groups in live birth and miscarriage rates per clinical pregnancy (P>0.05). Conclusion: Our findings indicate that the use of a firm catheter or tenaculum for IUI might result in a higher CPR, but might not have a considerable effect on the live birth rate (LBR). Further prospective randomized studies are required to determine the long-term effects of the catheter type or tenaculum use on IUI success.

223-227

Authors: Nadia Hossein-Zadeh; Morteza Bagheri; Isa Abdi Rad; Marziyeh Lozeie; Mahdieh Nasir-Zadeh

Background: 3,4-Methylenedioxymethamphetamine (MDMA) disrupts function of the endocrine system and different organs such as heart, blood vessels, kidney, liver and nervous systems. This study was conducted to evaluate impact of MDMA on apoptosis and Zinc in the MDMA-induced apoptosis of cultured Sertoli cells by measuring Caspase-3 gene expression. Materials and Methods: In this experimental study, Sertoli cells were incubated with MDMA (0, 0.5, 1, 3, 5 mM), Zinc (0, 8, 16, 32, 64 μM) and Zinc (8 μM) prior to adding MDMA (5 mM) for 24 and 48 hours. MTT assay was used for evaluating impacts of these conditions on the viability of Sertoli cells. Caspase-3 gene expression level was detected using quantitative reverse transcription PCR (qRT-PCR) in all of the tested groups. Results: Finding showed that cellular viability was decreased and level of Caspase-3 mRNA was increased in MDMA treated cells. Additionally, pre-treatment with Zinc (8 μM) attenuated MDMA-induced apoptosis and down-regulated caspase-3. The mean of caspase-3 mRNA level (fold change ± SE) was 3.98 ± 1.18, 0.31 ± 0.28, and 1.72 ± 0.28 in respectively MDMA (5 mM), Zinc (8 μM), and Zinc+MDMA groups vs. control group. The mean of Caspase-3 mRNA (fold change) was not statistically different in the tested groups (P>0.05), unless MDMA (5 mM) group (P = 0.008). Conclusion: We suggest that MDMA toxicity could be involved in apoptosis of Sertoli cells. In addition, Zinc could reduce MDMA-induced apoptosis by down-regulation of Caspase-3 mRNA levels.

234-239

Authors: Azadeh Ghaheri; Reza Omani-Samani; Mahdi Sepidarkish; Mostafa Hosseini; Saman Maroufizadeh

Background: The most common mental disorders in infertile patients are depression and anxiety. The four-item Patient Health Questionnaire-4 (PHQ-4) is a widely used tool that consists of the PHQ-2 depression and Generalized Anxiety Disorder-2 (GAD-2) scales. Given that PHQ-4 has not been validated in infertile patients, this study aimed to examine its reliability and validity in this population. Materials and Methods: Participants in this cross-sectional study consisted of 539 infertile patients from a referral fertility centre in Tehran, Iran. The PHQ-4, Hospital Anxiety and Depression Scale (HADS), World Health Organisation- Five Well-Being Index (WHO-5), Penn State Worry Questionnaire (PSWQ) and demographic/infertility questionnaires were administered to all participants. Factor structure and internal consistency of PHQ-4 were evaluated via confirmatory factor analysis (CFA) and Cronbach’s alpha, respectively. The convergent validity of this scale was examined by its relationship with HADS, WHO-5 and PSWQ. Results: CFA results provided support for a two-factor model of PHQ-4. Internal consistency of the PHQ-4 and its subscales both were elevated with Cronbach’s alpha coefficients of 0.767 (PHQ-4), 0.780 (PHQ-2) and 0.814 (GAD-2). Inter-item correlations were between 0.386 and 0.639, and corrected item-total correlations were between 0.576 and 0.687. PHQ-4, PHQ-2 and GAD-2 showed positive correlations with measures of HADS-anxiety, HADS-depression, and PSWQ and negative correlations with WHO-5, which confirmed convergent validity. Among demographic/fertility variables, we observed that gender, infertility duration, and failure in previous treatment were correlated with PHQ-4 and its subscales scores. Conclusion: The PHQ-4 is a reliable and valid ultra-brief screening instrument for measuring both anxiety and depressive symptoms in infertile patients.

247-255

Authors: Mahsa Saadati; Arezoo Bagheri

Background: Birth spacing, especially the first birth interval (FBI), is a suitable index to investigate the delayed fertility that results in a low fertility pattern. Non-parametric familiar alternatives to the Cox proportional hazard regression (CPH) model include survival trees that can automatically discover certain types of covariate interactions according to the survival length. The aim of this research is to study FBI influential factors by applying survival trees. Materials and Methods: In this cross-sectional study, 610 married women (aged 15-49 years), were selected from different regions of Tehran, Iran in the Winter and Spring of 2017. Classification and regression trees (CART) for the FBI survival tree were fitted by taking into consideration the predictors of each woman’s age, age at first marriage, educational level, partner’s educational level, activity, region, house ownership, kinship, partner’s race, marriage time attitude, and expenditure using R packages. Results: Since the PH assumption of the CPH model was not confirmed for the covariates of age at first marriage (P=0.001), kinship (P=0.000), partner’s race (P=0.001), and marriage time attitude (P=0.042), the results of this model were not valid. Thus, a CART survival tree was fitted. The validity of the fitted model in assessing FBI was confirmed by the significant result of the log rank test (P<0.01) for the terminal nodes and the value of the separation measure, which was greater than 1. The fitted tree had 13 terminal nodes and the most vital FBI predictor was women’s age. The longest FBI belonged to educated and employed women, ages 30-37 years. Conclusion: Analysing patterns of birth spacing by selecting the appropriate statistical method provides important information for health policymakers. In order to formulate appropriate demographic policies, it is essential to take into consideration age, educational level and job status of the women, all of which have essential roles on their decision to have children.

260-261

Authors: Antonio Simone Laganà; Marco Scioscia

Endometrial carcinoma (EC) has a worldwide incidence of 8.4 per 100,000 persons per year and is a leading cause of cancer mortality in women in developed countries after ovarian and cervical cancer (1). Among the gynecological diseases, polycystic ovary syndrome and uterine leiomyomas have been associated with a potential increased risk to develop EC, whereas less robust data are available for endometriosis and adenomyosis (2). The association between EC and adenomyosis, defined by the presence of ectopic endometrial glands and stroma within the myometrium, is still debated: on the one hand, adenomyosis is found with an incidence of 10 to 18% in EC specimen at final histology after hysterectomy.

264-271

Authors: Reihaneh Pirjani; Maryam Rabiei; Ameneh Abiri; Ashraf Moini

In this article, we reviewed and compared some of COVID-19 and pregnancy guidelines; this can be useful for pregnant women including those with a history of infertility specially those undergone assisted reproductive techniques (ART). The general advice given for prenatal care is to reduce face-to-face visits. All women who refer for prenatal visits should be evaluated for signs of the infection at the time of entry. The triage of suspected women should be done separately from other patients. Outpatient monitoring with a 14-day selfquarantine can be considered for asymptomatic infected women and for those with mild symptoms. Inpatient management criteria include moderate to severe symptoms and the target level of oxygen saturation is 92 to 95% in different guidelines. In the presence of fever, it is important to conduct a thorough examination of other causes of the fever. It is important to monitor fluid intake and output, maintain fluid and electrolyte balance and prevent fluid overload. Thromboembolic prophylaxis is recommended. Corticosteroid administration is based on obstetrics indications, while in critical ill cases, it should be based on multi-disciplinary teams (MDT) decision. A positive COVID-19 result in the absence of other obstetrics causes, cannot be considered an indication for delivery in mild and asymptomatic cases. In critically ill pregnant women, an individualized decision should be made about delivery time by the MDT. General anesthetic should be avoided unless inevitable for standard procedures such as intubation is an aerosol-generating procedure (AGP). There is agreement on the point that babies born to infected mothers, even if isolated from the mother at birth, should be considered a close contact of the mother and tested for COVID-19 and separated from other neonates. Breastfeeding is encouraged and hand hygiene and face mask during feeding are highly recommended by all guidelines

84-90

Authors: Hamid Ekrami, Mansoureh Movahedin, Fereshteh Koosha, Zohreh Mazaheri, Manijhe Mokhtari-Dizaji

Objective The study aimed to evaluate the impact of Calligonum extract and US radiation on sperm parameters of cryopreserved human semen samples. Materials and methods In this experimental study, twenty-five semen specimens were obtained from healthy semen donors and incubated in human tubal fluid (HTF) medium supplemented with 10% human serum albumin (HSA) for 45 minutes. Samples were treated with Calligonum extract (10 μg/ml) alone (CGM group) and US radiation (LIPUSexposed group) alone or a combination of both treatments (CGM+LIPUS). The US group received US stimulation (in both continuous and pulsed wave modes) at a frequency of 1 MHZ and intensity of 200 mW/cm2 for 200 seconds. Sperm morphology was assessed by Diff-Quik staining. The DNA fragmentation was evaluated the Halo sperm kit. Sperm parameters was analyzed by a computer-assisted semen analysis system. Reactive oxygen species (ROS) was assessed by flow cytometry. Results The results showed that the treatment with Calligonum extract significantly (P<0.05) increased the progressive motility of spermatozoa in the CGM group as compared with the control group. The application of low-intensity US significantly (P<0.05) decreased the motility and viability of spermatozoa in the US group when compared with the control group. Our findings also indicated that the use of both low-intensity US in continuous mode and Calligonum extract slightly increased progressive motility; however, such an increase was not statistically significant. The rate of DNA fragmentation was considerably higher (P<0.05) in control and LIPUS-exposed groups than the other groups. Conclusion Treatment of spermatozoa with Calligonum extract slightly improved the sperm parameters due to its antioxidant activity, on the other hand, according to our results, US radiation did not improve sperm parameters which may be due to interference with the motility of sperm, as well as its physical effects on spermatozoa.

102-109

Authors: Ajit Kumar Saxena, Meenakshi Tiwari, Mukta Agarwal, Aprajita Aniket Kumar

Objective The present study has been designed with the aim of evaluating A-kinase anchoring proteins 3 (AKAP3) and Procollagen-Lysine, 2-Oxoglutarate 5-Dioxygenase 3 (PLOD3) gene mutations and prediction of 3D protein structure for ligand binding activity in the cases of non-obstructive azoospermic male. Materials and methods Clinically diagnosed cases of non-obstructive azoospermia (n=111) with age matched controls (n=42) were included in the present case-control study for genetics analysis and confirmation of diagnosis. The sample size was calculated using Epi info software version 6 with 90 power and 95% confidence interval. Genomic DNA was isolated from blood (2.0 ml) and a selected case was used for whole exome sequencing (WES) using Illumina Hiseq for identification of the genes. Bioinformatic tools were used for decode the amino acid sequence from biological database (www.ncbi.nlm.nih.gov/protein). 3D protein structure of AKAP3 and PLOD3 genes was predicted using I-TASSER server and binding energy was calculated by Ramachandran plot. Results Present study revealed the mutation of AKAP3 gene, showing frameshift mutation at rs67512580 (ACT → -CT) and loss of adenine in homozygous condition, where, leucine changed into serine. Similarly, PLOD3 gene shows missense mutation in heterozygous condition due to loss of guanine in the sequence AGG→A-G and it is responsible for the change in post-translational event of amino acid where arginine change into lysine. 3D structure shows 8 and 4 pockets binding site in AKAP3 and PLOD3 gene encoded proteins with MTX respectively, but only one site bound to the receptor with less binding energy representing efficient model of protein structure. Conclusion These genetic variations are responsible for alteration of translational events of amino acid sequences, leading to protein synthesis change following alteration in the predicted 3D structure and functions during spermiogenesis, which might be a causative “risk” factor for male infertility.

116-121

Authors: Khodakaram Jahanbin, Mehri Ghafourian, Mohammad Rashno

Objective Several studies have shown that leukemia inhibitory factor (LIF) is one of the most important cytokines participating in the process of embryo implantation and pregnancy, while, the role of this factor on vascular endothelial factor-A (VEGF-A), as one of the most important angiogenic factor, has not been fully investigated yet. The aim of this study was to evaluate the effect of LIF on gene expression of VEGF in the choriocarcinoma cells (JEG-3). Materials and methods In this experimental study, JEG-3 choriocarcinoma cells were treated with different concentrations of LIF (1, 10, and 50 ng) for 6, 12, 24, 48 and 72 hours. Expression of VEGF was analyzed by real-time PCR. Delta CTs were subjected to one-way analysis of variance (ANOVA) and a post hoc Tukey’s test by SPSS version 25.0 software for data analyzing. Results In the stimulated cells, different concentrations of LIF caused significant decrease of VEGF gene expression (P<0.05) at 12, 24 and 48 hours. In contrast, it was increased after 72 hours (P<0.001). Analysis of data after 6 hours also showed that level of VEGF gene expression was significantly decreased by increasing LIF concentration (P<0.001). Conclusion Expression level of VEGF gene was decreased in trophoblast cells (except after 72 hours) under the effect of different concentrations of LIF in a time-dependent manner. So, this study showed that further studies are needed to determine the effect of LIF on other angiogenic factors in trophoblast cells.

130-136

Authors: Gracia Lasheras, Gemma Mestre-Bach, Elisabet Clua, Ignacio Rodríguez, Borja Farré-Sender

Objective Cross-border reproductive care (CBRC) refers to the movement of patients to foreign countries for fertility treatment. Limited evidence indicates that this phenomenon is associated with a risk of psychological distress, but few studies on the psychological impact of CBRC are currently available. The aim of this study was to compare the anxiety and depression levels of a group of cross-border patients with a local Spanish patient group, both of which underwent in vitro fertilization (IVF) treatment. We also sought to explore the clinical, sociodemographic and personality profiles of the CBRC group and local women. Materials and methods This present cross-sectional study was conducted on 161 infertile females (71 CBRC patients and 90 local women) who were undergoing IVF treatment. The following questionnaires were used to collect data: Spielberger State Anxiety Inventory (STAI-S), the Beck Depression Inventory-II (BDI-II) and the Zuckerman-Kuhlman Personality Questionnaire (ZKPQ). Sociodemographic, clinical, reproductive and CBRC variables were also recorded. Results CBRC patients, specifically CBRC oocyte recipients, showed higher levels of anxiety compared to local women. However, no significant differences in depression scores were found between both groups. Finally, when analysing personality, the Activity scale scores of the ZKPQ were found to be higher in CBRC oocyte recipients, which indicated a greater tendency for general activity and higher energy levels. Conclusion CBRC oocyte recipient women may have greater vulnerability to anxiety than local women prior to infertility treatment. Screening and psychological support protocols for anxiety in this population should be considered.

143-149

Authors: Zahra Safaei, Shabnam Bakhshalizadeh, Mohammad Hossein Nasr-Esfahani, Azadeh Akbari Sene, Vahid Najafzadeh, Mansoureh Soleimani, Reza Shirazi

Objective Polycystic ovary syndrome (PCOS) is an endocrine disorder diagnosed by anovulation hyperandrogenism. Hyperandrogenism increases apoptosis, which will eventually disturb follicular growth in PCOS patients. Since mitochondria regulate apoptosis, they might be affected by high incidence of follicular atresia. This may cause infertility. Since vitamin D3 has been shown to improve the PCOS symptoms, the aim of study was to investigate the effects vitamin D3 on mtDNA copy number, mitochondrial biogenesis, and membrane integrity of granulosa cells in a PCOS-induced mouse model. Materials and methods In this experimental study, the PCOS mouse model was induced by dehydroepiandrosterone (DHEA). Granulosa cells after identification by follicle-stimulating hormone receptor (FSHR) were cultured in three groups: 1. granulosa cells treated with vitamin D3 (100 nM for 24 hours), 2. granulosa cells without any treatments, 3. Non-PCOS granulosa cells (control group). Mitochondrial biogenesis gene (TFAM) expression was compared between different groups using real-time PCR. mtDNA copy number was also investigated by qPCR. The mitochondrial structure was evaluated by transmission electron microscopy (TEM). Hormonal levels were measured by an enzymelinked immunosorbent assay (ELISA) kit. Results The numbers of pre-antral and antral follicles increased in PCOS group in comparison with the non-PCOS group. Mitochondrial biogenesis genes were downregulated in granulosa cells of PCOS mice when compared to the non-PCOS granulosa cells. However, treatment with vitamin D3 increased mtDNA expression levels of these genes compared to PCOS granulosa cells with no treatments. Most of the mitochondria in the PCOS group were spherical with almost no cristae. Our results showed that in the PCOS group treated with vitamin D3, the mtDNA copy number increased significantly in comparison to PCOS granulosa cells with no treatments. Conclusion According to this study, we can conclude, vitamin D3 improves mitochondrial biogenesis and membrane integrity, mtDNA copy number in granulosa cells of PCOS mice which might improve follicular development and subsequently oocyte quality

154-158

Authors: Maryam Hafezi, Zahra Chekini, Mohammad Reza Zamanian

Recurrent hydatidiform mole is defined as episodes of two molar pregnancies in a female. Often, complete moles only derive androgenic nuclear genome. We described two cases with repeated molar pregnancies attempted to prevent future episodes by performing intracytoplasmic sperm injection (ICSI) and preimplantation genetic diagnosis (PGD) to assess genetic disorders. The first patient had previously six complete molar pregnancies and advised to carry out ICSI with ovum donation to achieve a normal pregnancy. The second case had previously five molar pregnancies and no XY embryos from the ICSI/PGD process. We had to (at the insistence of the patient) transfer XX embryos in this patient which resulted in a complete hydatidiform mole (CHM). Hence, available data based on our patients and previous studies demonstrated that oocyte might play a critical role in the pathophysiology of recurrent hydatidiform mole, while it has not been often considered.

10-16

Authors: Fatemeh Kalhori, Seyedeh Zahra Masoumi, Farshid Shamsaei, Youness Mohammadi, Mahnaz Yavangi

Background: Assisted reproductive technology (ARTs) such as in vitro fertilization (IVF) can lead to depressive symptoms in infertile women due to their low success and high costs. Mindfulness-based group counseling can decrease depressive symptoms by increasing mental concentration. The aim of the present study was to evaluate the effect of mindfulness-based group counseling on depression in infertile women undergoing IVF. Materials and Methods: The present clinical trial included 90 infertile women undergoing IVF treatment in an infertility center in 2016. Women were divided into two groups, intervention and control. Both groups completed a demographic questionnaire and the Beck depression inventory (BDI). Eight 90-minute sessions (two each week) of mindfulness-based group counseling were held with the intervention group, while the control group received treatment as normal. Following the intervention, the BDI was again completed by both groups. The data were analyzed and independent t tests and, paired t tests conducted at a significance level of P<0.05. Results: No statistically significant demographic differences were observed between the two groups. Women in the control group had a somewhat lower depressive symptom score than the intervention group before the intervention. However, compared with before, the depressive symptom score among women in the intervention group decreased significantly (48%) (P<0.001) after the intervention. In contrast, the depressive symptom score in control women was higher after the intervention than before. Conclusion: According to the findings of the present research, mindfulness-based group counseling is able to reduce depressive symptoms in infertile women under IVF treatment. Therefore, group counseling sessions are suggested for all depressed women undergoing infertility treatment (Registration number: IRCT2015082013405N14).

23-26

Authors: Mahboobeh Shirazi, Margan Ghaemi, Parichehr Pouransari, Neda Hajiha, Zeinab Shaker, Mohadeseh Ghazi, Fatemeh Davari Tanha, Batool Ghorbani

Background: The aim of this study was evaluation of the impact of single-dose methotrexate (MTX) treatment on ovarian reserve in women with ectopic pregnancy (EP) undergoing infertility treatment in Iranian population. Materials and Methods: This prospective cohort study was done between March 2015 and March 2017 in Tehran General Women Hospital, Tehran, Iran. We enrolled 20 patients with EP who conceived during infertility treatment and received a single-dose MTX (50 mg/m2) intramuscularly. Serum anti-Mullerian hormone (AMH), 17 beta-estradiol (E2), luteinizing hormone (LH), follicle-stimulating hormone (FSH) and antral follicle count (AFC) on transvaginal ultrasonography, were evaluated before and 8 weeks after administration of MTX. Results: AMH did not significantly vary after the administration of MTX, compared to before treatment value (P=0.36). FSH, E2 and AFC changes were not statistically significant, while increment of LH was significant (P=0.02). Conclusion: Results indicated that single-dose MTX treatment did not reduce ovarian reserve in women with EP. Further randomized controlled clinical trial studies with larger sample sizes, by using multiple dosages of MTX, and with long-term follow up are suggested to be done.

34-40

Authors: Dalia Khalife, Anwar Nassar, Ali Khalil, Johnny Awwad, Antoine Abu Musa, Antoine Hannun, Lina El Taha, Fatin Khalifeh, May Abiad, Ghina Ghazeeri

Background: The aim of this retrospective study is to investigate the cumulative live birth rate (CLBR) following one or more completed in vitro fertilization (IVF) cycles (up to 6 cycles) stratified by maternal age and type of infertility. Materials and Methods: In this retrospective study, five hundred forty-seven women who received 736 fresh ovarian stimulation/embryo transfer cycles between January 2016 and December 2016 were included in the study at a tertiary care center located in Lebanon. Results: In all women, the live birth rate for the first cycle was 33.0% [95% confidence interval (CI): 27.8-38.2]. The CLBR showed an increase with each successive fresh cycle to reach 56.9% (95% CI: 51.2-62.4) after 3 cycles and 67.9% (95% CI: of 62.5-73.0) after 6 cycles. The CLBR following 6 cycles reached 69.9% (95% CI: 63.8-75.6) in women younger than 35 years. In women older than 40 years, however, the live birth rate for the first cycle was significantly low at 3.1% (95% CI: 0.3-9.5) with a plateau in success rates after 4 cycles reaching 21.9% (95% CI: 9.2-40.0). Couples with different types of infertility had CLBRs ranging from 65% to 72%, with the exception of women with low ovarian reserve, where CLBRs reached 29.4% (95% CI: 10.3-56.0). Conclusion: The CLBR at a referral center in a Middle Eastern country reached 67.9 % after 6 cycles, with variations by age and type of infertility treatment. These findings are encouraging for patients insisting to extend their treatment beyond 4 to 5 cycles

46-50

Authors: Maryam Baazm, Ali Asghar Ghafarizadeh, Ali Reza Noshad Kamran, Cordian Beyer, Adib Zendedel

Background: Varicocele is a common cause of male infertility with multifactorial etiology. Inflammation is a characteristic pathological event that occurs in the testis tissue following the varicocele. The aim of this study was to investigate expression of nod-like receptor family, pyrin domain containing 3 (NLRP3) inflammasome components and cytokines in semen of varicocele and control subjects. Materials and Methods: In this case-control study, seminal plasma was collected from 32 varicocele patients (with grades 2 and 3) and 20 fertile men as control group. Semen analysis was performed in all subjects. Concentrations of interleukin-1b (IL-1b), IL-18 and caspase-1 in seminal plasma were measured by enzyme-linked immunosorbent assay (ELISA). Apoptosis-associated speck-like protein containing a caspase activation and recruitment domain, in addition to NALP3 were identified in seminal plasma by Western blot. Statistical significance between the mean values was determined by student’s t test. Results: According to our data, the level of IL-1b was significantly (P=0.03) increased in the seminal plasma of varicocele patients, compared to the control subjects. We analyzed amount of IL-18 in the both groups. The level of this interleukin was markedly (P=0.002) decreased in varicocele patients. No change was observed in the level of caspase-1 in both groups. Western blot analysis revealed that apoptosis associated speck-like protein (ASC, P=0.0002) and NLRP3 (P=0.005) were significantly elevated in the semen of varicocele patients. Conclusion: This study provides the first evidence of activation of NLRP3 components in semen of men with varicocele.

57-62

Authors: Farzaneh Bassiri, Marziyeh Tavalaee, Maurizio Dattilio, Mohammad Hossein Nasr-Esfahani

Background: Micronutrients in support to the carbon cycle were shown to reduce sperm DNA damage both in animal models and infertile men. Besides supporting DNA methylation, their positive effect may be mediated by an improved performance of the endogenous antioxidant system but this has not yet been proven in clinical settings. The present study aimed at evaluating the effects of micronutrient supplementation in infertile male partners of assisted reproductive technology (ART) resistant couples. Materials and Methods: In this experimental clinical trial study, infertile male partners of couples resistant to at least one ART cycle, with a sperm fragmentation rate >20% (TUNEL), underwent a 4-month oral supplementation with micronutrients in support to the carbon cycle including folates, B vitamins, zinc and cysteines. Semen, sperm DNA fragmentation (TUNEL), nuclear maturation (CMA3 and blue aniline staining) and lipid peroxidation (BODIPY) were assessed before and after treatment. The couples were followed-up to record clinical outcomes. Results: Forty-three patients completed the program but full data of pre- and post-treatment were available only for 25 patients. The treatment did not modify sperm concentration or motility but improved morphology. Nuclear maturation, DNA fragmentation and lipid peroxidation significantly improved after the treatment. Overall, 10 clinical pregnancies (23.3%) and 4 live births (9.3%) were recorded during the follow-up following expectant management (25 couples) or a new intracytoplasmic sperm injection (ICSI) cycle (18 couples). Conclusion: The micronutrients appeared to induce both DNA methylation, resulting in improved sperm nuclear maturation, and antioxidant defences, resulting in less DNA fragmentation and lipid peroxidation. The clinical outcomes were aligned with a possible positive effect on reproductive function. Micronutrients could be regarded as an alternative to antioxidants in correcting oxidative damage in infertile men; however, to confirm such findings, further clinical investigations are warranted (Registration number: IRCT201510207223N6).

68-71

Authors: Ansha Patel, Podila Satya Venkata Narasimha Sharma, Pratap Kumar

Fertility treatments began in several countries, including India, in the1970s. Despite various advancements in intra uterine insemination (IUI) and in vitro fertilization (IVF), empirical investigations on the psychological endurance and emotional tolerance of Indian women to such treatments are rather scarce. Thus, the aim of this study is to estimate the prevalence of psychiatric disorders in Indian women seeking fertility treatments. It is a cross-sectional study with three hundred women participants undergoing various treatments at the Manipal Assisted Reproductive Centre, Kasturba Medical College, Karnataka, India. Psychiatric disorders were assessed in women using the “ICD- 10 Classification of Mental and Behavioural Disorders” followed by descriptive data analysis. The results show that 78% of women have psychological issues and 45% of them have a diagnosable psychiatric condition. Adjustment Disorders, Anxiety Disorders and Mixed Anxiety and Depression Disorder are established as the top three categories of diagnoses. The findings of this study suggest that women have a high emotional stake in infertility treatments. The data highlights the need for modification of the existing treatment protocol (in Indian clinics) in ways that ensure the emotional wellbeing of patients.

76-77

Authors: Fabio Barra, Lorenzo Ferro Desideri, Umberto Leone Roberti Maggiore, Valerio Gaetano Vellone, Mattia Maramai, Carolina Scala, Simone Ferrero

Fabio Barra, Lorenzo Ferro Desideri, Umberto Leone Roberti Maggiore, Valerio Gaetano Vellone, Mattia Maramai, Carolina Scala, Simone Ferrero

257-270

Authors: Moustafa A. Gadalla, Robert J. Norman, Chau T Tay, Danielle S. Hiam, Angela Melder, Jyotsna Pundir, Shakila Thangaratinam, Helena J Teede, Ben W.J. Mol, Lisa J. Moran

Polycystic ovary syndrome (PCOS) is a common, complex condition that affects up to 18% of reproductive- aged women, causing reproductive, metabolic and psychological dysfunctions. We performed an overview and appraisal of methodological quality of systematic reviews that assessed medical and surgical treatments for reproductive outcomes in women with PCOS. Databases (MEDLINE, EMBASE, CINAHL PLUS and PROSPERO) were searched on the 15th of September 2017. We included any systematic review that assessed the effect of medical or surgical management of PCOS on reproductive, pregnancy and neonatal outcomes. Eligibility assessment, data extraction and quality assessment by the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) tool were performed in duplicate. We identified 53 reviews comprising 44 reviews included in this overview; the majority were moderate to high quality. In unselected women with PCOS, letrozole was associated with a higher live birth rate than clomiphene citrate (CC), while CC was better than metformin or placebo. In women with CC-resistant PCOS, gonadotrophins were associated with a higher live birth rate than CC plus metformin, which was better than laparoscopic ovarian drilling (LOD). LOD was associated with lower multiple pregnancy rates than other medical treatments. In women with PCOS undergo- ing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI), the addition of metformin to gonadotro- phins resulted in less ovarian hyperstimulation syndrome (OHSS), and higher pregnancy and live birth rates than gonadotrophins alone. Gonadotrophin releasing hormone (GnRH) antagonist was associated with less OHSS, gonadotrophin units and shorter stimulation length than GnRH agonist. Letrozole appears to be a good first line treatment and gonadotrophins, as a second line treatment, for anovulatory women with PCOS. LOD results in lower multiple pregnancy rates. However, due to the heterogeneous nature of the included popula- tions of women with PCOS, further larger scale trials are needed with more precise assessment of treatments according to heterogeneous variants of PCOS.

277-281

Authors: Elham Amirchaghmaghi, Farideh Malekzadeh, Mohammad Chehrazi, Zahra Ezabadi, Shokufeh Sabeti

Background It is thought that mothers who conceive via assisted reproductive technology (ART) may be at greater risk of postpartum depression (PPD) because of the problems and psychological stresses associated with ART treat- ment. The aim of the present study is to determine the occurrence of PPD among mothers who conceive by ART in comparison with mothers who naturally conceive. The Edinburgh Postnatal Depression Scale (EPDS) was used to assess PPD. Materials and Methods This historical cohort study investigated 406 mothers with infants aged 3-9 months. Three hundred and eight women with natural pregnancies were selected as the control group from mothers who referred to Tehran healthcare centres for infant vaccinations. The ART group consisted of 98 women who conceived via ART at Royan Institute. Participants completed a general questionnaire that asked about education, occupation, number of children, delivery method, history of infant hospitalization, breastfeeding, mothers’ and infants’ ages, cause of infertil- ity (ART group), and history of depression. A validated Persian version of the EPDS was used to measure depressive symptoms. Results The mean EPDS score in mothers who naturally conceived was 8.38 ± 0.35 in comparison with mothers who conceived via ART (7.59 ± 0.63). The proportions of women who reported PPD were 26.0% for the control group and 20.4% for the ART group. There was no statistically significant difference in PPD between the control and ART groups (P=0.26). Conclusion The occurrence of PPD in mothers who conceived via ART was similar to those who conceived naturally.

289-295

Authors: Ashraf Moini, Fatemeh Zafarani, Nadia Jahangiri, Shahideh Jahanian Sadatmahalleh, Maria Sadeghi, Mohammad Chehrazi, Firoozeh Ahmadi

Background The aim of this study was to investigate the effects of vaginal sildenafil on the outcome of patients with at least two unsuccessful in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) attempts. Materials and Methods In this randomized placebo-controlled trial study, a total of 66 infertile women aged ≤38 years, with a history of normal ovarian reserve, two prior consecutive failed IVF/ICSI attempts, human chorionic gonadotropin (hCG) day endometrial thickness <7 mm in all prior IVF/ICSI cycles, normal endometrial appear- ance by either hysteroscopy, hysterosonography, or hysterosalpingography enrolled in this study. The conventional gonadotropin-releasing hormone (GnRH) protocol was used for ovarian stimulation. The patients were randomly divided into three groups: vaginal sildenafil (suppository-100 mg/daily), vaginal placebo/sildenafil (suppository-100 mg/daily), and vaginal placebo (suppository). Each patient underwent colour Doppler ultrasound on day 14 of their previous cycle to investigate any abnormalities in the uterus and adnexa. Endometrial thickness, echo pattern, uterine artery resistance, and pulsatility indices were recorded pre- and post-treatment. The primary outcome measures were implantation, chemical and clinical pregnancy rates. For data analysis, SPSS version 20 software was used. In all tests, the significance level was considered less than 0.05. Results There was no significant difference between three groups in endometrial thickness on the hCG injection day. The chemical pregnancy in women who received sildenafil (alone or in combination with placebo) showed a two-fold increase in comparison to the placebo group. This increase was clinically meaningful, but according to sample size, it was statistically non-significant. The results of our study showed that the implantation was higher in women who received placebo/sildenafil compared to the other groups. The abortion rate was not statistically significant among the groups. Conclusion Vaginal sildenafil may conceivably improve chemical pregnancy rates in repeated IVF failure patients. Further randomized clinical trials using oral or vaginal sildenafil with higher sample size are recommended (Registra- tion number: NCT03192709).

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Authors: Samira Rezaei-Mojaz, Zohreh Nazmara, Mohammad Najafi, Mansoureh Movahedin, Zahra Zandieh, Peymaneh Shirinbayan, Mohsen Roshanpajouh, Hamid Reza Asgari, Mehdi Abbasi, Morteza Koruji

Background The aim of this study was to investigate two enkephalin-degrading enzymes, aminopeptidase N (APN/ CD13) and endopeptidase (NEP/CD10), gene and protein expression levels in sperm samples of fertile and heroin- addicted men, and the correlation between their expressions and semen quality. Materials and Methods In this case-controlled study, semen was collected from 24 normozoospermic healthy (as a control group) and 24 heroin-addicted men donors (as case or addiction group). Sperm cells isolated by Cook Medical gradient (40-80%) and followed up by swim-up techniques were used for real-time quantitative polymer- ase chain reaction (qPCR) and flow cytometry techniques to assess APN/CD13 and NEP/CD10 genes and proteins subsequently. Semen parameters were analyzed by computer-assisted sperm analysis. Results The findings revealed that there were significant differences in sperm total motility (41.07 ± 3.63 vs. 63.03 ± 3.31 %, P=0.0001), progressive motility (35.21 ± 2.64 vs. 20.93 ± 3.22%, P=0.001) and viability (69.9 ± 4.69 vs. 86.81 ± 1.26 %, P=0.002) in the addicted group vs. control ones. APN and NEP gene expression levels in the addicted group decreased compared with the control ones (1.00 ± 0.67 vs. 0.36 ± 0.13, P= 0.008 and 1.07 ± 0.11 vs. 0.52 ± 0.12 0.002, respectively). Flow cytometry analysis showed that the average percent of APN/CD13 in heroin consumers significantly decreased compared with the healthy ones, while NEP/CD10 rate between two groups was similar. We also observed that duration of drug dependence is correlated with sperm viability (r=-0.627, P=0.016) and motility (r=-0.410, P=0.05), NEP (r=-0.434, P= 0.049), and APN (r=-0.641, P=0.002) gene expression levels. Conclusion We conclude that semen quality and enkephalin-degrading enzymes were altered in heroin-addicted men. other confirming the internal validity of our estimates.

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Authors: Abdul Razzaq S Alsalman, Lamia A. Almashhedy, Abdulsamie H. Alta'ee, Mahmoud H. Hadwan

Background Uric acid (UA) is crucial for sperm metabolism as it protects seminal plasma against oxidative dam- age. Zinc also plays a central role in sperm metabolism. The current study was designed to investigate the role of zinc supplementation on qualitative and quantitative properties of seminal fluid, in parallel with the UA level and urate pathway enzymes in the semen of patients with asthenozoospermia. Materials and Methods The study was designed as a randomized controlled trial of 60 asthenozoospermic subfertile men. The current study, which was conducted during one year, involved 60 fertile and 60 asthenozoospermic subfertile men belonging to Hilla City, Iraq. Semen samples were obtained from the participants before and after treatment with zinc supplements. The levels of UA, xanthine oxidase (XO), adenosine deaminase (ADA) and 5'-nucleotidase (5'-NU) activities were determined in spermatozoa and seminal plasma of both groups. Results UA levels (P=0.034) and 5'-NU activity (P=0.046) were significantly lower but ADA (P=0.05) and XO (P=0.015) activities were significantly higher in infertile men than in healthy men. Treatment with zinc sulfate induced an increase in UA (P=0.001) level and 5'-NU activity (P=0.001), but a decrease in ADA (P=0.016) and XO (P=0.05) activities. Conclusion Zinc supplementation restores UA levels and the activities of enzymes involved in the urate pathway (XO and ADA) in the seminal plasma and spermatozoa of patients with asthenozoospermia, to reference values. Sup- plementation of Zn compounds enhances the qualitative and quantitative properties of semen (Registration number: NCT03361618).

330-338

Authors: Parisa Jamalzaei, Mojtaba Rezazadeh Valojerdi, Leila Montazeri, Hossein Baharvand

Background In the present study, the effects of alginate (ALG) concentration and ovarian cells (OCs) on the devel- opment and function of follicles were simultaneously evaluated. Materials and Methods In the first step of this experimental study, preantral follicles were isolated from the ovaries of 2-week-old mice, encapsulated in the absence or presence of OCs in 0.5, 0.75 and 1% ALG hydrogels, and cultured for 14 days. The morphology, diameter, survival and antrum formation rates of the follicles and the maturation of the oocytes were evaluated during culture. In the second step, preantral follicles were cultured in the best chosen ALG concentration, in both the absence and presence of OCs. Following these steps, the amount of DNA fragmentation, the expression levels of connexin 37 and connexin 43 proteins, the secretion levels of estradiol, progesterone and andros- tenedione by the follicles and the quality of mature (MII) oocytes were assessed. Results Our data revealed that in the absence of OCs, follicles of 0.5% group showed a higher survival rate than the 0.75 and 1% groups (71.87 vs. 52.52 and 40%, respectively, P<0.05). Nonetheless, the antrum formation rate of the 1% group was higher and its oocyte degeneration rate was lower than that in the other groups. Furthermore, it was observed that co-culture of follicles with OCs relatively increased the follicle diameter, survival, antrum formation, and germinal vesicle (GV) to GV break down (GVBD)/MII transition rates. At last, the comparison of 0.5%-OCs and 0.5%+OCs groups indicated that the co-culture condition resulted in more progesterone production (1.8 ± 0.2 vs. 3.2 ± 0.4 ng/ml, respectively, P<0.05) and also decreased oocytes’ cortical granule abnormalities (100 vs. 40% for 0.5%- OCs and 0.5%+OCs groups, respectively). Conclusion The present study revealed that 0.5% ALG hydrogel is relatively suitable for preantral follicle culture, and in the presence of OCs, it mimics the natural ovarian condition better than the higher concentrations of ALG hydrogel.

346-347

Authors: Abdelmonem Awad Hegazy

The ovarian reserve (OR) gradually decreases throughout the female fertile life. This continuous depletion in OR is irreversible. This occurs through a programmed cell death, known as apoptosis. Some factors hasten such depletion, such as chemo- and radio-therapy. Others have been investigated in trials to preserve the OR including gonadotropins, cytokines, growth hormones, nitric oxide and reorganization of the actin cytoskeleton. Loss of OR occurs normally at the menopausal age, a stage called menopausal ovarian senescence. At some periods, there are other sources for ovarian hormones that are away from the ovary, like during use of contraceptive pills and at pregnancy after formation of placenta. Future trials to preserve ovarian follicles at these periods might postpone the onset of menopause and hence lengthen the fertile female age.