International Journal of Fertility and Sterility

160-173

Authors: Ghobad Abangah; Tayebeh Rashidian; Marziyeh Parizad Nasirkandy; Milad Azami

Infertility is a serious health issue in the world affecting approximately 8-10% of couples worldwide. The meta-analysis study was performed to assess the prevalence and etiologic factors associated with infertility in Iran. We made sure that the implementation of study and reporting the results were consistent with the MOOSE and PRISMA guidelines, respectively. All stages of the research were conducted by two authors, and the disagreement at each stage of the research was resolved by consensus. On January 1, 2020, we started a detailed literature search on international online databases, and Iranian Online databases, as well as specialized journals, several authentic international publishers and Google Scholar. We reviewed the reference list of identified articles for missed articles and then searched online for them. Data analysis was performed to estimate the prevalence using a random effects model. The lifetime infertility prevalence was found to be 11.3% [95% confidence interval (CI): 8.6-14.7] and the current infertility was evaluated to be 3.7% (95% CI: 3.2-4.3). The prevalence of primary infertility (based on 45 articles consisting of 51,021 samples) as well as secondary infertility (based on 13 articles consisting of 35,683 samples) in Iran were estimated to be 18.3% (95% CI: 15.4-21.6) and 2.5% (95% CI: 1.6-4.0), respectively. The prevalence of female, male, both and unexplained causes was estimated to be 32.0% (95% CI: 27.6-36.8), 43.3% (95% CI: 38.2-48.6), 12.5% (95% CI: 9.6-16.2) and 13.6% (95% CI: 10.2-17.8), respectively. The prevalence of causes related to ovulation, uterine tubes, and endometriosis in infertile women was estimated to be 54.0% (95% CI: 45.6-62.2), 15.5% (95% CI: 11.3-21.0), 6.2% (95% CI: 3.5-10.6), and 5.4% (95% CI: 2.5-11.3), respectively. In summary, the estimate of infertility burden in Iran did not change between 1990 and 2017 and its prevalence remains high. This research presents a unified and up-to-date overview regarding the burden of infertility in Iran.

181-186

Authors: Seyedehhoura Hashemi; Arezoo Arabipoor; Solmaz Kohestani; Zahra Zolfaghary; Samira Vesali; Firouzeh Ghaffari

Background: To detect the predictive value of beta human chorionic gonadotropin (β-hCG) levels 16 days post embryo transfer (ET) regarding detection of an ectopic pregnancy (EP) in assisted reproductive technology (ART) cycles. Materials and Methods: In this cross-sectional study, we reviewed the database of Royan Institute from January 2011 to December 2014 and from January 2017 to December 2019 retrospectively. All cases with positive β-hCG levels sixteen days after ET were screened (n=4149). The pregnancies with oocyte or embryo donation and the multiple pregnancies based on the first ultrasound were excluded. All eligible singleton pregnancies with documented serum β-hCG levels at Royan institute laboratory (n=765) were included and then classified according to the type of pregnancy: EP (n=189) or non-EP (n=576). The data of the treatment cycle was extracted from the patients’ files. A receiver operating characteristic (ROC) curve was used to detect the predictive power of the first measurement of β-hCG level in distinguishing EP from ongoing pregnancy in the ART and intrauterine insemination (IUI) cycles separately. Sensitivity, specificity, area under the ROC curve and 95% confidence intervals (CI) were calculated for each of the estimates. Results: The mean levels of β-hCG 16 days after ET were remarkably higher in the ongoing pregnancy group than the EP group (1592.35 ± 87 IU/L vs. 369.69 ± 50.61 IU/L, P<0.001). The β-hCG thresholds predictive of ongoing pregnancy were 278 IU/L as the most suitable cut-off to predict viable pregnancy with a sensitivity of 72.8%, a specificity of 67.5%, a positive predictive value of 77.8%, standard error of 0.02, and a confidence interval of 73.8- 81.7%. However, this relationship was not found in IUI cycles. Conclusion: Based on these findings, if β-hCG levels 16 days after ET are below 278 IU/l, close follow-up is recommended, until either the diagnosis of EP or miscarriage is established.

195-200

Authors: Jenna Gale; Doron Shmorgun; Vanessa Bacal; Marie-Claude Leveille

Background: Timing of frozen embryo transfer (FET) within a purported window of implantation is of increasing interest, and there is a paucity of evidence surrounding the transfer of frozen embryos early within these frozen embryo transfer protocols. This study aimed to evaluate whether live birth rates were equivalent after FET of blastocysts 4 days after luteinizing hormone (LH) surge in a true natural cycle protocol, compared to a hormone replacement (HR) protocol. Materials and Methods: Single-centre, retrospective cohort study involving patients undergoing autologous frozen blastocyst transfer from January 1st, 2013, to December 31st, 2016. Cycles were grouped according to their protocol: true natural cycle (hormonal detection of LH surge with FET scheduled four days later) versus HR cycle (luteal phase gonadotropin-releasing hormone agonist suppression, oral or vaginal estradiol and intramuscular progesterone starting five days before FET). A total of 850 cycles were included, 501 true natural cycles and 349 HR cycles. The primary outcome was the live birth rate, secondary outcomes included clinical pregnancy rate and miscarriage. Logbinomial regression models were performed adjusting for a priori selected variables. Results: Adjusted resulted in live birth rates of 38.7 and 40.4%, [adjusted risk ratio (aRR): 0.96, 95% confidence interval (CI): 0.76-1.22, P=0.729] in the natural cycle and HR groups, respectively. The secondary outcome analyses did not demonstrate any statistically significant difference in the rate of positive human chorionic gonadotropin (hCG), clinical intrauterine pregnancy rate, or miscarriage rate. Conclusion: The timing of the FET four days after LH surge in a true natural cycle protocol results in equivalent live birth rates compared to a HR protocol. Results of this study suggest that the window of implantation within the natural cycle may be less finite than currently believed and further prospective studies evaluating the timing of frozen embryo transfer are warranted.

208-214

Authors: Nafiseh Khakzad; Fatemeh Ghaderi Barmi; Fateme Hammami; Tahereh Khaneh Zarrin; Hadiseh Beheshti Dafchahi; Sareh Rostami; Alireza Shahriary; Saman Seyfizadeh Saraabestan

Background: Semen hyperviscosity is a threatening cause of abnormal spermatozoa and infertility in men. We aimed to evaluate oxidative stress, antioxidants depletion and sperm apoptosis as main reasons for poor quality of spermatozoa in men with hyperviscous semen. Materials and Methods: In this cross-sectional study, ejaculate specimens were collected from fertile (n=102) and infertile men with hyperviscous semen (n=123) and without semen hyperviscosity (n=143). Total antioxidant capacity (TAC), glutathione (GSH), malondialdehyde (MDA), protein carbonyl (PC), 8-hydroxydeoxyguanosine (8-OHdG), and were measured in semen samples to estimate oxidative stress status. Gene expression pattern of BAX, CASPASE-9, CASPASE-3, and BCL2 was assessed to estimate sperm apoptosis. Results: The average of sperm count, normal morphology, normal motility, and sperm vitality in men with hyperviscous semen was significantly lower than infertile subjects without hyperviscous semen (P<0.01). Men with hyperviscous semen exhibited higher levels of PC (8.34 ± 1.03 nmol/mg vs. 6.01 ± 0.93 nmol/mg, P=0.008), MDA (1.14 ± 0.27 nmol/ ml vs. 0.89 ± 0.22 nmol/ml, P=0.031), 8-OHdG (259.71 ± 24.59 ng/ml vs. 197.13 ± 18.47 ng/ml, P=0.009), but lower TAC contents (1250.44 ± 66.23 μM/L vs. 1784.31 ± 89.87 μM/L, P=0.018) and GSH (3.82 ± 1.05 μM vs. 5.89 ± 0.87 μM, P=0.021) than men with non-viscous semen. The expression of BAX, CASPASE-3 and CASPASE-9 genes in men with hyperviscous semen was significantly increased by 1.39-fold (P=0.041), 1.47-fold (P=0.046), 1.29-fold (P=0.048), respectively, as compared with the infertile subjects without hyperviscous semen. However, BCL2 expression in infertile men without hyperviscous semen was higher compared to those with hyperviscous semen (1.36-fold, P=0.044). Conclusion: Hyperviscous semen is markedly associated with depletion of seminal plasma antioxidants, sperm membrane lipid peroxidation, DNA and protein oxidation, and sperm apoptosis. Antioxidant therapy might be considered as a valuable strategy to protect sperm cells against oxidative damage in cases with seminal fluid hyperviscosity.