Sustainable IVF: The Next Revolution in ART 2 1 140302 2 The birth of the first IVF baby in 1978 was a landmark in medical history and the catalyst for a revolution in reproductive medicine. In its early years, the field remained in its infancy, costly, and highly inefficient; poor and inconsistent clinical results frustrated both physicians and society, reflecting considerable skepticism. Over time, driven by scientific advances, more than 12 million babies have been born worldwide through assisted reproductive technology (ART). Today, IVF encompasses well-established diagnostic and therapeutic protocols, standing as one of the most commercially and scientifically robust areas of women’s health. This trajectory demonstrates how the simultaneous convergence of research and development (R&D), societal demand, and strategic execution can drive industrial scale-up. As this growth continues, the next wave of market expansion will stem from innovative technologies and subsequent globalization of IVF services. These forces will generate new demand, improve success rates, and enhance patient satisfaction, thereby securing the field’s long-term expansion (1). However, as ART spreads globally across diverse economic contexts, concerns are mounting regarding the environmental consequences of these services. IVF procedures rely heavily on disposable medical supplies; in fact, clinical outcomes remain highly dependent on the quality and sterility of these single-use plastics. While the overall environmental footprint of IVF may seem relatively small compared to broader healthcare sectors, its intensive per-patient reliance on high-grade consumables makes it a critical area for targeted sustainability efforts. Consequently, there is a growing imperative to make reproductive care more environmentally sus-tainable without compromising patient safety or clinical outcomes (2). The broader global implications of plastic reliance underscore the urgency of this transition. If current trends in plastic production and usage persist, the annual global health impact is projected to more than double, escalating from 2.1 million disability-adjusted life years (DALYs) lost in 2016 to 4.5 million DALYs by 2040 (3). This health burden is primarily driven by greenhouse gas emissions (accounting for approximately 40% of the burden), air pollution from manufacturing (~32%), and the release of toxic chemicals during the plastic life cycle (~27%) (3). Notably, isolated measures to increase the collection and recycling of plastic waste have shown limited efficacy in reducing this global health burden. Instead, comprehensive, systems-level interventions are required which could potentially reduce the global health impact of plastics by 43% by 2040 (3). Within this context, medical sub-specialties, particularly those highly dependent on plastics, must urgently re-evaluate their supply chains and operational practices. Because gametes, embryos, and reproductive tissues are exquisitely sensitive to environmental contaminants, chemical substances, and genotoxic agents, strict quality standards are mandated for materials used in ART. Furthermore, emerging evidence suggests that environmental and laboratory exposures during IVF may influence embryo development and potentially the long-term health of offspring, though definitive conclusions remain under investigation. Consequently, IVF consumables are manufactured under stringent quality assurance and biocompatibility requirements that often exceed those of standard medical applications. These rigorous processes demand greater energy consumption, high-purity raw materials, and extensive quality control, all of which generate significant waste and amplify the sector’s carbon footprint (2). Practical recommendations for reducing carbon footprint in IVF laboratories focus on improving sus-tainability without compromising laboratory performance. Key measures include reducing energy con-sumption by transitioning to renewable electricity, optimizing heating, ventilation, and air conditioning (HVAC) systems, and powering down non-essential equipment when not in use. Laboratories are also encouraged to improve building energy efficiency, optimize liquid nitrogen cryostorage management, and minimize waste by reducing single-use consumables whenever these can be performed without compromising safety. Sustainable procurement from environmentally responsible suppliers is recommended, utilizing life-cycle assessments to guide purchasing decisions. Recent evidence demonstrates that targeted sustainability interventions during oocyte retrieval and embryo transfer can substantially reduce material waste, by approximately 60% and 8%, respectively, without increasing clinical or laboratory infection rates. This highlights the feasibility of integrating sustainable practices into routine ART procedures. Finally, fostering a culture of sustainability through staff education, environmental monitoring, and the promotion of virtual meetings can further decrease a clinic’s carbon footprint (2, 4). Despite these practical solutions, the implementation of sustainable practices in IVF laboratories faces several technical, economic, and organizational barriers. Major obstacles include the high initial cost of sustainable technologies, the absolute reliance on single-use plastics to meet strict sterility requirements, and the substantial energy demands of cryostorage systems. Organizational barriers such as limited staff awareness, a lack of cohesive environmental regulations, insufficient leadership commitment, fragmented supply chains for sustainable products, and a lack of data on the long-term cost-effectiveness of these initiatives, further hinder widespread adoption (5). The transition toward "Green IVF" represents a critical evolution in reproductive medicine. Green IVF should not be viewed as a compromise between environmental responsibility and clinical excellence. As the field strives to innovate and improve clinical outcomes, equivalent focus must be directed toward mitigating the environmental impact of these interventions. Adopting sustainable practices is no longer merely an operational choice, but a clinical and ethical imperative for the next decade of reproductive care. Such a paradigm shift will not only optimize operational costs, potentially facilitating broader global access to infertility treatments, but will also ensure the long-term ecological and economic viability of ART services worldwide. 01 3 Mohammad Reza MR Sadeghi محمدرضا صادقی Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran sadeghi@avicenna.ac.ir No Keyword 140302.pdf Campbell A, Gardner DK, Meseguer M, Miller KA, Montag M, Palermo GD, et al. In vitro fertilization and andrology laboratory in 2030: expert visions. Fertil Steril. 2021;116(1):4-12.##Farlie F, Palmer GA, Cohen J, Calcagni C, Gorbunova A, Lawford Davies J, et al. Sustainability in the IVF laboratory: recommendations of an expert panel. Reprod Biomed Online. 2024;48(1):103600.##Deeney M, Hamelin L, Vialle C, Yan X, Green R, Yates J, et al. Global health burdens of plastics: a lifecycle assessment model from 2016 to 2040. Lancet Planet Health. 2026;10(1):101406.##Sluimer RA, van Tilborg TC, Oude Ophuis RJA, Verpoest WMJ, Dahhan T. Minimizing waste in medically assisted reproduction: a study on sustainability initiatives for oocyte retrieval and embryo transfer. Reprod Biomed Online. 2025;51(5):105081.##Aboueid S, Beyene M, Nur T. Barriers and enablers to implementing environmentally sustainable practices in healthcare: A scoping review and proposed roadmap. Healthc Manage Forum. 2023;36(6):405-13.##

Combined Progesterone Administration Versus Single-Route Administration for Luteal Phase Support in IVF: A Narrative Review of Current Evidence 2 1 140292 2 Background: Luteal phase support (LPS) with progesterone is essential for successful implantation and early pregnancy maintenance in IVF cycles. Although various administration routes exist (oral, vaginal, intramuscular, subcutaneous), the comparative effectiveness of combined (dual or triple) versus single-route progesterone regimens remains uncertain due to limited high-quality randomized controlled trials. Methods: A narrative review was conducted to evaluate studies comparing pregnancy outcomes in IVF cycles using combined versus single-route progesterone administration for LPS. A comprehensive literature search was performed to identify retrospective, prospective, and randomized controlled studies published in peer-reviewed journals. Data regarding clinical pregnancy, live birth, miscarriage, and implantation rates were collected and synthesized narratively due to heterogeneity among included studies. Results: Most studies did not demonstrate statistically significant differences in outcomes between single-route and combined progesterone regimens, particularly when dydrogesterone was included. However, certain combinations, especially those involving oral dydrogesterone alongside vaginal or intramuscular progesterone, were associated with improved live birth and clinical pregnancy rates. Despite these encouraging findings, the lack of adequately powered RCTs and the methodological variability among studies limit the generalizability of the results. Conclusion: While single-route progesterone administration remains effective for luteal phase support in IVF cycles, emerging evidence suggests that individualized combined regimens may enhance pregnancy outcomes. The physiological rationale for combined administration, offering both systemic and local endometrial support, is compelling. Further well-designed randomized controlled trials with standardized protocols are necessary to establish evidence-based guidelines for optimal LPS. 03 10 Vasiliki V Dourou Institute of Life, IASO General Hospital Institute of Life, IASO General Hospital Greece vdourou@gmail.com Georgios G Valsamakis Department of Obstetrics and Gynecology, Aretaieion Ηospital, National and Kapodistrian University of Athens (NKUA) Department of Obstetrics and Gynecology, Aretaieion Ηospital, National and Kapodistrian University of Athens (NKUA) Greece Olga O Triantafyllidou Department of Obstetrics and Gynecology, Aretaieion Ηospital, National and Kapodistrian University of Athens (NKUA) Department of Obstetrics and Gynecology, Aretaieion Ηospital, National and Kapodistrian University of Athens (NKUA) Greece Dimitrios D Tourlakis Department of Gynecologic Oncology, Hygeia Hospital Department of Gynecologic Oncology, Hygeia Hospital Greece Panagiotis P Vakas Department of Obstetrics and Gynecology, Aretaieion Ηospital, National and Kapodistrian University of Athens (NKUA) Department of Obstetrics and Gynecology, Aretaieion Ηospital, National and Kapodistrian University of Athens (NKUA) Greece Nikolaos N Vlahos Department of Obstetrics and Gynecology, Aretaieion Ηospital, National and Kapodistrian University of Athens (NKUA) Department of Obstetrics and Gynecology, Aretaieion Ηospital, National and Kapodistrian University of Athens (NKUA) Greece Combined administrationIVFLive birth rateLuteal phase supportPregnancy ratesProgesterone administration 140292.pdf Sun H, Gong TT, Jiang YT, Zhang S, Zhao YH, Wu QJ. Global, regional, and national prevalence and disability-adjusted life-years for infertility in 195 countries and territories, 1990-2017: results from the global burden of disease study 2017. Aging (Albany NY). 2019;11(23):10952-91. ##Ombelet W. WHO fact sheet on infertility gives hope to millions of infertile couples worldwide. Facts Views Vis Obgyn. 2020;12(4):249-51.##Wang J, Liu C, Fujino M, Tong G, Zhang Q, Li XK, et al. Stem cells as a resource for treatment of infertility-related diseases. Curr Mol Med. 2019;19(8):539-46.##Graham ME, Jelin AC, Hoon AH Jr, Wilms Floet AM, Levey E, Graham EM. Assisted reproductive technology: short- and long-term outcomes. Dev Med Child Neurol. 2023;65(1):38-49.##Gnoth C, Maxrath B, Skonieczny T, Friol K, Godehardt E, Tigges J. Final ART success rates: a 10-year survey. Hum Reprod. 2011;26(8):2239-46.##Haas DM, Hathaway TJ, Ramsey PS. Progestogen for preventing miscarriage in women with recurrent miscarriage of unclear etiology. Cochrane Database Syst Rev. 2019;10(10):CD003511.##Kumar P, Magon N. Hormones in pregnancy. Niger Med J. 2012;53(4):179-83.##Bulletti C, Bulletti FM, Sciorio R, Guido M. Progesterone: the key factor of the beginning of life. Int J Mol Sci. 2022;23(22):14138.##Hughes GC, Clark EA, Wong AH. The intracellular progesterone receptor regulates CD4 T cells and T cell-dependent antibody responses. J Leukoc Biol. 2013;93(3):369-75.##Deligdisch L. Hormonal pathology of the endometrium. Mod Pathol. 2000;13(3):285-94.##Pabuccu E, Pabuccu R, Gurgan T, Tavmergen E. Luteal phase support in fresh and frozen embryo transfer cycles. J Gynecol Obstet Hum Reprod. 2020:101838.##Polat M, Mumusoglu S, Bozdag G, Ozbek IY, Humaidan P, Yarali H. Addition of intramuscular progesterone to vaginal progesterone in hormone replacement therapy in vitrified-warmed blastocyst transfer cycles. Reprod Biomed Online. 2020;40(6):812-8. ##Di Guardo F, Midassi H, Racca A, Tournaye H, De Vos M, Blockeel C. Luteal phase support in IVF: comparison between evidence-based medicine and real-life practices. Front Endocrinol (Lausanne). 2020;11:500. ##Casarramona G, Lalmahomed T, Lemmen C, Eijkemans M, Broekmans F, Cantineau A, et al. The efficacy and safety of luteal phase support with progesterone following ovarian stimulation and intrauterine insemination: a systematic review and meta-analysis. Front Endocrinol (Lausanne). 2022;13:960393.##Almohammadi A, Raveendran A, Black M, Maheshwari A. The optimal route of progesterone administration for luteal phase support in frozen embryo transfer: a systematic review. Arch Gynecol Obstet. 2023;308(2):341-50.##Toriumi R, Horikawa M, Sato C, Shimamura N, Ishii R, Terashima M, et al. The addition of dydrogesterone improves outcomes in women with low progesterone levels receiving vaginal progesterone alone in HRT-FET cycles. Reprod Med Biol. 2023;22(1):e12511.##Jalaliani S, Davar R, Akbarzadeh F, Emami F, Eftekhar M. Addition of intramuscular to vaginal progesterone for luteal phase support in fresh embryo transfer cycles: a cross-sectional study. Int J Reprod Biomed. 2022;20(9):745-52.##Pabuccu EG, Pabuccu R, Evliyaoglu Ozdegirmenci O, Bostancı Durmus A, Keskin M. Combined intramuscular and vaginal progesterone versus vaginal progesterone for luteal support in cleavage-stage embryo transfer cycles. Gynecol Endocrinol. 2016;32(5):366-9.##Vuong LN, Pham TD, Le KTQ, Ly TT, Le HL, Nguyen DTN, et al. Micronized progesterone plus dydrogesterone versus micronized progesterone alone for luteal phase support in frozen-thawed cycles (MIDRONE): a prospective cohort study. Hum Reprod. 2021;36(7):1821-31. ##Vidal A, Dhakal C, Werth N, Weiss JM, Lehnick D, Kohl Schwartz AS. Supplementary dydrogesterone is beneficial as luteal phase support in artificial frozen-thawed embryo transfer cycles compared to micronized progesterone alone. Front Endocrinol (Lausanne). 2023;14:1128564.##Gawron IM, Chrostowski B, Derbisz K, Jach R, Pietrus M. Comparison of dydrogesterone plus progesterone gel with subcutaneous aqueous progesterone plus progesterone gel for luteal phase support in IVF cycles after previous failure. Ginekol Pol. 2023. [a head of print].##Devine K, Richter KS, Widra EA, McKeeby JL. Vitrified blastocyst transfer cycles with the use of only vaginal progesterone replacement with Endometrin have inferior ongoing pregnancy rates: results from the planned interim analysis of a three-arm randomized controlled noninferiority trial. Fertil Steril. 2018;109(2):266-75.##Xu H, Zhang XQ, Zhu XL, Weng HN, Xu LQ, Huang L, et al. Comparison of vaginal progesterone gel combined with oral dydrogesterone versus intramuscular progesterone for luteal support in hormone replacement therapy-frozen embryo transfer cycle. J Gynecol Obstet Hum Reprod. 2021;50(7):102110.##Gari S, Al-Jaroudi D. Adding Weekly Intramuscular Progesterone to a Twice Daily Vaginal Progesterone Capsule for Luteal Phase Support in IVF/ ICSI Cycles Results in Similar Live Birth Rates. JBRA Assist Reprod. 2022;26(1):33-7.##Asoglu MR, Celik C, Karakis LS, Findikli N, Gultomruk M, Bahceci M. Comparison of daily vaginal progesterone gel plus weekly intramuscular progesterone with daily intramuscular progesterone for luteal phase support in single, autologous euploid frozen-thawed embryo transfers. J Assist Reprod Genet. 2019;36(7):1481-7.##Wang Y, He Y, Zhao X, Ji X, Hong Y, Wang Y, et al. Crinone gel for luteal phase support in frozen-thawed embryo transfer cycles: a prospective randomized clinical trial in the Chinese population. PLoS One. 2015;10(7):e0133027.##Simon V, Robin G, Keller L, Ternynck C, Jonard S, Robin C, et al. Systematic use of long-acting intramuscular progesterone in addition to oral dydrogesterone as luteal phase support for single fresh blastocyst transfer: A pilot study. Front Endocrinol (Lausanne). 2022;13:1039579. ##

Embryo Culture Systems and Morphokinetics in IVF: The Role of Time-Lapse Monitoring and Artificial Intelligence in Embryo Selection 2 1 140299 2 Background: Embryo selection and culture conditions are critical determinants of success in assisted reproductive technology (ART). Despite advances, implantation and live birth rates following in vitro fertilization (IVF) remain suboptimal. This systematic review evaluated the effects of embryo culture media (sequential versus single-step), time-lapse monitoring (TLM), and artificial intelligence (AI)-based embryo selection on IVF outcomes. Methods: This systematic review followed PRISMA guidelines. PubMed, Scopus, and Web of Science were searched through June 2025. Twenty-nine studies involving over 18,500 IVF/intracytoplasmic sperm injection (ICSI) cycles were included. Methodological quality was assessed using RoB2, the Newcastle–Ottawa Scale, and CLAIM according to study design. Outcomes related to culture media, TLM-derived morphokinetics, and AI-based embryo assessment were synthesized narratively. Results: Sequential and single-step culture media produced comparable clinical outcomes, although single-step media showed a modest increase in blastocyst formation (57.1% vs. 53.2%; p=0.03). No significant differences were observed in clinical pregnancy or live birth rates. TLM was associated with higher ongoing pregnancy rates in descriptive analyses (45.1% vs. 34.8%; p<0.01) and reduced early pregnancy loss. AI-based embryo selection demonstrated strong predictive performance (AUC 0.76–0.91), although clinical validation varied across algorithms, indicating differences in predictive accuracy rather than consistent improvements in clinical outcomes. Conclusion: Culture media selection appears to have limited influence on clinical outcomes, whereas TLM and AI-assisted embryo selection show promise for improving embryo assessment. Integration of validated AI-driven TLM systems into IVF practice may enhance embryo selection efficiency. Further large, prospective studies are needed to establish standardized clinical protocols. 10 20 Sanaz S Ashouri Movassagh Department of Andrology and Embryology, Reproductive Biotechnology Research Center, Avicenna Research Institute, Academic Center for Education, Culture and Research (ACECR) Department of Andrology and Embryology, Reproductive Biotechnology Research Center, Avicenna Research Institute, Academic Center for Education, Culture and Research (ACECR) Iran Mahnaz M Heidari مهناز حیدری Department of Andrology and Embryology, Reproductive Biotechnology Research Center, Avicenna Research Institute, Academic Center for Education, Culture and Research (ACECR) Department of Andrology and Embryology, Reproductive Biotechnology Research Center, Avicenna Research Institute, Academic Center for Education, Culture and Research (ACECR) Iran Sepideh S Ashouri Movassagh Human and Animal Cell Bank, Iranian Biological Resource Center (IBRC), Academic Center for Education, Culture and Research (ACECR) Human and Animal Cell Bank, Iranian Biological Resource Center (IBRC), Academic Center for Education, Culture and Research (ACECR) Iran Mohammad Reza MR Sadeghi محمدرضا صادقی Department of Andrology and Embryology, Reproductive Biotechnology Research Center, Avicenna Research Institute, Academic Center for Education, Culture and Research (ACECR) Department of Andrology and Embryology, Reproductive Biotechnology Research Center, Avicenna Research Institute, Academic Center for Education, Culture and Research (ACECR) Iran sadeghi@avicenna.ac.ir, sadeghi281@gmail.com Artificial intelligenceCulture mediaEmbryo evaluationIn vitro fertilizationPregnancy rateTime-lapse imaging 140299.pdf Sfontouris IA, Martins WP, Nastri CO, Viana IG, Navarro PA, Raine-Fenning N, et al. Blastocyst culture using single versus sequential media in clinical IVF: a systematic review and meta-analysis of randomized controlled trials. J Assist Reprod Genet. 2016;33(10):1261-72.##Simopoulou M, Sfakianoudis K, Rapani A, Giannelou P, Anifandis G, Bolaris S, et al. Considerations regarding embryo culture conditions: from media to epigenetics. In Vivo. 2018;32(3):451-60.##Sachedina Parhar A, Mellor A, Moeed S, Grover SR. Accessory uterine cavities: a review of cases and an appeal for standard terminology. Fertil Steril. 2025;123(6):1101-13.##Xi Q, Yang Q, Wang M, Huang B, Zhang B, Li Z, et al. Individualized embryo selection strategy developed by stacking machine learning model for better in vitro fertilization outcomes: an application study. Reprod Biol Endocrinol. 2021;19(1):53.##Sacks GC, Mozes H, Ronn R, Elder-Geva T, Schonberger O, Ben-Ami I, et al. Time-lapse incubation for embryo culture-morphokinetics and environmental stability may not be enough: Results from a pilot randomized controlled trial. J Clin Med. 2024;13(6):1701. ##Lundin K, Park H. Time-lapse technology for embryo culture and selection. Ups J Med Sci. 2020;125(2):77-84.##Ribeiro IB. Mechanisms and effects of cell density of embryos in culture in in vitro fertilization processes in embryonary development [master's thesis]. Lisbon: Instituto Superior de Engenharia de Lisboa; 2021. 84 p.##Khosravi P, Kazemi E, Zhan Q, Malmsten JE, Toschi M, Zisimopoulos P, et al. Deep learning enables robust assessment and selection of human blastocysts after in vitro fertilization. NPJ Digital Med. 2019;2:21.##Berntsen J, Rimestad J, Lassen JT, Tran D, Kragh MF. Robust and generalizable embryo selection based on artificial intelligence and time-lapse image sequences. PLoS One. 2022;17(2):e0262661.##Shoham Z. Can elective single embryo transfer (eSET) with AI integration become the future of IVF? J IVF Worldw. 2025;3(1):32-41.##Bohlin T, Kurkkio E, Adolfsson E, Berntsen J, Johansen MN, Apter S, et al. Comparison of the deep learning tool iDAScore® and the current annotation model, KIDScore™ D5, for finding the embryo with best chance of pregnancy after elective single blastocyst transfer: a randomized multi-centre prospective pilot study. Reprod Biomed Online. 2024;48(Suppl 1):104025.##Liu H, Zhang Z, Gu Y, Dai C, Shan G, Song H, et al. Development and evaluation of a live birth prediction model for evaluating human blastocysts from a retrospective study. Elife. 2023;12:e83662.##Fitz VW, Kanakasabapathy MK, Thirumalaraju P, Kandula H, Ramirez LB, Boehnlein L, et al. Should there be an “AI” in TEAM? embryologists selection of high implantation potential embryos improves with the aid of an artificial intelligence algorithm. J Assist Reprod Genet. 2021;38(10):2663-70.##Liu H, Li D, Dai C, Shan G, Zhang Z, Zhuang S, et al. Automated morphological grading of human blastocysts from multi-focus images. IEEE Trans Autom Sci Eng. 2024;21(3):2584-92.##Wang G, Wang K, Gao Y, Chen L, Gao T, Ma Y, et al. A generalized AI system for human embryo selection covering the entire IVF cycle via multi-modal contrastive learning. Patterns (N Y). 2024;5(7):100985.##Hardarson T, Bungum M, Conaghan J, Meintjes M, Chantilis SJ, Molnar L, et al. Noninferiority, randomized, controlled trial comparing embryo development using media developed for sequential or undisturbed culture in a time-lapse setup. Fertil Steril. 2015;104(6):1452-9.e1-4.##AlSaad R, Abusarhan L, Odeh N, Abd-Alrazaq A, Choucair F, Zegour R, et al. Deep learning applications for human embryo assessment using time-lapse imaging: scoping review. Front Reprod Health. 2025;7:1549642.##Cimadomo D, Chiappetta V, Innocenti F, Saturno G, Taggi M, Marconetto A, et al. Towards automation in IVF: pre-clinical validation of a deep learning-based embryo grading system during PGT-A cycles. J Clin Med. 2023;12(5):1806.##Guo YH, Liu Y, Qi L, Song WY, Jin HX. Can time-lapse incubation and monitoring be beneficial to assisted reproduction technology outcomes? a randomized controlled trial using day 3 double embryo transfer. Front Physiol. 2022;12:794601.##Fauser BCJM, Nicholas D, Ahuja K. Chief Editor's 2021 annual report. Reprod Biomed Online. 2022;44(5):765-7.##Stimpfel M, Bacer-Kermavner L, Jancar N, Vrtacnik-Bokal E. The influence of the type of embryo culture media on the outcome of IVF/ICSI cycles. Taiwan J Obstet Gynecol. 2020;59(6):848-54.##Dieamant F, Petersen CG, Mauri AL, Comar V, Mattila M, Vagnini LD, et al. Single versus sequential culture medium: which is better at improving ongoing pregnancy rates? a systematic review and meta-analysis. JBRA Assist Reprod. 2017;21(3):240-6.##Braga D, Setti A, Morishima C, Iaconelli A, Borges E. Understanding the implications of follicular output rate (FORT) and follicle to oocyte index (FOI) on human embryo morphokinetics. J IVF Worldwide. 2024;2(1):1-11.##Rienzi L, Cimadomo D, Delgado A, Minasi MG, Fabozzi G, Del Gallego R, et al. Time of morulation and trophectoderm quality are predictors of a live birth after euploid blastocyst transfer: a multicenter study. Fertil Steril. 2019;112(6):1080-93.e1.##Salih M, Austin C, Warty R, Tiktin C, Rolnik D, Momeni M, et al. Embryo selection through artificial intelligence versus embryologists: a systematic review. Hum Reprod Open. 2023;2023(3):hoad031.##Liao Q, Zhang Q, Feng X, Huang H, Xu H, Tian B, et al. Development of deep learning algorithms for predicting blastocyst formation and quality by time-lapse monitoring. Commun Biol. 2021;4(1):415.##Bormann CL, Kanakasabapathy MK, Thirumalaraju P, Gupta R, Pooniwala R, Kandula H, et al. Performance of a deep learning based neural network in the selection of human blastocysts for implantation. Elife. 2020;9:e55301.##Theilgaard Lassen J, Fly Kragh M, Rimestad J, Nygård Johansen M, Berntsen J. Development and validation of deep learning based embryo selection across multiple days of transfer. Sci Rep. 2023;13(1):4235.##Zou H, Wang R, Morbeck DE. Diagnostic or prognostic? decoding the role of embryo selection on in vitro fertilization treatment outcomes. Fertil Steril. 2024;121(5):730-6.##

Prevalence and Factors Associated with Primary and Secondary Infertility Among Currently Married Women in India: A Secondary Analysis of National Family Health Survey-5 Data 2 1 140294 2 Background: Infertility is a important reproductive health issue that affects people worldwide. Despite its psychosocial and public health implications, population-level evidence on primary and secondary infertility remains limited. The purpose of study was to estimate the prevalence and determinants of primary and secondary infertility among married women of reproductive age in India using National Family Health Survey-5 (NFHS-5) data. Methods: A cross-sectional secondary data analysis of NFHS-5 (2019-2021) was conducted among 512,408 currently married women aged 15-49 years. Descriptive analysis was used to estimate prevalence of primary and secondary infertility. Chi-square test and multivariable logistic regression analysis were performed to identify factors associated with infertility. Results: The prevalence of primary infertility was 3.28% (95%CI:3.23-3.33), while secondary infertility was 13.9% (95%CI:13.85-14.05), indicating a higher burden of secondary infertility. Considerable state-wise variation was observed. Higher prevalence of primary infertility was reported in Karnataka, Telangana, Lakshadweep, and Goa, whereas secondary infertility was highest in Mizoram, Meghalaya, and Ladakh. Urban residence, smoking, overweight/obesity, thyroid disorders, and diabetes were significantly associated with both primary and secondary infertility. Delayed age at first marriage was positively associated with primary infertility, whereas increasing age was strongly associated with secondary infertility. Educational attainment and wealth index demonstrated varying associations across infertility types. Conclusion: Infertility affects a considerable proportion of married women in India, with secondary infertility contributing the larger share of the burden. The substantial regional and socio-demographic disparities observed highlight the need to integrate infertility prevention, surveillance, and equitable access to fertility care within reproductive health programs in India. 20 31 Vignesh V Kumar Department of Biostatistics, coGuide Academy Department of Biostatistics, coGuide Academy India Varun V Agiwal Department of Biostatistics, Indian Institute of Public Health Department of Biostatistics, Indian Institute of Public Health India Sirshendu S Chaudhuri Department of Biostatistics, Indian Institute of Public Health Department of Biostatistics, Indian Institute of Public Health India Ananta A Ghimire Department of Biostatistics, coGuide Academy Department of Biostatistics, coGuide Academy India Amarjeeth A Singh Department of Community Medicine and School of Public Health, PGI Department of Community Medicine and School of Public Health, PGI India Asha AS Vijay Department of Reproductive Medicine, Garbhagudi Institute of Reproductive Health and Research Department of Reproductive Medicine, Garbhagudi Institute of Reproductive Health and Research India Murali Mohan MM Reddy Gopireddy Department of Evidence Synthesis, coGuide Academy Department of Evidence Synthesis, coGuide Academy India Jayashree JG Kailash Department of Evidence Synthesis, coGuide Academy Department of Evidence Synthesis, coGuide Academy India jayashree.g@coguide.in InfertilityPrevalencePrimary infertilityReproductionSecondary infertilityWomen 140294.pdf World Health Organization (WHO). Infertility. Geneva: World Health Organization; 2025. Available from: https://www.who.int/news-room/fact-sheets/detail/infertility. 2025##Ombelet W, Lopes F. Fertility care in low- and middle-income countries. Reprod Fertil. 2024;5(3):e240042.##Gadapani Pathak B, Mburu G, Habib N, Kabra R, Kiarie J, Chowdhury R, et al. Prevalence and determinants of fertility care-seeking among women experiencing delayed conception in North India: a cross-sectional study. Front Reprod Health. 2026;8:1772807.##Dyer SJ, Patel M. The economic impact of infertility on women in developing countries a systematic review. Facts Views Vis Obgyn. 2012;4(2):102-9.##Nagajyothi KP, Santhosh A, Dash SS, Bhate J, Rao GK. Economic burden of infertility treatment: a mini-review on recent evidence. Int J Infertil Fetal Med. 2025;16(1):35-9.##Amodini KN, Chaudhuri S. Infertility management in India: issues and potential solutions. J Obstet Gynaecol India. 2023;73(4):368-9.##Cox CM, Thoma ME, Tchangalova N, Mburu G, Bornstein MJ, Johnson CL, et al. Infertility prevalence and the methods of estimation from 1990 to 2021: a systematic review and meta-analysis. Hum Reprod Open. 2022;2022(4):hoac051.##Purkayastha N, Sharma H. Prevalence and potential determinants of primary infertility in India: Evidence from Indian demographic health survey. Clin Epidemiol Global Health. 2021;9:162-70.##Kundu S, Ali B, Dhillon P. Surging trends of infertility and its behavioural determinants in India. PLoS One. 2023;18(7):e0289096.##Mahima M, Tiwari AK. Factors influencing secondary infertility: an analysis of NFHS data in India. Research Square [Preprint]. 2025 May 3.##Sahoo H, Chander Shekhar, Labhita Das. Primary and secondary infertility among women in India: prevalence and correlates. J Biosocial Sci. 2023.##Devi KS, Mehra D, Bahl D, Hamza M, Uppal L, Ghosh S, et al. Primary and secondary infertility in India: a systematic review and meta-analysis. Reprod Health. 2026;23(1):55.##Pallikadavath S, Irudaya Rajan S, Wilson C. Impact of low fertility and early age at sterilisation on women’s formal education and skill development in South India. J Pop Res. 2016;33(3):199-220.##Säävälä M. Understanding the prevalence of female sterilization in rural south India. Stud Fam Plann. 1999;30(4):288-301.##Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, Stevens GA. National, regional, and global trends in infertility prevalence since 1990: a systematic analysis of 277 health surveys. PLOS Med. 2012;9(12):e1001356.##te Velde ER, Pearson PL. The variability of female reproductive ageing. Hum Reprod Update. 2002;8(2):141-54.##Rutstein SO, Shah IH. Infecundity, infertility, and childlessness in developing countries. Calverton (MD): ORC Macro and the World Health Organization; 2004. 74 p. (DHS Comparative Reports No. 9).##Practice committee of the American society for reproductive medicine, Practice committee of the American society for reproductive medicine. Smoking and infertility: a committee opinion. Fertil Steril. 2018;110(4):611-8.##Silvestris E, De Pergola G, Rosania R, Loverro G. Obesity as disruptor of the female fertility. Reprod Biol Endocrinol. 2018;16(1):22.##Krassas GE, Poppe K, Glinoer D. Thyroid function and human reproductive health. Endocr Rev. 2010;31(5):702-55.##Codner E, Merino PM, Tena-Sempere M. Female reproduction and type 1 diabetes: from mechanisms to clinical findings. Hum Reprod Update. 2012;18(5):568-85.##

Altered Expression of GABPB1-IT1 and SLC9A3-AS1 Long Non-Coding RNAs in Recurrent Implantation Failure 2 1 140295 2 Background: Recurrent implantation failure (RIF) impairs assisted reproductive technology (ART) success, though its mechanisms remain unclear. Studies have implicated altered miRNA expression in the plasma and endometrium of patients with RIF. In this study, long non-coding RNA (lncRNA) expression in plasma was investigated, using RIF-specific lncRNA-miRNA-mRNA network as guide. Methods: This study included 30 women with RIF and 30 age-matched controls (Not RIF). RIF miRNA RNA-seq data (GSE108966) was downloaded from the Gene Expression Omnibus (GEO) database and used to identify differentially expressed miRNAs. Next, miRNet 2.0 database was used to integrate the latest miRNA-mRNA interactions; also, the linkages between lncRNA and miRNA were identified and the networks created. Plasma samples were collected from participants during the implantation window. Cell-free RNA was extracted from 500 µl of plasma using the TRIzol method, and statistical analyses were performed using Prism version 8.0. Results: Based on a lncRNA-miRNA-mRNA network analysis, two lncRNAs, including GABPB1-IT1 and SLC9A3-AS1, were selected for expression analysis in plasma. Notably, GABPB1-IT1 and SLC9A3-AS1 were significantly downregulated in RIF samples compared to controls. Conclusion: Our findings show that GABPB1-IT1 and SLC9A3-AS1 are significantly downregulated in the plasma of women with recurrent implantation failure. These findings suggest their potential involvement in RIF and warrant further studies to elucidate their biological functions and evaluate their utility as non-invasive biomarkers. 31 43 Majid M Zaki-Dizaji Human Genetics Research Center, Baqiyatallah University of Medical Sciences Human Genetics Research Center, Baqiyatallah University of Medical Sciences Iran Amir A Ebrahimi Department of Genetics, Tabriz University of Medical Sciences Department of Genetics, Tabriz University of Medical Sciences Iran Behnoosh B Jamshidi Human Genetics Research Center, Baqiyatallah University of Medical Sciences Human Genetics Research Center, Baqiyatallah University of Medical Sciences Iran Seyed Mohammad Hossein SMH Nemati Human Genetics Research Center, Baqiyatallah University of Medical Sciences Human Genetics Research Center, Baqiyatallah University of Medical Sciences Iran Reza R Saeedinia Student Research Committee, School of Medicine, Iran University of Medical Sciences (IUMS) Student Research Committee, School of Medicine, Iran University of Medical Sciences (IUMS) Iran Zohreh Z Heidary Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences Iran z.heidary2016@gmail.com Embryo implantationInfertilityLong non-coding RNAPlasmaRecurrent implantation failure 140295.pdf Coughlan C, Ledger W, Wang Q, Liu F, Demirol A, Gurgan T, et al. Recurrent implantation failure: definition and management. Reprod Biomed Online. 2014;28(1):14-38.##Busnelli A, Reschini M, Cardellicchio L, Vegetti W, Somigliana E, Vercellini P. How common is real repeated implantation failure? an indirect estimate of the prevalence. Reprod Biomed Online. 2020;40(1):91-7.##Cimadomo D, Craciunas L, Vermeulen N, Vomstein K, Toth B. Definition, diagnostic and therapeutic options in recurrent implantation failure: an international survey of clinicians and embryologists. Hum Reprod. 2021;36(2):305-17.##Mojarrad M, Hassanzadeh-Nazarabadi M, Tafazoli N. Polymorphism of genes and implantation failure. Int J Mol Cell Med. 2013;2(1):1-8.##Craciunas L, Gallos I, Chu J, Bourne T, Quenby S, Brosens JJ, et al. Conventional and modern markers of endometrial receptivity: a systematic review and meta-analysis. Hum Reprod Update. 2019;25(2):202-23.##Fazli F, Khanlarzadeh E, Pilehvari Sh. The impact of l-arginine on uterine artery resistance and pregnancy outcomes in frozen embryo transfer for IVF candidates with recurrent implantation failure: a clinical trial. J Reprod Infertil. 2025;26(1):19-27.##Zaki-Dizaji M, Saeedinia M, Derogar P, Jamshidi B, Masoumi M, Heidary Z. hsa_circ_0004121 and hsa_circ_0030162 differentially expressed in plasma of patients with recurrent implantation failure. Rep Biochem Mol Biol. 2024;13(3):428-37.##Nemeth K, Bayraktar R, Ferracin M, Calin GA. Non-coding RNAs in disease: from mechanisms to therapeutics. Nat Rev Genet. 2024;25(3):211-32.##Zahir M, Tavakoli B, Zaki-Dizaji M, Hantoushzadeh S, Majidi Zolbin M. Non-coding RNAs in recurrent implantation failure. Clin Chim Acta. 2024;553:117731.##Azhari F, Pence S, Hosseini MK, Balci BK, Cevik N, Bastu E, et al. The role of the serum exosomal and endometrial microRNAs in recurrent implantation failure. J Matern Fetal Neonatal Med. 2022;35(5):815-25.##Zeng H, Fu Y, Shen L, Quan S. MicroRNA signatures in plasma and plasma exosome during window of implantation for implantation failure following in-vitro fertilization and embryo transfer. Reprod Biol Endocrinol. 2021;19(1):180.##Chen P, Li T, Guo Y, Jia L, Wang Y, Fang C. Construction of circulating microRNAs-based non-invasive prediction models of recurrent implantation failure by network analysis. Front Genet. 2021;12:712150.##Yang Q, Gu WW, Gu Y, Yan NN, Mao YY, Zhen XX, et al. Association of the peripheral blood levels of circulating microRNAs with both recurrent miscarriage and the outcomes of embryo transfer in an in vitro fertilization process. J Transl Med. 2018;16(1):186.##Freis A, Keller A, Ludwig N, Meese E, Jauckus J, Rehnitz J, et al. Altered miRNA-profile dependent on ART outcome in early pregnancy targets Wnt-pathway. Reproduction. 2017;154(6):799-805.##Huang J, Song N, Xia L, Tian L, Tan J, Chen Q, et al. Construction of lncRNA-related competing endogenous RNA network and identification of hub genes in recurrent implantation failure. Reprod Biol Endocrinol. 2021;19(1):108.##Feng C, Shen JM, Lv PP, Jin M, Wang LQ, Rao JP, et al. Construction of implantation failure related lncRNA-mRNA network and identification of lncRNA biomarkers for predicting endometrial receptivity. Int J Biol Sci. 2018;14(10):1361-77.##Zhao H, Hu S, Qi J, Wang Y, Ding Y, Zhu Q, et al. Increased expression of HOXA11-AS attenuates endometrial decidualization in recurrent implantation failure patients. Mol Ther. 2022;30(4):1706-20.##Chen MY, Liao GD, Zhou B, Kang LN, He YM, Li SW. Genome-wide profiling of long noncoding RNA expression patterns in women with repeated implantation failure by RNA sequencing. Reprod Sci. 2019;26(1):18-25.##Ahmadi M, Pashangzadeh S, Moraghebi M, Sabetian S, Shekari M, Eini F, et al. Construction of circRNA-miRNA-mRNA network in the pathogenesis of recurrent implantation failure using integrated bioinformatics study. J Cell Mol Med. 2022;26(6):1853-64.##Zhao H, Chen L, Shan Y, Chen G, Chu Y, Dai H, et al. Hsa_circ_0038383-mediated competitive endogenous RNA network in recurrent implantation failure. Aging (Albany NY). 2021;13(4):6076-90.##Zhou T, Ni T, Li Y, Zhang Q, Yan J, Chen ZJ. circFAM120A participates in repeated implantation failure by regulating decidualization via the miR-29/ABHD5 axis. FASEB J. 2021;35(9):e21872.##Zhao F, Guo Y, Shi Z, Wu M, Lv Y, Song W. hsa_circ_001946 elevates HOXA10 expression and promotes the development of endometrial receptivity via sponging miR-135b. Diagn Pathol. 2021;16(1):44.##Ni T, Zhang Q, Li Y, Huang C, Zhou T, Yan J, et al. CircSTK40 contributes to recurrent implantation failure via modulating the HSP90/AKT/FOXO1 axis. Mol Ther Nucleic Acids. 2021;26:208-21.##Luo J, Zhu L, Zhou N, Zhang Y, Zhang L, Zhang R. Construction of circular RNA-microRNA-messenger RNA regulatory network of recurrent implantation failure to explore its potential pathogenesis. Front Genet. 2020;11:627459.##Liu L, Li L, Ma X, Yue F, Wang Y, Wang L, et al. Altered circular RNA expression in patients with repeated implantation failure. Cell Physiol Biochem. 2017;44(1):303-13.##Mattick JS, Amaral PP, Carninci P, Carpenter S, Chang HY, Chen LL, et al. Long non-coding RNAs: definitions, functions, challenges and recommendations. Nat Rev Mol Cell Biol. 2023;24(6):430-47.##Beylerli O, Gareev I, Sufianov A, Ilyasova T, Guang Y. Long noncoding RNAs as promising biomarkers in cancer. Noncoding RNA Res. 2022;7(2):66-70.##Razzaghi H, Heiat M, Khoncheh A, Abyazi MA, Zaki-Dizaji M. Platelet-derived circRNAs hsa_circ_0004771 and hsa_circ_0019120 differentially expressed in colorectal cancer and polyps. Rep Biochem Mol Biol. 2024;13(3):368-76.##Rekker K, Altmäe S, Suhorutshenko M, Peters M, Martinez-Blanch JF, Codoñer FM, et al. A two-cohort RNA-seq study reveals changes in endometrial and blood miRNome in fertile and infertile women. Genes (Basel). 2018;9(12):574.##Andrews S. FastQC: a quality control tool for high throughput sequence data. Cambridge (UK): Babraham Bioinformatics; 2010.##Bolger AM, Lohse M, Usadel B. Trimmomatic: a flexible trimmer for illumina sequence data. Bioinformatics. 2014;30(15):2114-20.##Friedländer MR, Mackowiak SD, Li N, Chen W, Rajewsky N. miRDeep2 accurately identifies known and hundreds of novel microRNA genes in seven animal clades. Nucleic Acids Res. 2012;40(1):37-52.##Love MI, Huber W, Anders S. Moderated estimation of fold change and dispersion for RNA-seq data with DESeq2. Genome Biol. 2014;15(12):550.##Chang L, Zhou G, Soufan O, Xia J. miRNet 2.0: network-based visual analytics for miRNA functional analysis and systems biology. Nucleic Acids Res. 2020;48(W1):W244-51.##Ruijter JM, Ramakers C, Hoogaars WM, Karlen Y, Bakker O, van den Hoff MJ, et al. Amplification efficiency: linking baseline and bias in the analysis of quantitative PCR data. Nucleic Acids Res. 2009;37(6):e45.##Feng F, Zhang R, Long L. LncRNA GABPB1-IT1 Is upregulated in ischemia-induced acute kidney injury and downregulates miR-204-5p to promote hypoxia-induced human renal proximal tubular epithelial cell apoptosis. Kidney Blood Press Res. 2024;49(1):480-9.##Luo C, Zhang J, Bo L, Wei L, Yang G, Gao S, et al. Construction of a ceRNA-based lncRNA-mRNA network to identify functional lncRNAs in premature ovarian insufficiency. Front Genet. 2022;13:956805.##Bai Y, Qu Y, Wu Z, Ren Y, Cheng Z, Lu Y, et al. Absolute quantification and analysis of extracellular vesicle lncRNAs from the peripheral blood of patients with lung cancer based on multi-colour fluorescence chip-based digital PCR. Biosens Bioelectron. 2019;142:111523.##Li J, Jing J, Liu J, Zhang D, Zhang L, Xie G. Integration of transcriptome and DNA methylation reveals the mechanism of cilia-related genes in recurrent miscarriage. Sci Rep. 2026;16(1):21324.##Xie J, Xie G, Chen Q, Xu Z, Bai W, Chen M. Identification of a novel lncRNA GABPB1-IT1 that is downregulated and predicts a poor prognosis in non-small cell lung cancer. Oncol Lett. 2019;18(1):838-45.##Li B, Wei Y, Ge Q, Duan Y, Guo L. lncRNA GABPB1 intronic transcript 1 upregulates pigment epithelium-derived factor via miR-93 to suppress cell proliferation in hepatocellular carcinoma. Oncol Lett. 2021;21(4):260.##Wang T, Cao C, Fan Y, Xu J, Hua T, Ding J, et al. GABPB1 plays a cancer-promoting role in non-small cell lung cancer. Discov Oncol. 2024;15(1):72.##Tan C, Du H, Wang Y, Zhao J, Cheng X, Lan H. LncRNA GABPB1-IT1 inhibits the tumorigenesis of renal cancer via the miR-21/PTEN axis. J Biochem Mol Toxicol. 2023;37(4):e23288.##Huang Y, Li L, Kang Z, Luo H, Lin X, Zhao S, et al. Prognostic model associated with necroptosis in colorectal cancer based on transcriptomic analysis and experimental validation. Front Biosci (Landmark Ed). 2024;29(3):98.##Dalla Torre M, Pittari D, Boletta A, Cassina L, Sitia R, Anelli T. Mitochondria remodeling during endometrial stromal cell decidualization. Life Sci Alliance. 2024;7(12):e202402627.##Yang ZF, Drumea K, Mott S, Wang J, Rosmarin AG. GABP transcription factor (nuclear respiratory factor 2) is required for mitochondrial biogenesis. Mol Cell Biol. 2014;34(17):3194-201.##Li J, Li D, Zhang X, Li C, Zhu F. Long noncoding RNA SLC9A3 AS1 increases E2F6 expression by sponging microRNA 486 5p and thus facilitates the oncogenesis of nasopharyngeal carcinoma. Oncol Rep. 2021;46(2):165.##Huang X, Huang M, Chen M, Chen X. lncRNA SLC9A3-AS1 promotes oncogenesis of NSCLC via sponging microRNA-760 and may serve as a prognosis predictor of NSCLC patients. Cancer Manag Res. 2022;14:1087-98.##Ye C, Qin S, Qiu S, Zhao L, Miao J, Chen Y, et al. A lncRNA-immune checkpoint-related gene signature predicts metastasis-free survival in prostate adenocarcinoma. Transl Androl Urol. 2022;11(12):1691-705.##Zhao L, Zhang H, Ren P, Sun X. LncRNA SLC9A3-AS1 knockdown increases the sensitivity of liver cancer cell to triptolide by regulating miR-449b-5p-mediated glycolysis. Biotechnol Genet Eng Rev. 2024;40(2):1389-405.##Zhou T, Nguyen S, Wu J, He B, Feng Q. LncRNA LOC730101 promotes darolutamide resistance in prostate cancer by suppressing miR-1-3p. Cancers (Basel). 2024;16(14):2594.##Chen KC, Chang ML, Lin CS, Rajneesh CP, Liao CH, You WC, et al. Insight into SLC9A3 deficiency-mediated micturition dysfunction caused by electrolyte imbalance. Biomed Pharmacother. 2023;158:114155.##Ruan YC, Chen H, Chan HC. Ion channels in the endometrium: regulation of endometrial receptivity and embryo implantation. Hum Reprod Update. 2014;20(4):517-29.##

Investigation of the Relationship between Vitamin D Levels and Oocyte Quality in Women Undergoing Intracytoplasmic Sperm Injection 2 1 140296 2 Background: Vitamin D supports oocyte development and ovarian steroidogenesis; deficiency is linked to preeclampsia and poor oocyte quality. The purpose of the current study was to investigate the relationship between vitamin D levels and oocyte quality in women undergoing ICSI cycles. Methods: In this case-control study, 252 women were identified from medical records and classified into high-quality (n=126) and low-quality oocyte groups (n=126). Serum vitamin D levels and anti-Müllerian hormone (AMH) were recorded. Oocyte quality was assessed by an embryologist using predefined criteria for morphology and maturity. Statistical analysis included Mann–Whitney tests and multivariable logistic regression (p<0.05). ROC analysis was applied to determine the optimal vitamin D cutoff, reporting AUC, sensitivity, and specificity and statistical significance was set at p<0.05. Results: Patients in the high-quality oocyte group had a higher median serum vitamin D level compared with those in the low-quality group (25.2 vs. 21.9 ng/ml). Logistic regression showed that sufficient vitamin D levels (≥18 ng/ml) were associated with increased odds of having high-quality oocytes (OR=1.85, 95%CI: 1.07–3.22). AMH levels were also positively associated with oocyte quality (OR=1.42, 95%CI: 1.11–1.82). The ROC analysis yielded an AUC of 0.61 (95%CI: 0.53–0.68), indicating modest discriminatory ability. Conclusion: Serum vitamin D levels are associated with oocyte quality in women undergoing ICSI cycles. While higher vitamin D levels are linked to better oocyte quality, no causal inference can be drawn from this case–control study design, and interventional studies are needed to evaluate whether correction of vitamin D deficiency improves reproductive outcomes. 43 50 Sara S Sadeghitabar Faculty of Medicine, Tehran Medical Sciences Branch, Islamic Azad University Faculty of Medicine, Tehran Medical Sciences Branch, Islamic Azad University Iran Ali A Sadeghitabar Monoclonal Antibody Research Center, Avicenna Research Institute, ACECR Monoclonal Antibody Research Center, Avicenna Research Institute, ACECR Iran Zohreh Z Lavasani Department of Obstetrics and Gynecology, Faculty of Medicine, Tehran Medical Sciences Branch, Islamic Azad University Department of Obstetrics and Gynecology, Faculty of Medicine, Tehran Medical Sciences Branch, Islamic Azad University Iran zohrehlavasanii@yahoo.com Afsaneh A Mohammadzadeh افسانه محمدزاده Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran af.mohammadzadeh@yahoo. com Anti- mullerian hormoneAssisted reproductive techniquesICSIFemale infertilityIn vitro fertilizationOocyte qualityVitamin D 140296.pdf Sabouti B, Talachian E, Riahi A, Fallah SH, Ebrahimi M, Shafie Sabet A. [Vitamin D has an active role in the immune system. This study is aimed to evaluate serum levels of 25-hydroxy vitamin D in children with burns]. Razi J Med Sci; 2015.22(136):138-44. Persian.##Hosseininejad N, Kalbasi Z, Afshar J. [Vitamin D and childhood pneumonia]. Razi J Med Sci; 2016; 22(140):109-116. Persian.##Nucci AM, Russell CS, Luo R, Ganji V, Olabopo F, Hopkins B, et al. The effectiveness of a short food frequency questionnaire in determining vitamin D intake in children. Dermato-endocrinol. 2013;5(1):205-10.##Xu F, Wolf S, Green O, Xu J. Vitamin D in follicular development and oocyte maturation. Reproduction. 2021;161(6):R129-37.##Liu X, Zhang W, Xu Y, Chu Y, Wang X, Li Q, et al. Effect of vitamin D status on normal fertilization rate following in vitro fertilization. Reprod Biol Endocrinol. 2019;17(1):59.##Lerchbaum E, Rabe T. Vitamin D and female fertility. Curr Opin Obstet Gynecol. 2014;26(3):145-50.##Grzechocinska B, Dabrowski FA, Cyganek A, Wielgos M. The role of vitamin D in impaired fertility treatment. Neuro Endocrinol Lett. 2013;34(8):756-62.##Rudick B, Ingles S, Chung K, Stanczyk F, Paulson R, Bendikson K. Characterizing the influence of vitamin D levels on IVF outcomes. Hum Reprod. 2012;27(11):3321-7.##Fabris A, Pacheco A, Cruz M, Puente JM, Fatemi H, Garcia-Velasco JA. Impact of circulating levels of total and bioavailable serum vitamin D on pregnancy rate in egg donation recipients. Fertil Steril. 2014;102(6):1608-12.##Cito G, Cocci A, Micelli E, Gabutti A, Russo GI, Coccia ME, et al. Vitamin D and male fertility: an updated review. World J Mens Health. 2020;38(2):164-77.##Mohammad Beigi R, Afkhamzadeh A, Daneshpour NS. The effect of calcium-vitamin D in efficacy of induction ovulation in infertile women with polycystic ovary syndrome. Iran J Obstet Gynecol Infertil. 2012;15(14):7-13.##Patra SK, Nasrat H, Goswami B, Jain A. Vitamin D as a predictor of insulin resistance in polycystic ovarian syndrome. Diabetes Metab Syndr. 2012;6(3):146-9.##Yildizhan R, Kurdoglu M, Adali E, Kolusari A, Yildizhan B, Sahin HG, et al. Serum 25-hydroxyvitamin D concentrations in obese and non-obese women with polycystic ovary syndrome. Arch Gynecol Obstet. 2009;280(4):559-63.##Ott J, Wattar L, Kurz C, Seemann R, Huber J, Mayerhofer K, et al. Parameters for calcium metabolism in women with polycystic ovary syndrome who undergo clomiphene citrate stimulation: a prospective cohort study. Eur J Endocrinol. 2012;166(5):897-902.##Bacopoulou F, Kolias E, Efthymiou V, Antonopoulos CN, Charmandari E. Vitamin D predictors in polycystic ovary syndrome: a meta‐analysis. Eur J Clin Invest. 2017;47(10):746-55.##Krul-Poel YH, Snackey C, Louwers Y, Lips P, Lambalk CB, Laven JS, et al. The role of vitamin D in metabolic disturbances in polycystic ovary syndrome: a systematic review. Eur J Endocrinol. 2013;169(6):853-65.##Paffoni A, Somigliana E, Vigano' P, Benaglia L, Cardellicchio L, Pagliardini L, et al. Vitamin D status in women with uterine leiomyomas. J Clin Endocrinol Metab. 2013;98(8):E1374-8.##Bulun SE. Endometriosis. N Engl J Med. 2009;360(3):268-79.##Ramin-Wright A, Schwartz ASK, Geraedts K, Rauchfuss M, Wölfler MM, Haeberlin F, et al. Fatigue–a symptom in endometriosis. Hum Reprod. 2018;33(8):1459-65.##Yildirim B, Guler T, Akbulut M, Oztekin O, Sariiz G. 1– alpha,25-dihydroxyvitamin D3 regresses endometriotic implants in rats by inhibiting neovascularization and altering regulation of matrix metalloproteinase. Postgrad Med. 2014;126(1):104-10.##Di Rosa M, Malaguarnera G, De Gregorio C, Palumbo M, Nunnari G, Malaguarnera L. Immuno-modulatory effects of vitamin D3 in human monocyte and macrophages. Cell Immunol. 2012;280(1):36-43.##Ersoy E, Ersoy AO, Yildirim G, Buyukkagnici U, Tokmak A, Yilmaz N. Vitamin D levels in patients with premature ovarian failure. Ginekol Pol. 2016;87(1):32-6.##Lata I, Tiwari S, Gupta A, Yadav S, Yadav S. To study the vitamin D levels in infertile females and correlation of Vitamin D deficiency with AMH levels in comparison to fertile females. J Hum Reprod Sci. 2017;10(2):86-90.##Gouvea TM, Cota e Souza LA, Lima AA. Correlation of serum anti-Mullerian hormone with hormonal and environmental parameters in Brazilian climacteric women. Sci Rep. 2022;12(1):12065.##McGovern PG. Is vitamin D important for in vitro fertilization success? Fertil Steril. 2020;114(5):962.##Yela DA, Quagliato IP, Benetti-Pinto CL. Quality of life in women with deep endometriosis: a cross-sectional study. Rev Bras Ginecol Obstet. 2020;42(2):90-5.##Rezaeiye RD, Mehrara A, Pour AMA, Fallahi J, Forouhari S. Impact of various parameters as predictors of the success rate of in vitro fertilization. Int J Fertil Steril. 2022;16(2):76-84.##Skoracka K, Ratajczak AE, Rychter AM, Dobrowolska A, Krela-Kaźmierczak I. Female fertility and the nutritional approach: the most essential aspects. Adv Nutr. 2021;12(6):2372-86.##Cozzolino M, Busnelli A, Pellegrini L, Riviello E, Vitagliano A. How vitamin D level influences in vitro fertilization outcomes: results of a systematic review and meta-analysis. Fertil Steril. 2020;114(5):1014-25.##Rudick BJ, Ingles SA, Chung K, Stanczyk FZ, Paulson RJ, Bendikson KA. Influence of vitamin D levels on in vitro fertilization outcomes in donor-recipient cycles. Fertil Steril. 2014;101(2):447-52.##Fekete M, Lehoczki A, Szappanos Á, Zábó V, Kaposvári C, Horváth A, et al. Vitamin D and colorectal cancer prevention: immunological mechanisms, inflammatory pathways, and nutritional implications. Nutrients. 2025;17(8):1351.##Virtanen JK, Nurmi T, Aro A, Bertone-Johnson ER, Hyppönen E, Kröger H, et al. Vitamin D supplementation and prevention of cardiovascular disease and cancer in the finnish vitamin D trial: a randomized controlled trial. Am J Clin Nutr. 2022;115(5):1300-10.##Muyayalo KP, Song S, Zhai H, Liu H, Huang DH, Zhou H, et al. Low vitamin D levels in follicular fluid, but not in serum, are associated with adverse outcomes in assisted reproduction. Arch Gynecol Obstet. 2022;305(2):505-17.##Fabris AM, Cruz M, Iglesias C, Pacheco A, Patel A, Patel J, et al. Impact of vitamin D levels on ovarian reserve and ovarian response to ovarian stimulation in oocyte donors. Reprod Biomed Online. 2017;35(2):139-44.##Sun Z, Wu H, Lian F, Zhang X, Pang C, Guo Y, et al. Human follicular fluid metabolomics study of follicular development and oocyte quality. Chromatographia. 2017;80:901-9.##Irani M, Minkoff H, Seifer DB, Merhi Z. Vitamin D increases serum levels of the soluble receptor for advanced glycation end products in women with PCOS. J Clin Endocrinol Metab. 2014;99(5):E886-90.##Irani M, Merhi Z. Role of vitamin D in ovarian physiology and its implication in reproduction: a systematic review. Fertil Steril. 2014;102(2):460-8.e3.##Neysanian G, Taebi M, Rezaeian A, Nasr-Esfahani MH, Jahangirifar M. The effects of serum and follicular fluid vitamin D levels on assisted reproductive techniques: a prospective cohort study. Int J Fertil Steril. 2021;15(4):280-5.##Dehghani Firouzabadi R, Elham R, Mozhgan R, Mahdavi Firouzabadi M. Value of follicular ﬂuid vitamin D in predicting the pregnancy rate in an IVF program. Arch Gynecol Obstet. 2013;289(1):201-6.##Nandi A, Sinha N, Ong E, Sonmez H, Poretsky L. Is there a role for vitamin D in human reproduction? Horm Mol Biol Clin Investig. 2016;25(1):15-28.##Abedi S, Taebi M, Esfahani MH. Effect of vitamin D supplementation on intracytoplasmic sperm injection outcomes: a randomized double-blind placebo-controlled trial. Int J Fertil Steril. 2019;13(1):18-23.##

Diagnostic Accuracy of the Kissing Ovaries Sign on Transvaginal Ultrasound for Prediction of Bowel Endometriosis in Women with Surgically Confirmed Endometriosis 2 1 140297 2 Background: Endometriosis is a common gynecological disorder. Non-invasive imaging markers that predict disease severity and bowel involvement are clinically valuable. The purpose of the current study was to evaluate the diagnostic performance of the kissing ovaries (KO) sign on transvaginal ultrasound for predicting bowel endometriosis and advanced disease. Methods: This retrospective diagnostic accuracy study included 252 women with surgically and histopathologically confirmed endometriosis who underwent laparoscopic surgery at Avicenna Fertility Center between 2019 and 2021. Preoperative transvaginal ultrasound findings were reviewed, and the presence of the KO sign was assessed. Associations with bowel endometriosis and disease severity were analyzed. Diagnostic performance metrics, chi-square and independent t-tests, ORs with 95% CIs, and multivariable logistic regression were used to evaluate predictors of bowel endometriosis. The p<0.05 was considered statistically significant. Results: The KO sign was significantly associated with advanced-stage disease (stage IV: 88.1% vs. 22.2%) and bowel involvement (61.1% vs. 12.7%; OR=10.3, 95%CI: 5.47–19.4). It also showed significant associations with pouch of Douglas obliteration, uterosacral ligament involvement, and fallopian tube involvement. No significant association was observed for bladder or appendiceal involvement. The KO sign demonstrated a sensitivity of 82.8%, specificity of 69.2%, and accuracy of 74.2% for predicting bowel endometriosis. In multivariable analysis, it remained an independent predictor of bowel involvement (adjusted OR=8.45, 95%CI: 4.62–15.48). The area under the ROC curve was 0.76. Conclusion: The KO sign on transvaginal ultrasound is a useful non-invasive imaging marker for predicting bowel endometriosis and advanced-stage disease, with good diagnostic performance and potential value in preoperative surgical planning. 50 57 Morvarid M Ahmadbeigi Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Roya R Padmehr Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran padmehrroya@gmail.com Khadijeh Kh Shadjoo Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Saman S Mohammadipour Department of Surgery, Bu-Ali Hospital, Tehran Medical Branch, Islamic Azad University Department of Surgery, Bu-Ali Hospital, Tehran Medical Branch, Islamic Azad University Iran Arash A Mohazzab Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Atefeh A Gorgin Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Roxana R Kargar Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Bowel endometriosisDiagnostic accuracyEndometriosisKissing ovariesTransvaginal ultrasound 140297.pdf Berek JS. Berek & Novak's gynecology. 15th ed. Philadelphia: Lippincott Williams & Wilkins; 2012.##Woodward PJ, Sohaey R, Mezzetti TP Jr. Endometriosis: radiologic-pathologic correlation. Radiographics. 2001;21(1):193-216; questionnaire 288-94.##Ghezzi F, Raio L, Cromi A, Duwe DG, Beretta P, Buttarelli M, et al. "Kissing ovaries": a sonographic sign of moderate to severe endometriosis. Fertil Steril. 2005;83(1):143-7.##Moyle PL, Kataoka MY, Nakai A, Takahata A, Reinhold C, Sala E. Nonovarian cystic lesions of the pelvis. Radiographics. 2010;30(4):921-38.##Kokilavani J, Indiran V. Kissing ovaries sign on MRI. Abdom Radiol (NY). 2018;43(10):2880-1.##Wellbery C. Diagnosis and treatment of endometriosis. Am Fam Physician.1999;60(6):1753-68.##Williams JC, Burnett TL, Jones T, Venkatesh SK, VanBuren WM. Association between kissing and retropositioned ovaries and severity of endometriosis: MR imaging evaluation. Abdom Radiol (NY). 2020;45(6):1637-44.##[No authors listed]. Practice bulletin no. 114: management of endometriosis (2010). Obstet Gynecol. 116(1):223-36.##Simoens S, Dunselman G, Dirksen C, Hummelshoj L, Bokor A, Brands I, et al. The burden of endometriosis: costs and quality of life of women with endometriosis and treated in referral centres. Hum Reprod. 2012;27(5):1292-9.##Lebovic DI, Mueller MD, Taylor RN. Immunology of endometriosis. Fertil Steril. 2001;75(1):1-10.##Mueller MD, Mazzucchelli L, Buri C, Lebovic DI, Dreher E, Taylor RN. Epithelial neutrophil-activating peptide 78 concentrations are elevated in the peritoneal fluid of women with endometriosis. Fertil Steril. 2003;79 Suppl 1:815-20.##Cheong YC, Shelton JB, Laird SM, Richmond M, Kudesia G, Li TC, et al. IL-1, IL-6 and TNF- concentrations in the peritoneal fluid of women with pelvic adhesions. Hum Reprod. 2002;17(1):69-75.##Wu MY, Ho HN. The role of cytokines in endometriosis. Am J Reprod Immunol. 2003;49(5):285-96.##Calhaz-Jorge C, Costa AP, Santos MC, Palma-Carlos ML. Peritoneal fluid concentrations of interleukin-8 in patients with endometriosis depend on the severity of the disorder and are higher in the luteal phase. Hum Reprod. 2003;18(3):593-7.##Taylor RN, Lebovic DI, Mueller MD. Angiogenic factors in endometriosis. Ann N Y Acad Sci. 2002;955:89-100.##Redwine DB. Ovarian endometriosis: a marker for more extensive pelvic and intestinal disease. Fertil Steril. 1999;72(2):310-5.##Timor-Tritsch LE, Lerner JP, Monteagudo A, Santos R. Transvaginal ultrasonographic characterization of ovarian masses by means of color flow-directed Doppler measurements and a morphologic scoring system. Am J Obstet Gynecol. 1993;168(3 Pt 1):909-13.##Lerner JP, Timor-Tritsch LE, Federman A, Abramovich G. Transvaginal ultrasonographic characterization of ovarian masses with an improved, weighted scoring system. Am J Obstet Gynecol. 1994;170(1 Pt 1):81-5.##Eskenazi B, Warner M, Bonsignore L, Olive D, Samuels S, Vercellini P. Validation study of nonsurgical diagnosis of endometriosis. Fertil Steril. 2001;76(5):929-35.##Exacoustos C, Zupi E, Carusotti C, Rinaldo D, Marconi D, Lanzi G, et al. Staging of pelvic endometriosis: role of sonographic appearance in determining extension of disease and modulating surgical approach. J Am Assoc Gynecol Laparosc. 2003;10(3):378-82.##Guerriero S, Ajossa S, Pascual MA, Rodriguez I, Piras A, Perniciano M, et al. Ultrasonographic soft markers for detection of rectosigmoid deep endometriosis. Ultrasound Obstet Gynecol. 2020;55(2):269-73.##Redwine DB, Wright JT. Laparoscopic treatment of complete obliteration of the cul-de-sac associated with endometriosis: long-term follow-up of en bloc resection. Fertil Steril. 2001;76(2):358-65.##Arici A, Oral E, Bukulmez O, Duleba A, Olive DL, Jones EE. The effect of endometriosis on implantation: results from the Yale university in vitro fertilization and embryo transfer program. Fertil Steril. 1996;65(3):603-7.##Barnhart K, Dunsmoor-Su R, Coutifaris C. Effect of endometriosis on in vitro fertilization. Fertil Steril. 2002;77(6):1148-55.##

The Effect of Serine Proteases and Their Inhibitors on In Vitro Fertilization Outcomes 2 1 140301 2 Background: Proteolysis imbalance can result in infertility. The purpose of the current study was to investigate the function of kininogen, neutrophil elastase, trypsin-like proteases, α1-protease inhibitor (α1-PI), and α2-macroglobulin (α2-MG) in blood, saliva, and follicular fluid as an indicator of the success of in vitro fertilization (IVF). Methods: In general, twenty-one women undergoing an IVF cycle, as well as a control group consisting of ten healthy women, were included. The proteinase activity was measured by the rate of hydrolysis of specific substrates. The proteinase inhibitor activity was determined by the intensity of trypsin inhibition. The analysis was conducted using R software (version 4.4.1). The significance level was set at p<0.05. Results: In women with infertility, blood activities of neutrophil elastase, α1-PI, and α2-MG were elevated, whereas kallikrein and prekallikrein activities were decreased, compared with controls. In follicular fluid, neutrophil elastase activity increased 3.4-fold, α1-PI 1.8-fold, and α2-MG 5.6-fold, whereas prekallikrein decreased by 85%, compared with women who had been infertile for fewer than five years (p<0.05). During pregnancy, kallikrein and α1- PI levels in follicular fluid were low, and unsuccessful IVF was associated with higher trypsin-like protease activity and an increased kallikrein/α1- PI ratio. Conclusion: High elastase- and trypsin-like proteinase activity, along with elevated α1- PI and α2- MG levels in blood was associated with IVF benefits. Salivary kininogenase and α2-MG can be early prognostic indicators for IVF outcomes. 57 70 Liudmila LV Spirina Department of Biochemistry and Molecular Biology, Siberian State Medical University Department of Biochemistry and Molecular Biology, Siberian State Medical University Russian Federation spirinalvl@mail.ru Olga OE Akbasheva Department of Biochemistry and Molecular Biology, Siberian State Medical University Department of Biochemistry and Molecular Biology, Siberian State Medical University Russian Federation Denis DA Dyakov Department of Biochemistry and Molecular Biology, Siberian State Medical University Department of Biochemistry and Molecular Biology, Siberian State Medical University Russian Federation Ksenia KD Kudisova Department of Biochemistry and Molecular Biology, Siberian State Medical University Department of Biochemistry and Molecular Biology, Siberian State Medical University Russian Federation Ekaterina EA Romanova Department of Biochemistry and Molecular Biology, Siberian State Medical University Department of Biochemistry and Molecular Biology, Siberian State Medical University Russian Federation Kira KA Sidorenkova Department of Obstetrics and Gynecology, Siberian State Medical University Department of Obstetrics and Gynecology, Siberian State Medical University Russian Federation Ilya IA Petrov Department of Obstetrics and Gynecology, Siberian State Medical University Department of Obstetrics and Gynecology, Siberian State Medical University Russian Federation Iuliia IG Samoilova Department of Pediatrics with a Course in Endocrinology, Siberian State Medical University Department of Pediatrics with a Course in Endocrinology, Siberian State Medical University Russian Federation Evgeny ED Merkulov Department of Biochemistry and Molecular Biology, Siberian State Medical University Department of Biochemistry and Molecular Biology, Siberian State Medical University Russian Federation Diana DL Shilova Department of Biochemistry and Molecular Biology, Siberian State Medical University Department of Biochemistry and Molecular Biology, Siberian State Medical University Russian Federation Marina MN Stakheeva Department of Biochemistry and Molecular Biology, Siberian State Medical University Department of Biochemistry and Molecular Biology, Siberian State Medical University Russian Federation Follicular fluidIn vitro fertilizationSalivaSerine proteasesα1-protease inhibitorα2-macroglobulin 140301.pdf World Health Organization. Infertility prevalence estimates, 1990–2021. Geneva: World Health Orga-nization; 2023. 79 p. Available from: https://www. who.int/publications/i/item/978920068315?utm_source=chatgpt.com##Russian Association of Human Reproduction. ART register: report for 2021. Saint Petersburg: Russian Association of Human Reproduction; 2023. 29 p. Available from: https://www.rahr.ru/d_registr_ otchet/RegistrVRT_2021.pdf##Franasiak JM, Alecsandru D, Forman EJ, Gemmell LC, Goldberg JM, Llarena N, et al. A review of the pathophysiology of recurrent implantation failure. Fertil Steril. 2021;117(3):1436-48.##Strizhakov AN, Ignatko IV, Davydov AI. Obstetri-cs: textbook. Moscow: GEOTAR-Media; 2020. 1072 p.##Gutiérrez JA, Gómez I, Chiarello DI, Salsoso R, Klein AD, Guzmán-Gutiérrez E, Toledo F, Sobrevia L. Role of proteases in dysfunctional placental vas-cular remodelling in preeclampsia. Biochim Bio-phys Acta Mol Basis Dis. 2020;1866(2):165448.##Strizhova NV, Dzhaguga VD. [Significance of the kallikrein-kinin system of the blood in obstetrics and gynecology]. Akush Ginekol (Mosk). 1988;(6):5-8. Russian.##Schuster R, Motola-Kalay N, Baranovski BM, Bar L, Tov N, Stein M, et al. Distinct anti-inflammatory properties of alpha1-antitrypsin and corticosteroids reveal unique underlying mechanisms of action. Cell Immunol. 2020;356:104177.##de Serres F, Blanco I. Role of alpha-1 antitrypsin in human health and disease. J Intern Med. 2014 Oct; 276(4):311-35.##Lagrange J, Lecompte T, Knopp T, Lacolley P, Regnault V. Alpha-2-macroglobulin in hemostasis and thrombosis: An underestimated old double-edged sword. J Thromb Haemost. 2022;20(4):806-15.##Ogloblina OG, Platonova LV, Paskhina TS. Meas-urement of trypsin- and elastase-like proteinases of polymorphonuclear leukocytes and the level of their acid-stable inhibitors in human bronchial se-cretions: methodological recommendations. Mos-cow; 1984. 14 p.##Paskhina TS, Krinskaya AV. Determination of kal-likrein activity in human serum/plasma. In: Sovre-mennye metody v biokhimii [Modern methods in biochemistry]. 1977. p. 70-2.##Nartikova VF, Paskhina TS. [Uniform method for determining the alpha 1-antitrypsin and alpha 2-macroglobulin activity in human blood serum (plasma)]. Vopr Med Khim. 1979;25(4):494-9. Russian.##R Core Team. Documentation for package ‘stats’ version 4.4.1. Vienna: R Foundation for Statistical Computing; 2024. Available from: https://search.r-project.org/R/refmans/stats/html/00Index.html ##Yakovleva N, Saprykina D, Vasiljeva E, Bettikher O, Godzoeva A, Kazantseva T, Zazerskaya I. Matrix metalloproteinase -12: A marker of pre-eclampsia? Placenta. 2022;129:36-42.##Orlov AV, Kudinova EI. Etiopathogenetic aspects of the development of placental insufficiency and fetal growth restriction. J Fundam Med Biol. 2016; (4):5-10.##Jugniot N, Voisin P, Bentaher A, Mellet P. Neu-trophil Elastase Activity Imaging: Recent Appro-aches in the Design and Applications of Activity-Based Probes and Substrate-Based Probes. Con-trast Media Mol Imaging. 2019;2019:7417192. ##Vorobjeva NV. Neutrophil Extracellular Traps: New Aspects. Moscow Univ Biol Sci Bull. 2020; 75(4):173-88.##Yang C, Keshavjee S, Liu M. Alpha-1 Antitrypsin for COVID-19 Treatment: Dual Role in Antiviral Infection and Anti-Inflammation. Front Pharmacol. 2020;11:615398.##Ozeri E, Mizrahi M, Shahaf G, Lewis EC. α-1 antitrypsin promotes semimature, IL-10-producing and readily migrating tolerogenic dendritic cells. J Immunol. 2012;189(1):146-53. ##Vandooren J, Itoh Y. Alpha-2-Macroglobulin in Inflammation, Immunity and Infections. Front Immunol. 2021;12:803244.##Kim KM, Chung KW, Jeong HO, Lee B, Kim DH, Park JW, et al. MMP2-A2M interaction increases ECM accumulation in aged rat kidney and its modulation by calorie restriction. Oncotarget. 2017;9(5):5588-99.##Widegren H, Erjefält J, Korsgren M, Andersson M, Greiff L. Effects of intranasal TNFalpha on gra-nulocyte recruitment and activity in healthy sub-jects and patients with allergic rhinitis. Respir Res. 2008;9(1):15.##Meyer P, Andersson M, Persson CG, Greiff L. Steroid-sensitive indices of airway inflammation in children with seasonal allergic rhinitis. Pediatr Allergy Immunol. 2003;14(1):60-5.##Harwood SL, Nielsen NS, Diep K, Jensen KT, Nielsen PK, Yamamoto K, et al. Development of selective protease inhibitors via engineering of the bait region of human α2-macroglobulin. J Biol Chem. 2021;297(1):100879.##Seitz R, Gürtler L, Schramm W. Thromboinflam-mation in COVID-19: Can α2 -macroglobulin help to control the fire? J Thromb Haemost. 2021;19(2):351-4.##Ireland JL, Jimenez-Krassel F, Winn ME, Burns DS, Ireland JJ. Evidence for autocrine or paracrine roles of alpha2-macroglobulin in regulation of es-tradiol production by granulosa cells and development of dominant follicles. Endocrinology. 2004; 145(6):2784-94.##Gao S, De Geyter C, Kossowska K, Zhang H. FSH stimulates the expression of the ADAMTS-16 protease in mature human ovarian follicles. Mol Hum Reprod. 2007;13(7):465-71.##Wasiluk A, Dabrowska M, Jaworski S, Prokopo-wicz J. [Levels of alpha-2-macroglobulin in blood serum of women giving birth to hypotrophic and eutrophic newborns]. Przegl Lek. 2000;57(12):717-9. Polish.##Bahabayi A, Yang N, Xu T, Xue Y, Ma L, Gu X, et al. Expression of matrix metalloproteinase-2,-7,-9 in serum during pregnancy in patients with pre-eclampsia: a prospective study. Int J Environ Res Public Health. 2022;19(21):14500.##Fischer U, Birkenmeier G, Horn LC. Localization of alpha(2)-macroglobulin receptor/low-density li-poprotein receptor in third-trimester human pla-centas: a preliminary immunohistochemical study. Gynecol Obstet Invest. 2001;52(1):22-5.##Markina LA, Zorina VN, Shramko SV, Zorina RM, Arkhipova SV, Bazhenova LG. [The serum levels of inflammatory reactants in women with inflammatory diseases of the uterine appendages, who participate in the in-vitro fertilization]. Klin Lab Diagn. 2008;(2):15-7. Russian.##Goettig P, Brandstetter H, Magdolen V. Surface loops of trypsin-like serine proteases as deter-minants of function. Biochimie. 2019;166:52-76.##Oncul S, Afshar-Kharghan V. The interaction between the complement system and hemostatic factors. Curr Opin Hematol. 2020;27(5):341-52.##Ferguson TEG, Reihill JA, Martin SL, Walker B. Novel inhibitors and activity-based probes targe-ting serine proteases. Front Chem. 2022;10:1006618.##Ossovskaya VS, Bunnett NW. Protease-activated receptors: contribution to physiology and disease. Physiol Rev. 2004;84(2):579-621.##Motta G, Juliano L, Chagas JR. Human plasma kallikrein: roles in coagulation, fibrinolysis, in-flammation pathways, and beyond. Front Physiol. 2023;14:1188816.##Bekassy Z, Lopatko Fagerström I, Bader M, Karp-man D. Crosstalk between the renin-angiotensin, complement and kallikrein-kinin systems in in-flammation. Nat Rev Immunol. 2022;22(7):411-28.##Ivanov I, Verhamme IM, Sun MF, Mohammed B, Cheng Q, Matafonov A, et al. Protease activity in single-chain prekallikrein. Blood. 2020;135(8):558-67.##Pampalakis G, Zingkou E, Panagiotidis C, Sotiro-poulou G. Kallikreins emerge as new regulators of viral infections. Cell Mol Life Sci. 2021;78(21-22):6735-44.##Clements J, Mukhtar A, Yan S, Holland A. Kallikreins and kinins in inflammatory-like events in the reproductive tract. Pharmacol Res. 1997;35 (6):537-40.##Strizhova NV, Dzhaguga VD. [The significance of the kallikrein-kinin system of blood in obstetrics and gynecology]. Akush Ginekol (Mosk). 1988;(6):5-8. Russian.##Yarovaya GA, Neshkova AE. Kallikrein-kinin system: past and present research (on the 90th anniversary of the discovery of the system). Russ J Bioorg Chem. 2015;41(3):245-59.##Ignatieva RE, Gustovarova TA, Babich EN, Kry-ukovsky AS. Violation of vascular endothelial function in women with premature ovarian insuf-ficiency. Bull Smolensk State Med Acad. 2016;15(3):93-100.##Dabi Y, Suisse S, Puchar A, Delbos L, Poilblanc M, Descamps P, et al. Endometriosis-associated in-fertility diagnosis based on saliva microRNA signatures. Reprod Biomed Online. 2023;46(1):138-49.##Wróbel M, Zuzanna Z, Ołdak Ł, Kalicka A, Mańka G, Kiecka M, et al. Evaluation of Proteasome and Immunoproteasome Levels in Plasma and Perito-neal Fluid in Patients with Endometriosis. Int J Mol Sci. 2023;24(18):14363.##Collodel G, Gambera L, Stendardi A, Nerucci F, Signorini C, Pisani C, et al. Follicular Fluid Com-ponents in Reduced Ovarian Reserve, Endo-metriosis, and Idiopathic Infertility. Int J Mol Sci. 2023;24(3):2589.##Ilika VV, Garvasiuk OV, Dogolich OІ, Iryna BV. The features of limited proteolysis in placental fibrinoid in combination with inflammation and iron deficiency anemia of pregnant women. Wiad Lek. 2023;76(5 pt 1):1022-8.##Fang Y, Jingjing F, Tiantain C, Huanhuan X, Qiaohua H. Impact of the number of previous embryo implantation failures on IVF/ICSI-ET pregnancy outcomes in patients younger than 40 years: a retrospective cohort study. Front Endo-crinol (Lausanne). 2023;14:1243402.##Cimadomo D, Capalbo A, Dovere L, Tacconi L, Soscia D, Giancani A, et al. Leave the past behind: women's reproductive history shows no association with blastocysts' euploidy and limited association with live birth rates after euploid embryo transfers. Hum Reprod. 2021;36(4):929-40.##

The First Successful Capacitation In Vitro Maturation of Oocyte in Indonesia: A Promising Strategy to Enhance IVF Accessibility for Infertile Couples 2 1 140300 2 Background: The identification of c-type natriuretic peptide (CNP) as a key upstream regulator of cyclic GMP (cGMP) levels has paved the way for innova-tive in vitro maturation (IVM) techniques, the so-called biphasic CAPA-IVM (capacitation IVM) approach. This method uses CNP to prevent early meiosis progression and has demonstrated enhanced oocyte maturation rates. This report highlights the successful use of the CAPA-IVM method in Indonesia. Case Presentation: Immature cumulus-oocyte complexes (COCs) were successfully retrieved from an infertile woman aged 37 years without prior ovarian stimulation. The obtained COCs were incubated in CAPA medium for 24 hr and then transferred to a maturation medium containing amphiregulin, insulin, human serum albumin, and recombinant FSH. After 30 hr, all immature oocytes reached the metaphase II (MII) stage, as evidenced by the first polar body extrusion and confirmed through spindle formation. Conclusion: CAPA-IVM system enabled all retrieved immature oocytes to reach the MII stage without prior ovarian stimulation. This finding supports its feasibility as a simplified IVF approach with the potential to reduce treatment costs, particularly in resource-limited settings. However, further clinical evalua-tion is required to confirm its effectiveness. 70 75 Andrew A Kan Morula IVF Jakarta Clinic Morula IVF Jakarta Clinic Indonesia Nining N Handayan IRSI Research and Training Centre IRSI Research and Training Centre Indonesia Arif A Sofyan Aziz Morula IVF Jakarta Clinic Morula IVF Jakarta Clinic Indonesia Pitra P Rahmawati Morula IVF Jakarta Clinic Morula IVF Jakarta Clinic Indonesia Arief A Boediono Morula IVF Jakarta Clinic Morula IVF Jakarta Clinic Indonesia Ivan I Sini Morula IVF Jakarta Clinic Morula IVF Jakarta Clinic Indonesia ivan.sini@apps.ipb.ac.id C-type oocytesIn vitro fertilizationIn vitro oocyte maturationNatriuretic peptide 140300.pdf Pincus G, Enzmann EV. The comparative behavior of mammalian eggs in vivo and in vitro: I. The activation of ovarian eggs. J Exp Med. 1935;62(5):665-75.##Edwards RG. Maturation in vitro of mouse, sheep, cow, pig, rhesus monkey and human ovarian oocytes. Nature. 1965;208(5008):349-51.##Cha KY, Koo JJ, Ko JJ, Choi DH, Han SY, Yoon TK. Pregnancy after in vitro fertilization of human follicular oocytes collected from nonstimulated cycles, their culture in vitro and their transfer in a donor oocyte program. Fertil Steril. 1991;55(1):109-13.##Trounson A, Wood C, Kausche A. In vitro maturation and the fertilization and developmental competence of oocytes recovered from untreated polycystic ovarian patients. Fertil Steril. 1994;62(2):353-62.##Gilchrist RB, Smitz J. Oocyte in vitro maturation: physiological basis and application to clinical practice. Fertil Steril. 2023;119(4):524-39.##Zhang M, Su YQ, Sugiura K, Xia G, Eppig JJ. Granulosa cell ligand NPPC and its receptor NPR2 maintain meiotic arrest in mouse oocytes. Science. 2010;330(6002):366-9.##Gilchrist RB, Ho TM, De Vos M, Sanchez F, Romero S, Ledger WL, Anckaert E, Vuong LN, Smitz J. A fresh start for IVM: capacitating the oocyte for development using pre-IVM. Hum Reprod Update. 2024;30(1):3-25.##Anckaert E, Ates G, Liveyns A, Van Ranst H, Mostinckx L, Cools W, et al. Effects of physiological oxygen tension on human cumulus-oocyte-complex metabolism during in vitro maturation: an exploratory study. J Ovarian Res. 2025;18(1):270.##Sanchez F, Le AH, Ho VNA, Romero S, Van Ranst H, De Vos M, et al. Biphasic in vitro maturation (CAPA-IVM) specifically improves the developmental capacity of oocytes from small antral follicles. J Assist Reprod Genet. 2019;36(10):2135-44.##Vuong LN, Le AH, Ho VNA, Pham TD, Sanchez F, Romero S, et al. Live births after oocyte in vitro maturation with a prematuration step in women with polycystic ovary syndrome. J Assist Reprod Genet. 2020;37(2):347-57.##

Inter-chromosomal Effect in a Robertsonian Translocation (13;14) Carrier with a Child Affected by Down Syndrome: A Case Report 2 1 140293 2 Background: Although the balanced carriers of Robertsonian translocations (ROBs) typically exhibit normal phenotypes, they may experience recurrent abortions or have offspring with chromosomal disorders. A proposed mechanism is the inter-chromosomal effect (ICE), where disrupted meiotic segregation may increase aneuploid gamete production. This study presents a male case carrier of t(13;14) who had a deceased child with Down syndrome (DS) and investigates t(13;14) as a potential factor contributing to the birth of a child with DS. Case Presentation: A couple with a history of recurrent abortions and a deceased child with DS was referred to a medical genetics laboratory. Karyotype analysis revealed that the male partner was a carrier of t(13;14) (45,XY,t(13;14)), while the female partner had a normal karyotype. The couple’s subsequent pregnancy resulted in a healthy female fetus inheriting t(13;14). The deceased child had a karyotype of 47, XY, +21, consistent with DS. In this study, the role of t(13;14) and ICE as potential contributors to the birth of a child with DS was explored. Conclusion: Prenatal screening for carriers of ROBs is strongly recommended to assess the risk of unbalanced chromosomal disorders in offspring. 75 80 Sahra S Sahraeean Dr. F. Nabipour Pathobiology laboratory Dr. F. Nabipour Pathobiology laboratory Iran Asiyeh A Jebelli Department of Cell and Molecular Biology, Faculty of Biological Sciences, Kharazmi University Department of Cell and Molecular Biology, Faculty of Biological Sciences, Kharazmi University Iran Saeed S Ghadimi Haddadan Legal Medicine Research Center, Iranian Legal Medicine Organization Legal Medicine Research Center, Iranian Legal Medicine Organization Iran Kobra K Tayyari Legal Medicine Research Center, Iranian Legal Medicine Organization Legal Medicine Research Center, Iranian Legal Medicine Organization Iran Leila L Emrahi Legal Medicine Research Center, Iranian Legal Medicine Organization Legal Medicine Research Center, Iranian Legal Medicine Organization Iran leila.emrahi@gmail.com Down syndromeInter-chromosomal effectRobertsonian translocation 140293.pdf Li PK, Lai FM, Lee JC, Lai KN. Glomemlonephritis associated with robertsonian translocation t (13; 14). Nephron. 1992;62(2):220-3.##Anton E, Blanco J, Egozcue J, Vidal F. Sperm FISH studies in seven male carriers of Robertsonian translocation t (13; 14)(q10; q10). Hum Reprod. 2004;19(6):1345-51.##Malekpour N, Kormi SMA, Azadbakht M, Yousefi M, Hasanzadeh-Nazar Abadi M. The survey of double Robertsonian translocation 13q; 14q in the pedigree of 44; XX woman: a case report. Int J Mol Cell Med. 2017;6(4):243-8.##Alfarawati S, Fragouli E, Colls P, Wells D. Embryos of robertsonian translocation carriers exhibit a mitotic interchromosomal effect that enhances genetic instability during early development. PLoS Genet. 2012;8(10):e1003025.##Jaiswal S, Upadhyay A, Ali A, Upadhyay S, Kumar A, Rai A. Two familial cases of robertsonian translocations 13; 14 and its clinical consequences. J Genet Syndr Gene Ther. 2016;7(1):1-4.##Sahraeean S, Jebelli A, Shahbazi Z, Piryaei F. Homozygosity for robertsonian translocation (14q; 15q) in a newborn with a familial history of recurrent abortion and newborns affected by hepatosplenomegaly: a case report. J Reprod Infertil. 2023;24(4):301-5.##Allen EG, Freeman SB, Druschel C, Hobbs CA, O’Leary LA, Romitti PA, et al. Maternal age and risk for trisomy 21 assessed by the origin of chromosome nondisjunction: a report from the Atlanta and National Down Syndrome Projects. Hum Genet. 2009;125(1):41-52.##Lejeune J. Autosomal disorders. Pediatrics. 1963;32:326-37.##Mateu-Brull E, Rodrigo L, Peinado V, Mercader A, Campos-Galindo I, Bronet F, et al. Interchromosomal effect in carriers of translocations and inversions assessed by preimplantation genetic testing for structural rearrangements (PGT-SR). J Assist Reprod Genet. 2019;36(12):2547-55.##Rogenhofer N, Dürl S, Ochsenkühn R, Neusser M, Aichinger E, Thaler C, et al. Case report: elevated sperm aneuploidy levels in an infertile Robertsonian translocation t (21; 21) carrier with possible interchromosomal effect. J Assist Reprod Genet. 2012;29(4):343-6.##Yoon PW, Freeman SB, Sherman SL, Taft LF, Gu Y, Pettay D, et al. Advanced maternal age and the risk of Down syndrome characterized by the meiotic stage of chromosomal error: a population-based study. Am J Hum Genet. 1996;58(3):628-33.##Miryounesi M, Diantpour M, Motevaseli E, Ghafouri-Fard S. Homozygosity for a Robertsonian translocation (13q; 14q) in a phenotypically normal 44, xx female with a history of recurrent abortion and a normal pregnancy outcome. J Reprod Infertil. 2016;17(3):184-7.##Xu S, Tang D, Fang K, Xia Y, Song J, Wang W, et al. Analysis of meiotic segregation patterns and interchromosomal effects in sperm from a Robertsonian translocation family. Biomed Res. 2014;25(2):233-9.##Douet-Guilbert N, Bris MJ, Amice V, Marchetti C, Delobel B, Amice J, Braekeleer MD, Morel F. Interchromosomal effect in sperm of males with translocations: report of 6 cases and review of the literature. Int J Androl. 2005;28(6):372-9.##Comazzetto S, Di Giacomo M, Rasmussen KD, Much C, Azzi C, Perlas E, et al. Oligoasthenoteratozoospermia and infertility in mice deficient for miR-34b/c and miR-449 loci. PLoS Genet. 2014;10(10):e1004597.##Korenberg JR, Chen X, Schipper R, Sun Z, Gonsky R, Gerwehr S, et al. Down syndrome phenotypes: the consequences of chromosomal imbalance. Proc Natl Acad Sci USA. 1994;91(11):4997-5001.##Vozdova M, Oracova E, Musilova P, Kasikova K, Prinosilova P, Gaillyova R, et al. Sperm and embryo analysis of similar t (7;10) translocations transmitted in two families. Fertil Steril. 2011;96(1):e66-70.##Anton E, Vidal F, Blanco J. Reciprocal translocations: tracing their meiotic behavior. Genet Med. 2008;10(10):730-8.##Fan J, Zhang X, Chen Y, Zhang J, Zhang L, Bi X, et al. Exploration of the interchromosomal effects in preimplantation genetic testing for structural rearrangements based on next‐generation sequencing. Mol Genet Genom Med. 2022;10(9):e2017.##Gianaroli L, Magli M, Ferraretti A, Munne S, Balicchia B, Escudero T, et al. Possible interchromosomal effect in embryos generated by gametes from translocation carriers. Hum Reprod. 2002;17(12):3201-7.##Van Hummelen P, Manchester D, Lowe X, Wyrobek AJ. Meiotic segregation, recombination, and gamete aneuploidy assessed in at (1;10)(p22.1;q22.3) reciprocal translocation carrier by three-and four-probe multicolor FISH in sperm. Am J Hum Genet. 1997;61(3):651-9.##Blanco J, Egozcue J, Clusellas N, Vidal F. FISH on sperm heads allows the analysis of chromosome segregation and interchromosomal effects in carriers of structural rearrangements: results in a translocation carrier, t (5;8)(q33;q13). Cytogenet Cell Genet. 1998;83(3-4):275-80.##Acar H, Yildirim MS, Çora T, Ceylaner S. Evaluation of segregation patterns of 21; 21 Robertsonian translocation along with sex chromosomes and interchromosomal effects in sperm nuclei of carrier by FISH technique. Mol Reprod Dev. 2002;63(2):232-6.##Hatakeyama C, Gao H, Harmer K, Ma S. Meiotic segregation patterns and ICSI pregnancy outcome of a rare (13;21) Robertsonian translocation carrier: a case report. Hum Reprod. 2006;21(4):976-9.##Syme RM, Martin RH. Meiotic segregation of a 21;22 robertsonian translocation. Hum Reprod. 1992;7(6):825-9.##Anton E, Vidal F, Blanco J. Interchromosomal effect analyses by sperm FISH: incidence and distribution among reorganization carriers. Syst Biol Reprod Med. 2011;57(6):268-78.##Zhang S, Lei C, Wu J, Zhou J, Xiao M, Zhu S, et al. Meiotic heterogeneity of trivalent structure and interchromosomal effect in blastocysts with robertsonian translocations. Front Genet. 2021;12:609563.##Guichaoua MR, Quack B, Speed RM, Noel B, Chandley AC, Luciani JM. Infertility in human males with autosomal translocations: meiotic study of a 14;22 robertsonian translocation. Hum Genet. 1990;86(2):162-6.##

Successful Intrauterine Insemination Following Estradiol Pretreatment in a Patient with Primary Ovarian Insufficiency: A Case Report 2 1 140298 2 characterized by impaired ovarian function to secrete gonadal hormones, leading to hypoestrogenism and amenorrhea before the age of 40. Oocyte depletion in POI significantly reduces the chance of spontaneous conception, making infertility a key concern. Various in vitro fertilization (IVF) stimulation protocols, including estrogen pretreatment, have been investigated to facilitate conception with autologous oocytes in patients with POI. The principle of estrogen pretreatment involves administering exogenous estrogen to suppress elevated pituitary gonadotropins (FSH and LH), thereby restoring normal follicular development. Case Presentation: This article presents a case of a 32-year-old patient with POI, characterized by severely diminished ovarian reserve, as evidenced by an AMH level of 0.03 ng/ml and an antral follicle count (AFC) of 1. Our patient had been attempting to conceive for 14 months and reported shortened menstrual cycles. Hysterosalpingography revealed bilaterally patent fallopian tubes, and the patient’s partner demonstrated normozoospermia. The patient was initially scheduled for IVF with controlled ovarian stimulation and estrogen pretreatment. However, a spontaneously matured follicle was detected during the course of estrogen therapy. Consequently, the patient was advised to undergo intrauterine insemination (IUI) following ovulation triggering with human chorionic gonadotropin (hCG). The procedure resulted in a clinical pregnancy and culminated in a term live birth. Conclusion: In POI patients using for estrogen pretreatment autologous oocytes, may enhance ovarian responsiveness. If a mature follicle emerges during estrogen pretreatment, ovulation induction with IUI offers a viable path to natural conception. 80 86 Trang TNK Huynh Department of Obstetrics and Gynecology, Pham Ngoc Thach University of Medicine Department of Obstetrics and Gynecology, Pham Ngoc Thach University of Medicine Vietnam Minh MPK Huynh Department of Infertility, Hung Vuong Hospital Department of Infertility, Hung Vuong Hospital Vietnam huynhminh1504@gmail.com Loc LT Ly Department of Infertility, Hung Vuong Hospital Department of Infertility, Hung Vuong Hospital Vietnam POIIn vitro fertilizationInfertilityInseminationOvulation induction 140298.pdf Beck-Peccoz P, Persani L. Premature ovarian failure. Orphanet J Rare Dis. 2006;1:9.##Ishizuka B. Current understanding of the etiology, symptomatology, and treatment options in premature ovarian insufficiency (POI). Front Endocrinol (Lausanne). 2021;12:626924.##Coulam CB, Adamson SC, Annegers JF. Incidence of premature ovarian failure. Obstet Gynecol. 1986;67(4):604-6.##Luborsky JL, Meyer P, Sowers MF, Gold EB, Santoro N. Premature menopause in a multi-ethnic population study of the menopause transition. Hum Reprod 2003;18(1):199-206.##Lagergeren K, Hammar M, Nedstrand E, Bladh M, Sydsjö G. The prevalence of primary ovarian insufﬁciency in Sweden; a national register study. BMC Womens Health. 2018;18(1):175.##Golezar S, Ramezani TF, Khazaei S, Ebadi A, Keshavarz Z. The global prevalence of primary ovarian insufﬁciency and early menopause: a metaanalysis. Climacteric. 2019;22(4):403-11.##ESHRE, ASRM, CREWHIRL and IMS Guideline Group on POI; Panay N, Anderson RA, Bennie A, Cedars M, Davies M, et al. Evidence-based guideline: premature ovarian insufficiency. Fertil Steril. 2025;123(2):221-36.##Poseidon Group (Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number), Alviggi C, Andersen C, Buehler K, Conforti A, De Placido G, et al. A new more detailed stratification of low responders to ovarian stimulation: from a poor ovarian response to a low prognosis concept. Fertil Steril. 2016;105(6):1452-3.##Blumenfeld Z. What is the best regimen for ovarian stimulation of poor responders in ART/ IVF? Front Endocrinol (Lausanne). 2020;11:192.##Tartagni M, Cicinelli E, De Pergola G, De Salvia MA, Lavopa C, Loverro G. Effects of pretreatment with estrogens on ovarian stimulation with gonadotropins in women with premature ovarian failure: a randomized, placebo-controlled trial. Fertil Steril. 2007;87(4):856-61.##Bradbury JT. Direct action of estrogen on the ovary of the immature rat. Endocrinology. 1961;68:115-9.##Ireland JJ, Richards JS. Acute effects of estradiol and follicle-stimulating hormone on speciﬁc binding of human [125 I] iodo-follicle-stimulating hormone to rat ovarian granulosa cells in vivo and in vitro. Endocrinology. 1978;102:876.##Check JH, Nowroozi K, Chase JS, Nazari A, Shapse D, Vaze M. Ovulation induction and preg-nancies in 100 consecutive women with hypergo-nadotropic amenorrhea. Fertil Steril. 1990;53(5):811-6.##Shapiro AG, Rubin A. Spontaneous pregnancy in association with hypergonadotropic ovarian failure. Fertil Steril. 1977;28(4):500-1.##Starup J, Philip J, Sele V. Oestrogen treatment and subsequent pregnancy in two patients with severe hypergonadotropic ovarian failure. Acta Endocrinol (Copenh). 1978;89(1):149-57.##Piedade KC, Spencer H, Persani L, Nelson LM. Optimizing fertility in primary ovarian insufficiency: case report and literature review. Front Genet. 2021;12:676262.##Bidet M, Bachelot A, Bissauge E, Golmard J, Gricourt S, Dulon J, et al. Resumption of ovarian function and pregnancies in 358 patients with premature ovarian failure. J Clin Endocrinol Metab. 2011;96(12):3864-72.##van Kasteren YM, Schoemaker J. Premature ovarian failure: a systematic review on therapeutic interventions to restore ovarian function and achieve pregnancy. Hum Reprod Update. 1999;5(5):483-92.##Nelson LM, Kimzey LM, White BJ, Merriam GR. Gonadotropin suppression for the treatment of karyotypically normal spontaneous premature ovarian failure: a controlled trial. Fertil Steril. 1992;57(1):50-5.##van Kasteren Y, Hoek A, Schoemaker J. Ovulation induction in premature ovarian failure: a placebocontrolled randomized trial combining pituitary suppression with gonadotropin stimulation. Fertil Steril. 1995;64(2):237-8.##Ishizuka B, Furuya M, Kimura M, Kamioka E, Kawamura K. Live birth rate in patients with premature ovarian insufficiency during long-term follow-up under hormone replacement with or without ovarian stimulation. Front Endocrinol (Lausanne). 2021;12:795724.##Nelson LM, Anasti JN, Kimzey LM, Defensor RA, Lipetz KJ, White BJ, et al. Development of luteinized graafian follicles in patients with karyotypically normal spontaneous premature ovarian failure. J Clin Endocrinol Metab. 1994;79(5):1470-5##