Standardized Infertility Treatments not only Ensure Maternal-Fetal Health but also Provide Higher Success Rates 2 1 572 2 In spite of sophisticated development in assisted reproductive techniques (ART) in the past three decades from birth of the first IVF baby, Louise Brown, in 1978, and increase in the success rate of infertility treat-ment up to 50%–60% in well-designed centers using standard protocols and intensive total quality manage-ment, these treatments face a few difficulties including multiple pregnancy and ovarian hyperstimulation syndrome (OHSS) that recently overshadowed the application of these methods. The rate of twin pregnancy is about 1% worldwide, however infertility treatment thorough ART increases its frequency up to 30% depending on the number and quality of transferred embryos, maternal age, quality of endometrium prepar-ation and prenatal care. Multiple pregnancies increase the risk of pregnancy loss, gestational hypertension in-cluding pre-eclampsia and eclampsia, gestational diabetes, severe bleeding, forceps delivery and other com-plications on the maternal side and the risks of prematurity and low birth weight that are accompanied by increased mortality and morbidity or permanent disabilities such as cerebral palsy and restriction of motor and intellectual abilities on the child side. Therefore, neonatal and infant mortality rates of twin to singleton pregnancies increase more than seven times (1). Quality and number of transferred embryos are a key factor in determining the frequency of twin or high order multiple pregnancies. Most studies have shown that increased number of transferred embryos directly increases the rate of multiple pregnancies; however this has not been proportionate with the increase in success rate (2). Consistently over time, infertile couples encounter a great deal of pressures from family, colleagues and community on one hand and high costs of repeating treatment cycles and gradual damage to their marital relationships on the other hand which eventually make them request transfer of higher numbers of embryos in each cycle. Infertile couples always wish to solve their infertility problem in the shortest possible length of time, while they may be less likely to think about the consequences of their request. Therefore, aside from resolving the infertility problem of infertile couples, one of the important roles of the treatment team is to provide a precise and complete consultation on the consequences and problems that they might face during and after of the treatment, especially multiple pregnancies. The other party involved in multiple pregnancies following infertility treatments is the medical team includ-ing the gynecologist, infertility specialist and embryologist. Obviously, some treatment teams looking to increase the success rate of their centers may make mistakes to increase the number of embryos based on the patient’s will. This mistake often occurs in centers that success rate is counted as the chemical and clinical pregnancy and most of these physicians do not follow the prenatal care of the pregnant women. However, recently success rate of ART was defined as the success in all stages of treatment from diagnostic procedures to delivery of healthy baby(s) with least possible cost and complication and even the baby’s future health (3). At present, some countries permit the transfer of more embryos based on the patient's condition and quality of embryos. In most of these countries all the infertility treatment costs are paid by the patients with partial coverage from insurance companies. However, in some other countries such as the UK and Australia, the number of embryos that can be transferred is limited even in the most difficult and repeated IVF failure cases. Interestingly, in most of these countries insurance coverage for infertility treatment and other therapies is complete and most insurance companies strongly oppose the transfer of more embryos due to complica-tions and costs of multiple pregnancies (4). Iran is among the first group, and most IVF centers believe that physicians should have the right to determine the number of embryos they transfer for each patient, rather than absolutely following a protocol for all patients that does not take into account the justification of the patients’ particular condition. Conse-quently, the rate of high order multiple pregnancies is high. The seventh article of this issue entitled "Specialists’ Attitude toward Appropriate Number of Transferable Embryos in Assisted Reproductive Technology in Iran" covers the infertility treatment doctors' views about the most appropriate number of transferred embryos. I hope this article and your comments and feedbacks will bring about change in treating physicians’ views and those of the policy-makers about the meaning of success in infertility treatment, especially the number of transferable embryos. With careful consideration and attention to the results of this study and the current situation of infertility treatment in the country, the need for more standardized protocols to maintain the health of the mother and the fetus and increase the success rate of these treatments is unequivocally clear. 239 241 Mohammad Reza MR Sadeghi محمدرضا صادقی Editor-in-chief Editor-in-chief Iran No Keyword 572.pdf Ravhon A, Hurwitz A. [Transfer of single embryo as a method to reduce twins pregnancy rate in in-vitro fertilization treatment]. Harefuah. 2002;141(3):301-5, 312. Hebrew.##Luke B, Brown MB, Stern JE, Grainger DA, Klein N, Cedars M. Effect of embryo transfer number on singleton and twin implantation pregnancy outcomes after assisted reproductive technology. J Reprod Med. 2010;55(9-10):387-94.##Van Voorhis BJ, Syrop CH. Cost-effective treatment for the couple with infertility. Clin Obstet Gynecol. 2000;43(4): 958-73.##Pandian Z, Bhattacharya S, Ozturk O, Serour GI, Templeton A. Number of embryos for transfer following in-vitro fertilisation or intra-cytoplasmic sperm injection. Cochrane Database Syst Rev. 2004;(4):CD003416.##

Prediction and Diagnosis of Poor Ovarian Response: The dilemma 2 1 2 Failure to respond adequately to standard protocols and to recruit adequate follicles is called ‘poor response’. This results in decreased oocyte production, cycle cancellation and, overall, is associated with a significantly diminished probability of pregnancy. It has been shown that ovarian reserve tests, such as basal FSH, antimullarian hormone (AMH), inhibin B, basal estradiol, antral follicular count (AFC), ovarian volume, ovarian vascular ﬂow, ovarian biopsy and multivariate prediction models, have little clinical value in the prediction of a poor response. Although recent evidence points that AMH and AFC may be better than other testsbut they still continue to be used and form the basis for the exclusion of women from fertility treatments. Despite the rigorous efforts made in this regard, a test that could reliably predict poor ovarian response in all clients that undergo IVF is currently lacking. 241 249 Ahmed A Badawy Ahmed Badawy College of Medicine, Al-Jouf University College of Medicine, Al-Jouf University Egypt ambadawy@yahoo.com Alaa A Wageah Alaa Wageah College of Medicine, Al-Jouf University College of Medicine, Al-Jouf University Egypt Mohamed M EL-Gharib College of Medicine, Al-Jouf University College of Medicine, Al-Jouf University Egypt Ezz Eldin E Osman Ezz Eldin Osman College of Medicine, Al-Jouf University College of Medicine, Al-Jouf University Egypt Controlled ovarian hyperstimulationFemale infertilityOvarian failurePoor ovarian response 474.pdf Shanbhag S, Aucott L, Bhattacharya S, Hamilton M A, McTavish AR. Interventions for 'poor responders' to controlled ovarian hyperstimulation (COH) in in-vitro fertilisation (IVF). Cochrane Database Syst Rev. 2007;(1):CD004379.##Venetis CA, Kolibianakis EM, Tarlatzi TB, Tarlatzis BC. Evidence-based management of poor ovarian response. Ann N Y Acad Sci. 2010;1205:199-206.##Ferraretti AP, La Marca A, Fauser BC, Tarlatzis B, Nargund G, Gianaroli L; ESHRE working group on Poor Ovarian Response Definition. ESHRE consensus on the definition of 'poor response' to ovarian stimulation for in vitro fertilization: the Bologna criteria. Hum Reprod. 2011;26(7):1616-24.##Society for Assisted Reproductive Technology and the American Society for Reproductive Medicine. Assisted reproductive technology in the United States: 2001 results generated from the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology registry. Fertil Steril. 2007;87(6):1253-66.##Kyrou D, Kolibianakis EM, Venetis CA, Papanikolaou EG, Bontis J, Tarlatzis BC. How to improve the probability of pregnancy in poor responders undergoing in vitro fertilization: a systematic review and meta-analysis. Fertil Steril. 2009;91(3):749-66.##Land JA, Yarmolinskaya MI, Dumoulin JC, Evers JL. High-dose human menopausal gonadotropin stimulation in poor responders does not improve in vitro fertilization outcome. Fertil Steril. 1996;65(5): 961-5.##Fridström M, Akerlöf E, Sjöblom P, Hillensjö T. Serum levels of luteinizing and follicle-stimulating hormones in normal and poor-responding patients undergoing ovarian stimulation with urofollitropin after pituitary downregulation. Gynecol Endocrinol. 1997;11(1):25-8.##Raga F, Bonilla-Musoles F, Casañ EM, Bonilla F. Recombinant follicle stimulating hormone stimulation in poor responders with normal basal concentrations of follicle stimulating hormone and oestradiol: improved reproductive outcome. Hum Reprod.1999; 14(6):1431-4.##Loutradis D, Drakakis P, Milingos S, Stefanidis K, Michalas S. Alternative approaches in the management of poor response in controlled ovarian hyperstimulation (COH). Ann N Y Acad Sci. 2003;997: 112-9.##Rombauts L, Suikkari AM, MacLachlan V, Trounson AO, Healy DL. Recruitment of follicles by recombinant human follicle-stimulating hormone commencing in the luteal phase of the ovarian cycle. Fertil Steril. 1998;69(4):665-9.##Surrey ES, Bower J, Hill DM, Ramsey J, Surrey MW. Clinical and endocrine effects of a microdose GnRH agonist flare regimen administered to poor responders who are undergoing in vitro fertilization. Fertil Steril. 1998;69(3):419-24.##Schoolcraft W, Schlenker T, Gee M, Stevens J, Wagley L. Improved controlled ovarian hyperstimulation in poor responder in vitro fertilization patients with a microdose follicle-stimulating hormone flare, growth hormone protocol. Fertil Steril. 1997;67(1):93-7.##Shaker AG, Fleming R, Jamieson ME, Yates RW, Coutts JR. Absence of effect of adjuvant growth hormone therapy on follicular responses to exogenous gonadotropins in women: normal and poor responders. Fertil Steril. 1992;58(5):919-23.##Toth TL, Awwad JT, Veeck LL, Jones HW Jr, Muasher SJ. Suppression and flare regimens of gonadotropin-releasing hormone agonist. Use in women with different basal gonadotropin values in an in vitro fertilization program. J Reprod Med. 1996;41(5):321-6.##Droesch K, Muasher SJ, Brzyski RG, Jones GS, Simonetti S, Liu HC, et al. Value of suppression with a gonadotropin-releasing hormone agonist prior to gonadotropin stimulation for in vitro fertilization. Fertil Steril. 1989;51(2):292-7.##Feldberg D, Farhi J, Ashkenazi J, Dicker D, Shalev J, Ben-Rafael Z. Minidose gonadotropin-releasing hormone agonist is the treatment of choice in poor responders with high follicle-stimulating hormone levels. Fertil Steril. 1994;62(2):343-6.##Olivennes F, Righini C, Fanchin R, Torrisi C, Hazout A, Glissant M, et al. A protocol using a low dose of gonadotrophin-releasing hormone agonist might be the best protocol for patients with high follicle-stimulating hormone concentrations on day 3. Hum Reprod. 1996;11(6):1169-72.##Karande V, Morris R, Rinehart J, Miller C, Rao R, Gleicher N. Limited success using the "flare" protocol in poor responders in cycles with low basal follicle-stimulating hormone levels during in vitro fertilization. Fertil Steril. 1997;67(5):900-3.##Yang JH, Wu MY, Chao KH, Chen SU, Ho HN, Yang YS. Long GnRH-agonist protocol in an IVF program. Is it appropriate for women with normal FSH levels and high FSH/LH ratios? J Reprod Med. 1997;42(10):663-8.##Manzi DL, Thornton KL, Scott LB, Nulsen JC. The value of increasing the dose of human menopausal gonadotropins in women who initially demonstrate a poor response. Fertil Steril. 1994;62(2): 251-6.##Ibrahim ZH, Matson PL, Buck P, Lieberman BA. The use of biosynthetic human growth hormone to augment ovulation induction with buserelin acetate/human menopausal gonadotropin in women with a poor ovarian response. Fertil Steril. 1991;55 (1):202-4.##van Rooij IA, Bancsi LF, Broekmans FJ, Looman CW, Habbema JD, te Velde ER. Women older than 40 years of age and those with elevated folliclestimulating hormone levels differ in poor response rate and embryo quality in in vitro fertilization. Fertil Steril. 2003;79(3):482-8.##Schachter M, Friedler S, Raziel A, Strassburger D, Bern O, Ron-el R. Improvement of IVF outcome in poor responders by discontinuation of GnRH ana-logue during the gonadotropin stimulation phase--a function of improved embryo quality. J Assist Reprod Genet. 2001;18(4):197-204.##Sallam HN, Ezzeldin F, Agameya AF, Rahman AF, El-Garem Y. Defining poor responders in assisted reproduction. Int J Fertil Womens Med. 2005;50(3):115-20.##Kailasam C, Keay SD, Wilson P, Ford WC, Jenkins JM. Defining poor ovarian response during IVF cycles, in women aged <40 years, and its relationship with treatment outcome. Hum Reprod. 2004;19(7):1544-7.##Yarali H, Esinler I, Polat M, Bozdag G, Tiras B. Antagonist/letrozole protocol in poor ovarian responders for intracytoplasmic sperm injection: a comparative study with the microdose flare-up protocol. Fertil Steril. 2009;92(1):231-5.##Gorgy A, Taranissi M. Defining and predicting the poor responder. Fertil Steril. 2001;75(1):226-7.##Wang PT, Lee RK, Su JT, Hou JW, Lin MH, Hu YM. Cessation of low-dose gonadotropin releasing hormone agonist therapy followed by high-dose gonadotropin stimulation yields a favorable ovarian response in poor responders. J Assist Reprod Genet. 2002;19(1):1-6.##Mahutte NG, Arici A. Poor responders: does the protocol make a difference? Curr Opin Obstet Gynecol. 2002;14(3):275-81.##Ubaldi FM, Rienzi L, Ferrero S, Baroni E, Sapienza F, Cobellis L, et al. Management of poor responders in IVF. Reprod Biomed Online. 2005;10 (2):235-46.##Pellicer A, Ardiles G, Neuspiller F, Remohí J, Simón C, Bonilla-Musoles F. Evaluation of the ovarian reserve in young low responders with normal basal levels of follicle-stimulating hormone using three-dimensional ultrasonography. Fertil Steril. 1998;70(4):671-5.##Nargund G, Bromhan D. Comparison of endocrinological and clinical profiles and outcome of IVF cycles in patients with one ovary and two ovaries. J Assist Reprod Genet. 1995;12(7):458-60.##Keay SD, Liversedge NH, Jenkins JM. Could ovarian infection impair ovarian response to gonadotrophin stimulation? Br J Obstet Gynaecol. 1998; 105(3):252-3.##Sharara FI, Beatse SN, Leonardi MR, Navot D, Scott RT Jr. Cigarette smoking accelerates the development of diminished ovarian reserve as evidenced by the clomiphene citrate challenge test. Fertil Steril. 1994;62(2):257-62.##Ragni G, De Lauretis Yankowski L, Piloni S, Vegetti W, Guermandi E, Colombo M, et al. In vitro fertilization for patients with poor response and occult ovarian failure: a randomized trial. Reprod Technol. 2000;10:98-102.##Loh S, Wang JX, Matthews CD. The influence of body mass index, basal FSH and age on the response to gonadotrophin stimulation in non-polycystic ovarian syndrome patients. Hum Reprod. 2002;17(5):1207-11.##Stillman RJ, Rosenberg MJ, Sachs BP. Smoking and reproduction. Fertil Steril. 1986;46(4):545-66.##Nikolaou D, Templeton A. Early ovarian ageing: a hypothesis. Detection and clinical relevance. Hum Reprod. 2003;18(6):1137-9.##Beckers NG, Macklon NS, Eijkemans MJ, Fauser BC. Women with regular menstrual cycles and a poor response to ovarian hyperstimulation for in vitro fertilization exhibit follicular phase characteristics suggestive of ovarian aging. Fertil Steril. 2002;78(2):291-7.##de Boer EJ, den Tonkelaar I, te Velde ER, Burger CW, Klip H, van Leeuwen FE, et al. A low number of retrieved oocytes at in vitro fertilization treatment is predictive of early menopause. Fertil Steril. 2002;77(5):978-85.##Martinez F, Barri PN, Coroleu B, Tur R, Sorsa Leslie T, Harris WJ, et al. Women with poor response to IVF have lowered circulating gonadotrophin surge-attenuating factor (GnSAF) bioactivity during spontaneous and stimulated cycles. Hum Reprod. 2002;17(3):634-40.##Ulug U, Turan E, Tosun SB, Erden HF, Bahceci M. Comparison of preovulatory follicular concentrations of epidermal growth factor, insulin-like growth factor-I, and inhibins A and B in women undergoing assisted conception treatment with gonadotropin-releasing hormone (GnRH) agonists and GnRH antagonists. Fertil Steril. 2007;87(4): 995-8.##Neulen J, Wenzel D, Hornig C, Wünsch E, Weissenborn U, Grunwald K, et al. Poor responder-high responder: the importance of soluble vascular endothelial growth factor receptor 1 in ovarian stimulation protocols. Hum Reprod. 2001;16(4): 621-6.##Pellicer A, Ballester MJ, Serrano MD, Mir A, Serra-Serra V, Remohi J, et al. Aetiological factors involved in the low response to gonadotrophins in infertile women with normal basal serum follicle stimulating hormone levels. Hum Reprod. 1994;9 (5):806-11.##Hernandez ER. Embryo implantation and GnRH antagonists: embryo implantation: the Rubicon for GnRH antagonists. Hum Reprod. 2000;15(6):1211-6.##Lee DW, Grasso P, Dattatreyamurty B, Deziel MR, Reichert LE Jr. Purification of a high molecular weight follicle-stimulating hormone receptor binding inhibitor from human follicular fluid. J Clin Endocrinol Metab. 1993;77(1):163-8.##Zeleznik AJ, Schuler HM, Reichert LE Jr. Gonadotropin-binding sites in the rhesus monkey ovary: role of the vasculature in the selective distribution of human chorionic gonadotropin to the preovulatory follicle. Endocrinology. 1981;109(2):356-62.##Loutradis D, Drakakis P, Vomvolaki E, Antsaklis A. Different ovarian stimulation protocols for women with diminished ovarian reserve. J Assist Reprod Genet. 2007;24(12):597-611.##Cameron IT, O'Shea FC, Rolland JM, Hughes EG, de Kretser DM, Healy DL. Occult ovarian failure: a syndrome of infertility, regular menses, and elevated follicle-stimulating hormone concentrations. J Clin Endocrinol Metab. 1988;67(6):1190-4.##Scott RT, Toner JP, Muasher SJ, Oehninger S, Robinson S, Rosenwaks Z. Follicle-stimulating hormone levels on cycle day 3 are predictive of in vitro fertilization outcome. Fertil Steril. 1989;51 (4):651-4.##Toner JP, Philput CB, Jones GS, Muasher SJ. Basal follicle-stimulating hormone level is a better predictor of in vitro fertilization performance than age. Fertil Steril. 1991;55(4):784-91.##Broekmans FJ, Kwee J, Hendriks DJ, Mol BW, Lambalk CB. A systematic review of tests predicting ovarian reserve and IVF outcome. Hum Reprod Update. 2006;12(6):685-718.##Mukherjee T, Copperman AB, Lapinski R, Sandler B, Bustillo M, Grunfeld L. An elevated day three follicle-stimulating hormone:luteinizing hormone ratio (FSH:LH) in the presence of a normal day 3 FSH predicts a poor response to controlled ovarian hyperstimulation. Fertil Steril. 1996;65(3):588-93.##Licciardi FL, Liu HC, Rosenwaks Z. Day 3 estradiol serum concentrations as prognosticators of ovarian stimulation response and pregnancy outcome in patients undergoing in vitro fertilization. Fertil Steril. 1995;64(5):991-4.##Seifer DB, Maclaughlin DT. Mullerian Inhibiting Substance is an ovarian growth factor of emerging clinical significance. Fertil Steril. 2007;88(3):539-46.##Oosterhuis GJ, Vermes I, Lambalk CB, Michgelsen HW, Schoemaker J. Insulin-like growth factor (IGF)-I and IGF binding protein-3 concentrations in fluid from human stimulated follicles. Hum Reprod. 1998;13(2):285-9.##Scott RT Jr, Hofmann GE, Oehninger S, Muasher SJ. Intercycle variability of day 3 follicle-stimulating hormone levels and its effect on stimulation quality in in vitro fertilization. Fertil Steril. 1990; 54(2):297-302.##Scott RT Jr, Hofmann GE. Prognostic assessment of ovarian reserve. Fertil Steril. 1995;63(1):1-11.##Seifer DB, Lambert-Messerlian G, Hogan JW, Gardiner AC, Blazar AS, Berk CA. Day 3 serum inhibin-B is predictive of assisted reproductive technologies outcome. Fertil Steril. 1997;67(1): 110-4.##Van Rooij IA, Broekmans FJ, te Velde ER, Fauser BC, Bancsi LF, de Jong FH, et al. Serum antiMüllerian hormone levels: a novel measure of ovarian reserve. Hum Reprod. 2002;17(12):3065-71.##Seifer DB, MacLaughlin DT, Christian BP, Feng B, Shelden RM. Early follicular serum müllerianinhibiting substance levels are associated with ovarian response during assisted reproductive technology cycles. Fertil Steril. 2002;77(3):468-71.##Hazout A, Bouchard P, Seifer DB, Aussage P, Junca AM, Cohen-Bacrie P. Serum antimüllerian hormone/müllerian-inhibiting substance appears to be a more discriminatory marker of assisted reproductive technology outcome than folliclestimulating hormone, inhibin B, or estradiol. Fertil Steril. 2004;82(5):1323-9.##Muttukrishna S, Suharjono H, McGarrigle H, Sathanandan M. Inhibin B and anti-Mullerian hormone: markers of ovarian response in IVF/ICSI patients? BJOG. 2004;111(11):1248-53.##Eldar-Geva T, Ben-Chetrit A, Spitz IM, Rabinowitz R, Markowitz E, Mimoni T, et al. Dynamic assays of inhibin B, anti-Mullerian hormone and estradiol following FSH stimulation and ovarian ultrasonography as predictors of IVF outcome. Hum Reprod. 2005;20(11):3178-83.##Tremellen KP, Kolo M, Gilmore A, Lekamge DN. Anti-mullerian hormone as a marker of ovarian reserve. Aust N Z J Obstet Gynaecol. 2005;45(1): 20-4.##Peñarrubia J, Fábregues F, Manau D, Creus M, Carmona F, Casamitjana R, et al. Previous cycle cancellation due to poor follicular development as a predictor of ovarian response in cycles stimulated with gonadotrophin-releasing hormone agonistgonadotrophin treatment. Hum Reprod. 2005;20 (3):622-8.##Nelson SM, Yates RW, Fleming R. Serum antiMüllerian hormone and FSH: prediction of live birth and extremes of response in stimulated cycles--implications for individualization of therapy. Hum Reprod. 2007;22(9):2414-21.##Lekamge DN, Barry M, Kolo M, Lane M, Gilchrist RB, Tremellen KP. Anti-Müllerian hormone as a predictor of IVF outcome. Reprod Biomed Online. 2007;14(5):602-10.##La Marca A, Giulini S, Tirelli A, Bertucci E, Marsella T, Xella S, et al. Anti-Müllerian hormone measurement on any day of the menstrual cycle strongly predicts ovarian response in assisted reproductive technology. Hum Reprod. 2007;22(3): 766-71.##Smeenk JM, Sweep FC, Zielhuis GA, Kremer JA, Thomas CM, Braat DD. Antimüllerian hormone predicts ovarian responsiveness, but not embryo quality or pregnancy, after in vitro fertilization or intracyoplasmic sperm injection. Fertil Steril. 2007; 87(1):223-6.##Lass A, Skull J, McVeigh E, Margara R, Winston RM. Measurement of ovarian volume by transvaginal sonography before ovulation induction with human menopausal gonadotrophin for in-vitro fertilization can predict poor response. Hum Reprod. 1997;12(2):294-7.##Gibreel A, Maheshwari A, Bhattacharya S, Johnson NP. Ultrasound tests of ovarian reserve; a systematic review of accuracy in predicting fertility outcomes. Hum Fertil (Camb). 2009;12(2):95-106.##Chang MY, Chiang CH, Hsieh TT, Soong YK, Hsu KH. Use of the antral follicle count to predict the outcome of assisted reproductive technologies. Fertil Steril. 1998;69(3):505-10.##Bancsi LF, Broekmans FJ, Eijkemans MJ, de Jong FH, Habbema JD, te Velde ER. Predictors of poor ovarian response in in vitro fertilization: a prospective study comparing basal markers of ovarian reserve. Fertil Steril. 2002;77(2):328-36.##Hendriks DJ, Broekmans FJ, Bancsi LF, de Jong FH, Looman CW, Te Velde ER. Repeated clomiphene citrate challenge testing in the prediction of outcome in IVF: a comparison with basal markers for ovarian reserve. Hum Reprod. 2005;20(1):163-9.##Engmann L, Sladkevicius P, Agrawal R, Bekir JS, Campbell S, Tan SL. Value of ovarian stromal blood flow velocity measurement after pituitary suppression in the prediction of ovarian responsiveness and outcome of in vitro fertilization treatment. Fertil Steril. 1999;71(1):22-9.##Navot D, Rosenwaks Z, Margalioth EJ. Prognostic assessment of female fecundity. Lancet. 1987;2(85 60):645-7.##Fanchin R, de Ziegler D, Olivennes F, Taieb J, Dzik A, Frydman R. 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Long-Term Administration of Artesunate Induces Reproductive Toxicity in Male Rats 2 1 2 Background: Artesunate is commonly used in malaria therapy. Many antimalarial drugs have been associated with male reproductive dysfunction. The effect of artesunate on male reproductive activities was studied using in–vivo and in-vitro experimental models. Methods: Adult male rats (n=6) were orally given artesunate (2.9 mg/kg body weight) on daily basis for five days. Artesunate (2.9 mg/kg body weight) was administered to another group of rats daily for six weeks, while there was a recovery group of rats too. The control animals received the vehicle only. At the end of the treatment, sperm characteristics, serum follicle stimulating hormone, luteinizing hormone and testosterone levels, testicular and epididymal histology and fertility were assessed. Cultured Sertoli cells were treated with 0.3 μM to 10 μM artesunate for five days after which Sertoli cell viability, double-stranded deoxyribonucleic acid (ds-DNA) integrity and genetic expression of Glial cell line-derived neurotrophic factor (GDNF) and transferrin were assessed. The data were analyzed using Graphpad Instat Statistical software. A probability value of p <0.05 was considered significant. Results: Artesunate did not cause any significant effects in short-term administration but significantly reduced the aforesaid parameters in long-term administration. There were visible lesions in the testicular and epididymal histological studies, although fertility was not significantly reduced. These changes were restored in the recovery experiment. In-vitro studies showed dose and duration dependent changes in Sertoli cell viability and ds-DNA integrity. However, transferrin and GDNF gene expressions were normal. Conclusion: The results suggest that long-term administration of artesunate could induce reversible infertility in rats which may act via distortion of blood–testis barrier formed by Sertoli cells. 249 261 Stephen S Akinsomisoye Olumide Stephen Akinsomisoye Olumide Department of Physiological Sciences, College of Health Sciences, Obafemi Awolowo University, Ile – Ife Department of Physiological Sciences, College of Health Sciences, Obafemi Awolowo University, Ile – Ife Nigeria stolakin@yahoo.co.uk Raji R Yinusa Raji Yinusa Department of Physiology, College of Medicine, University of Ibadan Department of Physiology, College of Medicine, University of Ibadan Nigeria ArtesunateEpididymisRatSertoli cellSpermTestisTestosterone 475.pdf Breman JG, Alilio MS, Mills A. Conquering the intolerable burden of malaria: what's new, what's needed: a summary. Am J Trop Med Hyg. 2004;71 (2 Suppl):1-15.##Sachs J, Malaney P. The economic and social burden of malaria. 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Frequency of Antisperm Antibodies in Infertile Women 2 1 2 Background: Infertility is one of the common problems seen in couples of reproductive age. Presence of antisperm antibodies in semen and serum are amongst the causes of immunoinfertility. This study was performed to determine antisperm antibodies in cervicovaginal secretions and serum of infertile women and also measure serum levels of immunoglobulins (IgG, IgM and IgA). Methods: The study consisted of 45 infertile women consulting the Kammal ElSammrari Hospital for infertility from 2008 to 2009 and the control group consisted of 30 fertile women. Serum levels of immunoglobulins (IgG, IgA and IgM) were measured in the participants using single radial immune diffusion. Antisperm antibodies (ASAs) were detected in the serum of both infertile and control groups using indirect immune fluorescence test. ASAs were also detected in cervicovaginal secretion using direct sperm agglutination test in both infertile and control groups. Results: Antisperm antibodies were found in the cervicovaginal secretions (62.2%) and sera (64.4%) of infertile women which were significantly higher (p <0.001) than those of the control group (3.3% and 3.3% respectively). There was a significant increase (p <0.001) in serum levels of IgG and IgA of infertile women (16.2 and 3.25 g/L respectively) compared with the healthy control group (7 and 1.2 g/L). Conclusion: Humoral immune response and antisperm antibodies may contribute to reproductive failure in couples of reproductive age. 261 266 Batool B Mutar Mahdi Batool Mutar Mahdi Al-Kindi College of Medicine, Baghdad University Al-Kindi College of Medicine, Baghdad University Iraq batool1966@yahoo.com Wafaa W Hazim Salih Wafaa Hazim Salih Al-Kindi College of Medicine, Baghdad University Al-Kindi College of Medicine, Baghdad University Iraq Annie A Edmond Caitano Annie Edmond Caitano Central Public Health Laboratory Central Public Health Laboratory Iraq Bassma B Maki Kadhum Bassma Maki Kadhum Al-Kindi College of Medicine, Baghdad University Al-Kindi College of Medicine, Baghdad University Iraq Dina D Sami Ibrahim Dina Sami Ibrahim Central Public Health Laboratory Central Public Health Laboratory Iraq Antisperm antibodyCervicovaginalImmunoflourescenceImmunoglobulinInfertility 476.pdf Koide SS, Wang L, Kamada M. Antisperm antibodies associated with infertility: properties and encoding genes of target antigens. Proc Soc Exp Biol Med. 2000;224(3):123-32.##Dondero F, Lenzi A, Gandini L, Lombardo F. Immunological infertility in humans. Exp Clin Immunogenet. 1993;10(2):65-72.##Meaker S. Some aspects of the problem of sterility. Boston Med Surg J. 1922;187:535-9.##Marín-Briggiler CI, Vazquez-Levin MH, Gonzalez Echeverría F, Blaquier JA, Miranda PV, Tezón JG. Effect of antisperm antibodies present in human follicular fluid upon the acrosome reaction and spermzona pellucida interaction. Am J Reprod Immunol. 2003;50(3):209-19.##Yazdi RS, Akbari Sene A, Kohpaee Z, Zadehmodaress Sh, Hosseini SJ, Fallahian M. The Correlation between Sexual Practices and the Development of Antisperm Antibodies. Int J Fertil Steril. 2009;2(4): 189-92.##Wang M, Shi JL, Cheng GY, Hu YQ, Xu C. The antibody against a nuclear autoantigenic sperm protein can result in reproductive failure. Asian J Androl. 2009;11(2):183-92.##Williams J, Samuel A, Naz RK. Presence of antisperm antibodies reactive with peptide epitopes of FA-1 and YLP12 in sera of immunoinfertile women. Am J Reprod Immunol. 2008;59(6):518-24.##Veaute C, Furlong LI, Bronson R, Harris JD, Vazquez-Levin MH. Acrosin antibodies and infertility. I. Detection of antibodies towards proacrosin/ acrosin in women consulting for infertility and evaluation of their effects upon the sperm protease activeities. Fertil Steril. 2009;91(4):1245-55.##Andreou E, Mahmoud A, Vermeulen L, Schoonjans F, Comhaire F. Comparison of different methods for the investigation of antisperm antibodies on spermatozoa, in seminal plasma and in serum. Hum Reprod. 1995;10(1):125-31.##Ahangari G, Naderimanesh H, Hossein-Nezhad A, Zouali M. A novel tissue engineering-based assay for immunological infertility. Scand J Immunol. 2008;68(4):463-8.##Carraher RP. The induction and activity of sperm immobilizing antibody in rabbit cervicovaginal secretion. Contraception. 1977;15(1):15-23.##Cantuária AA. Sperm immobilizing antibodies in the serum and cervicovaginal secretions of infertile and normal women. Br J Obstet Gynaecol. 1977;84 (11):865-8.##Doan T, Melvold R, Viselli S, Waltenbaugh C. Lippincott's Illustrated Reviews: Immunology. 5th ed. Philadelphia: Lippincott Williams & wilkins; 2008. 336 p.##Knobloch V, Wagner V, Zwinger A, Wagnerová M. [Quantitative determination of immunoglobulins in the serum of infertile women]. Zentralbl Gynakol. 1973;95(21):727-9. German.##Spizhenko NIu. [The level of immunoglobulins and antispermatic antibodies in the cervical mucus of infertile women with cervix uteri pathology]. Lik Sprava. 1997;(6):151-4. Ukrainian.##Clarke GN, Hsieh C, Koh SH, Cauchi MN. Sperm antibodies, immunoglobulins, and complement in human follicular fluid. Am J Reprod Immunol. 1984;5(4):179-81.##Stedronska J, Hendry WF. The value of the mixed antiglobulin reaction (MAR test) as an addition to routine seminal analysis in the evaluation of the subfertile couple. Am J Reprod Immunol. 1983;3 (2):89-91.##Naz RK. Modalities for treatment of antisperm antibody mediated infertility: novel perspectives. Am J Reprod Immunol. 2004;51(5):390-7.##Kapoor A, Talib VH, Verma SK. Immunological assessment of infertility by estimation of antisperm antibodies in infertile couples. Indian J Pathol Microbiol. 1999;42(1):37-43.##Lu JC, Huang YF, Lu NQ. Antisperm immunity and infertility. Expert Rev Clin Immunol. 2008;4 (1):113-26.##Waldman RH, Cruz JM, Rowe DS. Sperm migration-inhibiting antibody in human cervicovaginal secretions. Clin Exp Immunol. 1972;12(1):49-54.##Lombardo F, Gandini L, Dondero F, Lenzi A. Immunology and immunopathology of the male genital tract. Hum Reprod Update. 2001;7(5):450-6.##Mazumdar S, Levine AS. Antisperm antibodies: etiology, pathogenesis, diagnosis, and treatment. 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Idiopathic Recurrent Pregnancy Loss: Role of Paternal Factors; A Pilot Study 2 1 2 Background: This case-control study was designed with the aim of evaluating the role of sperm, oxidative stress and DNA damage in idiopathic recurrent pregnancy loss (iRPL). This pilot study is the first study done on the Indian population which reports the association between DFI, TAC and ROS in couples experiencing iRSA. Methods: Twenty infertile men with a history of iRPL and 20 fertile controls (having fathered a child a year earlier) were included in the study which was performed in Laboratory for Molecular Reproduction and Genetics, India, from March 2010 to July 2011. The female partners of the participants were normal on gynaecological examination and had normal endocrine and blood profiles. Conventional semen analysis was performed (concentration, motility, morphology; WHO criteria, 2010) within 1 hour of sample collection. Levels of reactive oxygen species (ROS) were assessed by luminol-dependant chemiluminescence. The total antioxidant capacity (TAC) was quantified by ELISA. The Sperm chromatin structure assay (SCSA) was performed by flow cytometry to determine DNA fragmentation Index (DFI). Statistical analysis was performed using SPSS version 15 and parameters were compared by Mann-Whitney test. Pearson correlation test was used to find the correlation between parameters and a p-value <0.05 was considered significant. Receiver operating characteristics (ROC) curve analysis was applied to find out the cut-off value of DNA fragmentation index. Results: No significant differences in age, seminal volume, liquefaction time, pH and sperm concentration were observed between the male partner of iRPL cases and the controls, but sperm morphology and motility were significantly (p <0.05) lower in the male partner of cases with idiopathic recurrent spontaneous abortion (RSA). The mean ROS levels observed were 47427.00 relative light unit (RLU)/min/20 million sperm in the male partners as com-pared to 13644.57 RLU/ min/20 million sperm in the controls (normal <15000 RLU/min/20 million). The mean TAC levels in the controls (6.95 mM trolox) were significantly (p <0.05) higher as compared to the male partners of women with IRPL (2.98 mM trolox). The average mean DFI of male partners were found to be 23.37±9.9 and the mean DFI of controls was 13.89±5.40. The mean DFI was significantly (p <0.05) higher when compared to the controls. The range of DFI in male partners was 8.50−44.07. However, in the controls the range was 7.70–23.50. Conclusion: Sperm DNA integrity is critical for normal embryonic development and birth of healthy offspring. Oxidative stress due to the imbalance between raised free radical levels and low total antioxidant capacity is one of the critical causes of DNA damage. Thus assay of oxidative stress and sperm genomic integrity is essential in couples with iRSA following natural and spontaneous conception. 267 277 Syed Nazar SN Imam Syed Nazar Imam Laboratory for Molecular Reproduction and Genetics, Department of Anatomy, All India Institute of Medical Sciences Laboratory for Molecular Reproduction and Genetics, Department of Anatomy, All India Institute of Medical Sciences India Monis M Bilal Shamsi Monis Bilal Shamsi Laboratory for Molecular Reproduction and Genetics, Department of Anatomy, All India Institute of Medical Sciences Laboratory for Molecular Reproduction and Genetics, Department of Anatomy, All India Institute of Medical Sciences India Kishlay K Kumar Kishlay Kumar Laboratory for Molecular Reproduction and Genetics, Department of Anatomy, All India Institute of Medical Sciences Laboratory for Molecular Reproduction and Genetics, Department of Anatomy, All India Institute of Medical Sciences India Dipika D Deka Dipika Deka Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences India Rima R Dada Rima Dada Laboratory for Molecular Reproduction and Genetics, Department of Anatomy, All India Institute of Medical Sciences Laboratory for Molecular Reproduction and Genetics, Department of Anatomy, All India Institute of Medical Sciences India rima_dada@rediffmail.com Oxidative stressReactive oxygen speciesRecurrent spontaneous abortionSperm DNA damageSperm chromatin structure assay 477.pdf Ford HB, Schust DJ. 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Adequate ovarian follicular status does not prevent the decrease in pregnancy rates associated with high sperm DNA fragmentation. Fertil Steril. 2008;89 (1):92-7.##Aitken RJ, Baker MA, Sawyer D. Oxidative stress in the male germ line and its role in the aetiology of male infertility and genetic disease. Reprod Biomed Online. 2003;7(1):65-70.##Aitken RJ, De Iuliis GN. Origins and consequences of DNA damage in male germ cells. Reprod Biomed Online. 2007;14(6):727-33.##Aitken RJ, De Iuliis GN, McLachlan RI. Biological and clinical significance of DNA damage in the male germ line. Int J Androl. 2009;32(1):46-56.##Dada R, Kumar R, Shamsi MB, Tanwar M, Pathak D, Venkatesh S, et al. Genetic screening in couples experiencing recurrent assisted procreation failure. Indian J Biochem Biophys. 2008;45(2):116-20.##Kumar R, Venkatesh S, Kumar M, Tanwar M, Shasmsi MB, Kumar R, et al. Oxidative stress and sperm mitochondrial DNA mutation in idiopathic oligoasthenozoospermic men. Indian J Biochem Biophys. 2009;46(2):172-7.##Venkatesh S, Kumar R, Deka D, Deecaraman M, Dada R. Analysis of sperm nuclear protein gene polymorphisms and DNA integrity in infertile men. Syst Biol Reprod Med. 2011;57(3):124-32.##Sikka SC, Rajasekaran M, Hellstrom WJ. Role of oxidative stress and antioxidants in male infertility. J Androl. 1995;16(6):464-8.##Makker K, Agarwal A, Sharma R. Oxidative stress & male infertility. Indian J Med Res. 2009;129(4): 357-67.##de Lamirande E, Gagnon C. Reactive oxygen species and human spermatozoa. I. Effects on the motility of intact spermatozoa and on sperm axonemes. J Androl. 1992;13(5):368-78.##de Lamirande E, Gagnon C. Reactive oxygen species and human spermatozoa. II. Depletion of adenosine triphosphate plays an important role in the inhibition of sperm motility. J Androl. 1992;13 (5):379-86.##Mahfouz R, Sharma R, Thiyagarajan A, Kale V, Gupta S, Sabanegh E, et al. Semen characteristics and sperm DNA fragmentation in infertile men with low and high levels of seminal reactive oxygen species. Fertil Steril. 2010;94(6):2141-6.##Alvarez JG, Touchstone JC, Blasco L, Storey BT. Spontaneous lipid peroxidation and production of hydrogen peroxide and superoxide in human spermatozoa. Superoxide dismutase as major enzyme protectant against oxygen toxicity. J Androl. 1987;8(5):338-48.##Aitken RJ, Harkiss D, Buckingham DW. Analysis of lipid peroxidation mechanisms in human spermatozoa. Mol Reprod Dev. 1993;35(3):302-15.##Darley-Usmar V, Wiseman H, Halliwell B. Nitric oxide and oxygen radicals: a question of balance. FEBS Lett. 1995;369(2-3):131-5.##Aitken RJ, West K, Buckingham D. Leukocytic infiltration into the human ejaculate and its association with semen quality, oxidative stress, and sperm function. J Androl. 1994;15(4):343-52.##Irvine DS, Twigg JP, Gordon EL, Fulton N, Milne PA, Aitken RJ. DNA integrity in human spermatozoa: relationships with semen quality. J Androl. 2000;21(1):33-44.##Saleh RA, Agarwal A, Kandirali E, Sharma RK, Thomas AJ, Nada EA, et al. Leukocytospermia is associated with increased reactive oxygen species production by human spermatozoa. Fertil Steril. 2002;78(6):1215-24.##Gomez E, Buckingham DW, Brindle J, Lanzafame F, Irvine DS, Aitken RJ. Development of an image analysis system to monitor the retention of residual cytoplasm by human spermatozoa: correlation with biochemical markers of the cytoplasmic space, oxidative stress, and sperm function. J Androl. 1996; 17(3):276-87.##Ochsendorf FR. Infections in the male genital tract and reactive oxygen species. Hum Reprod Update. 1999;5(5):399-420.##Hughes CM, Lewis SE, McKelvey-Martin VJ, Thompson W. A comparison of baseline and induced DNA damage in human spermatozoa from fertile and infertile men, using a modified comet assay. Mol Hum Reprod. 1996;2(8):613-9.##Bakos HW, Thompson JG, Feil D, Lane M. Sperm DNA damage is associated with assisted reproductive technology pregnancy. Int J Androl. 2008;31 (5):518-26.##Hud NV, Vilfan ID. Toroidal DNA condensates: unraveling the fine structure and the role of nucleation in determining size. Annu Rev Biophys Biomol Struct. 2005;34:295-318.##Brewer L, Corzett M, Lau EY, Balhorn R. Dynamics of protamine 1 binding to single DNA molecules. J Biol Chem. 2003;278(43):42403-8.##Steger K, Pauls K, Klonisch T, Franke FE, Bergmann M. Expression of protamine-1 and -2 mRNA during human spermiogenesis. Mol Hum Reprod. 2000;6(3):219-25.##Sakkas D, Mariethoz E, Manicardi G, Bizzaro D, Bianchi PG, Bianchi U. Origin of DNA damage in ejaculated human spermatozoa. Rev Reprod. 1999; 4(1):31-7.##Hammoud SS, Nix DA, Zhang H, Purwar J, Carrell DT, Cairns BR. Distinctive chromatin in human sperm packages genes for embryo development. Nature. 2009;460(7254):473-8.##Gineitis AA, Zalenskaya IA, Yau PM, Bradbury EM, Zalensky AO. Human sperm telomere-binding complex involves histone H2B and secures telomere membrane attachment. J Cell Biol. 2000;151 (7):1591-8.##

The Role of Cervical Cerclage in Pregnancy Outcome in Women with Uterine Anomaly 2 1 2 Background: Congenital uterine malformations are the result of disturbances in mullerian duct development. In patients with recurrent miscarriage, the reported frequency of uterine anomalies varies widely, from 1.8% to 37.6%. There are reports in which cervical cerclage has been shown to prevent preterm labor in uterine anomalies. The aim of this study was to compare the role of cervical cerclage in the pregnancy outcome of women with uterine anomaly. Methods: In this historical cohort study, 40 pregnant women with uterine anomaly were investigated for outcomes of pregnancy in regards to preterm and term deliveries. The participants were divided into two groups: the case group included 26 women with uterine anomaly for whom cervical cerclage was done and the control group was composed of 14 women with uterine anomaly in whom cervical cerclage was not performed. Comparison between the two groups was done and the data were analyzed by the use of chi square, Fisher’s exact test and t-test with SPSS software (version 11) and p <0.05 was considered significant. Results: In patients with bicornuate uterus and cervical cerclage, term delivery occurred in 76.2% and preterm delivery in 23.8%. In patients with bicornuate uterus and without cervical cerclage, term delivery occurred in 27.3% and preterm delivery in 72.7% (p <0.05). In patients with arcuate uterus and cervical cerclage, term and preterm deliveries were equal (50% vs. 50%), but in patients with arcuate uterus and without cervical cerclage, term and preterm deliveries occurred in 66.6% and 33.3% of the participants, respectively. Conclusion: Cervical cerclage is an effective procedure in bicornuate uterus for the prevention of preterm deliveries but it has no effect on the outcome of pregnancy in arcuate uterus. 277 280 Fakhrolmolouk F Yassaee Fakhrolmolouk Yassaee Department of Obstet . and Gynecol Faculty of Medicine, Shahid Beheshti Medical Sciences University Department of Obstet . and Gynecol Faculty of Medicine, Shahid Beheshti Medical Sciences University Iran dr_fyass@yahoo.com Leila L Mostafaee Leila Mostafaee Department of Obstet . and Gynecol Faculty of Medicine, Shahid Beheshti Medical Sciences University Department of Obstet . and Gynecol Faculty of Medicine, Shahid Beheshti Medical Sciences University Iran Cervical cerclagePrenatal outcomeUterine anomalies 478.pdf James DK, Steer PJ, Weiner CP, Gonik B. High Risk Pregnancy Management Options. 3rd ed. London: Elsevier; 2005. p. 107-8.##Simcox R, Shennan A. Cervical cerclage in the prevention of preterm birth. Best Pract Res Clin Obstet Gynaecol. 2007;21(5):831-42.##Reichman D, Laufer MR, Robinson BK. Pregnancy outcomes in unicornuate uteri: a review. Fertil Steril. 2009;91(5):1886-94.##Golan A, Langer R, Wexler S, Segev E, Niv D, David MP. Cervical cerclage--its role in the pregnant anomalous uterus. Int J Fertil. 1990;35(3):164-70.##Leo L, Arduino S, Febo G, Tessarolo M, Lauricella A, Wierdis T, et al. Cervical cerclage for malformed uterus. Clin Exp Obstet Gynecol. 1997;24(2):104-6.##Abramovici H, Faktor JH, Pascal B. Congenital uterine malformations as indication for cervical suture (cerclage) in habitual abortion and premature delivery. Int J Fertil. 1983;28(3):161-4.##Althuisius SM, Dekker GA, Hummel P, Bekedam DJ, van Geijn HP. Final results of the Cervical Incompetence Prevention Randomized Cerclage Trial (CIPRACT): therapeutic cerclage with bed rest versus bed rest alone. Am J Obstet Gynecol. 2001; 185(5):1106-12.##Pereira L, Cotter A, Gómez R, Berghella V, Prasert charoensuk W, Rasanen J, et al. Expectant management compared with physical examination-indicated cerclage (EM-PEC) in selected women with a dilated cervix at 14(0/7)-25(6/7) weeks: results from the EM-PEC international cohort study. Am J Obstet Gynecol. 2007;197(5):483.e1-8.##Cahill AG, Odibo A, Willers DM, Chang JJ, Shanks A, Goetzinger K. Cervical dilation in mid-pregnancy: expectant management versus cerclage: a study by Pereira et al. Am J Obstet Gynecol. 2007; 197(5):551-2.##Jorgensen AL, Alfirevic Z, Tudur Smith C, Williamson PR; cerclage IPD Meta-analysis Group. Cervical stitch (cerclage) for preventing pregnancy loss: individual patient data meta-analysis. BJOG. 2007;114(12):1460-76.##Incerti M, Ghidini A, Locatelli A, Poggi SH, Pezzullo JC. Cervical length < or = 25 mm in low-risk women: a case control study of cerclage with rest vs rest alone. Am J Obstet Gynecol. 2007;197(3): 315.e1-4.##Eskandar M, Shafiq H, Almushait MA, Sobande A, Bahar AM. Cervical cerclage for prevention of preterm birth in women with twin pregnancy. Int J Gynaecol Obstet. 2007;99(2):110-2.##Woodring TC, Klauser CK, Cromartie DA, Magann EF, Chauhan SP, Morrison JC. When is a cerclage indicated for cervical insufficiency? A literature review. J Miss State Med Assoc. 2006;47 (9):264-6.##

Married Iranian Women’s Knowledge, Attitude and Sense of Self-efficacy about Oral Contraceptives: Focus Group Discussion 2 1 2 Background: Oral contraceptive pills effectiveness is lower in actual use than in clinical trials. The views of a group of married Iranian women were sought as a step toward improving the enhanced use of contraceptive pills. Methods: Two focus groups of current pill users (n=13) and two focus groups of women not currently taking the pills (n=14) were held. Leaders trained facilitators; themes were identified from line-by-line analysis of transcripts. Results: The majority of the participants were primary school graduates with a mean age of 34 years. Knowledge about mechanisms of action was low; some women wanted more information. Both users and non-users recognized positive and negative characteristics of contraceptive pills. For non-users, physical and emotional side effects were the most important; and anecdotal information from their social network was more important. They tended to trust more traditional methods. For users, their own experience and more reality-based understanding of side-effects mitigated concerns about side-effects. They also felt that health clinic staff had a negative attitude toward the pills. A stronger expression of self-efficacy seemed to be associated with more positive attitudes toward oral contraceptive pills. Conclusion: Although Iran has had a government-funded family planning program since 1990, and pills are the single most popular modern contraceptive method, women who take OCPs can provide important information that could increase effective health education about their use. 281 289 Noushin N Peyman نوشین پیمان Department of Health Education, Mashhad University of Medical Sciences Department of Health Education, Mashhad University of Medical Sciences Iran peymanN@mums.ac.ir Deborah D Oakley Deborah Oakley School of Nursing, University of Michigan School of Nursing, University of Michigan USA ContraceptionFamily planningReproductive healthWomen’s health 479.pdf Mosher WD, Jones J. Use of contraception in the United States: 1982-2008. Vital Health Stat 23. 2010;(29):1-44.##Bongaarts J, Johansson E. Future trends in contraceptive prevalence and method mix in the developing world. Stud Fam Plann. 2002;33(1):24-36.##Iranian Ministry of Health. [DHS Survey: Population and Health in the Islamic Republic of Iran]. 1st ed. Tehran: Unicef, Iranian Ministry of Health and Medical Education; 2000. p. 1-167. Persian.##Shah NM, Shah MA, Chowdhury RI, Menon I. Reasons and correlates of contraceptive discontinuation in Kuwait. Eur J Contracept Reprod Health Care. 2007;12(3):260-8.##Karavus M, Cali S, Kalaca S, Cebeci D. Attitudes of married individuals towards oral contraceptives: a qualitative study in Istanbul, Turkey. J Fam Plann Reprod Health Care. 2004;30(2):95-8.##Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J, Nelson AL, Cates W, Stewart FH, Kowal D, editors. Contraceptive technology. New York: Ardent Media; 2007. p. 747–826.##Rahnama P, Hidarnia A, Shokravi FA, Kazemnejad A, Oakley D, Montazeri A. Why Iranian married women use withdrawal instead of oral contraceptives? A qualitative study from Iran. BMC Public Health. 2010;10:289.##Prachi R, Das GS, Ankur B, Shipra J, Binita K. A study of knowledge, attitude and practice of family planning among the women of reproductive age group in Sikkim. J Obstet Gynecol India. 2008;58 (1):63-7.##Bandura A. Psychological Modeling: Conflicting Theories. 2nd ed. New York: ldine Press; 2006. p. 56.##Aker S, Boke O, Dundar C, Peksen Y. The effects of temperament and character on the choice of contraceptive methods. Eur J Contracept Reprod Health Care. 2007;12(4):378-84.##Peyman N, Hidarnia A, Ghofranipour F, Kazemnezhad A, Oakley D, Khodaee G, et al. Self-efficacy: does it predict the effectiveness of contraceptive use in Iranian women? East Mediterr Health J. 2009;15(5):1254-62.##Peyman N, Oakley D. Effective contraceptive use: an exploration of theory-based influences. Health Educ Res. 2009;24(4):575-85.##Peyman N, Heidarnia A, Ghofranipour F, Kazemnejad A, Amin Shokravi F. [The influence of modified Steps to Behavior Change model on Oral Contraceptive use]. J Reprod Infertil. 2009;10(1): 58-70. Persian.##van Teijlingen E, Forrest K. The range of quailtative research methods in family planning and reproductive health care. J Fam Plann Reprod Health Care. 2004;30(3):171-3.##Silverman D. Qualitative research: theory, method and practice. 1st ed. London: Sage Publications; 2004. p. 283.##Bender DE, Ewbank D. The focus group as a tool for health research: issues in design and analysis. Health Transit Rev. 1994;4(1):63-80.##Naomi RH. Managing Moderator Stress: Take a Deep Breath. You Can Do This! Market Res. 2009; 21(1):28-9.##Patton MQ. Qualitative evaluation and research methods. 2nd ed. Newbury Park: Sage Publications; 1990. p. 132##Tang KC, Davis A. Critical factors in the determination of focus group size. Fam Pract. 1995;12(4): 474-5.##Fitzpatrick R, Boulton M. Qualitative methods for assessing health care. Qual Health Care. 1994;3(2): 107-13.##Creswell JW. Research design: qualitative, quantitative, and mixed methods approaches. 3rd ed. London: Sage Publications; 2008. p. 173-90##Rakhshani F, Mohammadi M. Contraception continuation rates and reasons for discontinuation in Zahedan, Islamic Republic of Iran. East Mediterr Health J. 2004;10(3):260-7.##Sullivan TM, Bertrand JT, Rice J, Shelton JD. Skewed contraceptive method mix: why it happens, why it matters. J Biosoc Sci. 2006;38(4):501-21.##Otoide VO, Oronsaye F, Okonofua FE. Why Nigerian Adolescents Seek Abortion Rather than Contraception: Evidence from Focus-Group Discussions. Int Fam Plan Perspect. 2001;27(2):77-81.##Sihvo S, Hemminki E, Kosunen E. Contraceptive health risks--women's perceptions. J Psychosom Obstet Gynaecol. 1998;19(3):117-25.##Popov AA, Visser AP, Ketting E. Contraceptive knowledge, attitudes, and practice in Russia during the 1980s. Stud Fam Plann. 1993;24(4):227-35.##Davis A, Wysocki S. Clinician/patient interaction: communicating the benefits and risks of oral contraceptives. Contraception. 1999;59(1 Suppl):39S-42S.##Taylor MJ, Farmer A, Craig C. Women's knowledge of the contraceptive pill: the results of a focus group. Br J Fam Plann. 1995;21(1):27-9.##Oddens BJ. Women's satisfaction with birth control: a population survey of physical and psycho-logical effects of oral contraceptives, intrauterine devices, condoms, natural family planning, and sterilization among 1466 women. Contraception. 1999;59(5):277-86.##

Specialists’ Attitude toward Appropriate Number of Transferable Embryos in Assisted Reproductive Technology in Iran 2 1 2 Background: In recent years, the high likelihood of the implantation of transferred embryos has led to an increase in the number of multiple pregnancies and consequently an increased risk of complications in fetuses and mothers. Since the aim of infertility treatment is the birth of a healthy child while preserving the mother’s health, therefore, attempts should be made to avoid multiple pregnancies as much as possible besides maintaining the women’s chance of pregnancy by transferring an appropriate number of embryos. Methods: The population under study consisted of specialists (gynecologists and embryologists) who worked in ART clinics across the country and had attended an infertility congress in Tehran in 2008. The devised questionnaire enquired about the infertility specialists’ attitude towards the appropriate number of transferable embryos. The questions were designed on a Likert scale of strongly agree, agree, indif-ferent, disagree and strongly disagree. The scores of the questionnaire ranged from 0–60 which were later scaled up to 100 for ease of data analysis. Accordingly, scores below 50 were considered as “negative”, 50−75 “moderate” and greater than 75 as “positive”. Results: Overall, 9.9% of the specialists gained a score less than 50 (negative view), 67.3% between 50−75 (moderate) and 22.8% greater than 75 (positive view). Conclusion: The infertility specialists in Iran are relatively reluctant to transfer a high number of embryos for infertility treatments. 289 295 Zohreh Z Behjati Ardakani Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Malihe Zaman M Momeniha Malihe Zaman Momeniha Avicenna Infertility Clinic, Avicenna Research Institute (ACECR) Avicenna Infertility Clinic, Avicenna Research Institute (ACECR) Iran Fereshteh F Azedi Fereshteh Azedi Nanobiotechnology Research Center, Avicenna Research Institute (ACECR) Nanobiotechnology Research Center, Avicenna Research Institute (ACECR) Iran Kourosh K Kamali Monoclonal Antibody Research Center, Avicenna Research Institute (ACECR) Monoclonal Antibody Research Center, Avicenna Research Institute (ACECR) Iran Mohammad Mehdi MM Akhondi محمدمهدی آخوندی Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran akhondi@avicenna.ac.ir Assisted Reproductive TechniquesComplicationsEmbryoMultiple pregnancies 480.pdf U.S. Department of Health and Human Services Centers for Disease Control and Prevention. Assisted Reproductive Technology Success Rates. Atlanta: Centers for Disease Control and Prevention (CDC); 2006 Ombelet W, Campo R. Affordable IVF for developing countries. Reprod Biomed Online. 2007;15 (3):257-65.##Wang YA, Healy D, Black D, Sullivan EA. Age specific success rate for women undertaking their first assisted reproduction technology treatment using their own oocytes in Australia, 2002-2005. Hum Reprod. 2008;23(7):1633-8.##Stern JE, Cedars MI, Jain T, Klein NA, Beaird CM, Grainger DA, et al. Assisted reproductive technology practice patterns and the impact of embryo transfer guidelines in the United States. Fertil Steril. 2007;88(2):275-82.##Human Fertilization Embryology Authority [Internet]. London: HFEA; Multiple births and single embryo transfer review; 2009 April 7 [cited 2011 Oct 10]; [about 1 screen]. Available from: http:// www.hfea.gov.uk/530.html##Helmerhorst FM, Perquin DA, Donker D, Keirse MJ. Perinatal outcome of singletons and twins after assisted conception: a systematic review of controlled studies. BMJ. 2004;328(7434):261.##Koudstaal J, Braat DD, Bruinse HW, Naaktgeboren N, Vermeiden JP, Visser GH. Obstetric outcome of singleton pregnancies after IVF: a matched control study in four Dutch university hospitals. Hum Reprod. 2000;15(8):1819-25##Pinborg A. IVF/ICSI twin pregnancies: risks and prevention. Hum Reprod Update. 2005;11(6):575-93.##Lukassen HG, Schönbeck Y, Adang EM, Braat DD, Zielhuis GA, Kremer JA. Cost analysis of singleton versus twin pregnancies after in vitro fertilization. Fertil Steril. 2004;81(5):1240-6.##Sundby J. Infertility in the Gambia: traditional and modern health care. Patient Educ Couns. 1997;31 (1):29-37.##Pinborg A, Loft A, Schmidt L, Andersen AN. Attitudes of IVF/ICSI-twin mothers towards twins and single embryo transfer. Hum Reprod. 2003;18(3): 621-7.##Ahmadi SM, Akhondi MA, Behjati Ardekani Z. Embryo reduction in multiple pregnancies. J Reprod Infertil. 2005;6(4):441-9.##Koivurova S, Hartikainen AL, Gissler M, Hemminki E, Klemetti R, Järvelin MR. Health care costs resulting from IVF: prenatal and neonatal periods. Hum Reprod. 2004;19(12):2798-805.##van Peperstraten AM, Hermens RP, Nelen WL, Stalmeier PF, Scheffer GJ, Grol RP, et al. Perceived barriers to elective single embryo transfer among IVF professionals: a national survey. Hum Reprod. 2008;23(12):2718-23.##Berin I, Engmann LL, Benadiva CA, Schmidt DW, Nulsen JC, Maier DB. Transfer of two versus three embryos in women less than 40 years old undergoing frozen transfer cycles. Fertil Steril. 2010;93 (2):355-9.##Lee TH, Chen CD, Tsai YY, Chang LJ, Ho HN, Yang YS. Embryo quality is more important for younger women whereas age is more important for older women with regard to in vitro fertilization outcome and multiple pregnancy. Fertil Steril. 2006;86(1):64-9.##Berkowitz RL, Lynch L, Stone J, Alvarez M, Berkowitz RL, Lynch L, et al. The current status of multifetal pregnancy reduction. Am J Obstet Gynecol. 1996;174(4):1265-72.##

Study of Body Image in Fertile and Infertile Men 2 1 2 Background: Body Image as a multidimensional entity is related to both physical and psychological aspects of the image one has of his or her own body. Lack/absence of an acceptable body image is one of the reasons of mental distress in infertile individuals. Methods: In this study, an equal number (No=120) of fertile and infertile men attending Avicenna Infertility Clinic (AIC) were enrolled. The participants were compared in regard to body image variables based on the "Multidimensional Body-Self Relations Questionnaire (MBSRQ)" consisting of 10 subscales. Data was analyzed by SPSS, version 11.5, using Chi square and independent t-tests. Results: Fertile men had a more positive body image as compared to infertile individuals. Significant statistical differences were observed when body image subscales were compared in both groups; in other words appearance evaluation, appearance orientation, Novy, health evaluation, health orientation, illness orientation, body satisfaction, overweight preoccupation and self-classified weight showed differences, while no significant difference was observed in regard to fitness orientation. Conclusion: It seems that the ability and efficiency of body image is affected by infertility leading to dissatisfaction of one’s body image. 295 299 Mohammad Mehdi MM Akhondi محمدمهدی آخوندی Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Asghar A Dadkhah Asghar Dadkhah Department of Clinical Psychology, University of welfare & Rehabilitation Department of Clinical Psychology, University of welfare & Rehabilitation Iran Ahmad A Bagherpour Ahmad Bagherpour Department of Clinical Psychology, University of welfare & Rehabilitation Department of Clinical Psychology, University of welfare & Rehabilitation Iran Zohreh Z Behjati Ardakani Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Kourosh K Kamali Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Sima S Binaafar Sima Binaafar Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Haleh H Kosari Haleh Kosari Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Behzad B Ghorbani بهزاد قربانی Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran B.Ghorbani@avicenna.ac.ir Body imageInfertilityMultidimensional Body-Self Relations QuestionnaireSelf perception 481.pdf Humphreys P, Paxton SJ. Impact of exposure to idealised male images on adolescent boys' body image. Body Image. 2004;1(3):253-66.##Edwards S, Launder C. Investigating muscularity concerns in male body image: development of the Swansea Muscularity Attitudes Questionnaire. Int J Eat Disord. 2000;28(1):120-4.##Connolly KJ, Edelmann RJ, Cooke ID, Robson J. The impact of infertility on psychological functioning. J Psychosom Res. 1992;36(5):459-68.##Smolak L, Levine MP, Thompson JK. The use of the sociocultural attitudes towards appearance questionnaire with middle school boys and girls. Int J Eat Disord. 2001;29(2):216-23.##Durand RJ, Castracane VD, Hollander DB, Tryniecki JL, Bamman MM, O'Neal S, et al. Hormonal responses from concentric and eccentric muscle contractions. Med Sci Sports Exerc. 2003;35(6):937-43.##Younesi SJ, Salagegheh A. [Body image in fertile and infertile women]. J Reprod Infertil. 2001;2(4): 14-21. Persian.##Fingeret MC, Gleaves DH. Sociocultural, feminist, and psychological influences on women's body satisfaction: a structural modeling analyss. Psychol Women Q. 2004;28(4):370-80.##Agliata D, Tantleff-Dunn S. The impact of media exposure on males’ body image. J Soc Clin Psychol. 2004;23(1):7-22.##Wheeler L. Individual differences in social comparison. In: Suls JM, Wheeler L. Handbook of social comparison: theory and research. New York: Kluwer Academic/Plenum; 2000. p. 141-58.##Naseri Tafti N, Pakdaman Sh, Asgari A. [The role of sport and personality traits in psychological development of students]. J Iran Psychol. 2008;5(1): 53-62. Persian.##Cooper-Hilbert B. Infertility and involuntary childlessness: helping couples cope. New York: Norton; 2001. p. 82-98##Haber D. Life review: implementation, theory, research, and therapy. Int J Aging Hum Dev. 2006; 63(2):153-71.##Cash TF. The multidimensional body-self relations questionnaire. Center for Disease Control and Prevention. Washington DC: National Health Interview Survey; 2002.##O'Dea JA, Caputi P. Association between socioeconomic status, weight, age and gender, and the body image and weight control practices of 6 to 19-year-old children and adolescents. Health Educ Res. 2001;16(5):521-32.##Connolly KJ, Edelmann RJ, Coke I. Distress and marital problems associated with infertility. J Reprod Infant Psychol. 1987;5(1):49-57.##Salter M. Altered body images. 2nd ed. London: Baillier; 1997. p. 78-85.##Daniluk J. Gender and infertility. In: Leiblum SR. Infertility. New York: John Wiley and Sons; 2001. p. 43-50.##Gibson DM, Myers JE. Gender and Infertility: A Relational Approach To Counseling Women. J Couns Dev. 2000;7(4):400-10.##Cash TF. The psychology of physical appearance: aesthetics, attributes, and images. In: Cash TF, Pruzinsky T, editors. Body images: development, deviance, and change. New York: Guilford Press; 1990. p. 112-25.##Humphreys P, Paxton SJ. Impact of exposure to idealised male images on adolescent boys’ body image. Body Image. 2004;1(3):253-66.##Menning BE. The emotional needs of infertile couples. Fertil Steril. 1980;34(4):313-9.##Greil AL. Infertility and psychological distress: a critical review of the literature. Soc Sci Med. 1997; 45(11):1679-704.##Nasseri M. Cultural similarities in psychological reactions to infertility. Psychol Rep. 2000;86(2): 375-8.##Lee SH, Kuo BJ. Chinese traditional childbearing attitudes and infertile couples in Taiwan. J Nurs Scholarsh. 2000;32(1):54.##Mahlstedt PP. The psychological component of infertility. Fertil Steril. 1985;43(3):335-46.##