Introduction of Sensitive and Specific Biomarkers Can Improve Infertility Treatment Success Rates 2 1 574 2 Approximately 20% of couples of reproductive age need assisted reproductive technologies to conceive, in spite of sophisticated improvement in the diagnosis and treatment of infertility. The cause of 30% of infer-tilities is unknown and less than 50% of couples are conceived by each treatment cycle using advanced as-sisted reproductive technologies. In the present clinical practice, many steps in the whole spectrum of diagnosis to treatment of infertility are based on the use of ambiguous biomarkers or less related ones. Moreover, there are even no specific bio-markers available to determine the causes and outcomes of infertility. Consequently, this condition leads to the blind performance of many diagnostic and treatment procedure with less desirable outcomes (1). Fortunately, introduction of more specific and sensitive biomarkers with less invasive methods has lead to early detection and efficient treatment of most diseases. Biomarkers have found wide application in research and clinic and they are useful for screening, risk assessment, diagnosis, stage determination and grading of diseases. They are also useful for the selection of treatment procedures and monitoring cure or recurrence of diseases. Application of new technologies such as genomics, proteomics, transcriptomics, metabolomics, microarray, CGH and other high throughput techniques has provided several potential biomarkers at four basic levels of cell biology including DNA, RNA, protein and metabolites for early diagnosis and treatment of diseases (2). Reproduction and infertility has not been left out from this progress. Most research on human reproduction and infertility aiming to increase the rate of take home baby and fetal-maternal health will not materialize without the availability of more sensitive, specific and non-invasive biomarkers. Moreover, efficient treatment of male or female infertility is dependent on the identification of a vast range of biomarkers to represent the exact information on ovarian reserve, ovarian response to stimulation protocols, number and quality of oocytes during stimulation, sperm quality, presence and quality of sperm in non-obstructive azoospermia, embryo quality, and endometrial receptivity. Nowadays, most biomarkers are based on the morphological criteria of gonads, gametes and embryos. Sev-eral studies have shown a poor correlation between clinical and functional outcomes with the results of con-ventional fertility evaluations (3). For example, sperm criteria including concentration, motility and morph-ology are well accepted as biomarkers for semen analysis and are first line biomarkers in evaluating male fertility, but in large numbers of men results of these biomarkers have been in contrast with the function and fertilizing ability of sperm. This means that many fertile men with severe abnormality in semen or vice versa many infertile men would seemingly have normal results (4). Therefore, it is the time to shift form morpho-logical and invasive biomarkers to non-invasive molecular biomarkers with high sensitivity and specificity. In the case of sperm biomarkers, molecular and functional biomarkers such as chromatin maturity and integ-rity are available now. Different staining and flow cytometric methods could detect and separate non-functional sperm with defective chromatin, but the evaluation procedure could lead to the destruction of the sperm before it can be used for ART. New generation of biomarkers should provide the exact information about ovaries, testis, sperm, oocytes, embryos and endometrium without any deleterious effects on their function during an IVF cycle. Although scientists actively are in search of new efficient biomarkers and verification process of biomarker function takes a long time, but it should be pointed out that infertile couples are eagerly awaiting increased ART suc-cess rates. 069 71 Mohammad Reza MR Sadeghi محمدرضا صادقی Editor-in-chief Editor-in-chief Iran No Keyword 574.pdf Ray A, Shah A, Gudi A, Homburg R. Unexplained infertility: an update and review of practice. Reprod Biomed Online. 2012 Mar 7. [Epub ahead of print]##Classen S, Staratschek-Jox A, Schultze JL. Use of genome-wide high-throughput technologies in biomarker development. Biomark Med. 2008;2(5):509-24.##Seli E, Robert C, Sirard MA. OMICS in assisted reproduction: possibilities and pitfalls. Mol Hum Reprod. 2010;16(8):513-30.##Muratori M, Marchiani S, Tamburrino L, Tocci V, Failli P, Forti G, et al. Nuclear staining identifies two populations of human sperm with different DNA fragmentation extent and relationship with semen parameters. Hum Reprod. 2008;23(5):1035-43.##

Investigating Marital Relationship in Infertility: A Systematic Review of Quantitative Studies 2 1 2 Background: Infertility is a complex issue that affects individuals and groups, and also it has serious implications for the mental and social well-being of those involved. The aim of this review was to assess marital relationship in the context of infertility, using data from infertile individuals or both couples. Methods: A literature search was undertaken using multiple databases (Medline, PsycInfo and Scopus) to identify and synthesize all relevant literature published from 1990 to 2011. All studies in the systematic review were confirmed using specific inclusion criteria; the methodological quality of these studies were examined according to a checklist. Results: Of the potential 794 articles, 18 studies were included in the final analysis, of which 6 were graded as high quality and 12 as moderate. The results indicated male factor infertility did not have a negative marital impact. In addition, infertile male participants expressed higher marital satisfaction than their wives. Infertile females had significantly less stable marital relationship compared to fertile females, which was associated with their socio-demographics and treatment experience. For infertile couples, the infertile subjects or their partners’ marital relationship was affected by either member’s infertility, experience specifically coping strategies. Moreover other factors such as sexual satisfaction, age of the infertile couples, education level, and congruency of couples’ perceptions of infertility were associated with the quality of martial relationship. Conclusion: Although the review can provide an outline of marital relationship in infertility, future studies should focus on the perspective from both infertile couple, across a range of different infertility types, including extended sample sizes and longitudinal study designs. In addition, more consideration should be given to qualitative study. 071 81 Peng P Tao Peng Tao Research and Education Center in Sexual Health, School of Public Health, Harbin Medical University Research and Education Center in Sexual Health, School of Public Health, Harbin Medical University China pengtao1@china.com Rosemary R Coates Rosemary Coates Department of Sexology, School of Public Health, Curtin University, Perth Department of Sexology, School of Public Health, Curtin University, Perth Australia Bruce B Maycock Bruce Maycock Curtin Health Innovation Research Institute, Curtin University Curtin Health Innovation Research Institute, Curtin University Australia FemaleInfertile couplesInfertilityMaleMarital relationship 487.pdf World Health Organization. Recent advances in medically assisted conception. Report of a WHO Scientific Group. 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Does infertility cause marital benefit? An epidemiological study of 2250 women and men in fertility treatment. Patient Educ Couns. 2005;59(3):244-51.##Abbey A, Andrews FM, Halman LJ. Provision and receipt of social support and disregard: what is their impact on the marital life quality of infertile and fertile couples? J Pers Soc Psychol. 1995;68 (3):455-69.##Chandra PS, Chaturvedi SK, lssac MK, Chitra H, Sudarshan CY, Beena MB. Marital life among infertile spouses: the wife’s perspective and its implications in therapy. Fam Ther. 1991;18(2):145-54.##Ramezanzadeh F, Aghssa MM, Jafarabadi M, Zayeri F. Alterations of sexual desire and satisfaction in male partners of infertile couples. Fertil Steril. 2006;85(1):139-43.##Hirsch AM, Hirsch SM. The effect of infertility on marriage and self-concept. J Obstet Gynecol Neonatal Nurs. 1989;18(1):13-20.##Chachamovich J, Chachamovich E, Fleck MP, Cordova FP, Knauth D, Passos E. Congruence of quality of life among infertile men and women: findings from a couple-based study. Hum Reprod. 2009;24(9):2151-7.##Schmidt L, Holstein BE, Boivin J, Tjørnhøj-Thomsen T, Blaabjerg J, Hald F, et al. High ratings of satisfaction with fertility treatment are common: findings from the Copenhagen Multi-centre Psychosocial Infertility (COMPI) Research Programme. Hum Reprod. 2003;18(12):2638-46.##Greil AL. Infertility and psychological distress: a critical review of the literature. Soc Sci Med. 1997; 45(11):1679-704.##Williams LM. Associations of stressful life events and marital quality. Psychol Rep. 1995;76(3 Pt 2): 1115-22.##Shek DT. Gender differences in marital quality and well-being in Chinese married adults. Sex Roles. 1995;32(11-12):699-715.##Terry DJ, Scott WA. Gender Differences In Correlates Of Marital Satisfaction. Aust J Psychol. 1987; 39(2):207-21.##Conger RD, Conger KJ, Elder Jr, Lorenz FO. Linking economic hardship to marital quality and instability. J Marriage Fam. 1990;52(3):643-56.##Chen Z, Tanaka N, Uji M, Hiramura H, Shikai N, Fujihara S, et al. The role of personalities in the marital adjustment of Japanese couples. Soc Behav Pers. 2007;35(4):561-72.##Afifi TO, MacMillan H, Cox BJ, Asmundson GJ, Stein MB, Sareen J. Mental health correlates of intimate partner violence in marital relationships in a nationally representative sample of males and females. J Interpers Violence. 2009;24(8):1398-417.##Ting-Toomey S. An analysis of verbal communication patterns in high and low marital adjustment groups. Hum Commun Res. 1983;9(4):306-19.##Karney BR, Bradbury TN. The longitudinal course of marital quality and stability: a review of theory, method, and research. Psychol Bull. 1995;118(1): 3-34.##Chachamovich JR, Chachamovich E, Ezer H, Fleck MP, Knauth DR, Passos EP. Agreement on perceptions of quality of life in couples dealing with infertility. J Obstet Gynecol Neonatal Nurs. 2010;39(5):557-65.##Booth A, Johnson DR. Declining health and marital quality. J Marriage Fam. 1994;56(1):218-23.##Newton TL, Kiecolt-Glaser JK. Hostility and erosion of marital quality during early marriage. J Behav Med. 1995;18(6):601-19.##Mols F, Vingerhoets AJ, Coebergh JW, van de Poll Franse LV. Quality of life among long-term breast cancer survivors: a systematic review. Eur J Cancer. 2005;41(17):2613-9.##Den Oudsten BL, Van Heck GL, De Vries J. Quality of life and related concepts in Parkinson's disease: a systematic review. Mov Disord. 2007;22 (11):1528-37.##Jackson N, Waters E; Guidelines for Systematic Reviews in Health Promotion and Public Health Taskforce. Criteria for the systematic review of health promotion and public health interventions. Health Promot Int. 2005;20(4):367-74.##Pullens MJ, De Vries J, Roukema JA. Subjective cognitive dysfunction in breast cancer patients: a systematic review. Psychooncology. 2010;19(11): 1127-38.##Kuijpers T, van der Windt DA, van der Heijden GJ, Bouter LM. Systematic review of prognostic cohort studies on shoulder disorders. Pain. 2004;109 (3):420-31.##Wells J, Barlow J, Stewart-Brown S. A systematic review of universal approaches to mental health promotion in schools. Health Educ. 2003;103(4): 197-220.##Ulbrich PM, Coyle AT, Llabre MM. Involuntary childlessness and marital adjustment: his and hers. J Sex Marital Ther. 1990;16(3):147-58.##Berg BJ, Wilson JF. Psychological functioning across stages of treatment for infertility. J Behav Med. 1991;14(1):11-26.##Pepe MV, Byrne T. Women's perceptions of immediate and long-term effects of failed infertility treatment on marital and sexual satisfaction. Fam Relat. 1991;40(3):303-9.##Levin JB, Sher TG, Theodos V. The effect of intracouple coping concordance on psychological and marital distress in infertility patients. J Clin Psychol Med Settings. 1997;4(4):361-72.##Markestad CL, Montgomery LM, Bartsch RA. Infertility and length of medical treatment effects on psychological, marital, and sexual functioning. Int J Rehabil Health. 1998;4(4):233-43.##Lee TY, Sun GH. Psychosocial response of Chinese infertile husbands and wives. Arch Androl. 2000;45(3):143-8.##Lee TY, Sun GH, Chao SC. The effect of an infertility diagnosis on the distress, marital and sexual satisfaction between husbands and wives in Taiwan. Hum Reprod. 2001;16(8):1762-7.##Peterson BD, Newton CR, Rosen KH. Examining congruence between partners' perceived infertility-related stress and its relationship to marital adjustment and depression in infertile couples. Fam Process. 2003;42(1):59-70.##Monga M, Alexandrescu B, Katz SE, Stein M, Ganiats T. Impact of infertility on quality of life, marital adjustment, and sexual function. Urology. 2004; 63(1):126-30.##Peterson BD, Newton CR, Rosen KH, Skaggs GE. Gender differences in how men and women who are referred for IVF cope with infertility stress. 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Lipid Peroxidation and Nitric Oxide Levels in Male Smokers' Spermatozoa and their Relation with Sperm Motility 2 1 2 Background: Nitric oxide (NO) is synthesized from L-arginine by a family of enzymes known as nitric oxide synthases. Low concentrations of NO is essential in biology and physiology of spermatozoa, but high amounts of NO is toxic and has negative effects on sperm functions. Moreover, sperm membrane contains high concentrations of polyunsaturated fatty acids that are highly susceptible to oxidative damage that interferes with fertilization ability. Therefore, we investigated the correlation between levels of sperm malondialdehyde (MDA) and NO with sperm motility in male smokers. Methods: Semen samples were collected from normozoospermic smoker (n=64) and nonsmoker (n=83) men. The content of sperm lipid peroxidation was determined by measuring malondialdehyde (MDA). The sperm NO were also measured using Griess reagent. Data was analyzed by SPSS, (version 15.0), using independent t-test and Pearson analysis. Results: The mean MDA and NO concentrations in the sperm of normozoospermic male smokers were significantly higher than the control group or normozoospermic nonsmokers, (p <0.001). A significant negative relationship was noted between sperm motility and sperm MDA levels (r=0.32- p=0.01); and sperm motility and sperm NO concentration (for nitrite, r=0.34, p=0.006 and for nitrate, r=-0.38, p=0.002). Conclusion: It was concluded that the increase in MDA and NO production in sperm can influence sperm motility in normozoospermic smokers. Therefore, it seems that cigarette smoking may affect the fertility of male smokers via increasing the amount of sperm MDA/lipid peroxidation and NO concentrations. 081 88 Mohammad Ali MA Ghaffari Mohammad Ali Ghaffari Physiology Research Center, Ahwaz Jundishapur University of Medical Sciences Physiology Research Center, Ahwaz Jundishapur University of Medical Sciences Iran ghaffarima@yahoo.com Morad M Rostami مراد رستمی Department of Biochemistry, School of Medicine, Ahwaz Jundishapur University of Medical Sciences Department of Biochemistry, School of Medicine, Ahwaz Jundishapur University of Medical Sciences Iran Cigarette smokingHuman spermLipid peroxidationNitric oxideSmoker men 496.pdf de Lamirande E, Gagnon C. Human sperm hyperactivation and capacitation as parts of an oxidative process. Free Radic Biol Med. 1993;14(2):157-66.##Henkel R. The impact of oxidants on sperm function. Andrologia. 2005;37(6):205-6.##Geva E, Bartoov B, Zabludovsky N, Lessing JB, Lerner-Geva L, Amit A. 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Biol Reprod. 1996;55(5):935-41.##Förstermann U, Closs EI, Pollock JS, Nakane M, Schwarz P, Gath I, et al. Nitric oxide synthase isozymes. Characterization, purification, molecular cloning, and functions. Hypertension. 1994;23(6 Pt 2):1121-31.##Burnett AL, Ricker DD, Chamness SL, Maguire MP, Crone JK, Bredt DS, et al. Localization of nitric oxide synthase in the reproductive organs of the male rat. Biol Reprod. 1995;52(1):1-7.##Herrero MB, Pérez Martínez S, Viggiano JM, Polak JM, de Gimeno MF. Localization by indirect immunofluorescence of nitric oxide synthase in mouse and human spermatozoa. Reprod Fertil Dev. 1996;8(5):931-4.##Herrero MB, Viggiano JM, Pérez Martínez S, de Gimeno MF. Evidence that nitric oxide synthase is involved in progesterone-induced acrosomal exocytosis in mouse spermatozoa. Reprod Fertil Dev. 1997;9(4):433-9.##Belén Herrero M, Chatterjee S, Lefièvre L, de Lamirande E, Gagnon C. Nitric oxide interacts with the cAMP pathway to modulate capacitation of human spermatozoa. Free Radic Biol Med. 2000; 29(6):522-36.##Zenzes MT. Smoking and reproduction: gene damage to human gametes and embryos. Hum Reprod Update. 2000;6(2):122-31.##Sepaniak S, Forges T, Gerard H, Foliguet B, Bene MC, Monnier-Barbarino P. The influence of cigarette smoking on human sperm quality and DNA fragmentation. Toxicology. 2006;223(1-2):54-60.##Pacifici R, Altieri I, Gandini L, Lenzi A, Pichini S, Rosa M, et al. Nicotine, cotinine, and trans-3-hydroxycotinine levels in seminal plasma of smokers: effects on sperm parameters. Ther Drug Monit. 1993;15(5):358-63.##Vine MF. Smoking and male reproduction: a review. Int J Androl. 1996;19(6):323-37.##Sofikitis N, Takenaka M, Kanakas N, Papadopoulos H, Yamamoto Y, Drakakis P, et al. Effects of cotinine on sperm motility, membrane function, and fertilizing capacity in vitro. 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Clinical relevance of oxidative stress and sperm chromatin damage in male infertility: an evidence based analysis. Int Braz J Urol. 2007;33(5):603-21.##Garrido N, Meseguer M, Simon C, Pellicer A, Remohi J. Pro-oxidative and anti-oxidative imbalance in human semen and its relation with male fertility. Asian J Androl. 2004;6(1):59-65.##Hsieh YY, Chang CC, Lin CS. Seminal malondialdehyde concentration but not glutathione peroxidase activity is negatively correlated with seminal concentration and motility. Int J Biol Sci. 2006;2(1):23-9.##Kobayashi T, Miyazaki T, Natori M, Nozawa S. Protective role of superoxide dismutase in human sperm motility: superoxide dismutase activity and lipid peroxide in human seminal plasma and spermatozoa. Hum Reprod. 1991;6(7):987-91.##Suleiman SA, Ali ME, Zaki ZM, el-Malik EM, Nasr MA. Lipid peroxidation and human sperm motility: protective role of vitamin E. J Androl. 1996;17(5):530-7.##Aleksandra K, Slawomir K, Ewa B. 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J Androl. 2000; 21(6):895-902.##Cocuzza M, Sikka SC, Athayde KS, Agarwal A. Clinical relevance of oxidative stress and sperm chromatin damage in male infertility: an evidence based analysis. Int Braz J Urol. 2007;33(5):603-21.##

Combination of Thrombophilic Gene Polymorphisms as a Cause of Increased the Risk of Recurrent Pregnancy Loss 2 1 2 Background: Recurrent pregnancy loss is (RPL) a heterogeneous condition. While the role of acquired thrombophilia has been accepted as an etiology for RPL, the contribution of specific inherited thrombophilic gene polymorphisms to the disorder has been remained controversial. Methods: One hundred women with a history of two or more consecutive abortions and 100 women with at least two live births and no miscarriages were included in the study and evaluated for the presence of 11 thrombophilic gene polymorphisms (Factor V LEIDEN, Factor V 4070 A/G, Factor V 5279 A/G, Factor XIII 103 G/T, Factor XIII 614 A/T, Factor XIII 1694 C/T, PAI-1 -675 4G/5G, ITGB3 1565 T/C, β-Fibrinogen -455G/A, MTHFR 677 C/T, MTHFR 1298 A/C) using PCR-RFLP technique. The data were statistically analyzed using Mann-Whitney test and logistic regression model. Results: There was no relation between factor XIII 103G/T gene polymorphism with increased risk of RPL. However, the other 10 gene polymorphisms were found to be associated with increased/decreased risk of RPL. Multiple logistic regression model for analyzing the simultaneous effects of these polymorphisms on the risk of RPL showed that six of these 11 polymorphisms (Factor V 1691G/A, Factor V 5279A/G, Factor XIII 614A/T, β-Fibrinogen -455G/A, ITGB3 1565T/C, and MTHFR 1298A/ C) were associated with RPL. Conclusion: It is possible to calculate the risk of abortion in a patient with RPL by determining only six of the 10 polymorphisms that are individually associated with RPL. 089 95 Raheleh R Torabi راحله ترابی Department of Medical Genetics, National Institute for Genetic Engineering and Biotechnology (NIGEB) Department of Medical Genetics, National Institute for Genetic Engineering and Biotechnology (NIGEB) Iran Saeed S Zarei سعید زارعی Monoclonal Antibody Research Center, Avicenna Research Institute (ACECR) Monoclonal Antibody Research Center, Avicenna Research Institute (ACECR) Iran Hojjat H Zeraati حجت زراعتی Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences Iran Amir Hassan AH Zarnani امیرحسن زرنانی Nanobiotechnology Research Center, Avicenna Research Institute (ACECR) Nanobiotechnology 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 Reza R Hadavi رضا هادوی Monoclonal Antibody Research Center, Avicenna Research Institute (ACECR) Monoclonal Antibody Research Center, Avicenna Research Institute (ACECR) Iran Elham E Savadi-Shiraz Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Mahmood M Jeddi-Tehrani محمود جدی‌تهرانی Monoclonal Antibody Research Center, Avicenna Research Institute (ACECR) Monoclonal Antibody Research Center, Avicenna Research Institute (ACECR) Iran mahjed@yahoo.com PCR-RFLPRecurrent Pregnancy LossThrombophilic gene 494.pdf Coulam CB, Jeyendran RS, Fishel LA, Roussev R. Multiple thrombophilic gene mutations rather than specific gene mutations are risk factors for recurrent miscarriage. Am J Reprod Immunol. 2006;55(5): 360-8.##Robertson L, Wu O, Langhorne P, Twaddle S, Clark P, Lowe GD, et al. Thrombophilia in pregnancy: a systematic review. Br J Haematol. 2006;132(2):171-96.##Seligsohn U, Lubetsky A. Genetic susceptibility to venous thrombosis. N Engl J Med. 2001;344(16): 1222-31.##Lunghi B, Iacoviello L, Gemmati D, Dilasio MG, Castoldi E, Pinotti M, et al. Detection of new polymorphic markers in the factor V gene: association with factor V levels in plasma. Thromb Haemost. 1996;75(1):45-8.##Bernardi F, Faioni EM, Castoldi E, Lunghi B, Castaman G, Sacchi E, et al. A factor V genetic component differing from factor V R506Q contributes to the activated protein C resistance phenotype. Blood. 1997;90(4):1552-7.##Folsom AR, Cushman M, Tsai MY, Aleksic N, Heckbert SR, Boland LL, et al. A prospective study of venous thromboembolism in relation to factor V Leiden and related factors. Blood. 2002;99(8):2720-5.##Jeddi-Tehrani M, Torabi R, Zarnani AH, Moham-madzadeh A, Arefi S, Zeraati H, et al. Analysis of plasminogen activator inhibitor-1, integrin beta3, Beta fibrinogen, and methylenetetrahydrofolate re-ductase polymorphisms in Iranian women with re-current pregnancy loss. Am J Reprod Immunol. 2011;66(2):149-56.##Anwar R, Gallivan L, Edmonds SD, Markham AF. Genotype/phenotype correlations for coagulation factor XIII: specific normal polymorphisms are associated with high or low factor XIII specific activity. Blood. 1999;93(3):897-905.##Dossenbach-Glaninger A, van Trotsenburg M, Dossenbach M, Oberkanins C, Moritz A, Krugluger W, et al. Plasminogen activator inhibitor 1 4G/5G polymorphism and coagulation factor XIII Val34Leu polymorphism: impaired fibrinolysis and early pregnancy loss. Clin Chem. 2003;49(7):1081-6.##Barbosa HC, Carvalho EC, Barini R, Siqueira LH, Costa DS, Annichino-Bizzacchi JM. Tyr204Phe and Val34Leu polymorphisms in two Brazilian ethnic groups and in patients with recurrent miscarriages. Fertil Steril. 2004;82(5):1455-7.##Gallivan L, Markham AF, Anwar R. The Leu564 factor XIIIA variant results in significantly lower plasma factor XIII levels than the Pro564 variant. Thromb Haemost. 1999;82(4):1368-70.##Kohler HP, Futers TS, Grant PJ. Prevalence of three common polymorphisms in the A-subunit gene of factor XIII in patients with coronary artery disease. Thromb Haemost. 1999;81(4):511-5.##van der Put NM, Gabreëls F, Stevens EM, Smeitink JA, Trijbels FJ, Eskes TK, et al. A second common mutation in the methylenetetrahydrofolate reductase gene: an additional risk factor for neuraltube defects? Am J Hum Genet. 1998;62(5):1044-51.##Altomare I, Adler A, Aledort LM. The 5, 10 methylenetetrahydrofolate reductase C677T mutation and risk of fetal loss: a case series and review of the literature. Thromb J. 2007;5:17.##Ciacci C, Tortora R, Scudiero O, Di Fiore R, Salvatore F, Castaldo G. Early pregnancy loss in celiac women: The role of genetic markers of thrombophilia. Dig Liver Dis. 2009;41(10):717-20.##Govindaiah V, Naushad SM, Prabhakara K, Krishna PC, Radha Rama Devi A. Association of parental hyperhomocysteinemia and C677T Methylene tetrahydrofolate reductase (MTHFR) polymorphism with recurrent pregnancy loss. Clin Biochem. 2009;42(4-5):380-6.##Ivanov P, Kovacheva K, Komsa-Penkova R, Konova E, Simeonova M, Popov I, et al. [Genetic variant C677T in the MTHFR in women with recurrent early fetal loss]. Akush Ginekol (Sofiia). 2007;46 (4):19-22. Bulgarian.##Altmäe S, Stavreus-Evers A, Ruiz JR, Laanpere M, Syvänen T, Yngve A, et al. Variations in folate pathway genes are associated with unexplained female infertility. Fertil Steril. 2010;94(1):130-7.##Gebhardt GS, Scholtz CL, Hillermann R, Odendaal HJ. Combined heterozygosity for methylenetetrahydrofolate reductase (MTHFR) mutations C677T and A1298C is associated with abruptio placentae but not with intrauterine growth restriction. Eur J Obstet Gynecol Reprod Biol. 2001;97(2):174-7.##Dossenbach-Glaninger A, van Trotsenburg M, Dossenbach M, Oberkanins C, Moritz A, Krugluger W, et al. Plasminogen activator inhibitor 1 4G/5G polymorphism and coagulation factor XIII Val34Leu polymorphism: impaired fibrinolysis and early pregnancy loss. Clin Chem. 2003;49(7):1081-6.##Kerlin B, Cooley BC, Isermann BH, Hernandez I, Sood R, Zogg M, et al. Cause-effect relation between hyperfibrinogenemia and vascular disease. Blood. 2004;103(5):1728-34.##Newman PJ, Derbes RS, Aster RH. The human platelet alloantigens, PlA1 and PlA2, are associated with a leucine33/proline33 amino acid polymorphism in membrane glycoprotein IIIa, and are distinguishable by DNA typing. J Clin Invest. 1989; 83(5):1778-81.##Yilmaz S, Bayan K, Tüzün Y, Batun S, Altintaş A. A comprehensive analysis of 12 thrombophilic mutations and related parameters in patients with inflammatory bowel disease: data from Turkey. J Thromb Thrombolysis. 2006;22(3):205-12.##Jeddi-Tehrani M, Torabi R, Mohammadzadeh A, Arefi S, Keramatipour M, Zeraati H, et al. Investigating association of three polymorphisms of coagulation factor XIII and recurrent pregnancy loss. Am J Reprod Immunol. 2010;64(3):212-7.##Torabi R, Ostad Karampour M, Mohammadzadeh A, Arefi S, Keramatipour M, Zarei S, et al. The Relationship between Polymorphisms of Blood Coagulation Factor V Gene and Recurrent Pregnancy Losses. J Reprod Infertil. 2009;9(4):305-16.##Hohlagschwandtner M, Unfried G, Heinze G, Huber JC, Nagele F, Tempfer C. Combined thrombophilic polymorphisms in women with idiopathic recurrent miscarriage. Fertil Steril. 2003;79(5):1141-8.##Sotiriadis A, Vartholomatos G, Pavlou M, Kolaitis N, Dova L, Stefos T, et al. Combined thrombophilic mutations in women with unexplained recurrent miscarriage. Am J Reprod Immunol. 2007;57 (2):133-41.##Brenner B, Sarig G, Weiner Z, Younis J, Blumenfeld Z, Lanir N. Thrombophilic polymorphisms are common in women with fetal loss without apparent cause. Thromb Haemost. 1999;82(1):6-9.##Sarig G, Younis JS, Hoffman R, Lanir N, Blumenfeld Z, Brenner B. Thrombophilia is common in women with idiopathic pregnancy loss and is associated with late pregnancy wastage. Fertil Steril. 2002;77(2):342-7.##Coulam CB, Jeyendran RS, Fishel LA, Roussev R. Multiple thrombophilic gene mutations rather than specific gene mutations are risk factors for recurrent miscarriage. Am J Reprod Immunol. 2006;55 (5):360-8.##Goodman CS, Coulam CB, Jeyendran RS, Acosta VA, Roussev R. Which thrombophilic gene mutations are risk factors for recurrent pregnancy loss? 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Body Mass Index (BMI) and Glucose Intolerance during Pregnancy in White European Women 2 1 2 Background: The risk of gestational diabetes mellitus (GDM) in accordance to Body Mass Index (BMI) is often based on studies where the calculation of BMI is frequently self-reported and is usually unreliable. We evaluated the risk of an abnormal oral glucose tolerance test (OGTT) in a population where BMI was measured and selective screening for GDM was practiced. Methods: We carried out a prospective observational study where 1935 white European women with a singleton pregnancy were recruited. In the first trimester maternal height and weight were measured digitally. Statistical analysis was performed using SPSS version 15.0. BMI centiles were calculated from the study population. A Chi-square test was used to test the differences in categorical variables between the groups. A p-value <0.05 was considered significant. Results: In 1935 women, 547 OGTTs were performed and 70 of these were abnormal. The prevalence of an abnormal OGTT was higher in women with Class 2 and 3 obesity compared to women with Class 1 obesity (23.3% vs. 10.1%, respectively; p= 0.008). The frequency of an abnormal OGTT was higher in women with a BMI ≥90th centile (≥33.1 kg/m2) compared to women with a BMI between the 80th and 90th centiles (≥29.3 and <33.1 kg/m2), (21.5% vs 8.1% respectively; p=0.005). Conclusion: When BMI is measured, we recommend to increase the cut-off point for selective screening of GDM to ≥33.0 kg/m2. This may decrease unnecessary obstetric interventions and healthcare costs. 095 100 Nadine N Farah Nadine Farah University College Dublin Centre for Human Reproduction, Coombe Women and Infants University Hospital University College Dublin Centre for Human Reproduction, Coombe Women and Infants University Hospital Ireland drnfarah@gmail.com Aoife A McGoldrick Aoife McGoldrick University College Dublin Centre for Human Reproduction, Coombe Women and Infants University Hospital University College Dublin Centre for Human Reproduction, Coombe Women and Infants University Hospital Ireland Chro C Fattah Chro Fattah University College Dublin Centre for Human Reproduction, Coombe Women and Infants University Hospital University College Dublin Centre for Human Reproduction, Coombe Women and Infants University Hospital Ireland Norah N O’Connor Norah O’Connor University College Dublin Centre for Human Reproduction, Coombe Women and Infants University Hospital University College Dublin Centre for Human Reproduction, Coombe Women and Infants University Hospital Ireland Mairead M M Kennelly Mairead M Kennelly University College Dublin Centre for Human Reproduction, Coombe Women and Infants University Hospital University College Dublin Centre for Human Reproduction, Coombe Women and Infants University Hospital Ireland Michael MJ Turner University College Dublin Centre for Human Reproduction, Coombe Women and Infants University Hospital University College Dublin Centre for Human Reproduction, Coombe Women and Infants University Hospital Ireland Body Mass IndexGestational Diabetes MellitusGlucose intoleranceMaternal obesity 495.pdf Torloni MR, Betrán AP, Horta BL, Nakamura MU, Atallah AN, Moron AF, et al. Prepregnancy BMI and the risk of gestational diabetes: a systematic review of the literature with meta-analysis. Obes Rev. 2009;10(2):194-203.##Griffin ME, Coffey M, Johnson H, Scanlon P, Foley M, Stronge J, et al. Universal vs. risk factor-based screening for gestational diabetes mellitus: detection rates, gestation at diagnosis and outcome. Diabet Med. 2000;17(1):26-32.##Hollander MH, Paarlberg KM, Huisjes AJ. Gestational diabetes: a review of the current literature and guidelines. Obstet Gynecol Surv. 2007;62(2):125-36.##Reece EA, Leguizamón G, Wiznitzer A. Gestational diabetes: the need for a common ground. Lancet. 2009;373(9677):1789-97.##Berger H, Crane J, Farine D, Armson A, De La Ronde S, Keenan-Lindsay L, et al. Screening for gestational diabetes mellitus. J Obstet Gynaecol Can. 2002;24(11):894-912.##Mires GJ, Williams FL, Harper V. Screening practices for gestational diabetes mellitus in UK obstetric units. Diabet Med. 1999;16(2):138-41.##Sathyapalan T, Mellor D, Atkin SL. Obesity and gestational diabetes. Semin Fetal Neonatal Med. 2010;15(2):89-93.##Solomon CG, Willett WC, Carey VJ, Rich-Edwards J, Hunter DJ, Colditz GA, et al. A prospective study of pregravid determinants of gestational diabetes mellitus. JAMA. 1997;278(13):1078-83.##Chu SY, Callaghan WM, Kim SY, Schmid CH, Lau J, England LJ, et al. Maternal obesity and risk of gestational diabetes mellitus. Diabetes Care. 2007; 30(8):2070-6.##Walker JD. NICE guidance on diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period. NICE clinical guideline 63. London, March 2008. Diabet Med. 2008;25(9):1025-7.##Niedhammer I, Bugel I, Bonenfant S, Goldberg M, Leclerc A. Validity of self-reported weight and height in the French GAZEL cohort. Int J Obes Relat Metab Disord. 2000;24(9):1111-8.##Gorber SC, Tremblay M, Moher D, Gorber B. A comparison of direct vs. self-report measures for assessing height, weight and body mass index: a systematic review. Obes Rev. 2007;8(4):307-26.##Shields M, Connor Gorber S, Tremblay MS. Associations between obesity and morbidity: effects of measurement methods. Obes Rev. 2008;9(5):501-2.##Fattah C, Farah N, O'Toole F, Barry S, Stuart B, Turner MJ. Body Mass Index (BMI) in women booking for antenatal care: comparison between selfreported and digital measurements. Eur J Obstet Gynecol Reprod Biol. 2009;144(1):32-4.##American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2012;35 Suppl 1:S64-71.##Davey RX, Hamblin PS. Selective versus universal screening for gestational diabetes mellitus: an evaluation of predictive risk factors. Med J Aust. 2001;174(3):118-21.##de Sereday MS, Damiano MM, González CD, Bennett PH. Diagnostic criteria for gestational diabetes in relation to pregnancy outcome. J Diabetes Complications. 2003;17(3):115-9.##Chiolero A, Peytremann-Bridevaux I, Paccaud F. Biased associations with obesity using self-reported body mass index. Obes Rev. 2008;9:503.##Yannakoulia M, Panagiotakos DB, Pitsavos C, Stefanadis C. Correlates of BMI misreporting among apparently healthy individuals: the ATTICA study. Obesity (Silver Spring). 2006;14(5):894-901.##Fattah C, O’Connor N, Farah N, Kennelly MM, Stuart B, Turner MJ. Normal body composition values in the first trimester of pregnancy. Int J Body Compos Res. 2010;8(2):37-40.##

Adolescent Males and Young Females in Tehran: Differing Perspectives, Behaviors and Needs for Reproductive Health and Implications for Gender Sensitive Interventions 2 1 2 Background: Despite cultural and religious prohibitions against premarital heterosexual relationships and intimacy, some recent evidence suggests some rise in premarital heterosexual interactions and relationships among young people. On the other hand, although HIV in Iran is a concentrated epidemic and mainly reported among high risk groups such as injecting drug users (IDUs), but there are evidences that the mode of transmission is shifting towards sexual contacts. This trend has caused concern among health policy makers in terms of prevention of STDs and HIV/AIDS particularly, among young people. This paper was prepared with the aim of highlighting how gender contributes to variation in reproductive health needs and conduct of young people in Iran. Method: This paper is based on a secondary analysis and compares comparable reproductive beliefs and conducts of women and men based on the data of two surveys conducted in Tehran in 2002 and 2005. A survey among 1385 adolescent males and another survey among 1743 female undergraduate students in four multidisciplinary universities in Tehran. Both surveys used anonymous self-administered questionnaires. To make the two samples comparable, the data of unmarried female university undergraduate students who resided in Tehran were merged with the data of adolescent male students who intended to pursue higher education. Common variables of the two surveys were identified, homogenized, merged and analysed. Results: Reproductive health knowledge among male adolescents was poor compared to that of their female peers. Although premarital friendships were moderately acceptable from view points of both males and females, the majority were against premarital sex, particularly among female participants. There were evidences of gender-based double standards in perceptions of premarital sexuality among both males and females; particularly, it was stronger among males than females. Male adolescents reported earlier and greater experiences of premarital hetero-sexual intimacy and sexual contact than females. Multiple partners were also more common among males than females. Females had a tendency to regret first sexual contact more than males, which reflects that first sex is more likely to be unplanned and unwanted among females compared to males. Conclusion: Significant gender–based double standards prevailed current sexual attitudes and conduct of young people in Iran. Gender norms which encourage unmarried men to practice premarital sex lead to an earlier transition of men to sexual relations and multiple sexual partners. Due to poor knowledge and various misconceptions about sexual health and lack of consistent contraceptive and condom use among adolescents and young people in Iran, both young men and women are susceptible to sexual and reproductive health hazards such as sexually transmitted infections (STIs), HIV/AIDS, pregnancy and unsafe abortion. Changing gender norms associated with sexuality may lead to promotion of safer sexual behaviors particularly among young people. Current reproductive health and HIV prevention programs should take into account gender-based double standards among young people and their unmet reproductive health needs. 101 111 Farideh F Khalajabadi Farahani Department of Population, Health and Family Planning, Population Studies and Research Centre in the Asia and the Pacific Department of Population, Health and Family Planning, Population Studies and Research Centre in the Asia and the Pacific Iran faridehfarahani@yahoo.com Iqbal I Shah Iqbal Shah Department of Reproductive Health and Research, World Health Organisation Department of Reproductive Health and Research, World Health Organisation Switzerland John J Cleland John Cleland Centre for Population Studies, London School of Hygiene and Tropical Medicine Centre for Population Studies, London School of Hygiene and Tropical Medicine England Mohammad Reza MR Mohammadi محمدرضا محمدی Department of Psychiatry, School of Medicine, Tehran University of Medical Sciences Department of Psychiatry, School of Medicine, Tehran University of Medical Sciences Iran AdolescentAttitudeGenderReproductive behaviorSexual behaviorYoung people 498.pdf Mahmoodi H, Sadeghi R. [Population, health, sustainable development with focus on young people; Challenges and issues]. In: Population Studies and Research Center in Asia and the Pacific. 4th Conference of the Population Association of Iran; 2008 Mar 4-5; Tehran. Tehran: Population Studies and Research Center in Asia and the Pacific; 2008. P. 67-99, Persian.##Saeednia M. [Collection of laws and regulations of children and adolescents]. 1st ed. Tehran: Pejman; 2006. p. 189-90.##Mohammad K, Farahani FK, Mohammadi MR, Alikhani S, Zare M, Tehrani FR, et al. Sexual risk-taking behaviors among boys aged 15-18 years in Tehran. J Adolesc Health. 2007;41(4):407-14.##Mohammadi MR, Mohammad K, Farahani FK, Alikhani S, Zare M, Tehrani FR, et al. Reproductive knowledge, attitudes and behavior among adolescent males in Tehran, Iran. Int Fam Plan Perspect. 2006; 32(1):35-44.##Farahani FK, Cleland J, Mehryar AH. Associations between family factors and premarital heterosexual relationships among female college students in Tehran. Int Perspect Sex Reprod Health. 2011;37(1): 30-9.##Khalaj Abadi Farahani F, Cleland J. Norms, attitude and sexual conduct of female college students in Tehran; Implications for sexual and reproductive health policy and research in Iran [PhD Thesis]. [London]: London School of Hygiene and Tropical Medicine; 2008. 325 p.##Mohammadi MR, Alikhani S, Khalaj Abadi Farahani F, Bahonar A. Parents' attitudes towards adolescent Boy's reproductive health needs and practice in Tehran. Iran J Psychiatry. 2007;2(1):13-24.##Fasula AM, Miller KS, Wiener J. The sexual double standard in African American adolescent women's sexual risk reduction socialization. Women Health. 2007;46(2-3):3-21.##Brown AD, Jejeebhoy SJ, Shah I, Yount KM. Sexual relations among young people in developing countries: evidence from WHO case studies. Occasional Paper No 4. Geneva: WHO, Department of Reproductive Health and Research; 2001. p. 6-43.##Isarabhakdi P. Factors associated with sexual behaviour and attitudes of never-married rural Thai youth. Warasan Prachakon Lae Sangkhom. 1999;8 (1):21-44.##Wang B, Li X, Stanton B, Kamali V, Naar-King S, Shah I, et al. Sexual attitudes, pattern of communication, and sexual behavior among unmarried outof-school youth in China. BMC Public Health. 2007;7:189.##Ozan S, Aras S, Semin S, Orcin E. Sexual attitudes and behaviors among medical students in Dokuz Eylul university, Turkey. Eur J Contracept Reprod Health Care. 2005;10(3):171-83.##Liu A, Kilmarx P, Jenkins RA, Manopaiboon C, Mock PA, Jeeyapunt S, et al. Sexual initiation, substance use, and sexual behavior and knowledge among vocational students in northern Thailand. Int Fam Plan Perspect. 2006;32(3):126-35.##White V, Greene M, Murphy E. Men and reproductive health programs: Influencing gender norms. Washington DC: The synergy project/social & scientific systems; 2003. 58 p.##Terry PE, Mhloyi M, Masvaure TB, Adlis SA. Gender equity and HIV/AIDS prevention: comparing gender differences in sexual practice and beliefs among Zimbabwe university students. Int Q Community Health Educ. 2005-2006;24(1):29-43.##Vesely SK, Wyatt VH, Oman RF, Aspy CB, Kegler MC, Rodine S, et al. The potential protective effects of youth assets from adolescent sexual risk behaviors. J Adolesc Health. 2004;34(5):356-65.##

Psychological Distress in Women with Polycystic Ovary Syndrome from Imam Khomeini Hospital, Tehran 2 1 2 Background: Polycystic ovary syndrome (PCOS) is a complex, multifaceted, heterogeneous disorder, affecting 4%-18% of reproductive-aged women and it is associated with reproductive, metabolic and psychological dysfunctions. PCOS affects quality of life and can worsen anxiety and depression either due to the features of PCOS or due to the diagnosis of a chronic disease. Methods: In this descriptive-analytical study, 81 patients with PCOS were recruited from Vali-e-Asr Reproductive Health Research Center. A questionnaire with items related to pieces of information about stress was used for data collection. Stress symptoms were assessed using the Understanding Yourself questionnaire. Statistical analyses were performed using SPSS Ver. 13.0 (SPSS Inc., Chicago, ILL, USA). The data are presented as mean±SD or as frequency with percentages. A p-value less than 0.05 was considered as statistically significant. Results: The descriptive results showed that 8 (9.9%) participants did not have any signs of stress, 32 (39.5%) had neurotic stress, 29 (35.8%) had high and 12 (14.8%) had extremely high levels of stress. The odds of high levels of anxiety in women with hirsutism was 3.1 (95% CI, 1.00-9.59). The odds of high levels of obsession in overweight patients was 3.2 (95% CI, 1.12-9.234). The odds of high levels of worries in patients with touchy personality was 3.4 (95% CI, 1.10-11.19) obsession score. Conclusion: The present study showed that clinical signs of PCOS were most closely associated with psychological distress which has important implications in the diagnosis and treatment of disorders. 111 116 Farideh F Zafari Zangeneh فریده ظفری زنگنه Vali-e- Asar Reproductive Health Research Center,Tehran Medical Sciences University Vali-e- Asar Reproductive Health Research Center,Tehran Medical Sciences University Iran Zangeneh14@gmail.com Mina M Jafarabadi مینا جعفرآبادی Vali-e- Asar Reproductive Health Research Center,Tehran Medical Sciences University Vali-e- Asar Reproductive Health Research Center,Tehran Medical Sciences University Iran Mohammad Mehdi MM Naghizadeh محمدمهدی نقی زاده Department of Community Medicine, Faculty of Medicine, Fasa University of Medical Sciences Department of Community Medicine, Faculty of Medicine, Fasa University of Medical Sciences Iran Nasrin N Abedi-Nia نسرین عابدی نیا Vali-e- Asar Reproductive Health Research Center,Tehran Medical Sciences University Vali-e- Asar Reproductive Health Research Center,Tehran Medical Sciences University Iran Fedyeh F Haghollahi فدیه حق‌اللهی Vali-e- Asar Reproductive Health Research Center,Tehran Medical Sciences University Vali-e- Asar Reproductive Health Research Center,Tehran Medical Sciences University Iran AnxietyHysteriaObsessionPolycystic ovary syndromeWorries 501.pdf Badawy A, Elnashar A. Treatment options for polycystic ovary syndrome. Int J Womens Health. 2011; 3:25-35.##Teede H, Deeks A, Moran L. Polycystic ovary syndrome: a complex condition with psychological, reproductive and metabolic manifestations that impacts on health across the lifespan. BMC Med. 2010;8:41.##Kitzinger C, Willmott J. 'The thief of womanhood: women's experience of polycystic ovarian syndrome. Soc Sci Med. 2002;54(3):349-61.##Trent ME, Rich M, Austin SB, Gordon CM. Quality of life in adolescent girls with polycystic ovary syndrome. Arch Pediatr Adolesc Med. 2002;156(6): 556-60.##Trent ME, Rich M, Austin SB, Gordon CM. Fertility concerns and sexual behavior in adolescent girls with polycystic ovary syndrome: implications for quality of life. J Pediatr Adolesc Gynecol. 2003;16 (1):33-7.##Trent M, Austin SB, Rich M, Gordon CM. Overweight status of adolescent girls with polycystic ovary syndrome: body mass index as mediator of quality of life. 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Postpartum Peripheral Symmetrical Gangrene: A Case Report 2 1 2 Background: Symmetrical peripheral gangrene is usually associated with underlying medical problems and it is seldom seen in pregnancy. Sepsis though common in a setting of delivery by unskilled midwife is rarely accompanied by symmetrical gangrene. Case Presentation: We report a case of symmetrical peripheral gangrene which occurred in the winter, triggered possibly by sepsis and a single dose of ergot. A high index of suspicion, early diagnosis and intervention with appropriate measures will result in favorable outcome in such cases. Conclusion: Although postpartum period is of high risk for sepsis and use of ergot alkaloids is common in labor but occurrence of peripheral symmetrical gangrene is rare. A high index of suspicion for the diagnosis and timely intervention will prevent irreparable damage and loss of limb. 117 120 Lipi L Sharma Lipi Sharma Department of Obstetrics and Gynecology, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital Department of Obstetrics and Gynecology, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital India www.lip.sharma14@gmail.com Sumita S Mehta Sumita Mehta Department of Obstetrics and Gynecology, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital Department of Obstetrics and Gynecology, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital India Shalini Sh Rajaram Shalini Rajaram Department of Obstetrics and Gynecology, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital Department of Obstetrics and Gynecology, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital India Rachna R Agarwal Rachna Agarwal Department of Obstetrics and Gynecology, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital Department of Obstetrics and Gynecology, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital India Sanjay S Gupta Sanjay Gupta Department of Surgery, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital Department of Surgery, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital India Neerja N Goel Neerja Goel Department of Obstetrics and Gynecology, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital Department of Obstetrics and Gynecology, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital India ErgotPeripheral symmetrical gangrenePostpartum 502.pdf Avrech OM, Golan A, Pansky M, Langer R, Caspi E. Raynaud's phenomenon and peripheral gangrene complicating scleroderma in pregnancy--diagnosis and management. Br J Obstet Gynaecol. 1992;99 (10):850-1##Smith CA, Pinals RS. Progressive systemic sclerosis and postpartum renal failure complicated by peripheral gangrene. J Rheumatol. 1982;9(3):455-8.##Dam AK, Mishra JC. Managing ergot-induced gangrene: the anesthesiologist as a key player. Anesth Analg. 2002;95(2):409-10.##Ghosh SK, Bandyopadhyay D, Ghosh A. Symmetrical peripheral gangrene: a prospective study of 14 consecutive cases in a tertiary-care hospital in eastern India. J Eur Acad Dermatol Venereol. 2010;24 (2):214-8.##