Methodological Considerations in Studying Sexual Behaviors of Young People in Iran 2 1 605 2 In recent years, there has been increasing number of studies about young people’s sexual behavior and its correlates in Iran (1-5). These findings will hopefully sensitize health policy makers to sexual risks (HIV, STIs, pregnancy, and abortion) among young people in general population and inform appropriate programs and interventions to protect young people from associated risks. However, some of these studies have important limitations that make the interpretation and generalization of the finding difficult, particularly at national level and will provide some biased results on this highly sensitive topic. Some of these methodological limitations are as follows: Some studies have assessed sexual behaviors of a specific sample of college students in a particular city, while explicitly or implicitly generalize the findings to Iranian youth. For instance, in the title and the main text, they tend to use Iranian youth instead of focusing on the study population which are college students in the particular city (3). College students in metropolitan cities tend to be more vanguard to new ideas and are more likely to be liberal in sexual attitudes and behaviors. Generally, unless we have a national representative sample, the rates cannot be generalized to the general population of young people. Moreover, the investigators need to acknowledge the heterogeneity between cities in the country in interpretation of the finding. Another issue is special features related to researches of sensitive subjects such as sexual behavior. Some studies which fail to get official consent from the institutions (schools or universities), they tend to interview students who are volunteers and volunteers tend to be more sexually curious and likely to be more interested to know about the topic or even might be more sexually experienced. They might see their participation as an opportunity to receive some information from the questionnaire or the interviewer (1), hence, researchers need to make sure that students who reject to participate are not different from volunteers. Similarly, the investigators need to make sure that respondents with missing data on sensitive questions are not different with those who responded. Obtaining a non-representative sample is another important limitation. If applying random sampling is not possible, using proportional probability to size (PPS) can be helpful. Because the sample comprises of different subgroups, for instance, students of government and private universities, or men and women, the proportion of these subgroups within the sample might be different with the proportion in the study population. Hence, if researchers failed to use PPS based on important subgroups; need to give appropriate weight to different subcategories at the analysis stage. This becomes more important when sexual behaviors of these subcategories are different and lack of weighting lead to biased results. For instance, studies showed that students in government universities are significantly more conservative in sexual attitudes and behaviors compared to students from private universities (1, 6). Hence, if a representative sample of students (both private and government) universities is considered, the same proportion of each type of university need to be selected in the sample as their proportion in the population, if these proportions are different, weighting is needed. There is little evidence of weighted sample in many of published papers (3, 4). Hence, samples which over-represent private students, will over estimate the sexuality of college students. One important issue is that studies of sexual behavior among unmarried youth in Iran showed that a considerable proportion of sexually experienced youth, particularly females do not practice vaginal intercourse and because of importance of virginity, they might involve in non-penetrative sex or even non-vaginal intercourse. These are named by young people as "incomplete sex" versus "complete sex" (1). Even some unmarried females refer "complete sex" as only "vaginal sex" and all other type of sex as "incomplete sex". If other non- vaginal penetrative sex is not considered as sexual intercourse, because of significant risks associated with these types of sex in terms of sexually transmitted diseases and HIV, this creates an underestimation in high risk sexual behavior. Qualitative studies will add more in-depth knowledge in this regard to the quantitative data. Some of these studies in Iran have not identified which exact term or phrase was used in the questionnaire for sexual experiences (sexual intercourse, or "Nazdiki Jensi" vs. sexual contact or "Tamas-e-Jensi"). Details about type of sex always are difficult to be asked in the questionnaire, but they are preferred, however, if it was not possible, at least they need to be acknowledged as a limitation. Some young people consider touching sex organ or sex by touch as sexual contact and report is as sexual experience. Studies should consider this important issue when conducting research on sexuality in societies like Iran which virginity and physical hymen is important for women. Management of data collection is another issue that needs to be clarified carefully. For instance, sometimes studies conducted among both men and women in a class (cluster), while, it is unclear how the investigator managed the data collection when both men and women were present in the class (3). Anonymity and confidentiality issue is another important methodological consideration which is needed to be emphasized. Critics always doubt that students in an institution tell the truth and report their sexual experiences without fear from the consequences for their position in the university. The investigators need to explain what strategies they applied to minimize this threat. Gender disparity in sexual attitude and behaviors is required to be taken into account. Although, sexual behavior among young people is subject to change by time, but it is unlikely that nearly similar percentages of females and males college students report premarital sex (39% and 41%, respectively), the rates were reported by a recent study among college students in a city in north Iran (3). I believe, it is a biased rate. Gender double standard in Iran is responsible for different sexual behaviors among men and women like many other societies. In a representative sample of female college students in Tehran, the capital of Iran, all types of sexual contact including intercourse was approximately 24% while only 11% was intercourse (1). The rate among male college students was also about 34% (6). Even the rate of vaginal intercourse among unmarried female college students in Tehran in 2005-6 was only 6.8% (1) and among male college students was about 20% (6). Despite that sexual attitude and practice have changed over the past century around the world (7), it was shown that still there is diversity between countries towards younger age at sex (8), while due to postponement of marriage, the proportion of young people who practice premarital sex is increasing. Environmental factors are responsible for such variation. Factors such as social norms, family and marriage still have important roles in preventing young people from premarital intercourse in Iran (9, 10). In developing countries in Asia, between 2-11% of females and 24-75% of males experience premarital sex before the age of 18 (11), based on studies among college students in selected metropolitan cities of Iran and taking into account the heterogeneity in the country, it seems that overall between 10-15% of females and about 20% of males get involved in premarital sexual intercourse before marriage. Even the corresponding rate among general young population is expected to be lower. However, significant minorities of young people are involved in premarital sex and this wills appropriate attention because there is no formal education on sexual health for unmarried people and they will be exposed to several health risks. Finally, recent interests on this topic among young scholars in Iran should be acknowledged. These methodological considerations need to be addressed carefully. Studies with robust methodology can help to provide scientific evidences on the level and determinants of high risk sexual behaviors among young people, to inform current programs to meet young people’s need in sexual and reproductive health. 171 173 Farideh F Khalajabadi-Farahani Department of Population, Health and Family Planning, National Institute for Population Research Department of Population, Health and Family Planning, National Institute for Population Research Iran faridehfarahani2@gmail.com No Keyword 605.pdf Khalajabadi Farahani F, Cleland J. Sexual norms, attitude and conduct among female college students in Tehran [dissertation]. [London]: School of Hygiene and Tropical Medicine; 2008.##Simbar M, Ramezani Tehrani F, Hashemi Z. [The needs of reproductive health of the university students of Ghazvin]. J Qazvin Univ Med Sci. 2003;28:5-13. Persian.##Vakilian K, Mousavi SA, Keramat A. Estimation of sexual behavior in the 18-to-24-years-old Iranian youth based on a crosswise model study. BMC Res Notes. 2014;7:28.##Mirmolaee ST, Abbas Sanjdari Z, Ghobari Banab B, Faghihzadeh S. [The study of sexual behaviours and related factors among female students of governmental schools in Tehran]. The 2nd Congress on Family and Sexual Disorders; 2005 May 30; Tehran, Iran: Shahed University; 2005. p. 7. Persian.##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.##Khalajabadi Farahani F, Akhondi M, Azin A, Shirzad M. HIV Risk- perception and sexual risk-taking behaviors among male college-students in Tehran. 2014. 150 p. Located at: Final Report, Research Deputy, Avicenna Research Institute (ARI), Tehran, Iran.##Wells BE, Twenge JM. Changes in young people’s sexual behavior and attitudes, 1943-1999: A cross-temporal meta-analysis. Rev Gen Psychol. 2005;9(3):249-61.##Wellings K, Collumbien M, Slaymaker E, Singh S, Hodges Z, Patel D, et al. Sexual behaviour in context: a global perspective. Lancet. 2006;368(9548):1706-28.##Khalajabadi Farahani F, Mohammadi M. Sexual behavior of young people in contemporary Iran; the role of social norms and family. 40th Annual Meeting of International Academy for Sex Research; 2014 June 25-28; Croatia, Dubrovik.##Khalajabadi Farahani F, Cleland J. Perceived norms on heterosexual relationships among female college students in Tehran; a mix method study. 1st Conference of Asian Population Association; 2010 Nov 16-20; New Delhi, India.##Brown A, Jejeebhoy S, Shah I, Yount K. Sexual relations among young people in developing countries: Evidence from WHO case studies. Occasional Papers of the Department of Reproductive Health and Research. Geneva: World Health Organization; 2001. Report No.:4 (WHO/RHR/01.8).##

Recurrent Implantation Failure: The Role of the Endometrium 2 1 597 2 The success rate of reproductive treatment methods depends on many different factors. The most important and discussed ones in the literature are maternal age, the causes of infertility, the ovarian response to stimulation, the influence of the male factor and sperm quality, embryo quality and the various uterine pathologies. Some couples fail repeatedly after transferring good quality embryos without any obvious reason and this becomes a major continuing problem after IVF/ICSI procedures. It can be speculated that in these couples, insufficiency of the endometrium might be a possible reason for implantation failure. This review article summarized current literature describing the consecutive endomertial procedures involved in successful embryo implantation. It is believed that efforts to align criteria for definition of recurrent implantation failure (RIF) and attempts to classify different RIF types would develop guidelines for treatment procedures which would result in an increase in patients’ opportunities to conceive. 173 184 Tanya T Timeva Specialized Ob/Gyn Hospital for Active Treatment Specialized Ob/Gyn Hospital for Active Treatment Bulgaria ttimeva@yahoo.com Atanas A Shterev Specialized Ob/Gyn Hospital for Active Treatment Specialized Ob/Gyn Hospital for Active Treatment Bulgaria Stanimir S Kyurkchiev Institute of Reproductive Health Institute of Reproductive Health Bulgaria DeciduaEmbryo implantationEndometriumIn Vitro fertilizationReproductive physiological phenomena 597.pdf Coughlan C, Ledger W, Wang Q, Liu F, Demirol A, Gurgan T, et al. Recurrent implantation failure: definition and management. Reprod Biomed Online. 2014;28(1):14-38.##Racowsky C. High rates of embryonic loss, yet high incidence of multiple births in human ART: is this paradoxical? Theriogenology. 2002;57(1):87-96.##Gnoth C, Godehardt D, Godehardt E, Frank-Herrmann P, Freundl G. Time to pregnancy: results of the German prospective study and impact on the management of infertility. Hum Reprod. 2003;18(9):1959-66.##Benkhalifa M, Demirol A, Sari T, Balashova E, Tsouroupaki M, Giakoumakis Y, et al. Autologous embryo-cumulus cells co-culture and blastocyst transfer in repeated implantation failures: a collaborative prospective randomized study. Zygote. 2012;20(2):173-80.##Urman B, Yakin K, Balaban B. Recurrent implantation failure in assisted reproduction: how to counsel and manage. A. General considerations and treatment options that may benefit the couple. Reprod Biomed Online. 2005;11(3):371-81.##Margalioth EJ, Ben-Chetrit A, Gal M, Eldar-Geva T. Investigation and treatment of repeated implantation failure following IVF-ET. Hum Reprod. 2006;21(12):3036-43.##Rinehart J. Recurrent implantation failure: definition. J Assist Reprod Genet. 2007;24(7):284-7.##Simon A, Laufer N. Repeated implantation failure: clinical approach. Fertil Steril. 2012;97(5):1039-43.##Coulam CB. Implantation failure and immunotherapy. Hum Reprod. 1995;10(6):1338-40.##Tan BK, Vandekerckhove P, Kennedy R, Keay SD. Investigation and current management of recurrent IVF treatment failure in the UK. BJOG. 2005;112(6):773-80.##Thornhill AR, deDie-Smulders CE, Geraedts JP, Harper JC, Harton GL, Lavery SA, et al. ESHRE PGD Consortium 'Best practice guidelines for clinical preimplantation genetic diagnosis (PGD) and preimplantation genetic screening (PGS)'. Hum Reprod. 2005;20(1):35-48.##Alpha Scientists in Reproductive Medicine and ESHRE Special Interest Group of Embryology. The Istanbul consensus workshop on embryo assessment: proceedings of an expert meeting. Hum Reprod. 2011;26(6):1270-83.##Johnston-MacAnanny EB, Hartnett J, Engmann LL, Nulsen JC, Sanders MM, Benadiva CA. Chronic endometritis is a frequent finding in women with recurrent implantation failure after in vitro fertilization. Fertil Steril. 2010;93(2):437-41.##Toth B, Wurfel W, Germeyer A, Hirv K, Makrigiannakis A, Strowitzki T. Disorders of implantation--are there diagnostic and therapeutic options? J Reprod Immunol. 2011;90(1):117-23.##Salker M, Teklenburg G, Molokhia M, Lavery S, Trew G, Aojanepong T, et al. Natural selection of human embryos: impaired decidualization of endometrium disables embryo-maternal interactions and causes recurrent pregnancy loss. PLoS ONE.2010;5(4):e10287.##Teklenburg G, Salker M, Molokhia M, Lavery S, Trew G, Aojanepong T, et al. Natural selection of human embryos: decidualizing endometrial stromal cells serve as sensors of embryo quality upon implantation. PLoS One. 2010;5(4):e10258.##Makrigiannakis A. Repeated implantation failure: Immunological aspects and evidence based treatment modalities. In: Makrigiannakis A, editor. Proceeding of MSRM International Meeting “Implantation-recurrent miscarriages science and clinical aspects”; 2010 Sept 24-26; Chania, Crete, Greece: Mediterranean Society for Reproductive Medicine; 2010. p. 21-2.##Gargett CE. Uterine stem cells: what is the evidence? Hum Reprod Update. 2007;13(1):87-101.##Cervello I, Simon C. Somatic stem cells in the endometrium. Reprod Sci. 2009;16(2):200-5.##Dimitrov R, Kyurkchiev D, Timeva T, Yunakova M, Stamenova M, Shterev A, et al. First-trimester human decidua contains a population of mesenchymal stem cells. Fertil Steril. 2010;93(1):210-9.##Kyurkchiev S, Shterev A, Dimitrov R. Assessment of presence and characteristics of multipotent stromal cells in human endometrium and decidua. Reprod Biomed Online. 2010;20(3):305-13.##Gargett CE, Schwab KE, Zillwood RM, Nguyen HP, Wu D. Isolation and culture of epithelial progenitors and mesenchymal stem cells from human endometrium. Biol Reprod. 2009;80(6):1136-45.##Mints M, Jansson M, Sadeghi B, Westgren M, Uzunel M, Hassan M, et al. Endometrial endothelial cells are derived from donor stem cells in a bone marrow transplant recipient. Hum Reprod. 2008;23(1):139-43.##Chan RW, Schwab KE, Gargett CE. Clonogenicity of human endometrial epithelial and stromal cells. Biol Reprod. 2004;70(6):1738-50.##Meng X, Ichim TE, Zhong J, Rogers A, Yin Z, Jackson J, et al. Endometrial regenerative cells: a novel stem cell population. J Transl Med. 2007;15;5:57.##Chan RW, Kaitu'u-Lino T, Gargett CE. Role of label-retaining cells in estrogen-induced endometrial regeneration. Reprod Sci. 2012;19(1):102-14.##Bergh PA, Navot D. The impact of embryonic development and endometrial maturity on the timing of implantation. Fertil Steril. 1992;58(3):537-42.##Elder K, Dale B, editors. In vitro fertilization. 3rd ed. Vol. 6, Implantation and early stages of fetal development. New York: Cambridge University Press; 2011. p. 82-92.##Lessey BA. Assessment of endometrial receptivity. Fertil Steril. 2011;96(3):522-9.##Macklon N. Factors affecting implantation. In: Makrigiannakis A, editor. Proceeding of MSRM International Meeting “Implantation-recurrent miscarriages science and clinical aspects”; 2010 Sept 24-26; Chania, Crete, Greece: Mediterranean Society for Reproductive Medicine; 2010. p. 14-5.##Dimitriadis E, White CA, Jones RL, Salamonsen LA. Cytokines, chemokines and growth factors in endometrium related to implantation. Hum Reprod Update. 2005;11(6):613-30.##Al-Rumaih HM, Price KM, Gillott DJ, Grudzinskas GJ. Proteomic analysis of uterine flushings from infertile women in the proliferative phase of the menstrual cycle with respect to estrogen level. Middle East Fertil Soc J. 2006;11(3):183-90.##Salamonsen LA, Edgell T, Rombauts LJ, Stephens AN, Robertson DM, Rainczuk A, et al. Proteomics of the human endometrium and uterine fluid: a pathway to biomarker discovery. Fertil Steril. 2013;99(4):1086-92.##Cheong Y, Boomsma C, Heijnen C, Macklon N. Uterine secretomics: a window on the maternal-embryo interface. Fertil Steril. 2013;99(4):1093-9.##Vilella F, Ramirez LB, Simon C. Lipidomics as an emerging tool to predict endometrial receptivity. Fertil Steril. 2013;99(4):1100-6.##Brosens JJ, Hodgetts A, Feroze-Zaidi F, Sherwin JR, Fusi L, Salker MS, et al. Proteomic analysis of endometrium from fertile and infertile patients suggests a role for apolipoprotein A-I in embryo implantation failure and endometriosis. Mol Hum Reprod. 2010;16(4):273-85.##Haouzi D, Dechaud H, Assou S, De Vos J, Hamamah S. Insights into human endometrial receptivity from transcriptomic and proteomic data. Reprod Biomed Online. 2012;24(1):23-34.##Devroey P, Bourgain C, Macklon NS, Fauser BC. Reproductive biology and IVF: ovarian stimulation and endometrial receptivity. Trends Endocrinol Metab. 2004;15(2):84-90.##Papanikolaou EG, Bourgain C, Fatemi H, Verpoest W, Polyzos NP, De Brabanter A, et al. Endometrial advancement after triggering with recombinant or urinary HCG: a randomized controlled pilot study. Reprod Biomed Online. 2010;21(1):50-5.##Aboulghar M. Stimulation protocols and implantation. In: Makrigiannakis A, editor. Proceeding of MSRM International Meeting “Implantation-recurrent miscarriages science and clinical aspects”; 2010 Sept 24-26; Chania, Crete, Greece: Mediterranean Society for Reproductive Medicine; 2010. p. 19.##Koler M, Achache H, Tsfrir A, Smith Y, Revel A, Reich R. Disrupted gene pattern in patients with repeated in vitro fertilization (IVF) failure. Hum Reprod. 2009;24(10):2541-8.##Revel A, Achache H, Stevens J, Smith Y, Reich R. MicroRNAs are associated with human embryo implantation defects. Hum Reprod. 2011;26(10):2830-40.##Diaz-Gimeno P, Horcajadas JA, Martinez-Conejero JA, Esteban FJ, Alama P, Pellicer A, et al. A genomic diagnostic tool for human endometrial receptivity based on the transcriptomic signature. Fertil Steril. 2011;95(1):50-60.##Diaz-Gimeno P, Ruiz-Alonso M, Blesa D, Bosch N, Martinez-Conejero JA, Alama P, et al. The accuracy and reproducibility of the endometrial receptivity array is superior to histology as a diagnostic method for endometrial receptivity. Fertil Steril. 2013;99(2):508-17.##Garrido-Gomez T, Ruiz-Alonso M, Blesa D, Diaz-Gimeno P, Vilella F, Simon C. Profiling the gene signature of endometrial receptivity: clinical results. Fertil Steril. 2013;99:1078-85.##Bhagwat SR, Chandrashekar DS, Kakar R, Davuluri S, Bajpai AK, Nayak S, et al. Endometrial receptivity: a revisit to functional genomics studies on human endometrium and creation of HGEx-ERdb. PLoS One. 2013;8(3):e58419.##Finn CA. Why do women and some other primates menstruate? Perspect Biol Med. 1987;30(4):566-74.##Dunn CL, Kelly RW, Critchley HO. Decidualization of the human endometrial stromal cell: an enigmatic transformation. Reprod Biomed Online. 2003;7(2):151-61.##Kennedy TG, Gillio-Meina C, Phang SH. Prostaglandins and the initiation of blastocyst implantation and decidualization. Reproduction. 2007;134(5):635-43.##Richards RG, Brar AK, Frank GR, Hartman SM, Jikihara H. Fibroblast cells from term human decidua closely resemble endometrial stromal cells: induction of prolactin and insulin-like growth factor binding protein-1 expression. Biol Reprod. 1995;52(3):609-15.##Sugino N, Kashida S, Karube-Harada A, Takiguchi S, Kato H. Expression of vascular endothelial growth factor (VEGF) and its receptors in human endometrium throughout the menstrual cycle and in early pregnancy. Reproduction. 2002;123(3):379-87.##Achache H, Tsafrir A, Prus D, Reich R, Revel A. Defective endometrial prostaglandin synthesis identified in patients with repeated implantation failure undergoing in vitro fertilization. Fertil Steril. 2010;94(4):1271-8.##Bulmer JN, Morrison L, Longfellow M, Ritson A, Pace D. Granulated lymphocytes in human endometrium: histochemical and immunohistochemical studies. Hum Reprod. 1991;6(6):791-8.##Nishikawa K, Saito S, Morii T, Hamada K, Ako H, Narita N, et al. Accumulation of CD16-CD56 natural killer cells with high affinity interleukin 2 receptors in human early pregnancy decidua. Int Immunol. 1991;3(8):743-50.##Flynn L, Byrne B, Carton J, Kelehan P, O'Herlihy C, O'Farrelly C. Menstrual cycle dependent fluctuations in NK and T-lymphocyte subsets from non-pregnant human endometrium. Am J Reprod Immunol. 2000;43(4):209-17.##Lachapelle MH, Miron P, Hemmings R, Roy DC. Endometrial T, B, and NK cells in patients with recurrent spontaneous abortion. Altered profile and pregnancy outcome. J Immunol. 1996;156(10):4027-34.##Matteo MG, Greco P, Rosenberg P, Mestice A, Baldini D, Falagario T, et al. Normal percentage of CD56bright natural killer cells in young patients with a history of repeated unexplained implantation failure after in vitro fertilization cycles. Fertil Steril. 2007;88(4):990-3.##Tuckerman E, Mariee N, Prakash A, Li TC, Laird S. Uterine natural killer cells in peri-implantation endometrium from women with repeated implantation failure after IVF. J Reprod Immunol. 2010;87(1-2):60-6.##Coulam CB, Krysa LW, Bustillo M. Intravenous immunoglobulin for in-vitro fertilization failure. Hum Reprod. 1994;9(12):2265-9.##Balasch J, Creus M, Fabregues F, Font J, Martorell J, Vanrell JA. Intravenous immunoglobulin preceding in vitro fertilization-embryo transfer for patients with repeated failure of embryo transfer. Fertil Steril. 1996;65(3):655-8.##Sher G, Zouves C, Feinman M, Maassarani G, Matzner W, Chong P, et al. A rational basis for the use of combined heparin/aspirin and IVIG immunotherapy in the treatment of recurrent IVF failure associated with antiphospholipid antibodies. Am J Reprod Immunol.1998;39(6):391-4.##Christiansen OB, Pedersen B, Rosgaard A, Husth M. A randomized, double-blind, placebo-controlled trial of intravenous immunoglobulin in the prevention of recurrent miscarriage: evidence for a therapeutic effect in women with secondary recurrent miscarriage. Hum Reprod. 2002;17(3):809-16.##Coulam CB, Acacio B. Does immunotherapy for treatment of reproductive failure enhance live births? Am J Reprod Immunol. 2012;67(4):296-304.##Stephenson MD, Kutteh WH, Purkiss S, Librach C, Schultz P, Houlihan E, et al. Intravenous immunoglobulin and idiopathic secondary recurrent miscarriage: a multicentered randomized placebo-controlled trial. Hum Reprod. 2010;25(9):2203-9.##Stephenson MD, Fluker MR. Treatment of repeated unexplained in vitro fertilization failure with intravenous immunoglobulin: a randomized, placebo controlled Canadian trial. Fertil Steril. 2000;74(6):1108-13.##Barash A, Dekel N, Fieldust S, Segal I, Schechtman E, Granot I. Local injury to the endometrium doubles the incidence of successful pregnancies in patients undergoing in vitro fertilization. Fertil Steril. 2003;79(6):1317-22.##Karimzadeh MA, Ayazi Rozbahani M, Tabibnejad N. Endometrial local injury improves the pregnancy rate among reccurent implantation failure patients undergoing in vitro fertilization/intracytoplasmic sperm injection: a randomised clinical trial. Aust N Z J Obstet Gynecol. 2009;49(6):677-80.##Zhou L, Li R, Wang R, Huang HX, Zhong K. Local injury to the endometrium in controlled ovarian hyperstimulation cycles improves implantation rates. Fertil Steril. 2008;89(5):1166-76.##Raziel A, Schachter M, Strassburger D, Bern O, Ron-El R, Friedler S. 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Accurate Diagnosis as a Prognostic Factor in Intrauterine Insemination Treatment of Infertile Saudi Patients 2 1 561 2 Background: The study meant to define the prognostic factors that help in prescribing intrauterine insemination (IUI) for infertility treatment which remains an area of continuous improvements. Methods: The diagnostic indications of a cohort of IUI-treated patients and their corresponding pregnancy rates (PRs) were randomly and prospectively studied among Saudi cohort of 303 patients for a period of 20 months. The indications of IUI cases were statistically analyzed for those eligible patients over a period of twenty months (January 2010 till August 2011), and the PR that corresponded to each group was investigated as well. P-value less than 0.05 was considered significant. Results: The highest PR, 18.87%, of the polycystic ovarian syndrome (PCOS)-only diagnosed patients, was significantly higher than the average PR of all other indications combined, 7.22%, (p=0.011, compared to all other groups combined). The second highest PR, 14.0%, of the tubal factor (TF)-only indication, was double the PR average of all other indications combined, though it did not reach significance. However, PCOS and TF accompanied by other indications caused the PR to drop to 5.88% and 5.56 %, respectively. However, a group of some hormonal-imbalance based indications had the least PR (0.0% to 2.70%). Those indications were elevated serum FSH, hyperprolactinemia, hypogonadotrophy, hypothyroidism and endometriosis. The rest of the indications had an average PR (8.33% to 11.11%). Conclusion: There is a reasonable chance of conception after IUI treatment for female factor infertility except in cases with sever hormonal imbalance. The PCOS cases having the best success chances. 184 190 Ahmed AM Isa Department of Obstetrics and Gynecology, College of Medicine, King Saud University Department of Obstetrics and Gynecology, College of Medicine, King Saud University Saudi Arabia isaahmed@hotmail.com Basim B Abu-Rafea Department of Obstetrics and Gynecology, College of Medicine, King Saud University Department of Obstetrics and Gynecology, College of Medicine, King Saud University Saudi Arabia Saleh SA Alasiri Department of Obstetrics and Gynecology, College of Medicine, King Saud University Department of Obstetrics and Gynecology, College of Medicine, King Saud University Saudi Arabia Johara J Al-Mutawa Department of Obstetrics and Gynecology, College of Medicine, King Saud University Department of Obstetrics and Gynecology, College of Medicine, King Saud University Saudi Arabia Saleh S Binsaleh Urology Division, Department of Surgery, College of Medicine, King Saud University Urology Division, Department of Surgery, College of Medicine, King Saud University Saudi Arabia Sameera S Al-Saif Department of Obstetrics and Gynecology, College of Medicine, King Saud University Department of Obstetrics and Gynecology, College of Medicine, King Saud University Saudi Arabia Aisha A Al-Saqer Department of Obstetrics and Gynecology, College of Medicine, King Saud University Department of Obstetrics and Gynecology, College of Medicine, King Saud University Saudi Arabia DiagnosisEndometriosisIntra uterine inseminationIUIMale factorPCOSPregnancy rateTubal Factor 561.pdf Iberico G, Vioque J, Ariza N, Lozano JM, Roca M, Llacer J. Analysis of factors influencing pregnancy rates in homologous intrauterine insemination. Fertil Steril. 2004;81(5):1308-13.##Kossakowski J, Stephenson M, Smith H. Intrauterine insemination with husband's sperm: comparison of pregnancy rates in couples with cervical factor, male factor, immunological factor and idiopathic infertility. Aust N Z J Obstet Gynaecol. 1993;33(2):183-6.##Allen NC, Herbert CM 3rd, Maxson WS, Rogers BJ, Diamond MP, Wentz AC. Intrauterine insemination: a critical review. Fertil Steril. 1985;44(5):569-80.##Nuojua-Huttunen S, Tomas C, Bloigu R, Tuomivaara L, Martikainen H. Intrauterine insemination treatment in subfertility: an analysis of factors affecting outcome. Hum Reprod. 1999;14(3):698-703.##Gezginc K, Gorkemli H, Celik C, Karatayli R, Cicek MN, Olakoglu MC. Comparison of single versus double intrauterine insemination. Taiwan J Obstet Gynecol. 2008;47(1):57-61.##Demirol A, Gurgan T. 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Comparison of Elaeagnus angustifolia Extract and Sildenafil Citrate on Female Orgasmic Disorders: A Randomized Clinical Trial 2 1 599 2 Background: Orgasmic disorder can create a feeling of deprivation and failure and provide mental problems, incompatibility and marital discord. This study aimed to compare the effects of Elaeagnus angustifolia flower extract and sildenafil citrate on female orgasmic disorder in women in 2013. Methods: In this randomized clinical trial, 125 women between 18-40 years old who suffered from orgasmic disorder were divided into three E. angustifolia, sildenafil citrate and control groups. The data were gathered using Female Sexual Function Index and through measurement of TSH and prolactin. The first intervention group had to consume 4.5 gr E. angustifolia extract in two divided doses for 35 days and the second one had to use 50 mg sildenafil citrate tablets for 4 weeks one hour before their sexual relationship. However, the control group had to consume the placebo. The data were analyzed using paired t-test, one-way ANOVA, and Bonferroni post-hoc test and p<0.05 was considered significant. Results: The frequency of orgasmic disorder before the intervention was 41.5%, 40.5%, and 57.1% in E. angustifolia, sildenafil citrate, and control groups, respectively (p=0.23). However, these measures were respectively 29.3%, 16.7%, and 50% after the intervention (p=0.004). A significant difference between the two groups regarding sexual satisfaction after the intervention (p=0.003) compared to the beginning of the study (p=0.356). Besides, the highest reduction of changes after the intervention (58.82%) was observed in the sildenafil citrate group. Conclusion: Both E. angustifolia extract and sildenafil citrate were effective in reduction of the frequency of orgasmic disorder in women. 190 199 Marzieh M Akbarzadeh Community Based Psychiatric Care Research Center, Department of Midwifery, Fatemeh (P.B.U.H) School of Nursing and Midwifery, Shiraz University of Medical Sciences, Community Based Psychiatric Care Research Center, Department of Midwifery, Fatemeh (P.B.U.H) School of Nursing and Midwifery, Shiraz University of Medical Sciences, Iran akbarzadm@sums.ac.ir Sanaz S Zeinalzadeh Department of Midwifery, School of Nursing and Midwifery, Shiraz University of Medical Sciences Department of Midwifery, School of Nursing and Midwifery, Shiraz University of Medical Sciences Iran Jaleh J Zolghadri Department of Obstetrics and Gynecology, School of Medicine, Shiraz University of Medical Sciences Department of Obstetrics and Gynecology, School of Medicine, Shiraz University of Medical Sciences Iran Abdolali A Mohagheghzadeh Department of Traditional Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences Department of Traditional Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences Iran Pouya P Faridi Department of Traditional Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences Department of Traditional Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences Iran Mehrab S Sayadi Department of Bio-statistics, Shiraz University of Medical Sciences Department of Bio-statistics, Shiraz University of Medical Sciences Iran Elaeagnus angustifoliaOrgasmic disorderSildenafil citrate 599.pdf Basson R. 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Vasopressin Effect on Operation Time and Frequency of Electrocauterization during Laparoscopic Stripping of Ovarian Endometriomas: A Randomized Controlled Clinical Trial 2 1 606 2 Background: The purpose of this study was to assess the vasopressin effect on operation time and the need for electrocauterization frequency and ovarian reserve during laparoscopic stripping of ovarian endometriomas. Methods: This was a randomized prospective clinical trial, in which twenty patients between 18-35 years with unilateral endometriomas were randomly divided in two groups of cases and controls. Laparoscopic cystectomy was performed by hydrodissection and stripping method in both groups with diluted vasopressin injected in cases, in comparison to only saline injection in controls. Ovarian hemostasis was achieved by bipolar electrocoagulation. The operation time and frequency of electrocoagulation were compared between two groups. The ovarian reserve was determined by ultrasound examination and laboratory assessment one month before and two months after surgery in two groups. Non parametric data was analyzed by Mann-Whitney test. The p-value less than 0.05 was considered statistically significant. Results: The operation time was less in cases than control group, but the difference was not statistically significant (p=0.065). The frequency of electrocoagulation for hemostasis was less in cases than controls but this difference was not statistically signiﬁcant (p=0.132). The antral follicle count decreased in both groups two months later, while no signiﬁcant difference was found between two groups. Conclusion: This study shows that diluted vasopressin decreases operation time and electrocauterization frequency during laparoscopic stripping of ovarian endometriomas; however, the difference between case and control group is not statistically signiﬁcant. 199 205 Marzieh M Ghafarnejad Department of Obstetrics and Gynecology, Women Hospital, Tehran University of Medical Sciences Department of Obstetrics and Gynecology, Women Hospital, Tehran University of Medical Sciences Iran ghafarin2@yahoo.com Mina M Akrami Department of Obstetrics and Gynecology, Women Hospital, Tehran University of Medical Sciences Department of Obstetrics and Gynecology, Women Hospital, Tehran University of Medical Sciences Iran Fatemeh F Davari-Tanha Department of Obstetrics and Gynecology, Women Hospital, Tehran University of Medical Sciences Department of Obstetrics and Gynecology, Women Hospital, Tehran University of Medical Sciences Iran Khadijeh Kh Adabi Department of Obstetrics and Gynecology, Women Hospital, Tehran University of Medical Sciences Department of Obstetrics and Gynecology, Women Hospital, Tehran University of Medical Sciences Iran Sepideh S Nekuie Women Hospital, Tehran University of Medical Sciences Women Hospital, Tehran University of Medical Sciences Iran ElectrocoagulationEndometriosisLaparoscopyVasopressin 606.pdf Coric M, Barisic D, Pavicic D, Karadza M, Banovic M. Electrocoagulation versus suture after laparoscopic stripping of ovarian endometriomas assessed by antral follicle count: preliminary results of randomized clinical trial. Arch Gynecol Obstet. 2011;283(2):373-8.##Ferrero S, Venturini PL, Gillott DJ, Remorgida V, Leone Roberti Maggiore U. Hemostasis by bipolar coagulation versus suture after surgical stripping of bilateral ovarian endometriomas: a randomized controlled trial. J Minim Invasive Gynecol. 2012;19(6):722-30.##Pados G, Tsolakidis D, Assimakopoulos E, Athanatos D, Tarlatzis B. Sonographic changes after laparoscopic cystectomy compared with three-stage management in patients with ovarian endometriomas: a prospective randomized study. Hum Reprod. 2010;25(3):672-7.##Muzii L, Bellati F, Bianchi A, Palaia I, Manci N, Zullo MA, et al. Laparoscopic stripping of endometriomas: a randomized trial on different surgical techniques. Part II: pathological results. Hum Reprod. 2005;20(7):1987-92.##Benaglia L, Somigliana E, Vighi V, Ragni G, Vercellini P, Fedele L. Rate of severe ovarian damage following surgery for endometriomas. Hum Reprod. 2010;25(3):678-82.##Hachisuga T, Kawarabayashi T. Histopathological analysis of laparoscopically treated ovarian endometriotic cysts with special reference to loss of follicles. Hum Reprod. 2002;17(2):432-5.##Ebert AD, Hollauer A, Fuhr N, Langolf O, Papadopoulos T. Laparoscopic ovarian cystectomy without bipolar coagulation or sutures using a gelantine-thrombin matrix sealant (FloSeal): first support of a promising technique. Arch Gynecol Obstet. 2009;280(1):161-5.##Hobday CD, Milam MR, Milam RA, Euscher E, Brown J. Postoperative small bowel obstruction associated with use of hemostatic agents. J Minim Invasive Gynecol. 2009;16(2):224-6.##Suzuki Y, Vellinga TT, Istre O, Einarsson JI. Small bowel obstruction associated with use of a gelatin-thrombin matrix sealant (FloSeal) after laparoscopic gynecologic surgery. J Minim Invasive Gynecol. 2010;17(5):641-5.##Saeki A, Matsumoto T, Ikuma K, Tanase Y, Inaba F, Oku H, et al. The vasopressin injection technique for laparoscopic excision of ovarian endometrioma: a technique to reducethe use of coagulation. J Minim Invasive Gynecol. 2010;17(2):176-9.##Beretta P, Franchi M, Ghezzi F, Busacca M, Zupi E, Bolis P. Randomized clinical trial of two laparoscopic treatments of endometriomas: cystectomy versus drainage and coagulation. Fertil Steril. 1998;70(6):1176-80.##Jadoul P, Kitajima M, Donnez O, Squifflet J, Donnez J. Surgical treatment of ovarian endometriomas: state of the art? Fertil Steril. 2012;98(3):556-63.##Vercellini P, Chapron C, De Giorgi O, Consonni D, Frontino G, Crosignani PG. Coagulation or excision of ovarian endometriomas? Am J Obstet Gynecol. 2003;188(3):606-10.##Busacca M, Marana R, Caruana P, Candiani M, Muzii L, Calia C, et al. Recurrence of ovarian endometrioma after laparoscopic excision. Am J Obstet Gynecol. 1999;180(3 Pt 1):519-23.##Tsolakidis D, Pados G, Vavilis D, Athanatos D, Tsalikis T, Giannakou A, et al. The impact on ovarian reserve after laparoscopic ovarian cystectomy versus three-stage management in patients with endometriomas: a prospective randomized study. Fertil Steril. 2010;94(1):71-7.##Var T, Batioglu S, Tonguc E, Kahyaoglu I. The effect of laparoscopic ovarian cystectomy versus coagulation in bilateral endometriomas on ovarian reserve as determined by antral follicle count and ovarian volume: a prospective randomized study. Fertil Steril. 2011;95(7):2247-50.##Roman H, Tarta O, Pura I, Opris I, Bourdel N, Marpeau L, et al. Direct proportional relationship between endometrioma size and ovarian parenchyma inadvertently removed during cystectomy, and its implication on the management of enlarged endometriomas. Hum Reprod. 2010;25(6):1428-32.##Alborzi S, Momtahan M, Parsanezhad ME, Dehbashi S, Zolghadri J, Alborzi S. A prospective, randomized study comparing laparoscopic ovarian cystectomy versus fenestration and coagulation in patients with endometriomas. Fertil Steril. 2004;82(6):1633-7.##Hart R, Hickey M, Maouris P, Buckett W, Garry R. Excisional surgery versus ablative surgery for ovarian endometriomata: a Cochrane Review. Hum Reprod. 2005;20(11):3000-7.##Donnez J, Nisolle M, Gillet N, Smets M, Bassil S, Casanas-Roux F. Large ovarian endometriomas. Hum Reprod. 1996;11(3):641-6.##Exacoustos C, Zupi E, Amadio A, Szabolcs B, De Vivo B, Marconi D, et al. Laparoscopic removal of endometriomas: sonographic evaluation of residual functioning ovarian tissue. Am J Obstet Gynecol. 2004;191(1):68-72.##Matsuzaki S, Houlle C, Darcha C, Pouly JL, Mage G, Canis M. Analysis of risk factors for the removal of normal ovarian tissue during laparoscopic cystectomy for ovarian endometriosis. Hum Reprod. 2009;24(6):1402-6.##Muzii L, Bianchi A, Croce C, Manci N, Panici PB. Laparoscopic excision of ovarian cysts: is the stripping technique a tissue-sparing procedure? Fertil Steril. 2002;77(3):609-14.##Fedele L, Bianchi S, Zanconato G, Bergamini V, Berlanda N. Bipolar electrocoagulation versus suture of solitary ovary after laparoscopic excision of ovarian endometriomas. J Am Assoc Gynecol Laparosc. 2004;11(3):344-7.##Tulandi T, Beique F, Kimia M. Pulmonary edema: a complication of local injection of vasopressin at laparoscopy. Fertil Steril. 1996;66(3):478-80.##Fletcher H, Frederick J, Hardie M, Simeon D. A randomized comparison of vasopressin and tourniquet as hemostatic agents during myomectomy. Obstet Gynecol. 1996;87(6):1014-8.##Ellis MH, Fredman B, Zohar E, Ifrach N, Jedeikin R. The effect of tourniquet application, tranexamic acid, and desmopressin on the procoagulant and fibrinolytic systems during total knee replacement. J Clin Anesth. 2001;13(7):509-13.##Shimanuki H, Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kinoshita K. The effect of vasopressin on local and general circulation during laparoscopic surgery. J Minim Invasive Gynecol. 2006;13(3):190-4.##Nezhat F, Admon D, Nezhat CH, Dicorpo JE, Nezhat C. Life-threatening hypotension after vasopressin injection during operative laparoscopy, followed by uneventful repeat laparoscopy. J Am Assoc Gynecol Laparosc. 1994;2(1):83-6.##Deschamps A, Krishnamurthy S. Absence of pulse and blood pressure following vasopressin injection for myomectomy. Can J Anaesth. 2005;52(5):552-3.##Hansen KR, Hodnett GM, Knowlton N, Craig LB. Correlation of ovarian reserve tests with histologically determined primordial follicle number. Fertil Steril. 2011;95(1):170-5.##

Effect of Metformin and Flutamide on Anthropometric Indices and Laboratory Tests in Obese/Overweight PCOS Women under Hypocaloric Diet 2 1 601 2 Background: This study was designed to investigate the effect of metformin and flutamide alone or in combination with anthropometric indices and laboratory tests of obese/overweight PCOS women under hypocaloric diet. Methods: This single blind clinical trial was performed on 120 PCOS women. At the beginning, hypocaloric diet was recommended for the patients. After one month while they were on the diet, the patients were randomly divided in 4 groups; metformin (500 mg, 3/day), flutamide (250 mg, 2/day), combined, metformin (500 mg, 3/day) with flutamide (250 mg, 2/day) and finally placebo group. The patients were treated for 6 months. Anthropometric indices and laboratory tests (fasting and glucose-stimulated insulin levels, lipid profile and androgens) were measured. A one-way ANOVA (Post Hoc) and paired t-test were performed to analyze data. A p≤0.05 was considered statistically significant. Results: After treatment, reduction in weight, BMI, hip circumference was significantly greater in the metformin group in comparison to other groups (p<0.05). In addition, the fasting insulin was significantly greater in metformin group and flutamide group in comparison to metformin+flutamide and placebo groups after treatment (p<0.05). Within groups, insulin level showed significant changes (before and after treatment) in metformin+flutamide group and LDL reduction was significant in flutamide group before and after treatment. Post hoc tukey and two-tailed with p≤0.05 were used to define statistical significance. Conclusion: Using combination of metformin and flutamide improves anthropometric indices and laboratory tests in obese/overweight PCOS women under hypocaloric diet. 205 214 Mania M Amiri Fatemezahra Infertility and Reproductive Health Research Center, Babol University of Medical Sciences Fatemezahra Infertility and Reproductive Health Research Center, Babol University of Medical Sciences Iran Masoumeh M Golsorkhtabar-Amiri Fatemezahra Infertility and Reproductive Health Research Center, Babol University of Medical Sciences Fatemezahra Infertility and Reproductive Health Research Center, Babol University of Medical Sciences Iran Sedigheh S Esmaeilzadeh Fatemezahra Infertility and Reproductive Health Research Center, Babol University of Medical Sciences Fatemezahra Infertility and Reproductive Health Research Center, Babol University of Medical Sciences Iran sesmael@yahoo.com Faeze F Ghofrani Fatemezahra Infertility and Reproductive Health Research Center, Babol University of Medical Sciences Fatemezahra Infertility and Reproductive Health Research Center, Babol University of Medical Sciences Iran Ali A Bijani Non-Communicable Pediatric Disease Research Center, Amirkola Children's Hospital, Babol University of Medical Sciences Non-Communicable Pediatric Disease Research Center, Amirkola Children's Hospital, Babol University of Medical Sciences Iran Leila L Ghorbani Obstetrics and Gynecology Department, Babol University of Medical Sciences Obstetrics and Gynecology Department, Babol University of Medical Sciences Iran Moloud M Agajani Delavar Fatemezahra Infertility and Reproductive Health Research Center, Babol University of Medical Sciences Fatemezahra Infertility and Reproductive Health Research Center, Babol University of Medical Sciences Iran Body weightFlutamideMetforminPolycystic ovary syndrome 601.pdf March WA, Moore VM, Willson KJ, Phillips DI, Norman RJ, Davies MJ. The prevalence of polycystic ovary syndrome in a community sample assessed under contrasting diagnostic criteria. Hum Reprod. 2010;25(2):544-51.##Franks S. Polycystic ovary syndrome. N Engl J Med. 1995;333(13):853-61.##Glueck CJ, Phillips H, Cameron D, Sieve-Smith L, Wang P. Continuing metformin throughout pregnancy in women with polycystic ovary syndrome appears to safely reducefirst-trimester spontaneous abortion: a pilot study. Fertil Steril. 2001;75(1):46-52.##Stamets K, Taylor DS, Kunselman A, Demers LM, Pelkman CL, Legro RS. A randomized trial of the effects of two types of short-term hypocaloric diets on weight loss in women with polycystic ovary syndrome. Fertil Steril. 2004;81(3):630-7.##Hoeger KM, Kochman L, Wixom N, Craig K, Miller RK, Guzick DS. A randomized, 48-week, placebo-controlled trial of intensive lifestyle modification and/or metformin therapy in overweight women with polycystic ovary syndrome: a pilot study. Fertil Steril. 2004;82(2):421-9.##Gambineri A, Pelusi C, Genghini S, Morselli-Labate AM, Cacciari M, Pagotto U, et al. Effect of flutamide and metformin administered alone or in combination in dieting obese women with polycystic ovary syndrome. Clin Endocrinol (Oxf). 2004;60(2):241-9.##Berek JS, Novak E. Berek & Novak's gynecology. 14th ed. Philadelphia: Lippincott William & Wilkins; 2007.##Nieuwenhuis-Ruifrok AE, Kuchenbecker WK, Hoek A, Middleton P, Norman RJ. Insulin sensitizing drugs for weight loss in women of reproductive age who are overweight or obese: systematic review and meta-analysis. Hum Reprod Update. 2009;15(1):57-68.##Glueck CJ, Aregawi D, Agloria M, Winiarska M, Sieve L, Wang P. Sustainability of 8% weight loss, reduction of insulin resistance, and amelioration of atherogenic-metabolic risk factors over 4 years by metformin-diet in women with polycystic ovary syndrome. Metabolism. 2006;55(12):1582-9.##Lord JM, Flight IH, Norman RJ. Insulin-sensitising drugs (metformin, troglitazone, rosiglitazone, pioglitazone, D-chiro-inositol) for polycystic ovary syndrome. Cochrane Database Syst Rev. 2003;(3):CD003053.##Ghazeeri GS, Nassar AH, Younes Z, Awwad JT. Pregnancy outcomes and the effect of metformin treatment in women with polycystic ovary syndrome: anoverview. Acta Obstet Gynecol Scand. 2012;91(6):658-78.##Morin-Papunen L, Rantala AS, Unkila-Kallio L, Tiitinen A, Hippelainen M, Perheentupa A, et al. Metformin improves pregnancy and live-birth rates in women with polycystic ovary syndrome (PCOS): a multicenter, double-blind, placebo-controlled randomized trial. J Clin Endocrinol Metab. 2012;97(5):1492-500.##Tang T, Lord JM, Norman RJ, Yasmin E, Balen AH. Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility. Cochrane Database Syst Rev. 2012;5:CD003053.##Eagleson CA, Gingrich MB, Pastor CL, Arora TK, Burt CM, Evans WS, et al. Polycystic ovarian syndrome: evidence that flutamide restores sensitivity of the gonadotropin-releasing hormone pulse generator to inhibition by estradiol and progesterone. J Clin Endocrinol Metab. 2000;85(11):4047-52.##Pasquali R, Gambineri A, Biscotti D, Vicennati V, Gagliardi L, Colitta D, et al. Effect of long-term treatment with metformin added to hypocaloric diet on body composition, fat distribution, and androgen and insulin levels in abdominally obese women with and without the polycystic ovary syndrome. J Clin Endocrinol Metab. 2000;85(8):2767-74.##Sahin I, Serter R, Karakurt F, Demirbas B, Culha C, Taskapan C, et al. Metformin versus flutamide in the treatment of metabolic consequences of non-obese young women with polycystic ovary syndrome: a randomized prospective study. Gynecol Endocrinol. 2004;19(3):115-24.##Gambineri A, Pelusi C, Genghini S, Morselli-Labate AM, Cacciari M, Pagotto U, et al. Effect of flutamide and metformin administered alone or in combination in dieting obese women with polycystic ovary syndrome. Clin Endocrinol (Oxf). 2004;60(2):241-9.##Gambineri A, Patton L, Vaccina A, Cacciari M, Morselli-Labate AM, Cavazza C, et al. Treatment with flutamide, metformin, and their combination added to a hypocaloric diet in overweight-obese women with polycystic ovary syndrome: a randomized, 12-month, placebo-controlled study. J Clin Endocrinol Metab. 2006;91(10):3970-80.##Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser. 2000;894:i-xii, 1-253.##Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod. 2004;19(1):41-7.##Cook H, Brennan K, Azziz R. Reanalyzing the modified Ferriman-Gallwey score: is there a simpler method for assessing the extent of hirsutism? Fertil Steril. 2011;96(5):1266-70.e1.##Guidlines for data processing and analaysis of the international physical activity questionnaire (IPQA)-short and long forms. Med Sci Sports Exerc. 2005;37(11Suppl):531-43.##Kelishadi R, Rabiei K, Khosravi A, Ardalan G, Gheiratmand R, Delavari A, et al. Assessment of physical activity in adolescents of Isfahan. J Shahrekord Univ Med Sci. 2001;3(2):55-66.##Clark AM, Ledger W, Galletly C, Tomlinson L, Blaney F, Wang X, et al. Weight loss results in significant improvement in pregnancy and ovulation rates in anovulatory obese women. Hum Reprod. 1995;10(10):2705-12.##Glazer NL, Hendrickson AF, Schellenbaum GD, Mueller BA. Weight change and the risk of gestational diabetes in obese women. Epidemiology. 2004;15(6):733-7.##Morin-Papunen LC, Vauhkonen I, Koivunen RM, Ruokonen A, Martikainen HK, Tapanainen JS. Endocrine and metabolic effects of metformin versus ethinyl estradiol-cyproterone acetate in obese women with polycystic ovary syndrome: a randomized study. J Clin Endocrinol Metab. 2000;85(9):3161-8.##Harborne L, Fleming R, Lyall H, Norman J, Sattar N. Descriptive review of the evidence for the use of metformin in polycystic ovary syndrome. Lancet. 2003;361(9372):1894-901.##Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403.##Tang T, Glanville J, Hayden CJ, White D, Barth JH, Balen AH. Combined lifestyle modification and metformin in obese patients with polycystic ovary syndrome. A randomized, placebo-controlled, double-blind multicentre study. Hum Reprod. 2006;21(1):80-9.##Wadden TA, Berkowitz RI, Womble LG, Sarwer DB, Phelan S, Cato RK, et al. Randomized trial of lifestyle modification and pharmacotherapy for obesity. N Engl J Med. 2005;353(20):2111-20.##Li XJ, Yu YX, Liu CQ, Zhang W, Zhang HJ, Yan B, et al. Metformin vs thiazolidinediones for treatment of clinical, hormonal and metabolic characteristics of polycystic ovary syndrome: a meta-analysis. Clin Endocrinol (Oxf). 2011;74(3):332-9.##Paradisi R, Fabbri R, Battaglia C, Venturoli S. Ovulatory effects of flutamide in the polycystic ovary syndrome. Gynecol Endocrinol. 2013;29(4):391-5.##

Relationship between Dietary Fat Intake, Its Major Food Sources and Assisted Reproduction Parameters 2 1 559 2 Background: High dietary fat consumption may alter oocyte development and embryonic development. This prospective study was conducted to determine the relation between dietary fat consumption level, its food sources and the assisted reproduction parameters. Methods: A prospective study was conducted on 240 infertile women. In assisted reproduction treatment cycle, fat consumption and major food sources over the previous three months were identified. The number of retrieved oocytes, metaphase ΙΙ stage oocytes numbers, fertilization rate, embryo quality and clinical pregnancy rate were also determined. The data were analyzed using multiple regression, binary logistic regression, chi-square and t-test. The p-value of less than 0.05 was considered significant. Results: Total fat intake adjusted for age, body mass index, physical activity and etiology of infertility was positively associated with the number of retrieved oocytes and inversely associated with the high embryo quality rate. An inverse association was observed between sausage and turkey ham intake and the number of retrieved oocytes. Also, oil intake level had an inverse association with good cleavage rate. Conclusion: The results revealed that higher levels of fat consumption tend to increase the number of retrieved oocytes and were adversely related to embryonic development. Among food sources of fat, vegetable oil, sausage and turkey ham intake may adversely affect assisted reproduction parameters. 214 222 Ashraf A Kazemi Reproductive Health Department, Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences Reproductive Health Department, Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences Iran Kazemi@nm.mui.ac.ir Fatemeh F Ramezanzadeh فاطمه رمضان زاده Reproductive Health Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences Reproductive Health Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences Iran Mohammad Hossein MH Nasr-Esfahani Reproductive Biomedicine Center, Royan Institute for Animal Biotechnology, ACECR, Department of Reproduction and Development Reproductive Biomedicine Center, Royan Institute for Animal Biotechnology, ACECR, Department of Reproduction and Development Iran Assisted reproductionDietary fatsEmbryo qualityPregnancy rate 559.pdf Cribier S, Morrot G, Zachowski A. 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Impact of dietary fatty acids on oocyte quality and development in lactating dairy cows. Biol Reprod. 2007;77(1):9-17.##Leroy JL, Van Soom A, Opsomer G, Goovaerts IG, Bols PE. Reduced fertility in high-yielding dairy cows: are the oocyte and embryo in danger? Part II. Mechanisms linking nutrition and reduced oocyte and embryo quality in high-yielding dairy cows. Reprod Domest Anim. 2008;43(5):623-32.##Petit HV, Cavalieri FB, Santos GT, Morgan J, Sharpe P. Quality of embryos produced from dairy cows fed whole flaxseed and the success of embryo transfer. J Dairy Sci. 2008;91(5):1786-90.##Campbell BK, Souza C, Gong J, Webb R, Kendall N, Marsters P, et al. Domestic ruminants as models for the elucidation of the mechanisms controlling ovarian follicle development in humans. Reprod Suppl. 2003;61:429-43.##Krajcovicova-Kudlackova M, Sebekova K, Schinzel R, Klvanova J. Advanced glycation end products and nutrition. Physiol Res. 2002;51(3):313-6.##Hsuuw YD, Chang CK, Chan WH, Yu JS. 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Zoroastrians Support Oocyte and Embryo Donation Program for Infertile Couples 2 1 600 2 Background: The main goal was to evaluate the attitudes and knowledge of Zoroastrians living in Iran towards oocyte donation (OD) and embryo donation (ED) program. Methods: This cross sectional study consisted of 318 Zoroastrians (n=175 for OD and n=143 for ED) of both sexes. The questionnaire form comprised two parts of general demographic characteristics of the participants and twenty multiple-choice questions about attitude and knowledge of participants towards OD and ED. For statistical analysis, the chi-square test was applied for comparison of data generated from ED and OD groups. Results: Majority of the participants supported OD (69.7%) and ED (71.3%) for infertile patients. In addition, 40% and 42% preferred donation program (OD and ED, respectively), compared to adoption. About 60% of the respondents believed that the donors have no right to find the child and claim it as their own. In addition, more than half of the respondents thought that the recipients of oocyte/embryo should never know the name and address of the donors. More than half of the participants did not know whether their religion accepts donation program or not. Approximately, 80% of respondents supported psychological counseling for both donors and recipients. Moreover, about 56% of the participants necessitated the advertisement on OD/ED program in the mass media. Conclusion: Our preliminary data showed that Zoroastrians supported both OD and ED program equally for infertile couples. 222 229 Iman I Halvaei Iman Halvaei Research and Clinical Center for Infertility, Shahid Sadoughi University of Medical Sciences Research and Clinical Center for Infertility, Shahid Sadoughi University of Medical Sciences Iran Mohammad Ali MA Khalili محمد علی خلیلی Research and Clinical Center for Infertility, Shahid Sadoughi University of Medical Sciences Research and Clinical Center for Infertility, Shahid Sadoughi University of Medical Sciences Iran khalili59@hotmail.com Saeed S Ghasemi-Esmailabad Research and Clinical Center for Infertility, Shahid Sadoughi University of Medical Sciences Research and Clinical Center for Infertility, Shahid Sadoughi University of Medical Sciences Iran Ali A Nabi Research and Clinical Center for Infertility, Shahid Sadoughi University of Medical Sciences Research and Clinical Center for Infertility, Shahid Sadoughi University of Medical Sciences Iran Farimah F Shamsi College of Health, Department of Biostatistics and Epidemiology, Shahid Sadoughi University of Medical Sciences College of Health, Department of Biostatistics and Epidemiology, Shahid Sadoughi University of Medical Sciences Iran Embryo donationIranOocyte donationZoroastrians 600.pdf Trounson A, Leeton J, Besanko M, Wood C, Conti A. Pregnancy established in an infertile patient after transfer of a donated embryo fertilized in vitro. Br Med J (Clin Res Ed). 1983;286(6368):835-8.##Lutjen P, Trounson A, Leeton J, Findlay J, Wood C, Renou P. The establishment and maintenance of pregnancy using in vitro fertilization and embryo donation in a patient with primary ovarian failure. Nature. 1984;307(5947):174-5.##Practice Committee of American Society for Reproductive Medicine; Practice Committee of Society for Assisted Reproductive Technology. 2008 Guidelines for gamete and embryo donation: a Practice Committee report. Fertil Steril. 2008;90(5 Suppl):S30-44.##Practice Committee of American Society for Reproductive Medicine; Practice Committee of Society for Assisted Reproductive Technology. Recommendations for gamete and embryo donation: a committee opinion. Fertil Steril. 2013;99(1):47-62.##Lee J, Yap C. Embryo donation: a review. Acta Obstet Gynecol Scand. 2003;82(11):991-6.##Li XH, Chen SU, Zhang X, Tang M, Kui YR, Wu X, et al. Cryopreserved oocytes of infertile couples undergoing assisted reproductive technology could be an important source of oocyte donation: a clinical report of successful pregnancies. Hum Reprod. 2005;20(12):3390-4.##Sunderam S, Chang J, Flowers L, Kulkarni A, Sentelle G, Jeng G, et al. Assisted reproductive technology surveillance--United States, 2006. MMWR Surveill Summ. 2009;58(5):1-25.##Schenker JG. Assisted reproductive practice: religious perspectives. Reprod Biomed Online. 2005;10(3):310-9.##Klein JU, Sauer MV. Ethics in egg donation: past, present, and future. Semin Reprod Med. 2010;28(4):322-8.##Isikoglu M, Senol Y, Berkkanoglu M, Ozgur K, Donmez L, Stones-Abbasi A. Public opinion regarding oocyte donation in Turkey: first data from a secular population among the Islamic world. Hum Reprod. 2006;21(1):318-23.##Khalili M, Isikoglu M, Ghasemi M. Attitudes of Christians and Muslims to an oocyte donation program in Iran. Eubios J Asian Int Bioeth. 2006;16:66-71.##Ghasemi N, Khalili MA, Tayyebi N. Knowledge and attitudes of infertile couples towards embryo donation program: A preliminary report from Iran. Ethics Sci Tech. 2007;2(1-2):89-96.##Mohagheghzadeh A, Zargaran A, Daneshamuz S. Cosmetic sciences from ancient Persia. Pharm Hist (Lond). 2011;41(2):18-23.##Foltz R. Zoroastrians in Iran: What Future in the Homeland? Middle East J. 2011;65(1):73-84.##Khalili MA, Isikoglu M, Tabibnejad N, Ahmadi M, Abed F, Parsanejad ME, et al. IVF staff attitudes towards oocyte donation: a multi-centric study from Iran and Turkey. Reprod Biomed Online. 2008;17 Suppl 3:61-6.##Van Voorhis BJ, Grinstead DM, Sparks AE, Gerard JL, Weir RF. Establishment of a successful donor embryo program: medical, ethical, and policy issues. Fertil Steril. 1999;71(4):604-8.##Guz H, Ozkan A, Sarisoy G, Yanik F, Yanik A. Psychiatric symptoms in Turkish infertile women. J Psychosom Obstet Gynaecol. 2003;24(4):267-71.##Yassini M, Khalili M, Hashemian Z. The level of anxiety and depression among Iranian infertile couples undergoing in vitro fertilization or intra cytoplasmic sperm injection cycles. J Res Med Sci. 2005;10(6):358-62.##Azargoshasb F. Gathas, the holy songs of Zarathushtra. 4th ed. Tehran: Fravahar; 2005.##Gurtin ZB. Banning reproductive travel: Turkey's ART legislation and third-party assisted reproduction. Reprod Biomed Online. 2011;23(5):555-64.##Afshar L, Bagheri A. Embryo donation in Iran: an ethical review. Dev World Bioeth. 2013;13(3):119-24.##Zahedi F, Larijani B. National bioethical legislation and guidelines for biomedical research in the Islamic Republic of Iran. Bull World Health Organ. 2008;86(8):630-4.##Finger R, Sommerfelt C, Freeman M, Wilson CK, Wade A, Daly D. A cost-effectiveness comparison of embryo donation with oocyte donation. Fertil Steril. 2010;93(2):379-81.##Schenker JG. Genetic material donation: sperm, oocyte, pre-embryo. Int J Gynaecol Obstet. 1993;43(3):247-55.##Urdapilleta L, Chillik C, Fernandez D. Do fertile and infertile people think differently about ovum donation? J Assist Reprod Genet. 2001;18(1):1-7.##Svanberg AS, Lampic C, Bergh T, Lundkvist O. Public opinion regarding oocyte donation in Sweden. Hum Reprod. 2003;18(5):1107-14.##Purewal S, van den Akker OB. British women's attitudes towards oocyte donation: ethnic differences and altruism. Patient Educ Couns. 2006;64(1-3):43-9.##Human Fertilization and Embryology Authority [Internet]. London: Human Fertilization and Embryology Authority (HFEA); 2013 October [cited 2014 Feb 20]. Available from: http://www.hfea. gov.uk/docs/8th_Code_of_Practice_Upto102013.pdf.##Steiner AZ, Paulson RJ. Oocyte donation. Clin Obstet Gynecol. 2006;49(1):44-54.##Ethics Committee of the American Society for Reproductive Medicine. Oocyte or embryo donation to women of advanced age: a committee opinion. Fertil Steril. 2013;100(2):337-40.##

Demons-Meigs Pseudosyndrome Mimicking the Symptoms of Pregnancy: A Case Report 2 1 603 2 Background: The Demons-Meigs syndrome should usually be evoked in case of presence of a typical triad: abdominopelvic mass, ascites and hydrothorax. Its diagnosis appears crucial to prevent the realization of unnecessary surgical procedures. Case Presentation: A 32-year-old woman presented in April 2012 to the emergency department of our maternity unit (General Hospital, Thiers, France) with an abdominal distension mimicking the symptoms of a pregnancy at term. Physical examination revealed a voluminous painful abdominopelvic mass, extended from the pelvis to the upper abdomen with a large right pleural effusion. Ultrasound and computed tomography showed it was a tumor measuring more than 300 mm in diameter with a right hydrothorax. Serum CA-125 level was 289 U/ml. Cytologic analysis of the pleural effusion didn’t show any malignant cells. In this study, Demons-Meigs syndrome was recognized. A laparoscopico-laparotomic management permitted an aspiration of 23 liters of a brownish liquid and an unilateral adnexectomy after pleural paracentesis was performed. Frozen section demonstrated benign mucinous cystadenoma. The final histologic findings objectified intracystic intestinal type ovarian mucinous borderline tumor. After multidisciplinary consultation, the patient was re-operated one month later. The exploration didn’t reveal any suspected lesions and appendectomy and omentectomy were performed. The postoperative course was uneventful. Serum CA-125 level was normal at the time of the reoperation and 24 months after the initial surgery. Conclusion: The preoperative recognition of a Demons-Meigs syndrome or a Demons’ pseudosyndrome is essential to avoid useless surgical procedures. 229 233 Erdogan E Nohuz Department of Obstetrics and Gynecology, General Hospital of Thiers Department of Obstetrics and Gynecology, General Hospital of Thiers France enohuz@yahoo.fr Maher M Alaboud Department of Obstetrics and Gynecology, General Hospital of Thiers Department of Obstetrics and Gynecology, General Hospital of Thiers France Bilal B El-Drayi Department of Anesthesiology and Critical Care Medicine, General Hospital of Thiers Department of Anesthesiology and Critical Care Medicine, General Hospital of Thiers France Stefano S Tamburro Department of Obstetrics and Gynecology, General Hospital of Grosseto Department of Obstetrics and Gynecology, General Hospital of Grosseto Italy Said S Kachkach Department of Radiology, General Hospital of Thiers Department of Radiology, General Hospital of Thiers France Janos J Varga Department of Surgery, General Hospital of Thiers Department of Surgery, General Hospital of Thiers France Abdominal massDemons-Meigs syndromeHydrothoraxMeigsOvarian benign tumor 603.pdf Brun JL. Demons syndrome revisited: a review of the literature. Gynecol Oncol. 2007;105(3):796-800.##Loue VA, Gbary E, Koui S, Akpa B, Kouassi A. Bilateral ovarian fibrothecoma associated with ascites, bilateral pleural effusion, and marked elevated serum CA-125. Case Rep Obstet Gynecol. 2013;2013:189072.##Loizzi V, Cormio G, Resta L, Fattizzi N, Vicino M, Selvaggi L. Pseudo-Meigs syndrome and elevated CA125 associated with struma ovarii. Gynecol Oncol. 2005;97(1):282-4.##Tamburro S, Nohuz E, Mage G, Canis M. Laparoscopic surgical approach for a borderline ovarian tumour of more than 25 cm. Gynecol Surg. 2010;7(3):267-9.##Mui MP, Tam KF, Tam FK, Ngan HY. Coexistence of struma ovarii with marked ascites and elevated CA-125 levels: case report and literature review. Arch Gynecol Obstet. 2009;279(5):753-7.##Urban BA, Fishman EK. Spiral CT of the female pelvis: clinical applications. Abdom Imaging. 1995;20(1):9-14.##Zhang H, Zhang GF, He ZY, Li ZY, Zhu M, Zhang GX. Evaluation of primary adnexal masses by 3T MRI: categorization with conventional MR imaging and diffusion-weighted imaging. J Ovarian Res. 2012;5(1):33.##Chen YY, Hsiao SM, Hsu YP, Lin HH, Wei MC. Borderline mucinous ovarian tumor presenting as pseudo-Meigs' syndrome. J Obstet Gynaecol Res. 2013;39(1):434-6.##

Successful Pregnancy Following Myomectomy for Giant Uterine Fibroid in an Infertile Woman 2 1 604 2 Abstract Background: Giant uterine fibroid is a rare tumor of the uterus, usually symptomatic requiring surgical intervention. Uterine fibroid is generally common among black women. Case Presentation: In this study, a case of 31 year old nullipara was reported who presented to the Gynaecology unit of Enugu State University Teaching Hospital (ESUTH), Nigeria with a history of progressive abdominal swelling of 8 years duration, six years duration of infertility and weight loss and dyspnoea on exertion. Physical examination and transabdominal ultrasound revealed a huge abdominopelvic mass. She had myomectomy. She had a histologically confirmed giant uterine fibroid that weighed 16.8 kg. She subsequently achieved a live birth. Conclusion: Giant uterine fibroids are relatively rare. It poses great challenges in its management. The surgical option of management should consider the fertility preservation and aspiration of couples especially in developing countries. 233 237 Euzebus EC Ezugwu Department of Obstetrics and Gynaecology, University of Nigeria, Teaching Hospital Department of Obstetrics and Gynaecology, University of Nigeria, Teaching Hospital Nigeria ezugwueuzebus@yahoo.com Chukwuemeka CA Iyoke Department of Obstetrics and Gynaecology, University of Nigeria, Teaching Hospital Department of Obstetrics and Gynaecology, University of Nigeria, Teaching Hospital Nigeria Frank FO Ezugwu Department of Obstetrics and Gynaecology, Enugu State University, Teaching Hospital Department of Obstetrics and Gynaecology, Enugu State University, Teaching Hospital Nigeria George G Ugwu Department of Obstetrics and Gynaecology, University of Nigeria, Teaching Hospital Department of Obstetrics and Gynaecology, University of Nigeria, Teaching Hospital Nigeria Giant leiomyomaGiant uterine fibroidInfertilityMyomectomyNigeria 604.pdf Steward RG, Denhartog HW, Katz AR. Giant uterine leiomyomata. Fertil Steril. 2011;95(3):1121.e15-7.##Nappi L, Matteo M, Giardina S, Rosenberg P, Indraccolo U, Greco P. Management of uterine giant myoma. Arch Gynecol Obs. 2008;278(1):61-3.##Speroff L, Fertiz MA. Clinical Gynaecologic endo-crinology and infertility. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p. 463-9.##Okogbo FO, Ezechi OC, Loto OM, Ezeobi PM. Uterine Leiomyomata in South Western Nigeria: a clinical study of presentations and management outcome. Afr Health Sci. 2011;11(2):271-8.##Okezie O, Ezegwui HU. Management of uterine fibroids in Enugu, Nigeria. J Obstet Gynaecol. 2006;26(4):363-5.##Costa Benavente L, Silva Barroso F, Avila Flores E. [Giant uterine myoma]. Ginecol Obstet Mex. 2005;73(10):563-5. Spanish.##Savulescu F, Iordache I, Albita O, Hristea R, Dumitru C, Iordache A, et al. Giant uterine leiomyoma. Chirurgia (Bucur). 2011;106(5):665-8.##Kjerulff KH, Langenberg P, Seidman JD, Stolley PD, Guzinski GM. Uterine leiomyomas. Racial differences in severity, symptoms and age at diagnosis. J Reprod Med. 1996;41(7):483-90.##Gajewska M, Kosinska-Kaczynska K, Marczewska J, Kaminski P. [Huge uterine leiomyoma with degenerative changes mimicking ovarian carcinoma--a case report]. Ginekol Pol. 2013;84(2):147-50. Polish.##Aydin C, Eris S, Yalcin Y, Sen Selim H. A giant cystic leiomyoma mimicking an ovarian malignancy. Int J Surg Case Rep. 2013;4(11):1010-2.##Van Balen F, Bos HMW. The social and cultural consequences of being childless in poor-resource. Facts Views Vis Obgyn. 2009;1(2):106-21.##Hackethal A, Bruggmann D, Leis A, Langde S, Stillger R, Munstedt K. Surgical management of uterine fibroids in Hesse, Germany, between 1998 and 2004. Fertil Steril. 2009;91(3):862-8.##