Unexplained Infertility, the Controversial Matter in Management of Infertile Couples 2 1 628 2 30% of infertile couples worldwide are diagnosed with unexplained or idiopathic infertility and the problem is defined as the lack of an obvious cause for a couple's infertility and the females’ inability to get pregnant after at least 12 cycles of unprotected intercourse or after six cycles in women above 35 years of age for whom all the standard evaluations are normal. The veracity of ‘unexplained infertility’ term has been challenged by many clinicians and researchers; they emphasize that the assignment of this title to an infertile couple is much dependent on the quantity, quality and nature of the applied diagnostic tests (1, 2). According to the ESHRE guidelines, necessary tests for unexplained infertility are semen analysis, assessment of ovulation and the luteal phase, and assessment of tubal patency by hysterosalpingogram or laparoscopy. However, there are controversial opinions about the value of endometrial biopsy, ovarian reserve (AMH, AFC), post-coital test and serum prolactin levels. Our inability to find the causes of couples’ infertility does not mean that there is no cause for the disorder. Extensive research should be conducted on other possible causes of failed conception such as ovarian and testicular dysfunctions, sperm and oocyte quality, fallopian transport defects, endometrial receptivity, implantation failures, and endometriosis (3, 4). Management of infertile couples with idiopathic cause needs individualized treatment. Several key variables including age, infertility history, treatment history, costs, and risks should be considered in selection of the suitable treatment plan. The rate of spontaneous conception in these couples is more than the couples with defined causes of infertility and several studies have reported that the rate of spontaneous pregnancy was 13-15% during the first year of attempt which increased to 35% during the next two years of attempt. Moreover, the rate could reach 80% in younger couples during the following three years of unprotected intercourse without any adjuvant therapy. The rate of spontaneous pregnancy drastically declines with infertility duration of more than 3 years and in women over 30 years of age. There are several mathematical models such as Hunault’s prognostic model to estimate the rate of spontaneous pregnancy. Therefore, when the chance of spontaneous conception for a couple is so high, no further fertility treatment is needed and the best plan for them would be expectant management (1, 3, 5). However, the main problem for treatment in these couples is disagreement of physicians on the management of unexplained subfertility. Many of infertility specialists are unaware of latest protocols and procedures approved by ESHRE, ASRM and other societies for managing unexplained infertility. Several other factors including lack of strong evidence, couples impatience for completion of standard protocols and dominance of ART treatment compared to other options in infertility clinics lead to diversity of clinical prac¬tice regarding unexplained infertility. Failure in implementation of standard practice for treatment of unexplained infertility leads to overtreatment in most of cases. This practice is mainly accompanied with misdiagnosis and undiagnosis of eligible cases for expectant management (5). Several expensive, time-consuming and risky therapies of Assisted Reproductive Technology (ART) bring about complications in infertility clinics. For many couples, ART will not increase the chance of pregnancy. It will be favorable for infertile couples and specialists that the first-line treatment would be simple, low-cost and noninvasive (5). The guideline of National Institute for Health and Care Excellence (NICE) on fertility suggests some treatment options regarding the above criteria for management of unexplained infertility. The age of women and infertility duration are important factors in offering specific therapy to a couple. Expectant management for 2 years is the best choice for good prognosis when the woman’s age is less than 30. This includes active medical intervention which requires the females to be aware of their ovulation time and the best period for unprotected intercourse. The main advantage of expectant management is avoiding multiple gestations which are accompanied with obstetric and prenatal complications, postnatal disability and the considerable burden on healthcare system can not be neglected in this regard. If the long period of expectant management cannot lead to pregnancy, ovulation induction by clomiphene and letrozole is not effective for these couples. Also insemination cycles without ovarian stimulation (COH) will have little benefit for them. COH/IUI (3-4 cycles) are effective in women under 35, but COH/IUI increase the risk of multiple gestations. However, COH/IUI is ineffective for couples with long duration of infertility (4). Couples over 35 and couples with long duration of infertility are suitable candidates for IVF. In comparison with COH/IUI, IVF shortens time to pregnancy and reduces the risk of multiple pregnancies. Failed fertilization is reported in 8.4%-22.7% of IVF cycles for couples with unexplained infertility; therefore, many clinics offer routine ICSI for these couples. It may result in an increase in the costs for each take home baby. However, several studies suggested split IVF/ICSI would be the best option for these couples since its cumulative pregnancy rates are higher than conventional IVF and the costs are less than those in ICSI (2). Prognosis of unexplained infertility and its response to above procedures is quite agreeable. However, some problems such as the limited number of these options and high dependence of specialist and couples on ART should not let the physicians offer additional expensive and experimental tests which waste the golden time of couples for pregnancy without any effective results. Through doing more research on reproductive biology and increasing our knowledge of gametogenesis, fertilization, embryo development, implantation and fetus-uterus crosstalk, more effective treatment options in future for infertile couples specially the ones with unexplained infertility would be provided. 01 3 Mohammad Reza MR Sadeghi محمدرضا صادقی Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Sadeghi@avicenna.ac.ir No Keyword 628.pdf Gelbaya TA, Potdar N, Jeve YB, Nardo LG. Definition and epidemiology of unexplained infertility. Obstet Gynecol Surv. 2014;69(2):109-15.##Johnson LN, Sasson IE, Sammel MD, Dokras A. Does intracytoplasmic sperm injection improve the fertilization rate and decrease the total fertilization failure rate in couples with well-defined unexplained infertility? A systematic review and meta-analysis. Fertil Steril. 2013;100(3):704-11.##Hatasaka H. New perspectives for unexplained infertility. Clin Obstet Gynecol. 2011;54(4):727-33.##Isaksson R, Tiitinen A. Present concept of unexplained infertility. Gynecol Endocrinol. 2004;18(5):278-90.##Nardelli AA, Stafinski T, Motan T, Klein K, Menon D. Assisted reproductive technologies (ARTs): evaluation of evidence to support public policy development. Reprod Health. 2014;11(1):76.##

Expression Patterns of VEGF and Flk-1 in Human Endometrium during the Menstrual Cycle 2 1 609 2 Background: The VEGF is essential in the process of tissue remodeling and angiogenesis. Limited data is available on the expression and regulation of VEGF and its receptors in the human endometrium. The aim of this study was evaluation of expression patterns of VEGF and Flk-1 in human endometrium during the menstrual cycle. Methods: Sixty paraffin-embedded blocks of endometrial tissues from the patients with normal menstrual cycles were obtained. Tissue samples were assembled into tissue microarray slides and classified by histological dating into five phases: the proliferative (n=14), peri-ovulatory (n=9), early-secretory (n=12), mid-secretory (n=11) and late-secretory (n=14) phases. Immunohistochemical staining was performed using VEGF or Flk-1 monoclonal antibodies. The intensity of immunostain-ing was evaluated by the semi-quantitative scoring method (HSCORE). Kruskal-Wallis one-way analysis of variance and Scheff’s post-hoc test were used for statistical analysis. A p-value of <0.05 was considered statistically significant. Results: VEGF and Flk-1 were expressed in the three components of the endometrium at various phases of the menstrual cycle. In the stroma, the expression of VEGF varied among the phases (p<0.05). The expression of Flk-1 in the luminal and glandular epithelium revealed stronger intensity of immunostaining as compared with the stroma at the different phases (p<0.05). The level of Flk-1 expression also showed significant differences among the phases in the glandular epithelium with greatest expression at late-secretory phase (p<0.05). Conclusion: Temporal and spatial distribution of VEGF and Flk-1 expression in the three components of human endometrium during menstrual cycle suggests the functional role of angiogenesis in the remodeling process of endometrial tissue. 03 10 Tsung-Hsuan T Lai Department of Obstetrics and Gynecology, Cathay General Hospital Department of Obstetrics and Gynecology, Cathay General Hospital Taiwan Nikos N Vlahos Second Department of Obstetrics and Gynecology, University of Athens Medical School, Aretaieion Hospital Second Department of Obstetrics and Gynecology, University of Athens Medical School, Aretaieion Hospital Greece Ie-Ming I Shih Department of Gynecology and Obstetrics, School of Medicine, Johns Hopkins University Department of Gynecology and Obstetrics, School of Medicine, Johns Hopkins University USA Yulian Y Zhao Yulian Zhao Department of Gynecology and Obstetrics, School of Medicine, Johns Hopkins University Department of Gynecology and Obstetrics, School of Medicine, Johns Hopkins University USA zhao1@jhmi.edu EndometriumFlk-1Menstrual cycleTissue microarrayVEGF 609.pdf Demir R, Yaba A, Huppertz B. Vasculogenesis and angiogenesis in the endometrium during menstrual cycle and im-plantation. Acta Histochem. 2010;112 (3):203-14.##Meduri G, Bausero P, Perrot-Applanat M. Expression of vascular endothelial growth factor receptors in the human en-dometrium: modulation during the menstrual cycle. Biol Reprod. 2000;62(2):439-47.##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 themenstrual cycle and in early pregnancy. Reproduction. 2002;123(3):379-87.##Achen MG, Jeltsch M, Kukk E, Makinen T, Vitali A, Wilks AF, et al. Vascular endothelial growth factor D (VEGF-D) is a ligand for the tyrosine kinases VEGF receptor 2 (Flk1) and VEGF receptor 3 (Flt4). Proc Natl Acad Sci USA. 1998;95(2):548-53.##Olofsson B, Korpelainen E, Pepper MS, Mandriota SJ, Aase K, Kumar V, et al. Vascular endothelial growth factor B (VEGF-B) binds to VEGF receptor-1 and regulates plasminogen activator activity in endothelial cells. Proc Natl Acad Sci USA. 1998;95(20):11709-14.##Koolwijk P, Peters E, van der Vecht B, Hornig C, Weich HA, Alitalo K, et al. Involvement of VEGFR-2 (kdr/flk-1) but not VEGFR-1 (flt-1) in VEGF-A and VEGF-C-induced tube formation by human microvascular endothelial cells in fibrin matrices in vitro. Angiogenesis. 2001;4(1):53-60.##Charnock-Jones DS, Sharkey AM, Rajput-Wil-liams J, Burch D, Schofield JP, Fountain SA, et al. Identification and localization of alternately spliced mRNAs for vascular endothelial growth factor in human uterus and estrogen regula-tion in endometrial carcinoma cell lines. Biol Reprod. 1993;48(5): 1120-8.##Shifren JL, Tseng JF, Zaloudek CJ, Ryan IP, Meng YG, Ferrara N, et al. Ovarian steroid regulation of vascular endothe-lial growth factor in the human endometrium: implications for angiogenesis during the menstrual cycle and in the path-ogenesis of endometriosis. J Clin Endocrinol Metab. 1996;81(8): 3112-8.##Qian Dong, Zhu Cheng. Functions of VEGF in female reproductive system. Chinese Science Bulletin. 2003;48(3):217-22.##Das SK, Chakraborty I, Wang J, Dey SK, Hoffman LH. Expression of vascular endothelial growth factor (VEGF) and VEGF-receptor messenger ribonucleic acids in the peri-implantation rabbit uterus. Biol Reprod. 1997;56(6):1390-9.##Chakraborty I, Das SK, Dey SK. Differential expression of vascular endothelial growth factor and its receptor mRNAs in the mouse uterus around the time of implantation. J Endocrinol. 1995;147(2): 339-52.##Evans PW, Wheeler T, Anthony FW, Osmond C. A longitudinal study of maternal serum vascular endothelial growth factor in early pregnancy. Hum Reprod. 1998;13(4):1057-62.##Moller B, Rasmussen C, Lindblom B, Olovsson M. Expression of the angiogenic growth factors VEGF, FGF-2, EGF and their receptors in normal human endometrium during the menstrual cycle. Mol Hum Reprod. 2001;7(1):65-72.##Gargett CE, Rogers PA. Human endometrial angi-ogenesis. Reproduction. 2001;121(2):181-6.##Noyes RW, Hertig AT, Rock J. Dating the endometrial biopsy. Am J Obstet Gynecol. 1975;122(2): 262-3.##Parker RL, Huntsman DG, Lesack DW, Cupples JB, Grant DR, Akbari M, et al. Assessment of interlaboratory variation in the immunohistochem-ical determination of estrogen receptor status using a breast cancer tissue microarray. Am J Clin Pathol. 2002;117(5):723-8.##Okada H, Tsuzuki T, Shindoh H, Nishigaki A, Yasuda K, Kanzaki H. Regulation of decidualization and angiogenesis in the human endometrium: mini review. J Obstet Gynaecol Res. 2014;40(5):1180-7.##Torry DS, Holt VJ, Keenan JA, Harris G, Caudle MR, Torry RJ. Vascular endothelial growth factor expression in cycling human endometrium. Fertil Steril. 1996;66(1):72-80.##Naresh B, Sengupta J, Bhargava V, Kinra G, Hu J, Ghosh D. Immunohistological localisation of vascular endothelial growth factor in human endometrium. Indian J Physiol Pharmacol. 1999;43(2): 165-70.##Fan X, Krieg S, Kuo CJ, Wiegand SJ, Rabinovitch M, Druzin ML, et al. VEGF blockade inhibits angiogenesis and reepithelialization of endometrium. FASEB J. 2008;22(10):3571-80.##Hyder SM, Stancel GM. Regulation of VEGF in the reproductive tract by sex-steroid hormones. Histol Histopathol. 2000;15(1):325-34.##Herve MA, Meduri G, Petit FG, Domet TS, Laze-nnec G, Mourah S, et al. Regulation of the vascular endothelial growth factor (VEGF) receptor Flk-1/KDR by estradiol through VEGF in uterus. J Endocrinol. 2006;188(1):91-9.##Okada H, Okamoto R, Tsuzuki T, Tsuji S, Yasuda K, Kanzaki H. Progestins inhibit estradiol-induced vascular endothe-lial growth factor and stromal cell-derived factor 1 in human endometrial stromal cells. Fertil Steril. 2011;96(3):786-91.##

Effects of Anethum graveolens L. (dill) on Oocyte and Fertility of Adult Female Rats 2 1 608 2 Background: Our previous studies revealed Anethum graveolens L. caused some changes in female reproductive system that induced infertility. Therefore, in this study, oocyte changes as one of probable reasons of infertility were investigated. Methods: In this study, 59 adult female rats were divided into 3 groups of control, low dose (0.5 g/kg) and high dose (5 g/kg) of dill seed aqueous extract (LDE and HDE) treated groups that were gavaged with 1 ml of each dose for 10 days (2 estrous cycles). Vaginal smears were prepared daily. Oocytes of superovulated animals were extracted and their morphometrical changes were measured (n=5). Oocyte cell membrane glycoconjugates were stained with UEA, PNA, and DBA-FITC lectins (n=5). Ultrastructural studies of oocytes were performed using TEM (n=5). The number, weight, and crown-rump length of newborns were examined in three groups after mating with untreated males (n=5). Data were analyzed using SPSS software. Results: Results demonstrated that the duration of the estrous cycle, the diestrus phase and progesterone concentration in the experimental groups increased significantly compared to the control group (p<0.05). Granulosa cells of corpus luteum in HDE-treated group were larger and clearer. The intensity reactions of galactose/N-acetylgalactoseamine terminal sugar of oocyte decreased insignificantly in experimental groups compared to the control group p>0.05. Duration of mating to pregnancy increased and the weight and crown-rump length of newborns decreased in experimental groups significantly (p<0.05). Conclusion: Dill seed aqueous extract can induce infertility without any effect on oocyte structure. 10 18 Malihezaman M Monsefi Biology Department, College of Sciences, Shiraz University Biology Department, College of Sciences, Shiraz University Iran Aazam A Ghasemi Biology Department, College of Sciences, Shiraz University Biology Department, College of Sciences, Shiraz University Iran Sanaz S Alaee Department of Reproductive Biology, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences Department of Reproductive Biology, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences Iran sanazalaee@yahoo.com Elham E Aliabadi Elham Aliabadi Anatomy Department, Medical School, Shiraz University of Medical Sciences Anatomy Department, Medical School, Shiraz University of Medical Sciences Iran Anethum graveolensGlycoconjugatesInfertilityOocyteZona pellucid 608.pdf Delaquis PJ, Stanich K, Girard B, Mazza G. Antimicrobial activity of individual and mixed fractions of dill, cilantro, coriander and eucalyptus essential oils. Int J Food Microbiol. 2002;74(1-2):101-9.##Satyanarayana S, Sushruta K, Sarma GS, Srinivas N, Subba Raju GV. Antioxidant activity of the aqueous extracts of spicy food additives--evaluation and comparison with ascorbic acid in in-vitro systems. J Herb Pharmacother. 2004;4(2):1-10.##Yazdanparast R, Alavi M. Antihyperlipidaemic and antihypercholesterolaemic effects of Anethum graveolens leaves after theremoval of furocoumarins. Cytobios. 2001;105(410):185-91.##Zheng GQ, Kenney PM, Lam LK. Anethofuran, carvone, and limonene: potential cancer chemopreventive agents from dill weed oil and caraway oil. Planta Med. 1992;58(4):338-41.##Hosseinzadeh H, Karimi GR, Ameri M. Effects of Anethum graveolens L. seed extracts on experimental gastric irritation models in mice. BMC Pharmacol. 2002;2:21.##Duke JA. Handbook of medicinal herbs. 2nd ed. London: CRC Press; 2002.##Weiss RF. Weiss’s herbal medicine. New York: Thieme; 2001.##Monsefi M, Ghasemi M, Bahaoddini A. The effects of Anethum graveolens L. on female reproductive system. Phytother Res. 2006;20(10):865-8.##Monsefi M, Ghasemi M, Bahaodini A. The effects of Anethum graveolens L on female reproductive system of rats. Daru. 2006;14(3):131–5.##Monsefi M, Pahlavan S. Effects of aqueous extract of Anethum graveolens L on male reproductive system of rats. J Biol Sci. 2007;7(5):815–8.##Monsefi M, Zahmati M, Masoudi M, Javidnia K. Effects of Anethum graveolens L. on fertility in male rats. Eur J Contracept Reprod Health Care. 2011;16(6):488-97.##Malihezaman M, Mojaba M, Elham H, Farnaz G, Ramin M. Anti-fertility effects of different fractions of Anethum graveolens L. extracts on female rats. Afr J Tradit Complement Altern Med. 2012;9(3):336-41.##US Department of Health and Human Services. Guide for the care and use of laboratory animals. 8th ed. Washington DC: NIH publication;1985. 246 p.##Fazel AR, Schulte BA, Spicer SS. Glycoconjugate unique to migrating primordial germ cells differs with genera. Anat Rec. 1990;228(2):177-84.##Hunter E. Practical electron microscopy: A beginner's Illustrated guide by Elaine Hunter. England: Cambridge University Press; 1993. p. 104-12.##Sadlier RMFS, editor. Cycles and seasons. England: Cambridge University Press; 1972. p. 85-102. (Austin CR, Short RV, editor. Reproduction in Mammals I: Germ cells and fertilization).##Berne RM, Levy MN, Koeppen BM, Stanton BA. Principles of Physiology. 7th ed. England: Cambridge University Press; 2000.##Evan WC. Trease and evans pharmacognosy. 14 th ed. London: Saunders; 1996.##Hung H. Inhibition of estrogen receptor alpha expression and function in MCF-7 cells by kaempferol. J Cell Physiol. 2004;198(2):197-208.##Kurzer MS, Xu X. Dietary phytoestrogens. Annu Rev Nutr. 1997;17:353-81.##Jimenez-Movilla M, Aviles M, Gomez-Torres MJ, Fernandez-Colom PJ, Castells MT, de Juan J, et al. Carbohydrate analysis of the zona pellucida and cortical granules of human oocytes by means of ultrastructural cytochemistry. Hum Reprod. 2004;19(8):1842-55.##Zhao M, Dean J. The zona pellucida in folliculogenesis, fertilization and early development. Rev Endocr Metab Disord. 2002;3(1):19-26.##Litscher ES, Wassarman PM. Egg extracellular coat proteins: from fish to mammals. Histol Histopathol. 2007;22(3):337-47.##Aviles M, El-Mestrah M, Jaber L, Castells MT, Ballesta J, Kan FW. Cytochemical demonstration of modification of carbohydrates in the mouse zona pellucid during folliculogenesis. Histochem Cell Biol. 2000;113(3):207-19.##El-Mestrah M, Kan FW. Distribution of lectin-binding glycosidic residues in the hamster follicular oocytes and their modificationsin the zona pellucid after ovulation. Mol Reprod Dev. 2001;60(4):517-34.##Lutsyk A, Sogomonian E. Structural, functional, and lectin histochemical characteristics of rat ovaries and endometrium in experimental hyper- and hypothyroidism. Folia Histochem Cytobiol. 2012;50(3):331-9.##Parillo F, Dall'Aglio C, Verini Supplizi A, Ceccarelli P, Gargiulo AM. Immunogold study on lectin binding in the porcine zona pellucid and granulosa cells. Eur J Histochem. 2003;47(4):353-8.##Talaei-Khozani T, Aminizadeh N, Aliabadi A, Mesbah SF, Zolghadr J. Lectin reactivity of expanded mouse blastocysts after exposure to sera from women with unexplained recurrent spontaneous abortion. Reprod Toxicol. 2005;20(4):531-7.##

Can Hyaluronan Binding Assay Predict the Outcome of Intrauterine Insemination in Couples with Unexplained or Mild Male Factor Infertility? 2 1 626 2 Background: The purpose of this study was to evaluate the prognostic effect of Hyaluronan Binding Assay (HBA) which has been used as a method of sperm selection for intracytoplasmic sperm injection procedure, on the outcome of intrauterine insemination (IUI) in couples with unexplained or mild male factor infertility. Methods: 77 infertile couples were enrolled in our study. On the day of IUI procedure, HBA test was performed by using fresh semen samples, and the rates of sperm binding to HBA were calculated. HBA values and semen parameters were compared. Fisher exact test was used to evaluate the relationship between HBA ratio and pregnancy status. Mann-Whitney U test was used to compare quantitative variables between pregnant and non-pregnant groups. The p<0.05 was considered statistically significant. Results: In this study, HBA ratio was 69(29.25%) and pregnancy rate was 14.29%. A significant positive correlation between HBA and total motile sperm count, inseminating sperm count, progressive motility, morphology, and sperm concentration (p<0.001, p<0.001, p:0.007, p<0.003, p:0.003 respectively) was observed. Although HBA values in pregnant group were higher than those in non-pregnant group, this result did not reach the statistically significant level (HBA: 67(20%) for non-pregnant group, 80.5(21.3%) for pregnant group). Also, no relationship between HBA values and pregnancy status was found. Moreover, there was no significant correlation between pregnancy status and HBA ratios based on the suggested cut-off value of 60 in literature (p=0.425). Conclusion: HBA does not predict the IUI outcome in couples with unexplained infertility or mild male factor infertility, but it can be used together with semen parameters to verify sperm quality. 18 24 Melahat M Yildirim Ankara Ataturk Training and Research Hospital, Department of Obstretrics and Gynecology, Bilkent Ankara Ataturk Training and Research Hospital, Department of Obstretrics and Gynecology, Bilkent Turkey melahatyildrim@yahoo. com Candan CI Duvan Turgut Ozal University Hospital, Department of Obstretrics and Gynecology Turgut Ozal University Hospital, Department of Obstretrics and Gynecology Turkey Aslihan A Pekel Turgut Ozal University Hospital, Department of Obstretrics and Gynecology Turgut Ozal University Hospital, Department of Obstretrics and Gynecology Turkey Aylin A Ayrim Turgut Ozal University Hospital, Department of Obstretrics and Gynecology Turgut Ozal University Hospital, Department of Obstretrics and Gynecology Turkey Hasan H Kafali Gazi University School of Medicine, Department of Obstretrics and Gynecology Gazi University School of Medicine, Department of Obstretrics and Gynecology Turkey Hyaluronan binding assayIntra uterine inseminationMild male factor infertilityPredictionUnexpained infertility 626.pdf Guzick DS, Overstreet JW, Factor-Litvak P, Brazil CK, Nakajima ST, Coutifaris C, et al. Sperm morphology, motility, and concentration in fertile and infertile men. N Engl J Med. 2001;345(19):1388-93.##Huszar G, Celik-Ozenci C, Vigue L. Sperm maturity and fertility: testing by hyaluronic acid binding. Abstarct 18th Annual meeting of the ESHRE. Hum Reprod. 2002;17(Suppl 1):9 O-024.##Huszar G, Ozenci CC, Cayli S, Zavaczki Z, Hansch E, Vigue L. Hyaluronic acid binding by human sperm indicates cellular maturity, viability, and unreacted acrosomal status. Fertil Steril. 2003;79 Suppl 3:1616-24.##Huszar G, Willetts M, Corrales M. Hyaluronic acid (Sperm Select) improves retention of sperm motility and velocity in normospermic and oligospermic specimens. Fertil Steril. 1990;54(6):1127-34.##Sbracia M, Grasso J, Sayme N, Stronk J, Huszar G. Hyaluronic acid substantially increases the retention of motility in cryopreserved/thawed human spermatozoa. Hum Reprod. 1997;12(9):1949-54.##Kornovski BS, McCoshen J, Kredentser J, Turley E. The regulation of sperm motility by a novel hyaluronan receptor. Fertil Steril. 1994;61(5):935-40.##Ranganathan S, Ganguly AK, Datta K. Evidence for presence of hyaluronan binding protein on spermatozoa and its possible involvement in sperm function. Mol Reprod Dev. 1994;38(1):69-76.##Kruger TF, Menkveld R, Stander FS, Lombard CJ, Van der Merwe JP, van Zyl JA, et al. Sperm morphologic features as a prognostic factor in in vitro fertilization. Fertil Steril. 1986;46(6):1118-23.##Gergely A, Kovanci E, Senturk L, Cosmi E, Vigue L, Huszar G. Morphometrical assessment of mature and diminished maturity human spermatozoa: sperm regions that reflect differences in maturity. Hum Reprod. 1999;14(8):2007-14.##Wu T, Akagbosu FT, Shen WH. Relationship between hyaluronan binding assay (HBA), motile sperm concentration, kruger morphology and pregnancy outcome in patients treated with intrauterine insemination (IUI). Fertil Steril. 2007;88(Suppl 1):361.##Boynukalin FK, Esinler I, Guven S, Gunalp S. Hyaluronan binding assay does not predict pregnancy rates in IUI cycles in couples with unexplained infertility. Arch Gynecol Obstet. 2012;286(6):1577-80.##Roudebush WE, Davis AL, Mitchell-Leef D, Elsner CW, JB Massey, HI Kort. Relationships between the sperm and the hyaluronan binding assay (HBA™) and intrauterine insemination pregnancy rates. Fertil Steril. 2005;84(Suppl 1):288-9.##Jakab A, Sakkas D, Delpiano E, Cayli S, Kovanci E, Ward D, et al. Intracytoplasmic sperm injection: a novel selection method for sperm with normal frequency of chromosomal aneuploidies. Fertil Steril. 2005;84(6):1665-73.##Pregl Breznik B, Kovacic B, Vlaisavljevic V. Are sperm DNA fragmentation, hyperactivation, and hyaluronan-binding ability predictive for fertilization and embryo development in in vitro fertilization and intracytoplasmic sperm injection? Fertil Steril. 2013 ;99(5):1233-41.##Cherr GN, Yudin AI, Li MW, Vines CA, Overstreet JW. Hyaluronic acid and the cumulus extracellular matrix induce increases in intracellular calcium in macaque sperm via the plasma membrane protein PH-20. Zygote. 1999;7(3):211-22.##Vines CA, Li MW, Deng X, Yudin AI, Cherr GN, Overstreet JW. Identification of a hyaluronic acid (HA) binding domain in the PH-20 protein that may function in cell signaling. Mol Reprod Dev. 2001;60(4):542-52.##Kovacs P, Kovats T, Sajgo A, Szollosi J, Matyas S, Kaali SG. The role of hyaluronic acid binding assay in choosing the fertilization method for patients undergoing IVF for unexplained infertility. J Assist Reprod Genet. 2011;28(1):49-54.##Tarozzi N, Nadalini M, Bizzaro D, Serrao L, Fava L, Scaravelli G, et al. Sperm-hyaluronan-binding assay: clinical value in conventional IVF under Italian law. Reprod Biomed Online. 2009;19 Suppl 3:35-43.##Nijs M, Creemers E, Cox A, Janssen M, Vanheusden E, Van der Elst J, et al. Relationship between hyaluronic acid binding assay and outcome in ART: a pilot study. Andrologia. 2010;42(5):291-6.##

Induction and Determination of Apoptotic and Necrotic Cell Death by Cadmium Chloride in Testis Tissue of Mouse 2 1 625 2 Background: Cadmium chloride which is potentially toxic is currently used in industry. The toxic effects of cadmium on testes have been reported to range from apoptosis to necrosis, with different effects on fertility. This research aimed to study the effect of different doses of cadmium on testicular tissues at acute stage by light and electron microscopy. Methods: Cadmium chloride was injected into mature Balb/c mice intraperitoneally in 7 doses. Five mice were studied in each group. After 48 hr, the testes were extracted and prepared for light microscopy. Then two concentrations (15 and 25 µM/kg) of them were selected for electron microscopic study based on histological changes. The cellular changes of luminal epithelium of seminiferous tubules were studied under an electron microscope. Histological and ultrastructural changes were reported. Results: The absence of sperm in the tubules was observed at 20 µM/kg concentration. At 25 µM/kg, histological destruction and epithelial damages were observed. Histological changes were not remarkable at 5 and 10 µM/kg. However, ultrastructural changes of seminiferous tubules at 20 µM/kg included spermatogonial cell death. At 25 µM/kg, vacuolation of Sertoli cells and death of spermatids as well as spermatocytes were observed. Cell death in the tubules was limited to germ cells. However, Sertoli cells exhibited architectural alterations without any cell death. Conclusion: Both apoptosis and necrosis occurred in testicular tissue by exposure to cadmium in a concentration-dependent manner. Gonadal cells were sensitive to cadmium administration. Supportive cells such as Sertoli cells in seminiferous tubules did not exhibit sensitivity to cadmium. 24 30 Behrooz B Niknafs Department of Anatomy, School of Medical Sciences, Tarbiat Modares University Department of Anatomy, School of Medical Sciences, Tarbiat Modares University Iran Niknafsbeh@yahoo.com Mojdeh M Salehnia مژده صالح نیا Department of Anatomy, School of Medical Sciences, Tarbiat Modares University Department of Anatomy, School of Medical Sciences, Tarbiat Modares University Iran Mahmood M Kamkar Department of Anatomy, School of Medical Sciences, Tarbiat Modares University Department of Anatomy, School of Medical Sciences, Tarbiat Modares University Iran ApoptosisCadmiumNecrosisSeminiferous tubules 625.pdf Thompson J, Bannigan J. Cadmium: toxic effects on the reproductive system and the embryo. Reprod Toxicol. 2008;25(3):304-15.##Hayes RB. The carcinogenicity of metals in humans. Cancer Causes Control. 1997;8(3):371-85.##Tomatis L. The IARC program on the evaluation of the carcinogenic risk of chemicals to man. Ann N Y Acad Sci. 1976;271:396-409.##Blanco A, Moyano R, Vivo J, Flores-Acuna R, Molina A, Blanco C, et al. Quantitative changes in the testicular structure in mice exposed to low doses of cadmium. Environ Toxicol Pharmacol. 2007;23(1):96-101.##El-Shahat AE, Gabr A, Meki A, Mehana E. Altered testicular morphology and oxidative stress induced by cadmium in experimental rats and protective effect of simultaneous green tea extract. Int J Morphol. 2009;27:757-64.##Santos FW, Oro T, Zeni G, Rocha JB, do Nascimento PC, Nogueira CW. Cadmium induced testicular damage and its response to administration of succimer and diphenyl diselenide in mice. Toxicol Lett. 2004;152(3):255-63.##Patra RC, Rautray AK, Swarup D. Oxidative stress in lead and cadmium toxicity and its amelioration. Vet Med Int. 2011;2011:457327.##Hikim APS, YueJia YHL, Wang C, Swerdloff RS, editors. Apoptotic signaling in male germ cells. New York: Cambridge University Press; 2011. 283 p. (Green DR, Reed JC, editors. Apoptosis: physiology and Pathology; vol. 25).##Angenard G, Muczynski V, Coffigny H, Pairault C, Duquenne C, Frydman R, et al. Cadmium increases human fetal germ cell apoptosis. Environ Health Perspect. 2010;118(3):331-7.##Sharma S, Kaur S. Histopathological effects of acute and chronic doses of cadmium on testes of albino mice. J Exp Zool India. 2012;15(1):107-11.##Zhou T, Jia X, Chapin RE, Maronpot RR, Harris MW, Liu J, et al. Cadmium at a non-toxic dose alters gene expression in mouse testes. Toxicol Lett. 2004;154(3):191-200.##Siu ER, Mruk DD, Porto CS, Cheng CY. Cadmium-induced testicular injury. Toxicol Appl Pharmacol. 2009;238(3):240-9.##Wong CH, Mruk DD, Lui WY, Cheng CY. Regulation of blood-testis barrier dynamics: an in vivo study. J Cell Sci. 2004;117(Pt 5):783-98.##Xu C, Johnson JE, Singh PK, Jones MM, Yan H, Carter CE. In vivo studies of cadmium-induced apoptosis in testicular tissue of the rat and its modulation by a chelating agent. Toxicology. 1996;107(1):1-8.##Ogawa Y, Itoh M, Hirai S, Suna S, Naito M, Qu N, et al. Cadmium exposure increases susceptibility to testicular autoimmunity in mice. J Appl Toxicol. 2013;33(7):652-60.##Waalkes MP, Anver M, Diwan BA. Carcinogenic effects of cadmium in the noble (NBL/Cr) rat: induction of pituitary, testicular, and injection site tumors and intraepithelial proliferative lesions of the dorsolateral prostate. Toxicol Sci. 1999;52(2):154-61.##Hew KW, Ericson WA, Welsh MJ. A single low cadmium dose causes failure of spermiation in the rat. Toxicol Appl Pharmacol. 1993;121(1):15-21.##Ji YL, Wang H, Zhao XF, Wang Q, Zhang C, Zhang Y, et al. Crosstalk between endoplasmic reticulum stress and mitochondrial pathway mediates cadmium-induced germ cell apoptosis in testes. Toxicol Sci. 2011;124(2):446-59.##Kim J, Soh J. Cadmium-induced apoptosis is mediated by the translocation of AIF to the nucleus in rat testes. Toxicol Lett. 2009;188(1):45-51.##Siu ER, Wong EW, Mruk DD, Sze KL, Porto CS, Cheng CY. An occludin-focal adhesion kinase protein complex at the blood-testis barrier: a study using the cadmium model. Endocrinology. 2009;150(7):3336-44.##Obianime AW, Roberts II. Antioxidants, cadmium-induced toxicity, serum biochemical and the histological abnormalities of the kidney and testes of the male Wistar rats. Niger J Physiol Sci. 2009;24(2):177-85.##Ognjanovic BI, Markovic SD, Ethordevic NZ, Trbojevic IS, Stajn AS, Saicic ZS. Cadmium-induced lipid peroxidation and changes in antioxidant defense system in the rat testes: protective role of coenzyme Q(10) and vitamin E. Reprod Toxicol. 2010;29(2):191-7.##Oliveira H, Lopes T, Almeida T, Pereira Mde L, Santos C. Cadmium-induced genetic instability in mice testis. Hum Exp Toxicol. 2012;31(12):1228-36.##Akinloye O, Arowojolu AO, Shittu OB, Anetor JI. Cadmium toxicity: a possible cause of male infertility in Nigeria. Reprod Biol. 2006;6(1):17-30.##

Comparison of Letrozole versus Tamoxifen Effects in Clomiphen Citrate Resistant Women with Polycystic Ovarian Syndrome 2 1 602 2 Background: The objective of this prospective randomized study was to make a comparison between the effects of letrozole and tamoxifen (TMX) in ovulation induction in clomiphene (CC)-resistant women with polycystic ovarian syndrome (PCOS). Methods: The study comprised a total of 60 infertile women (180 cycles) with CC-resistant PCOS selected from the clinics affiliated to the Department of Obstetrics and Gynecology of Tanta University. Patients were randomized to treatment with 2.5 mg of letrozole daily (30 patients, 90 cycles) or 20 mg of TMX daily (30 patients, 90 cycles) for 5 days from day 5 of menses and 10000 IU hCG when mature follicles become ≥18 mm in diameter. The chi-square and t-test were used for comparing two groups and p<0.05 was considered significant. Results: The total number of follicles (≥18 mm) in the letrozole group was more than TMX group. The endometrial thickness at the time of hCG administration was significantly higher (p<0.05, at 95% CI) in the letrozole group than that of TMX group (10.2±0.7 vs. 9.1±0.2 mm). Ovulation occurred in 23.33% of cycles in the letrozole group and in 8.89% in the TMX group, whereas pregnancy occurred in 5.56% of the letrozole group and 2.22% of the TMX group. Conclusion: Both letrozole and TMX should be considered as optional therapies for CC-resistant women. In addition, letrozole was superior to TMX in achieving a higher pregnancy and ovulation rate and also lesser side effects in comparison to tamoxifen. 30 36 Mohamed M EL-Gharib Department of Obstetrics and Gynecology, Faculty of Medicine, Tanta University Department of Obstetrics and Gynecology, Faculty of Medicine, Tanta University Egypt mohgharib@hotmail.com Amal AE Mahfouz Department of Obstetrics and Gynecology, Faculty of Medicine, Tanta University Department of Obstetrics and Gynecology, Faculty of Medicine, Tanta University Egypt Manal M Farahat Department of Obstetrics and Gynecology, Faculty of Medicine, Tanta University Department of Obstetrics and Gynecology, Faculty of Medicine, Tanta University Egypt Clomiphene resistanceInfertilityLetrozoleOligomenorrheaOvulation inductionPolycystic ovary syndromeTamoxifen 602.pdf Weil S, Vendola K, Zhou J, Bondy CA. Androgen and follicle-stimulating hormone interactions in primate ovarian follicle development. J Clin Endocrinol Metab. 1999;84(8):2951-6.##Elnashar A, Abdelmageed E, Fayed M, Sharaf M. Clomiphene citrate and dexamethazone in treatment of clomiphene citrate-resistant polycystic ovary syndrome: a prospective placebo-controlled study. Hum Reprod. 2006;21(7):1805-8.##Badawy A, Allam A, Abulatta M. Extending clomiphene treatment in clomiphene-resistant women with PCOS: a randomized controlled trial. Reprod Biomed Online. 2008;16(6):825-9.##Badawy A, Mosbah A, Shady M. Anastrozole or letrozole for ovulation induction in clomiphene-resistant women with polycystic ovarian syndrome: a prospective randomized trial. Fertil Steril. 2008;89(5):1209-12.##Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Consensus on infertility treatment related to polycystic ovary syndrome. Fertil Steril. 2008;89(3):505-22.##Akhtar M, Njar VC, Wright JN. Mechanistic studies on aromatase and related C-C bond cleaving P-450 enzymes. J Steroid Biochem Mol Biol. 1993;44(4-6):375-87.##Casper RF. Letrozole: ovulation or superovulation? Fertil Steril. 2003;80(6):1335-7.##Brown J, Farquhar C, Beck J, Boothroyd C, Hughes E. Clomiphene and anti-oestrogens for ovulation induction in PCOS. Cochrane Database Syst Rev. 2009;7(4):CD002249.##Legro RS, Barnhart HX, Schlaff WD, Carr BR, Diamond MP, Carson SA, et al. Clomiphen, metformin, or both for infertility in the polycystic ovary syndrome. N Engl J Med. 2007;356(6):551–66.##Mitwally MF, Casper RF. Aromatase inhibitors for the treatment of infertility. Expert Opin Investig Drugs. 2003;12(3):353-71.##Ganesh A, Goswami SK, Chattopadhyay R, Chaudhury K, Chakravarty B. Comparison of letrozole with continuous gonadotropins and clomiphene-gonadotropin combination for ovulation induction in 1387 PCOS women after clomiphene citrate failure: a randomized prospective clinical trial. J Assist Reprod Genet. 2009;26(1):19-24.##Tehrani Nejad ESh, Abediasl Z, Rashidi BH, Azimi Nekoo E, Shariat M, Amirchaghmaghi E. Comparison of the efficacy of the aromatase inhibitor letrozole and clomiphen citrate gonadotropins in controlled ovarian hyperstimulation: a prospective, simply randomized, clinical trial. J Assist Reprod Genet. 2008;25(5):187–90.##Sioufi A, Gauducheau N, Pineau V, Marfil F, Jaouen A, Cardot JM, et al. Absolute bioavailability of letrozole in healthy post-menopausal women. Biopharm Drug Dispos. 1997;18(9):779-89.##Ehrmann DA. Polycystic ovary syndrome. N Engl J Med. 2005;352(12):1223-36.##Kilic-Okman T, Kucuk M, Altaner S. Comparison of the effects of letrozole and clomiphen citrate on ovarian follicles, endometrium, and hormone levels in the rat. Fertil Steril. 2003;80(6):1330–2.##Holzer H, Casper R, Tulandi T. A new era in ovulation induction. Fertil Steril. 2006;85(2):277-84.##Boostanfar R, Jain JK, Mishell DR Jr, Paulson RJ. A prospective randomized trial comparing clomiphene citrate with tamoxifen citrate for ovulation induction. Fertil Steril. 2001;75(5):1024-6.##Karimi ZM, Ghaforzadeh M, Karimzadeh MA, Bokaei M. Comparison between effect of adding tamoxifen to clomiphene and only clomiphene for infertility managment in PCO-patients (At infertility & Bahman clinic, 2001-2003, Yazd, Iran). Iran J Obstet Gynecol Infertil. 2002;5(2):10-4.##Steiner AZ, Terplan M, Paulson RJ. Comparison of tamoxifen and clomiphen citrate for ovulation induction: a metaanalysis. Hum Reprod. 2005;20(6):1511-5.##Dhaliwal LK, Suri V, Gupta KR, Sahdev S. Tamoxifen: An alternative to clomiphene in women with polycystic ovary syndrome. J Hum Reprod Sci. 2011;4(2):76-9.##

Attitudes about Sex Selection and Sex Preference in Iranian Couples Referred for Sex Selection Technology 2 1 613 2 Background: Gender preference is prevalent in some communities and using medical techniques to choose the baby’s sex may cause the gender discrimination and gender imbalance in communities. Therefore, evaluating the gender preferences and attitudes towards using sex selection technologies seems to be necessary. Methods: This cross-sectional study was conducted in Avicenna Fertility Center. Participants were 100 women with one child who were referred for sex selection. Data were collected through self-developed questionnaires. The questions were designed by the researchers at the experts’ panel. To determine the validity of the questionnaire, the viewpoints of professors specialized in these issues were obtained. The statistical analysis of the data was performed using SPSS software (Version 11.5), and p<0.05 was considered significant. Results: Tendency toward the male was more than female sex (55.5% male, 15.5% female and 28.5% no tendency). Majority of participants agreed with sex selection with medical reason and sex selection in order to balance the family. Women’s level of education had positive effect on agreements to fetal sex selection with medical and non-medical reasons (p<0.001). Conclusion: Although gender preferences were toward the male sex but this preference was not very strong. Most participants agreed with non-medical sex selection for balancing the sex composition of their children. It doesn’t seem that non-medical sex selection for family balancing causes severe sex imbalance in Iran. 36 43 Seyedeh Fatemeh SF Ahmadi Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Mahdi M Shirzad Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Koorosh K Kamali Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Fahimeh F Ranjbar Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Zohreh Z Behjati-Ardakani Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Mohammad Mehdi MM Akhondi محمدمهدی آخوندی Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran akhondi@avicenna.ac.ir AttitudeGender preferenceIranSex selection 613.pdf Wilkowska-Trojniel M, Zdrodowska-Stefanow B, Ostaszewska-Puchalska I, Redzko S, Przepiesc J, Zdrodowski M. The influence of Chlamydia trachomatis infection on spontaneous abortions. Adv Med Sci. 2009;54(1):86-90.##Bekler C, Kultursay N, Ozacar T, Sayiner A, Yalaz M, Akisu M. Chlamydial infections in term and preterm neonates. Jpn J Infect Dis. 2012;65(1):1-6.##Rours GI, Duijts L, Moll HA, Arends LR, de Groot R, Jaddoe VW, et al. Chlamydia trachomatis infection during pregnancy associated with preterm delivery: a population-based prospective cohort study. Eur J Epidemiol. 2011;26(6):493-502.##Choi SJ, Park SD, Jang IH, Uh Y, Lee A. The prevalence of vaginal microorganisms in pregnant women with preterm labor and preterm birth. Ann Lab Med. 2012;32(3):194-200.##Fatholahzadeh B, Bahador A, Haghighi Hasanabad M, Bazarjani F, Haghighi F. Comparative screening of Chlamydia trachomatis infection in women population in tehran, iran. Iran Red Crescent Med J. 2012;14(5):289-93.##Folger AT. Maternal Chlamydia trachomatis infections and preterm birth: the impact of early detection and eradication during pregnancy. Matern Child Health J. 2014;18(8):1795-802.##Haghighi Hasanabad M, Mohammadzadeh M, Bahador A, Fazel N, Rakhshani H, Majnooni A. Prevalence of Chlamydia trachomatis and Mycoplasma genitalium in pregnant women of Sabzevar-Iran. Iran J Microbiol. 2011;3(3):123-8.##Silva MJ, Florencio GL, Gabiatti JR, Amaral RL, Eleuterio Junior J, Goncalves AK. Perinatal morbidity and mortality associated with chlamydial infection: a meta-analysis study. Braz J Infect Dis. 2011;15(6):533-9.##Taheri Beni B, Motamedi H, Ardakani MR. Genotyping of the prevalent Chlamydia trachomatis strains involved in cervical infections in women in Ahvaz, Iran. J Med Microbiol. 2010;59(Pt 9):1023-8.##Rours GI, de Krijger RR, Ott A, Willemse HF, de Groot R, Zimmermann LJ, et al. Chlamydia trachomatis and placental inflammation in early preterm delivery. Eur J Epidemiol. 2011;26(5):421-8.##Juhl CS, Christensen M, Bor IP. [No firm evidence for screening for Chlamydia in connection with spontaneous abortion]. Ugeskr Laeger. 2013;175(6):354-7. Danish.##Ghazvini K, Ahmadnia H, Ghanaat J. Frequency of Chlamydia trachomatis among male patients with urethritis in northeast of Iran detected by polymerase chain reaction. Saudi J Kidney Dis Transpl. 2012;23(2):316-20.##Michou IV, Constantoulakis P, Makarounis K, Georgoulias G, Kapetanios V, Tsilivakos V. Molecular investigation of menstrual tissue for the presence of Chlamydia trachomatis, Ureaplasma urealyticumand Mycoplasma hominis collected by women with a history of infertility. J Obstet Gynaecol Res. 2014;40(1):237-42.##Silveira MF, Erbelding EJ, Ghanem KG, Johnson HL, Burke AE, Zenilman JM. Risk of Chlamydia trachomatis infection during pregnancy: effectiveness of guidelines-based screening in identifying cases. Int J STD AIDS. 2010;21(5):367-70.##Fallah F, Kazemi B, Goudarzi H, Badami N, Doostdar F, Ehteda A, et al. Detection of Chlamydia trachomatis from urine specimens by PCR in women with cervicitis. Iran J Pub Health. 2005;34(2):20-6.##Chamani-Tabriz L, Tehrani MJ, Zeraati H, Asgari S, Tarahomi M, Moini M, et al. [A molecular survey of Chlamydia trachomatis infection in married women: a cross sectional study on 991 women]. TUMJ. 2008;66(7):485-91. Persian.##Chamani-Tabriz L, Jeddi Tehrani M, Mosavi-Jarrahi A, Zeraati H, Ghasemi J, Asgari S, et al. [The prevalence of Chlamydia trachomatis infection by molecular analysis of urine samples in women attending OB & GYN clinics in Tehran. J Reprod Infertil]. 2006;7(3):234-42. Persian.##Hashemi FB, Pourakbari B, Yazdi JZ. Frequency of Chlamydia trachomatis in women with cervicitis in Tehran, Iran. Infect Dis Obstet Gynecol. 2009;2009:67014.##Arsovic A, Nikolov A, Sazdanovic P, Popovic S, Baskic D. Prevalence and diagnostic significance of specific IgA and anti-heat shock protein 60 Chlamydia trachomatis antibodies in subfertile women. Eur J Clin Microbiol Infect Dis. 2014;33(5):761-6.##Hollegaard S, Vogel I, Thorsen P, Jensen IP, Mordhorst CH, Jeune B. Chlamydia trachomatis C-complex serovars are a risk factor for preterm birth. In Vivo. 2007;21(1):107-12.##Avasthi K, Garg T, Gupta S, Grewal RK, Ram S. A study of prevalence of Chlamydia trachomatis infection in women with first trimester pregnancy losses. Indian J Pathol Microbiol. 2003;46(1):133-6.##Baczynska A, Hvid M, Lamy P, Birkelund S, Christiansen G, Fedder J. Prevalence of Mycoplasma genitalium, Mycoplasma hominis and Chlamydia trachomatis among Danish patients requesting abortion. Syst Biol Reprod Med. 2008;54(3):127-34.##Vigil P, Tapia A, Zacharias S, Riquelme R, Salgado AM, Varleta J. First-trimester pregnancy loss and active Chlamydia trachomatis infection: correlation and ultrastructural evidence. Andrologia. 2002;34(6):373-8.##Silveira MF, Ghanem KG, Erbelding EJ, Burke AE, Johnson HL, Singh RH, et al. Chlamydia trachomatis infection during pregnancy and the risk of preterm birth: a case-control study. Int J STD AIDS. 2009;20(7):465-9.##Sozio J, Ness RB. Chlamydial lower genital tract infection and spontaneous abortion. Infect Dis Obstet Gynecol. 1998;6(1):8-12.##Andrews WW, Klebanoff MA, Thom EA, Hauth JC, Carey JC, Meis PJ, et al. Midpregnancy genitourinary tract infection with Chlamydia trachomatis: association with subsequent preterm delivery in women with bacterial vaginosis and Trichomonas vaginalis. Am J Obstet Gynecol. 2006;194(2):493-500.##Abdul-Karim ET, Abdul-Muhymen N, Al-Saadie M. Chlamydia trachomatis and rubella antibodies in women with full-term deliveries and women with abortion in Baghdad. East Mediterr Health J. 2009;15(6):1407-11.##Howie SE, Horner PJ, Horne AW. Chlamydia trachomatis infection during pregnancy: known unknowns. Discov Med. 2011;12(62):57-64.##

Sexual and Reproductive Behaviors among Undergraduate University Students in Mashhad, a City in Northeast of Iran 2 1 620 2 Background: The incidence of sexual transmitted infections (STIs) and HIV/AIDS is globally higher in young people. This study evaluated the prevalence of sexual reproductive behaviors among undergraduate students of Mashhad, Iran. Methods: The study was conducted on 605 students in twelve non-medical faculties of a great university of Mashhad. A self-administered questionnaire was completed on demographic information, sexual contact in the lifetime and during the last three months, and age of first sex. Kaplan-Meier statistic was used to calculate the mean age of initiation of sex. A p<0.05 was considered statistically significant. Results: After exclusion of individuals over 25 years of age, among 590 students with a mean age of 20.8±1.5 years included in the analysis, 71.4% were female and 85.3% were single. Prevalence of at least one sexual contact in life was 15.1% and 35.3% of single sexually experienced students reported to have sex in the last three months. The lifetime prevalence of sexual relationship in males was significantly higher than females (32.9% vs. 7.6%, p<0.001). The mean age of first sexual experience was 23.7 years with a significant difference between both sexes (p<0.001). In single sexually experienced students, the mean age at first sex was 17.6±3.3 years, 24% started sexual activity at <15 years, 34.3% had at least 3 partners and only 40.6% stated using condom in their last sex. Conclusion: Although very small proportion of females reported premarital sex, a significant minority of male students experienced sexual and risky behaviors. Therefore, the use of educational programs on related issues to reduce the risk of STIs/ HIV among youth including university students seems to be a necessity. 43 49 Mohammad Reza MR Hedayati-Moghaddam Research Center for HIV/AIDS, HTLV and Viral Hepatitis, Iranian Academic Center for Education, Culture & Research (ACECR), Mashhad Branch Research Center for HIV/AIDS, HTLV and Viral Hepatitis, Iranian Academic Center for Education, Culture & Research (ACECR), Mashhad Branch Iran drhedayati@acecr.ac.ir, drhedayati@yahoo.com Iman I Eftekhar zadeh Mashhadi Research Center for HIV/AIDS, HTLV and Viral Hepatitis, Iranian Academic Center for Education, Culture & Research (ACECR), Mashhad Branch Research Center for HIV/AIDS, HTLV and Viral Hepatitis, Iranian Academic Center for Education, Culture & Research (ACECR), Mashhad Branch Iran Farhad F Fathimoghadam Research Center for HIV/AIDS, HTLV and Viral Hepatitis, Iranian Academic Center for Education, Culture & Research (ACECR), Mashhad Branch Research Center for HIV/AIDS, HTLV and Viral Hepatitis, Iranian Academic Center for Education, Culture & Research (ACECR), Mashhad Branch Iran Seyed Javad SJ Pourafzali Research Center for HIV/AIDS, HTLV and Viral Hepatitis, Iranian Academic Center for Education, Culture & Research (ACECR), Mashhad Branch Research Center for HIV/AIDS, HTLV and Viral Hepatitis, Iranian Academic Center for Education, Culture & Research (ACECR), Mashhad Branch Iran AdolescentIranMashhadReproductive behaviorRisk-takingSexual behaviorStudents 620.pdf Statistical Centre of Iran. National Population and Housing Census, 2011: Selected Findings. Tehran: Statistical Center of Iran, Office of the Head, Public Relations and International Cooperation; 2012. p. 27.##Latifnejad Roudsari R, Javadnoori M, Hasanpour M, Hazavehei SM, Taghipour A. Socio-cultural challenges to sexual health education for female adolescents in Iran. Iran J Reprod Med. 2013;11(2):101-10.##Selected Findings of the 2011 National Population and Housing Census [Internet]. Tehran: Statistical Center of Iran. Mean age at first marriage by sex, 1976-2011; 2011 [cited 2014 Nov 13]. Available from: www.amar.org.ir/Portals/1/Iran/census-2.pdf##Simbar M, Tehrani FR, Hashemi Z. Reproductive health knowledge, attitudes and practices of Iranian college students. East Mediterr Health J. 2005;11(5-6):888-97.##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.##Rahmanian F, Simbar M, Ramezankhani A, Zayeri F. Gender sensitive STIs/HIV/AIDS prevention policies: A qualitative study. Health. 2014;6:1246-54.##UNAIDS. Global report: UNAIDS report on the global AIDS epidemic 2013. Geneva: UNAIDS; 2013. p. A11.##Schoeneberger M, Logan TK, Leukefeld C. Gender roles, HIV risk behaviors, and perceptions of using female condoms among college students. Popul Res Policy Rev. 1999;18(1-2):119-36.##UNAIDS: Epidemiological slides – GAP report [Internet]. Geneva: UNAIDS Secretariat; 2009-2014. 2014 Epi slides; 2014 July [cited 2014 Nov 21]. Available from: http://www.unaids.org/sites/default/files/media_asset/01_Epi_slides_2014July.pdf##Centre for Diseases Management, Iranian Ministry of Health and Medical Education. [Third wave of HIV? Asib-e- Penhan; Newsletter on HIV/AIDS and risky behavior]. Tehran: Iranian Ministry of Health and Medical Education; 2007. p. 16. Persian.##Babikian T, Freier MC, Hopkins GL, DiClemente R, McBride D, Riggs M. An assessment of HIV/AIDS risk in higher education students in Yerevan, Armenia. AIDS Behav. 2004;8(1):47-61.##Eisenberg M, Wechsler H. Substance use behaviors among college students with same-sex and opposite-sex experience: results from a national study. Addict Behav. 2003;28(5):899-913.##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.##Yamamoto K. Cross-sectional study on attitudes toward sex and sexual behavior among Japanese college students. J Physiol Anthropol. 2006;25(3): 221-7.##MUMS [Internet]. Mashhad: Mashhad University of Medical Sciences. General information about Mashhad [cited 2014 Nov 21]; [about 7 screens]. Available from: http://www.mums.ac.ir/main/en/mashhadinfo##MUMS: HIV/ADIS [Internet]. Mashhad: Mashhad University of Medical Science. HIV/ADIS Statistics in Khorasan; 2013 Aug 9 [Cited 2014 Nov 21]; [about 2 screens]. Available from: http:// www.mums.ac.ir/shares/aids/bahrainis4/xls/amr_ostani_90far2(1).xlsx##Farahani FK, Cleland J, Mehryar AH. Correlates and determinants of reproductive behavior among female university students in Tehran. J Reprod Infertil. 2012;13(1):39-51.##Reinisch JM, Hill CA, Sanders SA, Ziemba-Davis M. High-risk sexual behavior at a midwestern university: a confirmatory survey. Fam Plann Perspect. 1995;27(2):79-82.##Gelibo T, Belachew T, Tilahun T. Predictors of sexual abstinence among Wolaita Sodo university students, South Ethiopia. Reprod Health. 2013;10:18.##Ma Q, Ono-Kihara M, Cong L, Xu G, Zamani S, Ravari SM, et al. Sexual behavior and awareness of Chinese university students in transition with implied risk of sexually transmitted diseases and HIV infection: a cross-sectional study. BMC Public Health. 2006;6:232.##Duyan V, Agalar F, Sayek I. Surgeons' attitudes toward HIV/AIDS in Turkey. AIDS Care. 2001;13 (2):243-50.##Farahani FK, Shah I, Cleland J, Mohammadi MR. Adolescent males and young females in Tehran: differing perspectives, behaviors and needs for reproductive health and implications for gender sensitive interventions. J Reprod Infertil. 2012;13(2): 101-10.##Hojat M, Shapurian R, Nayerahmadi H, Farzaneh M, Foroughi D, Parsi M, et al. Premarital sexual, child rearing, and family attitudes of Iranian men and women in the United States and in Iran. J Psychol. 1999;133(1):19-31.##Lieber E, Chin D, Li L, Rotheram-Borus MJ, Detels R, Wu Z, et al. Sociocultural contexts and communication about sex in China: informing HIV/STD prevention programs. AIDS Educ Prev. 2009;21(5):415-29.##Wellings K, Field B. Sexual behaviour in young people. Baillieres Clin Obstet Gynaecol. 1996;10 (1):139-60.##Zelnik M, Shah FK. First intercourse among young Americans. Fam Plann Perspect. 1983;15(2):64-70.##Dickson N, Paul C, Herbison P, Silva P. First sexual intercourse: age, coercion, and later regrets reported by a birth cohort. BMJ. 1998;316(7124):29-33.##Liu H, Xie J, Yu W, Song W, Gao Z, Ma Z, et al. A study of sexual behavior among rural residents of China. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;19(1):80-8.##Senf JH, Price CQ. Young adults, alcohol and condom use: what is the connection? J Adolesc Health. 1994;15(3):238-44.##Narring F, Wydler H, Michaud PA. First sexual intercourse and contraception: a cross-sectional survey on the sexuality of 16-20-year-olds in Switzerland. Schweiz Med Wochenschr. 2000;130(40): 1389-98.##Upchurch DM, Levy-Storms L, Sucoff CA, Aneshensel CS. Gender and ethnic differences in the timing of first sexual intercourse. Fam Plann Perspect. 1998;30(3):121-7.##Sen B. Does alcohol-use increase the risk of sexual intercourse among adolescents? Evidence from the NLSY97. 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A Rare Case of Bilateral Ectopic Pregnancy and Differential Diagnosis of Gestational Trophoblastic Disease 2 1 612 2 Background: Bilateral ectopic pregnancy is a rare condition and is divided in two subgroups, primary and secondary, based on history of assisted reproductive technology. Case Presentation: A 30 year old primigravid woman with history of infertility and ovulation induction presented to a hospital in Kashan in year 2013. She had vaginal bleeding, abdominal pain and ultrasound findings suggested early pregnancy. Due to high titer of β-HCG, gestational trophoblastic disease was proposed and D8C was done in referral and admission to gyneco-oncology ward in Tehran. Repeat sonography suggested ectopic pregnancy in left side and repeat β-HCG level showed an increase of 19435 mIU/ml. Laparotomy findings revealed bilateral ampullary ectopic pregnancy. Bilateral salpingostomy followed by one course of methotrexate was prescribed. Conclusion: Bilateral ectopic gestation should be considered as a rare differential diagnosis for ectopic pregnancy. In this study, bigger size and rupture in left side was observed. 49 53 Maliheh M Arab Preventative Gynecology Research Center (PGRC), Imam Hossein Medical Center, Shahid Beheshti University of Medical Sciences Preventative Gynecology Research Center (PGRC), Imam Hossein Medical Center, Shahid Beheshti University of Medical Sciences Iran drmarab@yahoo.com Seyyedeh Neda SN Kazemi Preventative Gynecology Research Center (PGRC), Imam Hossein Medical Center, Shahid Beheshti University of Medical Sciences Preventative Gynecology Research Center (PGRC), Imam Hossein Medical Center, Shahid Beheshti University of Medical Sciences Iran Zahra Z Vahedpoorfard Kashan University of Medical Sciences Kashan University of Medical Sciences Iran Adeleh A Ashoori Preventative Gynecology Research Center (PGRC), Imam Hossein Medical Center, Shahid Beheshti University of Medical Sciences Preventative Gynecology Research Center (PGRC), Imam Hossein Medical Center, Shahid Beheshti University of Medical Sciences Iran Ectopic pregnancyReproduction TechniquesRupture 612.pdf Oron G, Tulandi T. A pragmatic and evidence-based management of ectopic pregnancy. J Minim Invasive Gynecol. 2013;20(4):446-54.##De Los Rios JF, Castaneda JD, Miryam A. Bilateral ectopic pregnancy. J Minim Invasive Gynecol. 2007;14(4):419-27.##Bloch AJ, Bloch SA, Lyon M. Correlation of β-human chorionic gonadotropin with ultrasound diagnosis of ectopic pregnancy in the ED. Am J Emerg Med. 2013;31(5):876-7.##Ghaffari F, Eftekhari Yazdi P, Kiani K. A case report of bilateral tubal ectopic pregnancy following day 5 embryo transfer. Arch Med Sci. 2011;7(6):1087-8.##Sergent F, Verspyck E, Marpeau L. [Management of ectopic pregnancies complicating in vitro fertilization: a remarkable case of bilateral ectopic pregnancy with independent courses of the pregnancies]. J Gynecol Obstet Biol Reprod (Paris). 2003;32(3 Pt 1):256-60. French.##Mahmood NA, Sandhu AK. Ruptured ovarian cysts and bilateral ectopic pregnancy complicating a case of severe ovarian hyperstimulation syndrome. Saudi Med J. 2005;26(6):982-4.##Shenoy JV, Choudhary V, Giles RW. Bilateral ectopic pregnancy. J Obstet Gynaecol. 2005;25(6):612-3.##Marcovici I, Scoccia B. Spontaneous bilateral tubal ectopic pregnancy and failed methotrexate therapy: a case report. Am J Obstet Gynecol. 1997;177(6):1545-6.##Fernandez H, Capmas P, Lucot JP, Resch B, Panel P, Bouyer J, et al. Fertility after ectopic pregnancy: the DEMETER randomized trial. Hum Reprod. 2013;28(5):1247-53.##Rani VRS, Puliyath G. Viable intrauterine pregnancy after spontaneous bilateral tubal ectopics in a multiparous woman: a case report. J Med Case Rep. 2013;7:159.##Derchin W, Hemstock J, Weder Ch. Bilateral simultaneous tubal pregnancies. Can Med Assoc J. 1956;75(8):669-72.##Geiger GL, McGhee N Jr. Bilateral ruptured tubal pregnancies associated with oral contraceptives. J Natl Med Assoc. 1971;63(5):321-2.##Brady J, Wilson M. Spontaneous bilateral tubal ectopic pregnancy. J R Soc Med. 2005;98(3):120-1.##

Replacement Therapy for Gaucher Disease during Pregnancy: A Case Report 2 1 624 2 Background: Gaucher disease is a lysosomal storage disorder due to deficiency of glucocerebrosidase enzyme. In this study, a case of enzyme-treated woman during her pregnancy was reported. Case Presentation: A 27-year old woman with type I Gaucher disease was managed for pregnancy until delivery. She underwent elective splenectomy at age 26 years and was treated with 19-38 units/kg of imiglucerase. A conservative approach with close monitoring of both mother and baby was planned. Results: In the 39th week of pregnancy, a healthy male baby of 3180 g was delivered via cesarean section. Conclusion: Apart from mild hematological complications, the pregnancy, the delivery and the puerperium were uneventful. In this case report, the issue of therapy and risk assessment in pregnancy in patients with type I Gaucher disease was discussed. 53 58 Stefano SR Giannubilo Department of Clinical Sciences, Polytechnic University of Marche Department of Clinical Sciences, Polytechnic University of Marche Italy s.giannubilo@univpm.it Angela A Pasculli Department of Clinical Sciences, Polytechnic University of Marche Department of Clinical Sciences, Polytechnic University of Marche Italy Elisa E Tidu Department of Clinical Sciences, Polytechnic University of Marche Department of Clinical Sciences, Polytechnic University of Marche Italy Andrea A Ciavattini Department of Clinical Sciences, Polytechnic University of Marche Department of Clinical Sciences, Polytechnic University of Marche Italy DeliveryGaucher diseaseImiglucerasePregnancySplenectomy 624.pdf Cox TM, Schofield JP. Gaucher's disease: clinical features and natural history. Baillieres Clin Haematol. 1997;10(4):657-89.##Pinto R, Caseiro C, Lemos M, Lopes L, Fontes A, Ribeiro H, et al. Prevalence of lysosomal storage diseases in Portugal. Eur J Hum Genet. 2004;12(2):87-92.##Granovsky-Grisaru S, Aboulafia Y, Diamant YZ, Horowitz M, Abrahamov A, Zimran A. Gynecologic and obstetric aspects of Gaucher's disease: a survey of 53 patients. Am J Obstet Gynecol. 1995;172(4 Pt 1):1284-90.##Elstein Y, Eisenberg V, Granovsky-Grisaru S, Rabinowitz R, Samueloff A, Zimran A, et al. Pregnancies in Gaucher disease: a 5-year study. Am J Obstet Gynecol. 2004;190(2):435-41.##Zlotogora J, Sagi M, Zeigler M, Bach G. Gaucher disease type I and pregnancy. Am J Med Genet. 1989;32(4):475-7.##Gillis S, Hyam E, Abrahamov A, Elstein D, Zimran A. Platelet function abnormalities in Gaucher disease patients. Am J Hematol. 1999;61(2):103-6.##Barton NW, Brady RO, Dambrosia JM, Di Bisceglie AM, Doppelt SH, Hill SC, et al. Replacement therapy for inherited enzyme deficiency--macrophage-targeted glucocerebrosidase for Gaucher's disease. N Engl J Med. 1991;324(21):1464-70.##Grabowski GA, Barton NW, Pastores G, Dambrosia JM, Banerjee TK, McKee MA, et al. Enzyme therapy in type 1 Gaucher disease: comparative efficacy of mannose-terminated glucocerebrosidase from natural and recombinant sources. Ann Intern Med. 1995;122(1):33-9.##FDA: Drug Approval Package [Internet]. Silver Spring: Food and Drug Administration; c1998-2002. Center for drug evaluation and research, approval letter, application number 21-348; 2003 Jul 7 [cited 2007 Jul 31]; [about 2 screens]. Available from: http://www.accessdata.fda.gov/drugsatfda_docs/nda/2003/21-348_Zavesca.cfm.##EMA: Committee for Proprietary Medicinal Products [Internet]. London; European Medicines Agency; c1995-2012. Committee for Medicinal Products for Human Use (CHMP); 2012 Feb 20 [cited 2012 Feb 20]; [about 3 screens]. Available from: http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Summary_for_the_public/human/000435/WC500046724.pdf.##Zimran A, Morris E, Mengel E, Kaplan P, Belmatoug N, Hughes DA, et al. The female Gaucher patient: the impact of enzyme replacement therapy around key reproductive events (menstruation, pregnancy and menopause). Blood Cells Mol Dis. 2009;43(3):264-88.##Elstein D, Granovsky-Grisaru S, Rabinowitz R, Kanai R, Abrahamov A, Zimran A. Use of enzyme replacement therapy for Gaucher disease during pregnancy. Am J Obstet Gynecol. 1997;177(6):1509-12.##Weinreb NJ, Charrow J, Andersson HC, Kaplan P, Kolodny EH, Mistry P, et al. Effectiveness of enzyme replacement therapy in 1028 patients with type 1 Gaucher disease after 2 to 5 years of treatment: a report from the Gaucher Registry. Am J Med. 2002;113(2):112-9.##Cox TM, Aerts JM, Belmatoug N, Cappellini MD, vom Dahl S, Goldblatt J, et al. Management of non-neuronopathic Gaucher disease with special reference to pregnancy, splenectomy, bisphosphonate therapy, use of biomarkers and bone disease monitoring. J Inherit Metab Dis. 2008;31(3):319-36.##Grabowski GA. Gaucher disease: considerations in prenatal diagnosis. Prenat Diagn. 2000;20(1):60-2.##Laine F, Guyader D, Turlin B, Moirand R, Deugnier Y, Brissot P. [Hyper-ferritinemia and Gaucher disease]. Gastroenterol Clin Biol. 1996;20(5):512-3. French.##Young KR, Payne MJ. Obstetric aspects of Gaucher's disease. Br J Obstet Gynaecol. 1985;92(9):993.##Starzyk K, Richards S, Yee J, Smith SE, Kingma W. The long-term international safety experience of imiglucerase therapy for Gaucher disease. Mol Genet Metab. 2007;90(2):157-63.##Houlton MC, Jackson MB. Gaucher's disease and pregnancy. Obstet Gynecol. 1978;51(5):619-20.##Dell'Oste C, Vincenti F. Anaesthetic management of children with type II and III Gaucher disease. Minerva Pediatr. 1997;49(10):495-8.##Brown DL, Wedel DJ, editors. Spinal, epidural and caudal anesthesia. New York: Churchill Livingstone Inc; 1990. 1377 p. (Miller RD, editor. Anesthesia; vol. 25).##Akdag A, Oguz SS, Ezgu F, Erdeve O, Uras N, Dilmen U. A newborn case with perinatal-lethal Gaucher disease due to R463H homozygosity complicated by C677T homozygosity in the MTHFR gene. J Pediatr Endocrinol Metab. 2011;24(5-6):381-3.##Sekijima Y, Ohashi T, Ohira S, Kosho T, Fukushima Y. Successful pregnancy and lactation outcome in a patient with Gaucher disease receiving enzyme replacement therapy, and the subsequent distribution and excretion of imiglucerase in human breast milk. Clin Ther. 2010;32(12):2048-52.##Mrsic M, Fumic K, Vrcic H, Kristina Potocki, Ranka Stern-Padovan, Maja Prutki, et al. Successful pregnancy on enzyme replacement therapy with cerezyme. Clin Ther. 2007;29:S84-S85.##Aporta Rodriguez R, Escobar Vedia JL, Navarro Castro AM, Aguilar Garcia G, Cabrera Torres A. Alglucerase enzyme replacement therapy used safely and effectively throughout the whole pregnancy of a Gaucher disease patient. Haematologica. 1998;83(9):852-3.##