Poor Quality Embryos Hamper the Development of High Quality Ones 2 1 711 2 Embryo quality and embryo selection are critical criteria for embryo transfer and subsequently success of assisted reproductive technologies (ART). Transfer of good quality embryos is associated with increased implantation, pregnancy and live birth rates and also decreased pregnancy loss and prenatal complications in comparison with transfer of embryos with impaired quality. Furthermore, advance in embryo culture techniques and embryo selection criteria and technologies lead to a decrease in number of transferred embryos without significant decline in ART success. Therefore, elective single embryo transfer (eSET) is recently the dominant discourse in the community and infertility clinics. An important concern of eSET is reduced multiple pregnancy and its prenatal complications as a major complication of ART. Since more than one embryo is produced in IVF cycle, surplus embryos with appropriate quality are frozen for future transfer in frozen/thawed cycles. There are treatment cycles in which the number and quality of embryos are not sufficient for freezing/thawing. The question always arises in these cycles is that "Does simultaneous transfer of low and top quality embryos have determining impact on treatment success or not?". It was previously believed and recent finding reported that the low quality embryos have no impact on implantation and development of top quality embryos; even, many low quality embryos have the potential for implantation and successful pregnancy. As a result, twin pregnancy is 9.5% in cycles with transfer of one top quality and one low quality embryo; however, it is zero in eSET and 10.6% in cycles with two top quality embryos (1). Although other studies provide different conclusions, the transfer of low quality embryos can impair implantation and development of top quality embryos. So, it is recommended to transfer top quality embryos alone despite the minimum number of fresh/frozen embryos in transfer cycles (2). If this is true, the question arises that how poor-quality embryos influence development and implantation of the embryos with good quality. Review of in vitro studies on prolonged culture of embryos confirms the in vivo findings. Group culture of day 3 good and low quality embryos influences the rate of high quality blastocyst formation in comparison with separate culture of low and high quality embryos. It has been postulated that different toxic compounds such as ammonia and reactive oxygen species (ROS) produced by low quality embryos have deleterious effects on quantity and quality of developed blastocysts (3). In addition, endometrial epithelial cells (EECs) and stromal cells (ESCs) of uterine tissues are very responsive to human embryos following in vitro culture. Top quality embryos enhance diffrentiation, decidualization, secretion of chemokine and growth factors that promote encapsulation and implatation of blastocyst. Therefore, good quality embryos actively intract with endometrium and promote their immplantation. In contrast, poor quality embryos inhibit selective migratory response of decidualizing ESCs and subsequent active encapsulation of themselves (4). Thus, in vitro culture of embryo and the co-culture with ESCs verified the recent report of El-danasouri et al. on negative effects of poor quality embryos on implantation of good quality ones in tranfer cycles. Of course, it also should not be ignored that embryo assess-ments are now based on morphometric criteria which are not accurate and precise parameters. Hence, in some cases, this assessment is not consistent with functional markers of embryos. The support for this claim are the many reports on successful pregnancy following transfer of poor quality embryos or simultaneous transfer of one top and one poor quality embryo in one cycle and the incidence of having twins is 9.5% among cases (1). In spite of the supporting evidence for influence of embryo quality on the implantation, it should be noted that all of these studies have been retrospective. The final confirmation of these findings requires numerous prospective studies with more stringent design on larger samples. Regarding partial verification of this issue, IVF centers should avoid simultaneous transfer of good and poor quality embryos in fresh and frozen/thawed cycles as much as possible. It is recommended that poor quality embryos be cultured separately and subsequently transferred or frozen if they could develop to high quality blastocysts. 211 213 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 711.pdf Wintner EM, Hershko-Klement A, Tzadikevitch K, Ghetler Y, Gonen O, Wintner O, et al. Does the transfer of a poor quality embryo together with a good quality embryo affect the In Vitro Fertilization (IVF) outcome? J Ovarian Res. 2017;10(1):2.##El-Danasouri I, Sterzik K, Rinaldi L, Pacchiarotti A, DeSanto M, Selman H. Effect of transferring a morphologically im-paired embryo with a good quality embryo on the pregnancy and implantation rates. Eur Rev Med Pharmacol Sci. 2016;20(3):394-8.##Tao T, Robichaud A, Mercier J, Ouellette R. Influence of group embryo culture strategies on the blastocyst development and pregnancy outcome. J Assist Reprod Genet. 2013;30(1):63-8.##Weimar CH, Macklon NS, Post Uiterweer ED, Brosens JJ, Gellersen B. The motile and invasive capacity of human endo-metrial stromal cells: implications for normal and impaired reproductive function. Hum Reprod Update. 2013;19(5):542-57.##

Isolation, Culture and Characterization of Human Sertoli Cells by Flow Cytometry: Development of Procedure 2 1 696 2 Background: The sertoli cells in the testis create unique and safe environment to protect seminiferous tubules from auto antigens and invading pathogens. These cells produce the survival factor of the blood-testis barrier and produce special materials such as androgen binding proteins and contribute to the coordinated action of spermatogenesis. Given that the sertoli cells play an essential role in spermatogenesis and the lack of these cells leads to the disruption of spermatogenesis, it is necessary to investigate the behavior and performance of these cells. To achieve this goal, the cells must first be extracted. The aim of this study was to develop a procedure to isolate, culture, and characterize human sertoli cells. Methods: In order to isolate the sertoli cells of azoospermia patients who underwent (testicular sperm extraction) TESE surgery, washing up and multi_stage enzyme digestion of single cells, culture on petri dishes impregnated with datura stramonium lectin agglutinin (DSA) were done and then the cells were passaged for several times and isolated. For more purification, flow cytometry method with FSH receptor antibody was used. Immunocytochemistry assays and Elisa test for identification of these cells were employed. Results: The purification method resulted in more than 97% purity. The nature of sertoli cells was confirmed by morphology evaluation, detecting anti-mullerian hormone in sertoli cell culture media and the presence of FSH receptor on sertoli cells. Conclusion: This study introduced and applied a method to isolate, culture, and purify human sertoli cells with high purity which made possible further researches on these cells. 213 217 Mohammad Reza MR Lakpour Department of Andrology, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR Department of Andrology, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR Iran Samaneh S Aghajanpour Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR Iran Morteza M Koruji Department of Anatomical Sciences, School of Medicine, Iran University of Medical Sciences Department of Anatomical Sciences, School of Medicine, Iran University of Medical Sciences Iran Abdolhossein A Shahverdi Department of Embryology, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR Department of Embryology, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR Iran Mohammad Ali MA Sadighi-Gilani Department of Urology, Shariati Hospital, Tehran University of Medical Sciences Department of Urology, Shariati Hospital, Tehran University of Medical Sciences Iran Marjan M Sabbaghian Department of Andrology, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR Department of Andrology, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR Iran Reza R Aflatoonian Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR Iran Majid M Rajabian-Naghandar Biology Department, Payam Noor University Biology Department, Payam Noor University Iran CharacterizationCultureFlow cytometryIsolationSertoli cells 696.pdf Diemer T, Huwe P, Ludwig M, Hauck EW, Weidner W. Urogenital infection and sperm motility. Andrologia. 2003;35(5):283-7.##Head JR, Billingham RE. Immune privilege in the testis. II. Evaluation of potential local factors. Transplantation. 1985;40(3):269-75.##Josso N, di Clemente N, Gouédard L. Anti-Müllerian hormone and its receptors. Mol Cell Endocrinol. 2001;179(1-2):25-32.##Wang H, Wang H, Xiong W, Chen Y, Ma Q, Ma J, et al. Evaluation on the phagocytosis of apoptotic spermatogenic cells by Sertoli cells in vitro through detecting lipid droplet formation by Oil Red O staining. Reproduction. 2006;132(3):485-92.##Khanehzad M, Abolhasani F, Koruji SM, Ragerdi Kashani I, Aliakbari F. The roles of Sertoli cells in fate determinations of spermatogonial stem cells. Tehran Univ Med J. 2016;73(12):878-87.##Scarpino S, Morena AR, Petersen C, Fröysa B, Söder O, Boitani C. A rapid method of Sertoli cell isolation by DSA lectin, allowing mitotic analyses. Mol Cell Endocrinol. 1998;146(1-2):121-7.##Koruji M, Movahedin M, Mowla SJ, Gourabi H, Arfaee AJ. Efficiency of adult mouse spermatogonial stem cell colony formation under several culture conditions. In Vitro Cell Dev Biol Anim. 2009;45(5-6):281-9.##Mirzapour T, Movahedin M, Tengku Ibrahim TA, Koruji M, Haron AW, Nowroozi MR, et al. Effects of basic fibroblast growth factor and leukaemia inhibitory factor on proliferation and short-term culture of human spermatogonial stem cells. Andrologia. 2012;44 Suppl 1:41-55.##Kanatsu-Shinohara M, Ogonuki N, Inoue K, Miki H, Ogura A, Toyokuni S, et al. Long-term proliferation in culture and germline transmission of mouse male germline stem cells. Biol Reprod. 2003;69(2):612-6.##Izadyar A, Farhadian N, Chenarani N. Molecular dynamics simulation of doxorubicin adsorption on a bundle of functionalized CNT. J Biomol Struct Dyn. 2016;34(8):1797-805.##Dufour JM, Dass B, Halley KR, Korbutt GS, Dixon DE, Rajotte RV. Sertoli cell line lacks the immunoprotective properties associated with primary Sertoli cells. Cell Transplant. 2008;17(5):525-34.##Takeda K, Akira S. Toll-like receptors in innate immunity. Int Immunol. 2005;17(1):1-14.##

Antimicrobial Properties of Amniotic and Chorionic Membranes: A Comparative Study of Two Human Fetal Sacs 2 1 701 2 Background: There is evidence of antibacterial properties of human chorioamniotic layer. However, the distinctive contribution of its individual parts, amniotic and chorionic membranes, to these effects is still unknown. The aim of present study was comparison of the antibacterial effects between amniotic and chorionic membranes. Methods: Chorioamniotic layer was removed from placenta belonging to 43 healthy mothers whose infants were delivered by caesarean section. Their amniotic and chorionic fetal tissues were manually peeled in sterile conditions. The antibacterial effects of all membrane samples were evaluated on 8 standard strains of bacterial collection using disk diffusion method on bacteriologic media. Results of bacterial growth inhibition in the presence of amniotic or chorionic membranes were measured and recorded as median±IQR. For data analysis and statistical comparison of samples, Kruskal-Wallis and Mann-Whitney U-test were applied using SPSS (v. 18). Results: Amniotic and chorionic membranes significantly showed different level of growth inhibitory effects on 8 bacterial strains including seven pathogens: E. coli, Bacillus cereus, Klebsiella pneumonia, Streptococcus pyogenes, Pseudomonas aeruginosa, Staphylococcus aureus, Shigella flexneri and one probiotic: Lactobacillus plantarum (p=0.018 and p<0.001, respectively). The number of bacterial growth inhibition zones around chorionic membranes was more than of what found around amniotic membranes. Conclusion: The superiority of antibacterial effects of the chorionic membrane compared with the amniotic membrane can represent the key role of maternal part in placenta in protecting the fetus against possible infections. The antimicrobial effect of amniotic and chorionic membranes is significantly different on various bacteria. 218 225 Majid M Zare-Bidaki Infectious Diseases Research Center, Faculty of Paramedical Sciences, Birjand University of Medical Sciences Infectious Diseases Research Center, Faculty of Paramedical Sciences, Birjand University of Medical Sciences Iran Sajad S Sadrinia Faculty of Dentistry, Birjand University of Medical Sciences Faculty of Dentistry, Birjand University of Medical Sciences Iran Soheila S Erfani Faculty of Medicine, Birjand University of Medical Sciences Faculty of Medicine, Birjand University of Medical Sciences Iran Ehsan E Afkar Deputy of Research and Technology, Birjand University of Medical Sciences Deputy of Research and Technology, Birjand University of Medical Sciences Iran Nahid N Ghanbarzade Faculty of Medicine, Birjand University of Medical Sciences Faculty of Medicine, Birjand University of Medical Sciences Iran Nghanbarzadeh@gmail.com Amniotic membraneAntibacterial effectChorionic membrane 701.pdf Stirling KM, Hussain N, Sanders MM, Campbell W. Association between maternal genital mycoplasma colonization and histologic chorioamnionitis in preterm births. J Neonatal Perinatal Med. 2016;9(2):201-9.##Nadeau HC, Subramaniam A, Andrews WW. Infection and preterm birth. Semin Fetal Neonatal Med. 2016;21(2):100-5.##Vinturache AE, Gyamfi-Bannerman C, Hwang J, Mysorekar IU, Jacobsson B; Preterm Birth International Collaborative (PREBIC). Maternal microbiome - A pathway to preterm birth. Semin Fetal Neonatal Med. 2016;21(2):94-9.##Yoneda N, Yoneda S, Niimi H, Ueno T, Hayashi S, Ito M, et al. Polymicrobial amniotic fluid infection with Mycoplasma/Ureaplasma and other bacteria induces severe intra-amniotic inflammation associated with poor perinatal prognosis in preterm labor. Am J Reprod Immunol. 2016;75(2):112-25.##Stock SJ, Kelly RW, Riley SC, Calder AA. Natural antimicrobial production by the amnion. Am J Obstet Gynecol. 2007;196(3):255.e1-6.##Sadler TW. Langman's medical embryology. 12th ed. Philadelphia: Lippincott Williams & Wilkins; 2015. 400 p.##Talmi YP, Sigler L, Inge E, Finkelstein Y, Zohar Y. Antibacterial properties of human amniotic membranes. Placenta. 1991;12(3):285-8.##Kjaergaard N, Hein M, Hyttel L, Helmig RB, Schonheyder HC, Uldbjerg N, et al. Antibacterial properties of human amnion and chorion in vitro. Eur J Obstet Gynecol Reprod Biol. 2001;94(2):224-9.##Sangwan VS, Basu S. Antimicrobial properties of amniotic membrane. Br J Ophthalmol. 2011;95(1):1-2.##Zare Bidaki M, Lessani T, Khazaie Z. [Evaluation of anti-bacterial effects of chorionic membranes in vitro]. Birjand Univ Med Sci J. 2012;19(2):140-6. Persian.##Parthasarathy M, Sasikala R, Gunasekaran P, Raja J. Antimicrobial activity of human amniotic and chorionic membranes. J Acad Ind Res. 2014;2(10):545-7.##Clinical and Laboratory Standards Institute (CLSI). Performance standard for antimicrobial susceptibility testing standard M02-A12. Clinical and Laboratory Standards Institute; 2015. 16 p.##Soltan-Dallal MM, Kalafi Z, Rastegar-Lari A, Hosseini S, Rahimi-Foroushani A, Deilami-Khiabani Z, et al . The effect of reduced bacterial dilution on human amniotic membrane antibacterial activity, in vitro. Zahedan J Res Med Sci. 2013;15(5):6-8.##Asi Tehrani F, Peirovi H, Niknejad H. [Determination of antibacterial effect of the epithelial and mesenchymal surfaces of amniotic membrane on Escherichia coli, Staphylococcus aureus]. Qom Univ Med Sci J. 2013;7(4):12-22. Persian.##Cunha SP, Berezowski AT, Costa MW, Costa JC, Ribeiro dos Santos R, Duarte G. Demonstration of the presence of IgA in the human chorioamniotic membrane. Int J Gynaecol Obstet. 1984;22(2):107-10.##Berezoswski AT, Cunha SP, da Costa JC, Bacchi CE. Quantification of immunoglobulin A in chorioamniotic membrane of patients with premature rupture of membranes. Int J Gynaecol Obstet. 1994;47(1):23-6.##Ganz T. Defensins: antimicrobial peptides of innate immunity. Nat Rev Immunol. 2003;3(9):710-20.##Szukiewicz D, Alkhalayla H, Pyzlak M, Watroba M, Szewczyk G, Wejman J. Human beta-defensin 1, 2 and 3 production by amniotic epithelial cells with respect to human papillomavirus (HPV) infection, HPV oncogenic potential and the mode of delivery. Microb Pathog. 2016;97:154-65.##Buhimschi IA, Jabr M, Buhimschi CS, Petkova AP, Weiner CP, Saed GM. The novel antimicrobial peptide beta3-defensin is produced by the amnion: a possible role of the fetal membranes in innate immunity of the amniotic cavity. Am J Obstet Gynecol. 2004;191(5):1678-87.##Denison FC, Kelly RW, Calder AA, Riley SC. Secretory leukocyte protease inhibitor concentration increases in amniotic fluid with the onset of labour in women: characterization of sites of release within the uterus. J Endocrinol. 1999;161(2):299-306.##Majchrzak-Gorecka M, Majewski P, Grygier B, Murzyn K, Cichy J. Secretory leukocyte protease inhibitor (SLPI), a multifunctional protein in the host defense response. Cytokine Growth Factor Rev. 2016;28:79-93.##Williams SE, Brown TI, Roghanian A, Sallenave JM. SLPI and elafin: one glove, many fingers. Clin Sci (Lond). 2006;110(1):21-35.##Kanyshkova TG, Buneva VN, Nevinsky GA. Lactoferrin and its biological functions. Biochemistry (Mosc). 2001;66(1):1-7.##Higa K, Shimmura S, Shimazaki J, Tsubota K. Hyaluronic acid-CD44 interaction mediates the adhesion of lymphocytes by amniotic membrane stroma. Cornea. 2005;24(2):206-12.##Yoshio H, Tollin M, Gudmundsson GH, Lagercrantz H, Jornvall H, Marchini G, et al. Antimicrobial polypeptides of human vernix caseosa and amniotic fluid: implications for newborn innate defense. Pediatr Res. 2003;53(2):211-6.##Espinoza J, Chaiworapongsa T, Romero R, Edwin S, Rathnasabapathy C, Gomez R, et al. Antimicrobial peptides in amniotic fluid: defensins, calprotectin and bacterial/permeability-increasing protein in patients with microbial invasion of the amniotic cavity, intra-amniotic inflammation, preterm labor and premature rupture of membranes. J Matern Fetal Neonatal Med. 2003;13(1):2-21.##Tambor V, Kacerovsky M, Andrys C, Musilova I, Hornychova H, Pliskova L, et al. Amniotic fluid cathelicidin in PPROM pregnancies: from proteomic discovery to assessing its potential in inflammatory complications diagnosis. PLoS One. 2012;7(7):e41164.##

Vitrification Increased Vacuolization of Human Spermatozoa: Application of MSOME Technology 2 1 702 2 Background: Sperm vitrification is a technique of ice and cryoprotectant free cryopreservation by direct plunging of sperm suspension into liquid nitrogen (LN2). The aim of this study was to investigate the influence of cryoprotectant free-vitrification on human sperm fine structure by MSOME technology and the fertility potential by zona binding assay (ZBA). Methods: 20 normo-ejaculates were prepared by swim up technique, and supernatants were divided into two parts of fresh and vitrified groups. For vitrification, sperm was dropped into LN2. Sperm motility, morphology, viability and MSOME were evaluated for each sample. In MSOM morphologically normal sperm (class 1), ≤2 small vacuoles (class 2), and one large vacuole or >2 small vacuoles (class 3) were evaluated. Also, fertility potential was evaluated by zona binding assay. Data was analyzed using paired t-test or Willcoxon’s test and p-value <0.05 was considered significant. Results: Vitrification significantly reduced both progressive motility, viability and morphology. Also, normal morphology of spermatozoa decreased significantly after vitrification. In MSOME evaluation, normal motile spermatozoa (Class 1) decreased from 23.00±12.44 to 16.00.56±10.79 after vitrification (p=0.008). Although spermatozoa classes 2 and 3 were increased, the difference was not significant. Moreover, fertility potential of motile spermatozoa was reduced after vitrification (9.0±13.87 vs. 13.40±22.73; p=0.07). Conclusion: Vitrification increased the rate of vacuolization in motile sperm head. Therefore, MSOME technology is recommended for assessment of sperm fine morphology in ICSI program used cryopreserved spermatozoa. 225 231 Sara S Taherzadeh 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 Azam A Agha-Rahimi اعظم آقارحیمی 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 Fatemeh F Anbari 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 Shahin Sh Ghazali 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 Guido G Macchiarelli Department of Life, Health and Environmental Sciences, University of L’Aquila Department of Life, Health and Environmental Sciences, University of L’Aquila Italy MSOMESpermVitrificationZona binding assay 702.pdf Mossad H, Morshedi M, Toner JP, Oehninger S. Impact of cryopreservation on spermatozoa from infertile men: impli-cations for artificial insemination. Arch Androl. 1994;33(1):51-7.##O'Connell M, McClure N, Lewis SE. The effects of cryopreservation on sperm morphology, motility and mitochondrial function. Hum Reprod. 2002;17(3):704-9.##Punyatanasakchai P, Sophonsritsuk A, Weerakiet S, Wansumrit S, Chompurat D. Comparison of cryopreserved hu-man sperm in vapor and liquid phases of liquid nitrogen: effect on motility parameters, morphology, and sperm function. Fertil Steril. 2008;90(5):1978-82.##Lee CY, Lee CT, Wu CH, Hsu CS, Hsu MI. Kruger strict morphology and post-thaw progressive motility in cryo-preserved human spermatozoa. Andrologia. 2012;44 Suppl 1:81-6.##Isachenko E, Isachenko V, Katkov II, Dessole S, Nawroth F. Vitrification of mammalian spermatozoa in the absence of cryoprotectants: from past practical difficulties to present success. Reprod Biomed Online. 2003;6(2):191-200.##Agha-Rahimi A, Khalili MA, Nabi A, Ashourzadeh S. Vitrification is not superior to rapid freezing of normozoospermic spermatozoa: effects on sperm par-ameters, DNA fragmentation and hyaluronan binding. Reprod Biomed Online. 2014;28(3):352-8.##Oliveira JB, Petersen CG, Massaro FC, Baruffi RL, Mauri AL, Silva LF, et al. Motile sperm organelle morphology ex-amination (MSOME): intervariation study of normal sperm and sperm with large nuclear vacuoles. Reprod Biol Endocrinol. 2010;8:56.##Luna D, Hilario R, Dueñas-Chacón J, Romero R, Zavala P, Villegas L, et al. The IMSI procedure improves laboratory and clinical outcomes without compromising the aneuploidy rate when compared to the classical ICSI procedure. Clin Med Insights Reprod Health. 2015;9:29-37.##Shalom-Paz E, Anabusi S, Michaeli M, Karchovsky-Shoshan E, Rothfarb N, Shavit T, et al. Can intra cytoplasmatic morphologically selected sperm injection (IMSI) technique improve outcome in patients with repeated IVF-ICSI fail-ure? a comparative study. Gynecol Endocrinol. 2015;31(3):247-51.##Orief YI, Elabd MM, Said THM, Ahmed NAAJ. Comparative study between intracytoplasmic morphologically selected sperm injection versus intra-cytoplasmic sperm injection in patients with severe male factor infertility and repeated intra cytoplasmic sperm injection failure. Int J Reprod Contra-cept Obstet Gynecol. 2016;5(4):1102-7.##Perdrix A, Rives N. Motile sperm organelle morphology examination (MSOME) and sperm head vacuoles: state of the art in 2013. Hum Reprod Update. 2013;19(5):527-41.##Garolla A, Fortini D, Menegazzo M, De Toni L, Nicoletti V, Moretti A, et al. High-power microscopy for selecting spermatozoa for ICSI by physiological status. Reprod Biomed Online. 2008;17(5):610-6.##Berkovitz A, Eltes F, Lederman H, Peer S, Ellen-bogen A, Feldberg B, et al. How to improve IVF-ICSI outcome by sperm selection. Reprod Biomed Online. 2006;12(5):634-8.##Antinori M, Licata E, Dani G, Cerusico F, Versaci C, d'Angelo D, et al. Intracytoplasmic morphologically selected sperm injection: a prospective randomized trial. Reprod Biomed Online. 2008;16(6):835-41.##Ghazali S, Talebi AR, Khalili MA, Aflatoonian A, Esfandiari N. Large nuclear vacuoles in spermatozoa negatively af-fect pregnancy rate in IVF cycles. Iran J Reprod Med. 2015;13(7):425-32.##Boitrelle F, Albert M, Theillac C, Ferfouri F, Ber-gere M, Vialard F, et al. Cryopreservation of human spermatozoa decreases the number of motile normal spermatozoa, induces nuclear vacuolization and chromatin decondensation. J Androl. 2012;33(6):1371-8.##World Health Organization, Department of Reproductive Health and Research. WHO laboratory manual for the examination and processing of human semen. Geneva: WHO Press; 2010. 287 p.##Isachenko E, Isachenko V, Weiss JM, Kreienberg R, Katkov II, Schulz M, et al. Acrosomal status and mitochondrial activity of human spermatozoa vitrified with sucrose. Reproduction. 2008;136(2):167-73.##Sermondade N, Dupont C, Faure C, Boubaya M, Cédrin-Durnerin I, Chavatte-Palmer P, et al. Body mass index is not associated with sperm-zona pel-lucida binding ability in subfertile males. Asian J Androl. 2013;15(5):626-9.##Cassuto NG, Bouret D, Plouchart JM, Jellad S,Vanderzwalmen P, Balet R, et al. A new real-time morphology classification for human spermatozoa: a link for fertilization and improved embryo quality. Fertil Steril. 2009;92(5):1616-25.##Khalili MA, Adib M, Halvaei I, Nabi A. Vitrification of neat semen alters sperm parameters and DNA integrity. Urol J. 2014;11(2):1465-70.##Cassuto NG, Hazout A, Hammoud I, Balet R, Bou-ret D, Barak Y, et al. Correlation between DNA defect and sperm-head morphology. Reprod Biomed Online. 2012;24(2):211-8.##Fortunato A, Boni R, Leo R, Nacchia G, Liguori F, Casale S, et al. Vacuoles in sperm head are not associated with head morphology, DNA damage and reproductive success. Reprod Biomed Online. 2016;32(2):154-61.##Gatimel N, Leandri R, Parinaud J. Sperm vacuoles are not modified by freezing--thawing procedures. Reprod Biomed Online. 2013;26(3):240-6.##Agha-Rahimi A, Khalili MA, Nottola SA, Migliet-ta S, Moradi A. Cryoprotectant-free vitrification of human spermato-zoa in new artificial seminal fluid. Andrology. Andrology. 2016;4(6):1037-44.##Green CE, Watson PF. Comparison of the capacitation-like state of cooled boar spermatozoa with true capacitation. Reproduction. 2001;122(6):889-98.##Vadnais ML, Roberts KP. Seminal plasma proteins inhibit in vitro- and cooling-induced capacitation in boar spermato-zoa. Reprod Fertil Dev. 2010;22(6):893-900.##Ozkavukcu S, Erdemli E, Isik A, Oztuna D, Karahu-seyinoglu S. Effects of cryopreservation on sperm parameters and ultrastructural morphology of human spermatozoa. J Assist Reprod Genet. 2008;25(8):403-11.##

The Window of Implantation Is Closed by Estrogen via Insulin-Like Growth Factor 1 Pathway 2 1 705 2 Background: The opening and closing of the implantation window is important for successful pregnancy in eutherians. The recent study demonstrated that the window of uterine receptivity was prepared by the sole action of progesterone in mice, but the mechanism to close the window remained to be elucidated. Methods: The pregnant mice were ovariectomized on the evening on the third day of pregnancy with a single injection of medroxyprogesterone acetate to induce delayed implantation (DI). Several treatments were applied to DI mice. The uterine receptivity after treatment was assessed by examining cell proliferation in the uterine luminal epithelium (LE). The gene expressions in the endometrium were investigated by RNA-seq. The p<0.05 was considered significant. Results: Cell proliferation in the LE ceased only when the window of implantation was open. Estrogen (E2) stimulated cell proliferation in the LE rendered the uterus refractory. The high throughput gene expression analysis by RNA-Seq showed that the insulin-like growth factor 1 (IGF1) pathway was the candidate to close the implantation window under E2. In vivo administration of IGF1 to delayed implantation mice resulted in proliferation in the LE cells. Conclusion: This study demonstrated that the window of uterine receptivity was closed by E2, which was mediated by the IGF1 pathway. 231 242 Ryosuke R Kobayashi Laboratory of Animal Morphology, Division of Biofunctional Development, Graduate School of Bioagricultural Sciences, Nagoya University Laboratory of Animal Morphology, Division of Biofunctional Development, Graduate School of Bioagricultural Sciences, Nagoya University Japan Jumpei J Terakawa Laboratory of Animal Morphology, Division of Biofunctional Development, Graduate School of Bioagricultural Sciences, Nagoya University Laboratory of Animal Morphology, Division of Biofunctional Development, Graduate School of Bioagricultural Sciences, Nagoya University Japan Tsutomu T Omatsu Research and Education Center for Prevention of Global Infectious Diseases of Animals, Tokyo University of Agriculture and Technology Research and Education Center for Prevention of Global Infectious Diseases of Animals, Tokyo University of Agriculture and Technology Japan Yupadee Y Hengjan Laboratory of Animal Morphology, Division of Biofunctional Development, Graduate School of Bioagricultural Sciences, Nagoya University Laboratory of Animal Morphology, Division of Biofunctional Development, Graduate School of Bioagricultural Sciences, Nagoya University Japan Tetsuya T Mizutani Research and Education Center for Prevention of Global Infectious Diseases of Animals, Tokyo University of Agriculture and Technology Research and Education Center for Prevention of Global Infectious Diseases of Animals, Tokyo University of Agriculture and Technology Japan Yasushige Y Ohmori Laboratory of Animal Morphology, Division of Biofunctional Development, Graduate School of Bioagricultural Sciences, Nagoya University Laboratory of Animal Morphology, Division of Biofunctional Development, Graduate School of Bioagricultural Sciences, Nagoya University Japan Eiichi E Hondo Laboratory of Animal Morphology, Division of Biofunctional Development, Graduate School of Bioagricultural Sciences, Nagoya University Laboratory of Animal Morphology, Division of Biofunctional Development, Graduate School of Bioagricultural Sciences, Nagoya University Japan ehondo@agr.nagoyau.ac.jp Embryo implantationEstrogenInsulin-like growth factor 1Mouse 705.pdf Wang H, Dey SK. 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Should Subclinical Hypothyroidism Be an Exclusion Criterion for the Diagnosis of Polycystic Ovary Syndrome? 2 1 703 2 Background: The purpose of the study was to examine whether patients with subclinical hypothyroidism (SCH) should be excluded before making a diagnosis of polycystic ovary syndrome (PCOS). Methods: Seven hundred sixteen patients, 462 with true PCOS, 31 with PCOS-SCH, and 223 normal cycling women were enrolled. Clinical, metabolic, and hormonal parameters among the groups were investigated. Continuous variables were compared by one-way analysis of variance. Proportions were compared using Z test. Fisher test was used to compare categorical variables. Simple correlation was performed using Spearman’s coefficient. Correlation between thyroid stimulating hormone (TSH) and dependent variables were performed using backward multiple regression. The significance level was set at 0.05. Results: True polycystic ovary and polycystic ovary with subclinical hypothyroidism patients presented similar anthropometrical parameters. C-peptide was higher in polycystic ovary patients than in the other groups (p=0.014). Prevalence of glucose intolerance (p=0.186) and insulin resistance (p=0.293) was not statistically different in polycystic ovary and polycystic ovary with subclinical hypothyroidism. TSH levels showed positive correlation with lean body mass (p=0.032), total cholesterol (p=0.046, insulin (p=0.048) and prolactin (p=0.047). Backward multiple regression model retained TC, insulin, and PRL as predictors of TSH levels (p=0.011). Conclusion: Anthropometric parameters and ovary morphology were similar in both PCOS and PCOS-with-SCH patients. Regarding hormones, only C-peptide was higher in PCOS group. TSH correlated with total cholesterol, insulin, and prolactin. Before PCOS diagnosis, the exclusion criterion thyroid dysfunction should be standardized and subclinical hypothyroidism should not exclude a diagnosis of PCOS. 242 251 Sebastião SF de-Medeiros Federal University of Mato Grosso, Cuiabá Federal University of Mato Grosso, Cuiabá Brazil de.medeiros@terra.com.br Márcia MM Yamamoto Tropical Institute of Reproductive Medicine and Menopause, Cuiabá Tropical Institute of Reproductive Medicine and Menopause, Cuiabá Brazil Matheus MAS de-Medeiros Tropical Institute of Reproductive Medicine and Menopause, Cuiabá Tropical Institute of Reproductive Medicine and Menopause, Cuiabá Brazil Jacklyne JS Barbosa Tropical Institute of Reproductive Medicine and Menopause, Cuiabá Tropical Institute of Reproductive Medicine and Menopause, Cuiabá Brazil Robert RJ Norman University of Adelaide, Robinson Research Institute and Fertility SA University of Adelaide, Robinson Research Institute and Fertility SA Australia HyperandrogenismHypothyroidismPolycystic ovary syndromeThyroid hormones 703.pdf Kousta E, White DM, Cela E, McCarthy MI, Franks S. The prevalence of polycystic ovaries in women with infertility. Hum Reprod. 1999;14(11):2720-3.##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.##Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril. 2004;81(1):19-25.##Pasquali R, Patton L, Pagotto U, Gambineri A. Metabolic alterations and cardiovascular risk factors in the polycystic ovary syndrome. Minerva Ginecol. 2005;57(1):79-85.##Krassas GE, Pontikides N, Kaltsas T, Papadopoulou P, Paunkovic J, Paunkovic N, et al. Disturbances of menstruation in hypothyroidism. Clin Endocrinol (Oxf). 1999;50(5):655-9.##Ghosh S, Kabir SN, Pakrashi A, Chatterjee S, Chakravarty B. Subclinical hypothyroidism: a determinant of polycystic ovary syndrome. Horm Res. 1993;39(1-2):61-6.##Mueller A, Schöfl C, Dittrich R, Cupisti S, Oppelt PG, Schild RL, et al. Thyroid-stimulating hormone is associated with insulin resistance independently of body mass index and age in women with polycystic ovary syndrome. Hum Reprod. 2009;24(11):2924-30.##Maratou E, Hadjidakis DJ, Kollias A, Tsegka K, Peppa M, Alevizaki M, et al. Studies of insulin resistance in patients with clinical and subclinical hypothyroidism. Eur J Endocrinol. 2009;160(5):785-90.##Sridhar GR, Nagamani G. Hypothyroidism presenting with polycystic ovary syndrome. J Assoc Physicians India. 1993;41(2):88-90.##Hollowell JG, Staehling NW, Flanders WD, Hannon WH, Gunter EW, Spencer CA, et al. Serum TSH, T(4), and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III). J Clin Endocrinol Metab. 2002;87(2):489-99.##Billic-Komarica E, Beciragic A, Junuzovic D. The Importance of HbA1c Control in Patients with Subclinical Hypothyroidism. Mater Sociomed. 2012;24(4):212-9.##Kvetny J, Heldgaard PE, Bladbjerg EM, Gram J. Subclinical hypothyroidism is associated with a low-grade inflammation, increased triglyceride levels and predicts cardiovascular disease in males below 50 years. Clin Endocrinol (Oxf). 2004;61(2):232-8.##Althaus BU, Staub JJ, Ryff-De Lèche A, Oberhänsli A, Stähelin HB. LDL/HDL-changes in subclinical hypothyroidism: possible risk factors for coronary heart disease. Clin Endocrinol (Oxf). 1988;28(2):157-63.##Azziz R, Woods KS, Reyna R, Key TJ, Knochenhauer ES, Yildiz BO. The prevalence and features of the polycystic ovary syndrome in an unselected population. J Clin Endocrinol Metab. 2004;89(6):2745-9.##Huang A, Brennan K, Azziz R. Prevalence of hyperandrogenemia in the polycystic ovary syndrome diagnosed by the National Institutes of Health 1990 criteria. Fertil Steril. 2010;93(6):1938-41.##Welt CK, Gudmundsson JA, Arason G, Adams J, Palsdottir H, Gudlaugsdottir G, et al. Characterizing discrete subsets of polycystic ovary syndrome as defined by the Rotterdam criteria: the impact of weight on phenotype and metabolic features. J Clin Endocrinol Metab. 2006;91(12):4842-8.##Carmina E, Rosato F, Jannì A, Rizzo M, Longo RA. Extensive clinical experience: relative prevalence of different androgen excess disorders in 950 women referred because of clinical hyperandrogenism. J Clin Endocrinol Metab. 2006;91(1):2-6.##Dittrich R, Kajaia N, Cupisti S, Hoffmann I, Beckmann MW, Mueller A. Association of thyroid-stimulating hormone with insulin resistance and androgen parameters in women with PCOS. Reprod Biomed Online. 2009;19(3):319-25.##Enzevaei A, Salehpour S, Third M, Saharkhiz N. Subclinical hypothyroidism and insulin resistance in polycystic ovary syndrome: is there a relationship? Iran J Reprod Med. 2014;12(7):481-6.##Rotondi M, Cappelli C, Magri F, Botta R, Dionisio R, Iacobello C, et al. Thyroidal effect of metformin treatment in patients with polycystic ovary syndrome. Clin Endocrinol (Oxf). 2011;75(3):378-81.##Ganie MA, Laway BA, Wani TA, Zargar MA, Nisar S, Ahamed F, et al. Association of subclinical hypothyroidism and phenotype, insulin resistance, and lipid parameters in young women with polycystic ovary syndrome. Fertil Steril. 2011;95(6):2039-43.##Baloch Z, Carayon P, Conte-Devolx B, Demers LM, Feldt-Rasmussen U, Henry JF, et al. Laboratory medicine practice guidelines. Laboratory support for the diagnosis and monitoring of thyroid disease. Thyroid. 2003;13(1):3-126.##DHSS/MRC Group on Obesity Research, Waterlow JC, James WPT, Great Britain, Department of Health and Social Security and Medical Research Council. Research on obesity: A repot of the DHSS/MRC group. Hher Majesty’s Stationary office, London; 1976. 94 p.##Valdez R. 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Arq Bras Endocrinol Metabol. 2013;57(6):437-44.##Wild RA, Vesely S, Beebe L, Whitsett T, Owen W. Ferriman Gallwey self-scoring I: performance assessment in women with polycystic ovary syndrome. J Clin Endocrinol Metab. 2005;90(7):4112-4.##Lujan ME, Chizen DR, Pierson RA. Diagnostic criteria for polycystic ovary syndrome: pitfalls and controversies. J Obstet Gynaecol Can. 2008;30(8):671-9.##Benetti-Pinto CL, Berini Piccolo VR, Garmes HM, Teatin Juliato CR. Subclinical hypothyroidism in young women with polycystic ovary syndrome: an analysis of clinical, hormonal, and metabolic parameters. Fertil Steril. 2013;99(2):588-92.##Pei YJ, Wang AM, Zhao Y, Yan L, Li M, White RE, et al. Studies of cardiovascular risk factors in polycystic ovary syndrome patients combined with subclinical hypothyroidism. Gynecol Endocrinol. 2014;30(8):553-6.##Huang R, Zheng J, Li S, Tao T, Liu W. 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The Relationship Between Uterine Artery two-dimensional Color Doppler Measurement and Pregnancy Outcome: A Prospective Observational Study 2 1 700 2 Background: The purpose of the study was to evaluate the role of uterine blood flow parameters measured by uterine artery two-dimensional (2D)-power color doppler (PCD) ultrasound in predicting fertility outcomes in women undergoing IVF-ET cycles. Methods: In this prospective observational study, a total of 188 infertile women who underwent IVF-ET cycles were investigated. Uterine artery 2D-PD measurements were taken during early follicular phase and on day of trigger. Pulsatility Index (PI), Resistant Index (RI), Peak Systolic Velocity (PSV), and Systolic/Diastolic ratio (S/D) were measured. Statistical correlation was sought between the doppler parameters and fertility outcomes. Results: The pregnancy rate was 40.43% (76/188). The women who conceived (n=76) (Group A) were found to have mean age of 31.2±3.9 years whereas the non-pregnant group of women (n=112) (Group B) had mean age of 31.45±4.25 years. The mean PI measurements subsequently during early follicular phase and on the day of hCG trigger between group A and group B were comparable (2.09±1.15 versus 1.9±0.95; p=0.385 and 1.86±1.12 versus 2.03±1.0; p=0.192, respectively). No significant changes in the uterine artery PSV values and S/D values and RI were noted during the cycle. Conclusion: Uterine artery doppler evaluation in women undergoing IVF cycles was not predictive of the pregnancy outcomes. 251 257 Sudha S Prasad Sudha Prasad Department of IVF and Reproductive Medicine, Maulana Azad Medical College & Associated Lok Nayak Hospitals Department of IVF and Reproductive Medicine, Maulana Azad Medical College & Associated Lok Nayak Hospitals India ivfmamc@gmail.com Ritu R Goyal Department of IVF and Reproductive Medicine, Maulana Azad Medical College & Associated Lok Nayak Hospitals Department of IVF and Reproductive Medicine, Maulana Azad Medical College & Associated Lok Nayak Hospitals India Yogesh Y Kumar Department of IVF and Reproductive Medicine, Maulana Azad Medical College & Associated Lok Nayak Hospitals Department of IVF and Reproductive Medicine, Maulana Azad Medical College & Associated Lok Nayak Hospitals India Poonam P Nayar Mata Chanan Devi Hospital Mata Chanan Devi Hospital India Supriya S Hajela Department of IVF and Reproductive Medicine, Maulana Azad Medical College & Associated Lok Nayak Hospitals Department of IVF and Reproductive Medicine, Maulana Azad Medical College & Associated Lok Nayak Hospitals India Aswathy A Kumaran Department of IVF and Reproductive Medicine, Maulana Azad Medical College & Associated Lok Nayak Hospitals Department of IVF and Reproductive Medicine, Maulana Azad Medical College & Associated Lok Nayak Hospitals India Rajesh R Vairagi Department of IVF and Reproductive Medicine, Maulana Azad Medical College & Associated Lok Nayak Hospitals Department of IVF and Reproductive Medicine, Maulana Azad Medical College & Associated Lok Nayak Hospitals India Shalini Sh Chauhan Department of IVF and Reproductive Medicine, Maulana Azad Medical College & Associated Lok Nayak Hospitals Department of IVF and Reproductive Medicine, Maulana Azad Medical College & Associated Lok Nayak Hospitals India Doppler ultrasoundFollicular phaseIVF-ETPregnancy outcomesUterine artery 700.pdf National center for chronic disease prevention and health promotion. 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Ultrasound Obstet Gynecol. 1991;1(4):272-4.##Favre R, Bettahar K, Grange G, Ohl J, Arbogast E, Moreau L, et al. Predictive value of transvaginal uterine Doppler assessment in an in vitro fertilization program. Ultrasound Obstet Gynecol. 1993;3(5):350-3.##Bassil S, Magritte JP, Roth J, Nisolle M, Donnez J, Gordts S. Uterine vascularity during stimulation and its correlation with implantation in in-vitro fertilization. Hum Reprod. 1995;10(6):1497-501.##Zaidi J, Pittrof R, Shaker A, Kyei-Mensah A, Campbell S, Tan SL. Assessment of uterine artery blood flow on the day of human chorionic gonadotropin administration by transvaginal color Doppler ultrasound in an in vitro fertilization program. Fertil Steril. 1996;65(2):377-81.##Tsai YC, Chang JC, Tai MJ, Kung FT, Yang LC, Chang SY. Relationship of uterine perfusion to outcome of intrauterine insemination. J Ultrasound Med. 1996;15(9):633-6.##Tekay A, Martikainen H, Jouppila P. 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Maternal and Fetal Tuberous Sclerosis: Do We Know Enough as an Obstetrician? 2 1 710 2 Background: Tuberous sclerosis, also known as tuberous sclerosis complex (TSC), is a rare genetic condition that mainly causes hamartomas to develop in different parts of the body. TSC, an autosomal dominant trait with variable penetrance, can adversely affect maternal and fetal outcome. Case Presentation: In this paper, a case of maternal and fetal tuberous sclerosis having fetal cardiac rhabdomyoma detected in utero at 26 weeks was reported who subsequently had fetal demise at 31 weeks. Conclusion: Tuberous sclerosis is a rare genetic condition that mainly causes development of hamartomas. In tuberous sclerosis, a cardiac rhabdomyoma is the only sign that can be detected prenatally. In maternal tuberous sclerosis, fetal ECHO is advisable after 24 weeks. A pregnancy complicated by maternal or fetal tuberous sclerosis deserves careful observation and the fetus should undergo prenatal fetal Doppler echocardiography and if possible magnetic resonance imaging for evaluation of other fetal structures including brain and renal parenchyma, so that parents can be counseled regarding its future prognostic implications. Tuberous sclerosis can lead to poor fetal outcome including intrauterine fetal death; hence regular antenatal follow up is required. Genetic counseling is recommended for couples who have a family history of tuberous sclerosis and who want to have children. Prenatal diagnosis is available for families with a known gene mutation or history of this condition. 257 261 Nalini N Sharma Department of Obstetrics and Gynecology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences Shillong Department of Obstetrics and Gynecology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences Shillong India Nalinisharma100@rediffmail.com Shriram SR Sharma Department of Neurology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences Shillong Department of Neurology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences Shillong India Jion JL Thiek Department of Obstetrics and Gynecology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences Shillong Department of Obstetrics and Gynecology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences Shillong India Ahanthem A Singh Department of Obstetrics and Gynecology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences Shillong Department of Obstetrics and Gynecology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences Shillong India Kalita K Arnab Department of Radiology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences Shillong Department of Radiology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences Shillong India Lynser L Donboklang Department of Radiology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences Shillong Department of Radiology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences Shillong India PregnancyTuberous sclerosis complexTuberous sclerosis 710.pdf Daroff RB, Fenichel GM, Jankovic J, Mazziotta JC. Bradley’s Neurology in clinical practice. 6 th ed. Philadelphia: Elsevier; 2012. p. 1508-14.##Agrawal SN, Kulkarni YA, Deshmukh YR, Jane SD. Tuberous Sclerosis in Pregnancy. Our Dermatol On-line. 2014;5(2):160-2.##Gupta N, Singh N, Sarangi S, Dalmia S, Mittal S. Fe-tal cardiac rhabdomyoma with maternal tuberous sclerosis complicating pregnancy. Arch Gynecol Obstet. 2008;278(2):169-70.##King JA, Stamilio DM. Maternal and fetal tuberous sclerosis complicating pregnancy: a case report and overview of the literature. Am J Perinatol. 2005;22(2):103-8.##Bonebrake L, Rai K, Yankowitz J. Outcomes of pregnancies complicated by maternal tuberous sclerosis. Proc Obstet Gynecol. 2012;2(3):1-2.##Khanna PC, Godinho S, Pungavkar SA, Patkar DP. Ultrafast MRI in the prenatal diagnosis of Bourne ville's tuberous sclerosis. Neurol India. 2005;53(3):349-50.##Pipitone S, Mongiovì M, Grillo R, Gagliano S, Spe-randeo V. Cardiac rhabdomyoma in intrauterine life: clinical fea-tures and natural history. A case series and review of published reports. Ital Heart J. 2002;3(1):48-52.##

The Importance of Fertility Preservation Counseling in Patients with Gynecologic Cancer 2 1 708 2 It is estimated that gynecologic cancer has an incidence of 17% in the world (1). The most common gynecologic cancer is endometrial cancer with an incidence of 53% (2, 3). Although in most cases endometrial cancer manifests during menopause, in 25% of cases it can affect women in premenopausal age and in 2% of cases under the age of 40 (2). The treatment of this type of gynecological cancer is usually surgical and includes hysterectomy and bilateral salpingo oophorectomy (4-6). Adjuvant chemotherapy and/or radiotherapy is recommended in cases at high risk of recurrence and in the later stages of cancer (2, 6). Ovarian cancer is the second most common gynecological malignancy and the leading cause of death for gynecologic cancer in Western countries (2). In most cases, it is diagnosed in advanced stages and mainly affects women aged between 55 and 65. The treatment of ovarian cancer usually involves a combination of surgery and chemotherapy (7-9). Cervical cancer is the second cancer in women worldwide. However, in Western countries, thanks to the diffusion of prevention campaigns through systematic screening program for women aged between 25 and 65, the incidence of this cancer has been greatly reduced (10). Cervical cancer is often diagnosed in reproductive age and surgical treatment may be placed alongside radiation therapy (2, 11). Thanks to progress made in the field of gynecologic oncology, the survival rate for women with gynecologic cancer is greatly increased over the years. Consequently, a primary objective in these cases is to gradually improve the quality of life of patients. Indeed, the experience of a gynecological cancer has a very strong impact on the psychological well-being of women; surgical treatment and chemotherapy can impair female identity and also sexual functioning (2, 3, 12-14). Several studies confirm that women with gynecologic cancer experience low levels of quality of life, anxiety and depressive symptoms, suicidal thoughts, feelings of anger and shame, and low self-esteem (1, 3, 12-17). Moreover, when cancer affects women in child-bearing age, treatments can jeopardize reproductive capacity. The possible infertility due to cancer in women can be more devastating than the cancer itself and the possibility to have a child after cancer can be an important incentive in the therapeutic process (18-20). In the light of these general considerations, techniques for fertility preservation in women with gynecologic cancer can be very important for the improvement of quality of life of these patients (19-21). In Italy, according to the Guidelines for the preservation of fertility in cancer patients published in 2003, a conservative therapy for fertility preservation may be proposed in case of good prognosis and only in the presence of close follow-up and in cancer centers with experience and adequate follow-up protocols (22). Several international studies have shown that an adequate counseling about the fertility preservation treatments is associated with an improved quality of life of women who survive from a gynecological cancer (19-22). However, in many cases, there is not adequate information about this type of treatment. The aforementioned Guidelines recommend that reproductive counseling should be offered immediately after the cancer diagnosis in order to come to an agreement with the patient about the best fertility preservation technique which varies depending on the cancer and reproductive prognosis (22). Reproductive counseling requires a multidisciplinary approach since it is necessary not only to choose the most appropriate preservation technique according to the prognosis and the risk of infertility related to cancer treatments, but also to assess the real motivation of woman to face a pregnancy and to become mother (22, 23). Therefore, the presence of the psychologist, along with the oncologist and the specialist in reproductive medicine, is important to convey correct information to patients with gynecological cancer who wish to preserve their procreative capacity (24, 25). In conclusion, it is appropriate to conduct further research about this topic in order to minimize the impact of cancer treatments on quality of life and psychological well-being of women with gynecological cancer. Conflict of Interest The authors report no conflicts of interest. Acknowledgement The authors alone are responsible for the content and writing of the paper. No specific funding was obtained. 261 264 Salvatore SG Vitale Unit of Gynecology and Obstetrics, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University of Messina Unit of Gynecology and Obstetrics, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University of Messina Italy Valentina VL La Rosa Unit of Psychodiagnostics and Clinical Psychology, University of Catania Unit of Psychodiagnostics and Clinical Psychology, University of Catania Italy psicolarosa@gmail.com Agnese AM Rapisarda Department of General Surgery and Medical Surgical Specialties, University of Catania Department of General Surgery and Medical Surgical Specialties, University of Catania Italy Antonio AS Laganà Unit of Gynecology and Obstetrics, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University of Messina Unit of Gynecology and Obstetrics, Department of Human Pathology in Adulthood and Childhood “G. 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Updates Surg. 2016;68(2):149-54.##Rossetti D, Vitale SG, Gulino FA, Cignini P, Rapi-sarda AMC, Biondi A, et al. Concomitant chemo-radiation treatment in selected stage I endometrioid endometrial cancers. Eur J Gynaecol Oncol. 2016;37(5):657-61.##Vitale SG, Marilli I, Lodato M, Tropea A, Cianci A. The role of cytoreductive surgery in advanced-stage ovarian can-cer: a systematic review. Updates Surg. 2013;65(4):265-70.##Bellia A, Vitale SG, Laganà AS, Cannone F, Hou-venaeghel G, Rua S, et al. Feasibility and surgical outcomes of con-ventional and robot-assisted laparo-scopy for early-stage ovarian cancer: a retrospective, multicenter analysis. Arch Gynecol Obstet. 2016;294(3):615-22.##Rossetti D, Vitale SG, Gulino FA, Rapisarda AMC, Valenti G, Zigarelli M, et al. Laparoendoscopic single-site surgery for the assessment of peritoneal carcinomatosis resectability in patients with ad-vanced ovarian cancer. Eur J Gynaecol Oncol. 2016;37(5):671-3.##Thigpen SC, Geraci SA. Cancer Screening 2016. Am J Med Sci. 2016;352(5):493-501.##Kokka F, Bryant A, Brockbank E, Powell M, Oram D. Hysterectomy with radiotherapy or chemo-therapy or both for women with locally advanced cervical cancer. Cochrane Database Syst Rev. 2015;(4):CD010260.##Iżycki D, Woźniak K, Iżycka N. Consequences of gynecological cancer in patients and their partners from the sexual and psychological perspective. Prz Menopauzalny. 2016;15(2):112-6.##Vitale SG, La Rosa VL, Rapisarda AM, Laganà AS. Comment on: "The consequences of gynaec-ological cancer in patients and their partners from the sexual and psychological perspective". Prz Menopauzalny. 2016;15(3):186-7.##Becker M, Malafy T, Bossart M, Henne K, Gitsch G, Denschlag D. Quality of life and sexual func-tioning in endome-trial cancer survivors. Gynecol Oncol. 2011;121(1):169-73.##Vitale SG, La Rosa VL, Rapisarda AM, Laganà AS. Comment on: "Anxiety and depression in pa-tients with advanced ovarian cancer: a prospective study". J Psychosom Obstet Gynaecol. 2017;38(1):83-84.##Mielcarek P, Nowicka-Sauer K, Kozaka J. Anxiety and depression in patients with advanced ovarian cancer: a prospective study. J Psychosom Obstet Gynaecol. 2016;37(2):57-67.##Laganà AS, La Rosa VL, Rapisarda AM, Vitale SG. Comment on: "Needs and priorities of women with endometrial and cervical cancer". J Psycho-som Obstet Gynaecol. 2017;38(1):85-86.##Vitale SG, La Rosa VL, Rapisarda AM, Laganà AS. Psychology of infertility and assisted repro-ductive treatment: the Italian situation. J Psycho-som Obstet Gynaecol. 2017;38(1):1-3.##Angarita AM, Johnson CA, Fader AN, Christian-son MS. Fertility Preservation: A Key Survivorship Issue for Young Women with Cancer. Front Oncol. 2016;6:102.##Letourneau JM, Ebbel EE, Katz PP, Katz A, Ai WZ, Chien AJ, et al. Pretreatment fertility counsel-ing and fertility preservation improve quality of life in reproductive age women with cancer. Can-cer. 2012;118(6):1710-7.##Reh AE, Lu L, Weinerman R, Grifo J, Krey L, No-yes N, et al. Treatment outcomes and quality-of-life assessment in a university-based fertility pre-servation program: results of a registry of female cancer patients at 2 years. J Assist Reprod Genet. 2011;28(7):635-41.##AIOM: Scientific Documents [Internet]. Milan: Italian Association of Medical Oncology. c2017. Guidelines "Preserva-tion of fertility in cancer patients"; 2015 [cited 2016 Dec 1]; [about 2 screens]. Available from: http://www.aiom.it/ professionisti/documenti-scientifici/linee-guida/preservazione-fertilita/1,713,1,###Baysal Ö, Bastings L, Beerendonk CC, Postma SA, IntHout J, Verhaak CM, et al. Decision-making in female fertility preservation is balancing the ex-pected burden of fertility preservation treatment and the wish to conceive. Hum Reprod. 2015;30 (7):1625-34.##Lawson AK, Klock SC, Pavone ME, Hirshfeld-Cytron J, Smith KN, Kazer RR. Psychological Counseling of Female Fertility Preservation Pa-tients. J Psychosoc Oncol. 2015;33(4):333-53.##Bastings L, Baysal Ö, Beerendonk CC, IntHout J, Traas MA, Verhaak CM, et al. Deciding about fer-tility preservation after specialist counselling. Hum Reprod. 2014;29(8):1721-9.##