How Can Personalized Medicine Improve Assisted Reproduction Technology Outcomes? 2 1 720 2 Personalized medicine or precision medicine was first defined for management of cancer patients with the idea that information of patient’s genes, proteins, metabolites and environment can be applied for its individualized management and it encompasses prevention, screening, diagnosis, prognosis, treatment, follow up, detection of recurrence and categorization of patient to defined subgroups for more effective treatment. Current evidence suggests the relative success of this approach in cancer patients. The development and implementation of personalized medicine required a set of objectives and valid biomarkers through genomics, transcriptomics, proteomics and metabolomics knowledge of huge samples cohorts regarding confounding factors, such as age, gender, habits, diet, and environment. For the first time, human genome sequencing cost up to $3 billion; however, it costs less than $5000 recently and it continues to decline in price and time rapidly. This is the direct approach for genetic biomarker discovery through genome and transcriptome but the current metabolomics and proteomics techniques require high expertise, labor, and infrastructure, and therefore are more expensive than genomics and transcriptomics technologies at present (1). Personalized medicine in reproductive medicine is still in its nonage since it is not yet a fully strengthened mature arena. Reproductive medicine is at the priliminary stage of discovering and validating genomic, protein and metabolite biomarkers. Perhaps what is currently being offered as personalized treatment of infertile patient is more based on "the best expert opinion of the attending clinician" than " the best evidence-based data available". Clinicians from all disciplines now accepted the concept "one size does not fit all" accordingly to their practice in diagnosis and treatments should consider patients’ specific molecular profiles. The past and present "one size fits all" practice would inescapably hamper some patients from more efficient treatments. Albert Einstein wrote: "If you want different results, do not do the same". This concept is representative of our current practice in reproductive medicine; "failed IVF cycles followed by repeating the same cycles for all couples". Thus, the consequence of this approach is facing with hordes of infertile couples as the victims of repeated implantation failure (RIF) (2). Historical facts show that inability of reproductive medicine in applying personalized therapy for efficient treatment is remunerated by transfer of numerous embryos to guarantee higher chance of successful pregnancy. The consequence of this practice is dangerous situations of multiple pregnancies in %30-40 of IVF cycles (3). At the first glance, infertility treatment suffers from lack of standardization in the field reproductive medicine.The most evident variations are in oocyte and embryo grading, endometrial assessment, semen analysis, and also in diagnosis and treatment within and between clinics, technicians and physicians that lead to varying success rates between clinics and even different physicians in one clinic. Another feature of reproductive medicine is that it is not "personalized" to only one individual but in reality, you are faced with at least three different individuals; the mother, father and embryos. Another complication is personalization of different biological systems; the egg, sperm, embryo and uterus. Even more importantly, one or more systems may be involved in etiology of infertility and its efficient treatment in a particular couple with great impact on treatment outcomes (3). Preliminary data on large cohorts of samples revealed genetic biomarkers linked to spontaneous ovulation for PCOS patients, efficacy of low molecular weight heparin for the prevention of spontaneouse abortion, specific allells of FSH receptor linked with OHSS or poor response to controlled ovarian hyperstimulation. The other clinically available biomarkers are anti-Mullerian hormone (AMH) levels and antral follicle count (AFC) for tailoring gonadotropin dosage, and also the expression of 238 genes as the transcriptomic signature of endometrium entitled as endometrial receptivity array (ERA). It personalized embryo transfer via personalization of implantation window and determination of proper time for embryo transfer in patients with repeated implantation failures (3, 4). Finally, reproductive medicine requires identification and verification of ideal biomarkers that personalize the entire process to make possible convenient preventive and/or preferable targeted therapy including prevention, screening, diagnosis, prognosis and treatment such as prediction of ovarian reserve, stimulation outcome, gametes and embryos quality, endometrial receptivity, ectopic pregnancy, and probability of pre-eclampsia and preterm labor. Therefore, the answer to above question would not be very accurate in the present situation. It requires identification of new biomarkers from genomics, transcriptomics, proteomics, and metabolomics data in several available large databases and subsequently verification and validation of each biomarker through prospective large randomized clinical trials. 265 267 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 720.pdf Beim PY, Elashoff M, Hu-Seliger TT. Personalized reproductive medicine on the brink: progress, opportunities and challenges ahead. Reprod Biomed Online. 2013;27(6):611-23.##Simón C. Personalized assisted reproductive technology. Fertil Steril. 2013;100(4):922-3.##Simon C, Sakkas D, Gardner DK, Critchley HO. Biomarkers in reproductive medicine: the quest for new answers. Hum Reprod Update. 2015;21(6):695-7.##Collins SC. Precision reproductive medicine: multigene panel testing for infertility risk assessment. J Assist Reprod Genet. 2017 May 3. [Epub ahead of print].##

The Challenge of Human Spermatozoa Proteome: A Systematic Review 2 1 712 2 Currently, there are 20,197 human protein-coding genes in the most expertly curated database (UniProtKB/Swiss-Pro). Big efforts have been made by the international consortium, the Chromosome-Centric Human Proteome Project (C-HPP) and independent researchers, to map human proteome. In brief, anno 2017 the human proteome was outlined. The male factor contributes to 50% of infertility in couples. However, there are limited human spermatozoa proteomic studies. Firstly, the development of the mapping of the human spermatozoa was analyzed. The human spermatozoa have been used as a model for missing proteins. It has been shown that human spermatozoa are excellent sources for finding missing proteins. Y chromosome proteome mapping is led by Iran. However, it seems that it is extremely challenging to map the human spermatozoa Y chromosome proteins based on current mass spectrometry-based proteomics technology. Post-translation modifications (PTMs) of human spermatozoa proteome are the most unexplored area and currently the exact role of PTMs in male infertility is unknown. Additionally, the clinical human spermatozoa proteomic analysis, anno 2017 was done in this study. 267 280 Kambiz K Gilany کامبیز گیلانی Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran k.gilany@avicenna.ac.ir Arash A Minai-Tehrani Nanobiotechnology Research Center, Avicenna Research Institute, ACECR Nanobiotechnology Research Center, Avicenna Research Institute, ACECR Iran Mehdi M Amini Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Niloofar N Agharezaee Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Babak B Arjmand Metabolomics and Genomics Research Center, Endocrinology and Metabolism Molecular Cellular Sciences Institute, Tehran University of Medical Sciences Metabolomics and Genomics Research Center, Endocrinology and Metabolism Molecular Cellular Sciences Institute, Tehran University of Medical Sciences Iran HumanProteomeProteomicsSpermatozoaY Chromosome 712.pdf Pruitt KD, Tatusova T, Maglott DR. 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Elevated Levels of Serum Vascular Endothelial Growth Factor-A Are Not Related to NK Cell Parameters in Recurrent IVF Failure 2 1 706 2 Background: Vascular Endothelial Growth Factor and NK cells have an inter-related role in angiogenesis that is critical for placentation and success of in vitro fertilization. An attempt was made to assess a possible relationship between the two in this study. Methods: A case control study was performed comparing the serum levels of VEGF-A and its receptor VEGF-R1 with levels of NK cells, activated NK cells and NK cytotoxicity in 62 women with Repeated Implantation Failure (RIF). The healthy control group consisted of 72 women of similar age, without known issues in achieving pregnancy or evidence of autoimmunity. Levels of VEGF-A and VEGF-R1 were quantified by ELISA methods with standard curve interpolation. NK cell subsets were determined with flow cytometry using fluorescent-tagged anti-CD56, anti-CD16, anti-CD3 and anti-CD69. NK cytotoxicity was performed by incubating peripheral blood mononuclear cells and K562 cultured cells with propidium iodide, steroid, intralipid and intravenous immunoglobulin, using previously described methods. Statistical analysis involved Mann-Whitney-U and Spearman’s rank correlation testing with p-values defined as <0.05. Results: It was found that VEGF-A levels were significantly raised in women with RIF compared to healthy controls (362.9 vs. 171.6 pg/ml, p<0.0001), with no difference in VEGF-R1 levels between groups (1499 vs. 1202 pg/ml, p=0.4082). There was no correlation between VEGF-A or VEGF-R1 and the absolute levels of circulating NK cells, CD69 activated NK cells or NK cytotoxicity. Conclusion: The absence of correlation between VEGF-A or VEGF-R1 and NK cells suggests VEGF secretion and regulation is independent of NK cell activity in RIF. 280 288 Rhea R Bansal Department of Immunology and Allergy, St Helier Hospital Department of Immunology and Allergy, St Helier Hospital United Kingdom Brian B Ford Department of Immunology and Allergy, St Helier Hospital Department of Immunology and Allergy, St Helier Hospital United Kingdom Shree S Bhaskaran Department of Immunology and Allergy, St Helier Hospital Department of Immunology and Allergy, St Helier Hospital United Kingdom Meenyau M Thum Fertility Clinic, Lister Hospital Fertility Clinic, Lister Hospital United Kingdom Amolak A Bansal Department of Immunology and Allergy, St Helier Hospital Department of Immunology and Allergy, St Helier Hospital United Kingdom amolak.bansal@esth.nhs.uk NK cell cytotoxicityRecurrent failed IVFSoluble fms-like tyrosine kinase 1 (s-FLT-1)Vascular endothelial growth factor 706.pdf Tan BK, Vandekerckhove P, Kennedy R, Keay SD. 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Ultra-low Doses of Follicle Stimulating Hormone and Progesterone Attenuate the Severity of Polycystic Ovary Syndrome Features in a Hyperandrogenized Mouse Model 2 1 713 2 Background: Polycystic-ovary syndrome (PCOS) is a reproductive illness characterized by hyperandrogenism and anovulation. Using hyperandrogenized mice, it was demonstrated that the oral administration of incremental dose of follicle stimulating hormone (FSH) attenuated some of PCOS characteristics. This work aimed to study the effect of ultra-low doses of combined FSH and progesterone orally administered on PCOS murine model. Moreover, the effect of sequential kinetic activation of administered hormones was tested. Methods: Thirty-two female mice were used as animal model (four groups of eight animals each). Mice were hyperandrogenized by injection of dehyidroepiandro-sterone diluted in sesame oil. Control group received only oil. Simultaneously, each animal daily received per os an activated or a not-activated combination of FSH (0.44 pg) plus progesterone (0.44 pg) or saline solution as control. Serum testosterone, estradiol, progesterone and luteinizing hormone were analyzed as endocrine markers and a morphological study of antral follicle was conducted. Data were analyzed by one-way ANOVA, followed by multiple comparison test. The p<0.05 was considered significant. Results: Dehyidroepiandrosterone treatment increased both estradiol and progesterone serum levels, besides testosterone, while reduced luteinizing hormone (p<0.05); histological examination revealed an increase of cystic follicles (p<0.05). Irrespective of activation, the combined FSH and progesterone treatments restored estradiol level (p>0.05 vs. control group) and reduced cystic signs in the follicles (p<0.05 vs. dehyidroepiandrosterone treatment). Conclusion: This study indicate that ultra-low doses of FSH and progesterone orally administrated can reduce the sternness of PCOS in the mouse model and open a route for the study of innovative approaches for PCOS treatment. 288 298 Irene I Tessaro Reproductive and Developmental Biology Laboratory, Department of Health, Animal Science and Food Safety, University of Milan Reproductive and Developmental Biology Laboratory, Department of Health, Animal Science and Food Safety, University of Milan Italy Silvia S Modina Reproductive and Developmental Biology Laboratory, Department of Health, Animal Science and Food Safety, University of Milan Reproductive and Developmental Biology Laboratory, Department of Health, Animal Science and Food Safety, University of Milan Italy Valentina V Lodde Reproductive and Developmental Biology Laboratory, Department of Health, Animal Science and Food Safety, University of Milan Reproductive and Developmental Biology Laboratory, Department of Health, Animal Science and Food Safety, University of Milan Italy Giulia G Sivelli Reproductive and Developmental Biology Laboratory, Department of Health, Animal Science and Food Safety, University of Milan Reproductive and Developmental Biology Laboratory, Department of Health, Animal Science and Food Safety, University of Milan Italy Federica F Franciosi Reproductive and Developmental Biology Laboratory, Department of Health, Animal Science and Food Safety, University of Milan Reproductive and Developmental Biology Laboratory, Department of Health, Animal Science and Food Safety, University of Milan Italy Laura L Terzaghi Reproductive and Developmental Biology Laboratory, Department of Health, Animal Science and Food Safety, University of Milan Reproductive and Developmental Biology Laboratory, Department of Health, Animal Science and Food Safety, University of Milan Italy Patrizia P Luchini Department of Pharmacological and Biomolecular Sciences, University of Milan Department of Pharmacological and Biomolecular Sciences, University of Milan Italy Cristiano C Rumio Interdepartmental Centre for the Study of Biological Effects of Nano-Concentrations (CREBION), University of Milan Interdepartmental Centre for the Study of Biological Effects of Nano-Concentrations (CREBION), University of Milan Italy Alberto AM Luciano Reproductive and Developmental Biology Laboratory, Department of Health, Animal Science and Food Safety, University of Milan Reproductive and Developmental Biology Laboratory, Department of Health, Animal Science and Food Safety, University of Milan Italy alberto.luciano@unimi.it Follicle cystFSHMousePolycystic ovary syndromeProgesteroneSequential kinetic activationUltra-low dose 713.pdf Barthelmess EK, Naz RK. 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Computational Analysis of High Risk Missense Variant in Human UTY Gene: A Candidate Gene of AZFa Sub-region 2 1 715 2 Background: The human Ubiquitously transcribed tetratricopeptide repeat gene, Y-linked (UTY) gene encodes histone demethylase involved in protein-protein interactions. UTY protein evidence at protein level predicted intracellular and secreted protein. UTY is also involved in spermatogenesis process. Methods: The high-risk non-synonymous single nucleotide polymorphism in the coding region of the UTY gene was screened by SNP database and identified missense variants were subjected to computational analysis to understand the effect on protein function, stability and structure by SIFT, PolyPhen 2, PANTHER, PROVEAN, I-Mutant 2, iPTREE-STAB, ConSurf, ModPred, SPARKS-X, QMEAN, PROCHECK, project HOPE and STRING. Results: A total of 151 nsSNPs variants were retrieved in UTY gene out of which one missense variant (E18D) was predicted to be damaging or deleterious using SIFT, PolyPhen 2, PANTHER and PROVEAN. Additionally, E18D variant showed less stability, high conservation and having role in post translation modification using i-Mutant 2 and iPTREE-STAB, ConSurf and ModPred, respectively. The predicted 3D model of UTY using SPARKS-X with z-score of 15.16 was generated and validated via QMEAN (Z-score of 0.472) and PROCHECK which plots Ramachandran plot (85.3% residues in most favored regions, 12.3% in additionally allowed regions, 2.0% in generously allowed regions and 4.0% were in disallowed regions) and it indicates a good quality model. STRING showed that UTY interacts with ten different proteins. Conclusion: This study revealed that SNP data available on database was deduced to find out the most damaging nsSNPs i.e. rs3212293 (E18D). Therefore, it provides useful information about functional SNPs for future prospects concerning infertility in men. 298 307 Mili M Nailwal P.G. Department of Genetics, Ashok & Rita Patel Institute of Integrated Study & Research in Biotechnology and Allied Sciences (ARIBAS) P.G. Department of Genetics, Ashok & Rita Patel Institute of Integrated Study & Research in Biotechnology and Allied Sciences (ARIBAS) India Jenabhai JB Chauhan P.G. Department of Genetics, Ashok & Rita Patel Institute of Integrated Study & Research in Biotechnology and Allied Sciences (ARIBAS) P.G. Department of Genetics, Ashok & Rita Patel Institute of Integrated Study & Research in Biotechnology and Allied Sciences (ARIBAS) Iran jenabhaichauhan@aribas.edu.in, jbc109@gmail.com, chauhanjena@gmail.com AZFaComputational analysisMale infertilityMissensensSNPUTY gene 715.pdf Naasse Y, Charoute H, El Houate B, Elbekkay C, Razoki L, Malki A, et al. 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Y Chromosome Microdeletions in Infertile Men with Non-obstructive Azoospermia and Severe Oligozoospermia 2 1 714 2 Background: The purpose of the study was to investigate the frequencies and types of Y chromosome microdeletions in infertile men and to analyze the relationship between the levels of reproductive hormones and Y microdeletions. Methods: A total of 1,226 infertile men were screened for Y chromosome microdeletions using multiplex PCR assay. Karyotype analysis was performed on peripheral blood lymphocytes with standard G-banding. Serum reproductive hormone levels were measured. Results: Out of 1,226 infertile patients, 134 (10.93%) had Y microdeletions. One hundred seven of 765 (13.99%) non-obstructive azoospermic patients and 27 of 133 (20.30%) severe oligozoospermic patients had Y microdeletions. Among the 134 infertile men with Y microdeletions, the most frequent microdeletions were detected in the AZFc region, followed by AZFbc, AZFb, AZFa, AZFabc(Yq), Yp(SRY)+Yq, and partial AZFc regions. Karyotype analysis was available for 130 of the 134 patients with Y microdeletions. Of them, 36 (27.69%) patients had sex chromosomal abnormalities. Levels of FSH and LH in patients with AZFc microdeletion were significantly lower, while those in patients with Yp(SRY)+Yq were significantly higher than in patients without Y microdeletions. Level of testosterone in patients with AZFabc(Yq) or Yp(SRY)+Yq was significantly lower than that in patients without Y microdeletions. However, there was no significant difference in the levels of reproductive hormones between all patients with and without Y microdeletions. Conclusion: These results highlight the need for Y chromosome microdeletion screening for correct diagnosis of male infertility. Obtaining reliable genetic information for assisted reproductive techniques can prevent unnecessary treatment and vertical transmission of genetic defects to offspring. 307 316 Shin SY Kim Laboratory of Medical Genetics, Medical Research Institute, Cheil General Hospital and Women's Healthcare Center Laboratory of Medical Genetics, Medical Research Institute, Cheil General Hospital and Women's Healthcare Center Korea Hyun HJ Kim Laboratory of Medical Genetics, Medical Research Institute, Cheil General Hospital and Women's Healthcare Center Laboratory of Medical Genetics, Medical Research Institute, Cheil General Hospital and Women's Healthcare Center Korea Bom BY Lee Laboratory of Medical Genetics, Medical Research Institute, Cheil General Hospital and Women's Healthcare Center Laboratory of Medical Genetics, Medical Research Institute, Cheil General Hospital and Women's Healthcare Center Korea So SY Park Laboratory of Medical Genetics, Medical Research Institute, Cheil General Hospital and Women's Healthcare Center Laboratory of Medical Genetics, Medical Research Institute, Cheil General Hospital and Women's Healthcare Center Korea Hyo HS Lee Department of Urology, Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine Department of Urology, Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine Korea Ju JT Seo Department of Urology, Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine Department of Urology, Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine Korea jtandro@cgh.co.kr Male infertilityNon-obstructive azoospermiaReproductive hormoneSevere oligozoospermiaY chromosome microdeletion 714.pdf Hopps CV, Mielnik A, Goldstein M, Palermo GD, Rosenwaks Z, Schlegel PN. 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Controlled Ovarian Hyperstimulation with Intrauterine Insemination Is More Successful After r-hCG Administration Than Spontaneous LH Surge 2 1 716 2 Background: The purpose of this study was to evaluate whether clinical pregnancy rate is affected by timing intrauterine insemination (IUI) according to serum LH surge, r-hCG trigger, or a combination of LH surge and r-hCG trigger in controlled ovarian hyperstimulation (COH) cycles for patients with a variety of infertility etiologies. Methods: The last 365 consecutive COH-IUI cycles performed at ONE Fertility Burlington in 2014 were reviewed and categorized according to method of IUI timing. Associations between categorical variables were analyzed using a combination of Chi-square and Fisher’s Exact tests, and between continuous variables using independent sample t-tests and logistic regression to a level of significance of p<0.05. Results: The overall clinical pregnancy rate in this sample was 18.1% (66/365). Administration of r-hCG prior to IUI resulted in a higher clinical pregnancy rate compared with spontaneous serum LH surge: 18.2% vs. 5.8%, p=0.012. Patients in whom r-hCG was administered concomitantly with a serum LH surge had a higher clinical pregnancy than the r-hCG trigger group (30.8% vs. 18.2%, p=0.004) and LH surge group (30.8% vs. 5.8%, p<0.001). A sub-group analysis revealed that patients receiving r-FSH, rather than clomiphene or letrozole, had a significantly higher clinical pregnancy rate after r-hCG trigger as compared to the LH surge group (21.7% vs. 2.1%, p=0.01). Conclusion: In subfertile couples undergoing COH-IUI, r-hCG administration was associated with an increased clinical pregnancy rate compared with spontaneous serum LH surge. When r-hCG was administered concomitantly with a serum LH surge, this benefit was amplified. The effect appears to be of particular importance in r-FSH-medicated cycles. 316 323 Evan E Taerk Division of Gynecologic Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McMaster University, Hamilton Division of Gynecologic Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McMaster University, Hamilton Canada etaerk@onefertility.com Edward E Hughes Division of Gynecologic Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McMaster University, Hamilton Division of Gynecologic Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McMaster University, Hamilton Canada Cassandra C Greenberg Division of Gynecologic Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McMaster University, Hamilton Division of Gynecologic Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McMaster University, Hamilton Canada Michael M Neal Division of Gynecologic Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McMaster University, Hamilton Division of Gynecologic Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McMaster University, Hamilton Canada Shilpa S Amin Division of Gynecologic Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McMaster University, Hamilton Division of Gynecologic Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McMaster University, Hamilton Canada Mehrnoosh F Faghih Division of Gynecologic Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McMaster University, Hamilton Division of Gynecologic Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McMaster University, Hamilton Canada Megan M Karnis Division of Gynecologic Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McMaster University, Hamilton Division of Gynecologic Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McMaster University, Hamilton Canada Controlled ovarian hyperstimulationhCGInfertilityIntra uterine inseminationLH surgeSubfertility 716.pdf Hughes EG. The effectiveness of ovulation induction and intrauterine insemination in the treatment of persistent infertility: a meta-analysis. Hum Reprod. 1997;12(9):1865-72.##Federman CA, Dumesic DA, Boone WR, Shapiro SS. Relative efficiency of therapeutic donor insemination using a luteinizing hormone monitor. Fertil Steril. 1990;54(3):489-92.##Curie-Cohen M, Luttrell L, Shapiro S. Current practice of artificial insemination by donor in the United States. N Engl J Med. 1979;300(11):585-90.##Martinez AR, Bernadus RE, Voorhorst FJ, Vermeiden JP, Schoemaker J. A controlled study of human chorionic gonadotrophin induced ovulation versus urinary luteinizing hormone surge for timing of intrauterine insemination. Hum Reprod. 1991;6(9):1247-51.##Deaton JL, Clark RR, Pittaway DE, Herbst P, Bauguess P. Clomiphene citrate ovulation induction in combination with a timed intrauterine insemination: the value of urinary luteinizing hormone versus human chorionic gonadotropin timing. Fertil Steril. 1997;68(1):43-7.##Fuh KW, Wang X, Tai A, Wong I, Norman RJ. Intrauterine insemination: effect of the temporal relationship between the luteinizing hormone surge, human chorionic gonadotrophin administration and insemination on pregnancy rates. Hum Reprod. 1997;12(10):2162-6.##Garcia-Velasco JA, Arici A, Zreik TG. Endogenous LH surge detection versus administration of HCG to correctly time intrauterine insemination: which provides a better pregnancy rate? Hum Reprod. 2000;15(4):975-6.##Zreik TG, García-Velasco JA, Habboosh MS, Olive DL, Arici A. Prospective, randomized, crossover study to evaluate the benefit of human chorionic gonadotropin-timed versus urinary luteinizing hormone-timed intrauterine inseminations in clomiphene citrate-stimulated treatment cycles. Fertil Steril. 1999;71(6):1070-4.##Mitwally MF, Abdel-Razeq S, Casper RF. Human chorionic gonadotropin administration is associated with high pregnancy rates during ovarian stimulation and timed intercourse or intrauterine insemination. Reprod Biol Endocrinol. 2004;2:55.##Kyrou D, Kolibianakis EM, Fatemi HM, Grimbizis GF, Theodoridis TD, Camus M, et al. Spontaneous triggering of ovulation versus HCG administration in patients undergoing IUI: a prospective randomized study. Reprod Biomed Online. 2012;25(3):278-83.##Allen NC, Herbert CM 3rd, Maxson WS, Rogers BJ, Diamond MP, Wentz AC. Intrauterine insemination: a critical review. Fertil Steril. 1985;44(5):569-80.##Temporal relationships between ovulation and defined changes in the concentration of plasma estradiol-17 beta, luteinizing hormone, follicle-stimulating hormone, and progesterone. I. Probit analysis. World Health Organization, Task Force on Methods for the Determination of the Fertile Period, Special Programme of Research, Development and Research Training in Human Reproduction. Am J Obstet Gynecol. 1980;138(4):383-90.##Testart J, Frydman R. Minimum time lapse between luteinizing hormone surge or human chorionic gonadotropin administration and follicular rupture. Fertil Steril. 1982;37(1):50-3.##Cantineau AE, Janssen MJ, Cohlen BJ. Synchronised approach for intrauterine insemination in subfertile couples. Cochrane Database Syst Rev. 2010;(4):CD006942.##Fluhr H, Carli S, Deperschmidt M, Wallwiener D, Zygmunt M, Licht P. Differential effects of human chorionic gonadotropin and decidualization on insulin-like growth factors-I and -II in human endometrial stromal cells. Fertil Steril. 2008;90(4 Suppl):1384-9.##Farhi J, Orvieto R, Gavish O, Homburg R. The association between follicular size on human chorionic gonadotropin day and pregnancy rate in clomiphene citrate treated polycystic ovary syndrome patients. Gynecol Endocrinol. 2010;26(7):546-8.##Shalom-Paz E, Marzal A, Wiser A, Hyman J, Tulandi T. Does optimal follicular size in IUI cycles vary between clomiphene citrate and gonadotrophins treatments? Gynecol Endocrinol. 2014;30(2):107-10.##Arici A, Carr BR, Byrd W. Comparison of two LH monitoring methods in women undergoing intrauterine insemination. In: Proceedings of the 48th Annual Meeting of The American Fertility Society. San Antonio, TX. November 2-5, 1992:S70.##Irons DW, Singh M. Evaluation of transvaginal sonography combined with a urinary luteinizing hormone monitor in timing donor insemination. Hum Reprod. 1994;9(10):1859-62.##Cohlen BJ, te Velde ER, Scheffer G, van Kooij RJ, Maria de Brouwer CP, van Zonneveld P. The pattern of the luteinizing hormone surge in spontaneous cycles is related to the probability of conception. Fertil Steril. 1993;60(3):413-7.##Macklon NS, Fauser BC. Impact of ovarian hyperstimulation on the luteal phase. J Reprod Fertil Suppl. 2000;55:101-8.##

Value of "Three Dimensional Multidetector CT Hysterosalpingography" in Infertile Patients with Non-Contributory Hysterosalpingography: A Prospective Study 2 1 707 2 Background: Infertility is a common health problem requiring imaging to delineate the anatomical causes in women. Three dimensional multi-detector computed tomography hysterosalpingography (3D-MDCT-HSG) offers an easy workup for uterine, tubal and peritoneal factors. Methods: To present the spectrum of uterine, tubal and peritoneal factors on 3D- MDCT-HSG and determine its diagnostic accuracy for female factor infertility, a prospective study was conducted on 25 infertile women with non-diagnostic HSG from November 2012 to March 2014. Sixty four slice MDCT acquired the scan during pre-ovulatory phase by contrast instillation into uterine cavity. A blinded reviewer interpreted the 3D-MDCT-HSG and results were compared with final diagnosis made on hystero-laproscopy in 22 patients. Diagnostic accuracy of 3D-MDCT-HSG for various factors was expressed as sensitivity, specificity, positive and negative predictive value. Results: MDCT-HSG demonstrated definite findings in 96% of patients having non-diagnostic HSG. In this study, tubal, uterine and peritoneal abnormalities were present in 68.75%, 56% and 32% of cases, respectively. 48 tubes in 25 patients were evaluated of which 22 tubes were blocked constituting the commonest finding present in 15 (60%) patients. The sensitivity, specificity, positive predictive value and negative predictive value for uterine factors was 83.33% ,100%, 100% and 96.84%, respectively, for tubal factors 93.55%, 94.68%, 85.29% and 96.83%, respectively and for peritoneal factors 62.5%, 92%, 71.43% and 88.46%, respectively. Mean effective radiation dose was 1.76±0.18 mSv in MDCT-HSG. Conclusion: 3D-MDCT-HSG can detect various factors responsible for female infertility especially tubal and uterine; in cases where HSG fails to clearly delineate the pathology. 323 333 Shuchi S Bhatt Department of Radio-Diagnosis, University College of Medical Sciences, Delhi University Department of Radio-Diagnosis, University College of Medical Sciences, Delhi University India drshuchi@hotmail.com Murtaza M Sumbul Department of Radio-Diagnosis, University College of Medical Sciences, Delhi University Department of Radio-Diagnosis, University College of Medical Sciences, Delhi University India Rajpal R Rajpal Department of Radio-Diagnosis, University College of Medical Sciences, Delhi University Department of Radio-Diagnosis, University College of Medical Sciences, Delhi University India Gita G Radhakrishnan Guru Teg Bahadur Hospital Guru Teg Bahadur Hospital India Female factorHystero-laparoscopyHysterosalpangiographyInfertilityMultidetector CT 707.pdf Rutstein SO, Shah IH. Infecundity, infertility, and childlessness in developing countries. Calverton, Maryland, USA: ORC Macro and the World Health Organization; 2004 Sept. 74 p. Report No.: DHS Comparative Reports No 9.##Irvine DS. Epidemiology and aetiology of male infertility. Hum Reprod. 1998;13 Suppl 1:33-44.##Steinkeler JA, Woodfield CA, Lazarus E, Hillstrom MM. Female infertility: a systematic approach to radiologic imaging and diagnosis. Radiographics. 2009;29(5):1353-70.##Shalev J, Meizner I, Bar-Hava I, Dicker D, Mashiach R, Ben-Rafael Z. Predictive value of transvaginal sonography performed before routine diagnostic hysteroscopy for evaluation of infertility. Fertil Steril. 2000;73(2):412-7.##Ragni G, Diaferia D, Vegetti W, Colombo M, Arnoldi M, Crosignani PG. Effectiveness of sonohysterography in infertile patient work-up: a comparison with transvaginal ultrasonography and hysteroscopy. Gynecol Obstet Invest. 2005;59(4):184-8.##Alborzi S, Dehbashi S, Khodaee R. Sonohysterosalpingographic screening for infertile patients. Int J Gynaecol Obstet. 2003;82(1):57-62.##Imaoka I, Wada A, Matsuo M, Yoshida M, Kitagaki H, Sugimura K. MR imaging of disorders associated with female infertility: use in diagnosis, treatment, and management. Radiographics. 2003;23(6):1401-21.##Saunders RD, Shwayder JM, Nakajima ST. Current methods of tubal patency assessment. Fertil Steril. 2011;95(7):2171-9.##Rastogi R. Role of imaging in female infertility [Dr. K.M. Rai Memorial Oration Award]. Indian J Radiol Imaging. 2010;20(3):168-73.##Swart P, Mol BW, van der Veen F, van Beurden M, Redekop WK, Bossuyt PM. The accuracy of hysterosalpingography in the diagnosis of tubal pathology: a meta-analysis. Fertil Steril. 1995;64(3):486-91.##Sulak PJ, Letterie GS, Coddington CC, Woodward JE, Klein TA. Histology of proximal tubal occlusion. Fertil Steril. 1987;48(3):437-40.##Carrascosa P, Capuñay C, Baronio M, Martín López E, Vallejos J, Borghi M, et al. 64-Row multidetector CT virtual hysterosalpingography. Abdom Imaging. 2009;34(1):121-33.##Carrascosa PM, Capuñay C, Vallejos J, Martín López EB, Baronio M, Carrascosa JM. Virtual hysterosalpingography: a new multidetector CT technique for evaluating the female reproductive system. Radiographics. 2010;30(3):643-61.##Brown SE, Coddington CC, Schnorr J, Toner JP, Gibbons W, Oehninger S. Evaluation of outpatient hysteroscopy, saline infusion hysterosonography, and hysterosalpingography in infertile women: a prospective, randomized study. Fertil Steril. 2000;74(5):1029-34.##Afzali N, Ahmadi F, Akhbari F. Various hysterosalpingography findings of female genital tuberculosis: A case series. Iran J Reprod Med. 2013;11(6):519-24.##Valentini AL, Muzii L, Marana R, Catalano GF, Summaria V, Felici F, et al. Improvement of hysterosalpingographic accuracy in the diagnosis of peritubal adhesions. AJR Am J Roentgenol. 2000;175(4):1173-6.##Patil M. Assessing tubal damage. J Hum Reprod Sci. 2009;2(1):2-11.##Carrascosa P, Baronio M, Capuñay C, López EM, Sueldo C, Papier S. Clinical use of 64-row multislice computed tomography hysterosalpingography in the evaluation of female factor infertility. Fertil Steril. 2008;90(5):1953-8.##Zanetti E, Ferrari LR, Rossi G. Classification and radiographic features of uterine malformations: hysterosalpingographic study. Br J Radiol. 1978;51(603):161-70.##Salim R, Regan L, Woelfer B, Backos M, Jurkovic D. A comparative study of the morphology of congenital uterine anomalies in women with and without a history of recurrent first trimester miscarriage. Hum Reprod. 2003;18(1):162-6.##Shaaban MM, Awwad IM, Al Beblawy MM, Khalil TH. Comparison between multidetector computed tomography and hysterosalpingography in assessment of infertile couples. Middle East Fertil Soc J. 2013;18(3):191-5.##Karasick S, Goldfarb AF. Peritubal adhesions in infertile women: diagnosis with hysterosalpingography. AJR Am J Roentgenol. 1989;152(4):777-9.##Perisinakis K, Damilakis J, Grammatikakis J, Theocharopoulos N, Gourtsoyiannis N. Radiogenic risks from hysterosalpingography. Eur Radiol. 2003;13(7):1522-8.##

Pregnancy Luteoma in Ectopic Pregnancy: A Case Report 2 1 719 2 Background: Pregnancy luteoma is a rare non neoplastic condition of the ovary. It is usually asymptomatic and found incidentally during imaging in pregnancy or during cesarean section. Pregnancy luteoma can also occur after ectopic pregnancy. Case Presentation: A 30 year old female presented to G.B. Pant Hospital, Andaman and Nicobar Islands institute of Medical Sciences, Port Blair in October 2015 with abdominal pain. After initial investigations, exploratory laporotomy was done for ruptured ectopic pregnancy. Enlarged ovary was removed along with the ruptured portion of fallopian tube. Histopathological examination revealed solid aggregates of large cells with abundant eosinophilic cytoplasm; diagnosis of pregnancy luteoma was given. Conclusion: It must be considered in the differential diagnosis of ovarian masses in pregnant females that early diagnosis of this entity may avoid unnecessary radical surgery. 333 336 Rupinder RK Brar Andaman and Nicobar Islands Institute of Medical Sciences Andaman and Nicobar Islands Institute of Medical Sciences India drrupinderbrar@gmail. com Jyotsna JN Bharti Andaman and Nicobar Islands Institute of Medical Sciences Andaman and Nicobar Islands Institute of Medical Sciences India Jitendra JS Nigam Andaman and Nicobar Islands Institute of Medical Sciences Andaman and Nicobar Islands Institute of Medical Sciences India Sahil S Sehgal Andaman and Nicobar Islands Institute of Medical Sciences Andaman and Nicobar Islands Institute of Medical Sciences India Hena HS Singh Dayanand Medical College and Hospital Dayanand Medical College and Hospital India Pushpanjali P Ojha Andaman and Nicobar Islands Institute of Medical Sciences Andaman and Nicobar Islands Institute of Medical Sciences India Ectopic pregnancyOvarian massesPregnancy luteoma 719.pdf Irving JA, Clement PB, editors. Nonneoplastic lesions of the ovary. USA: Springer US; 2010. 1203 p. (Kurman RJ, Hedrick Ellenson L, Ronnett BM, editors. Blaustein’s Pathology of the Female Genital tract; vol 1).##Rosai J. Rosai and Akerman’s surgical pathology. 10th ed. New York: Elsevier; 2011. p. 1555-60.##Lalwani N, Patel S, Ha KY, Shanbhogue AK, Nagar AM, Chintapalli KN, et al. Miscellaneous tumour-like lesions of the ovary: cross-sectional imaging review. Br J Radiol. 2012;85(1013):477-86.##Young RH, Dudley AG, Scully RE. Granulosa cell, Sertoli-Leydig cell, and unclassified sex cord-stromal tumors associated with pregnancy: a clinicopathological analysis of thirty-six cases. Gynecol Oncol. 1984;18(2):181-205.##Honoré LH, O'Hara KE. Incidental pregnancy luteoma associated with ectopic tubo-ovarian pregnancy: evidence in favor of origin from theca interna of an atretic follicle. Eur J Obstet Gynecol Reprod Biol. 1978;8(1):15-9.##Spitzer RF, Wherrett D, Chitayat D, Colgan T, Dodge JE, Salle JL, et al. Maternal luteoma of pregnancy presenting with virilization of the female infant. J Obstet Gynaecol Can. 2007;29(10):835-40.##Mazza V, Di Monte I, Ceccarelli PL, Rivasi F, Falcinelli C, Forabosco A, et al. Prenatal diagnosis of female pseudohermaphroditism associated with bilateral luteoma of pregnancy: case report. Hum Reprod. 2002;17(3):821-4.##Kumar RV, Ranjan DS, Rao BR, Rao ES. Maternal luteoma of pregnancy: a rare case report. J Dr NTR Univ Health Sci. 2014;3(4):267-9.##Nanda A, Gokhale UA, Pillai GR. Bilateral pregnancy luteoma: a case report. Oman Med J. 2014;29(5):371-2.##Masarie K, Katz V, Balderston K. Pregnancy luteomas: clinical presentations and management strategies. Obstet Gynecol Surv. 2010;65(9):575-82.##

Environmental Impact on Reproductive Health: Can Biomarkers Offer Any Help? 2 1 709 2 Environmental health is broadly defined as the aspects of human health determined by physical, chemical, biological and social factors in the environment and encompasses the assessment and control of those factors. The exogenous and endogenous environmental health determinants include all that surround us, and environmental impact includes not only physical, chemical and biological factors, but also hormones, diet and lifestyle. As most humans develop in a predictable fashion, growing from a fertilized egg to fetus, newborn, toddler, child, adolescent, and adult, there is little doubt that environment is a powerful modifier of the human reproduction and development (1). Starting 20 years ago, there has been a steady growth in the number of laboratories involved in the investigation on environmental impact on molecular reprogramming during the most critical windows of development, such as pre-conception, pre-implantation, the fetal period, and early childhood. And considerable evidence demonstrates that the gene-environmental regulation of gene expression is crucial, besides change in the DNA sequence (1, 2). The epigenetic information is often stored as chemical modifications falling into two main categories: 1- DNA methylation and 2- changes to the histone proteins that package the genome. By regulating DNA accessibility and chromatin structure, these chemical alterations influence how the genome is translated across diverse developmental stages (3). Untangling all the components of gene-environmental regulation might be problematic in conventional human setting. In this broadest sense, if contributions of multiple factors are substantial and likely to increase susceptibility to reproductive ailments, the effects of these should be apparent in the "normal" tissue prior to the development of disease. As the examination of the role of gene-environmental regulation in the developmental re-programming in humans’ remains relatively new, it is unlikely that a single approach will stand out as being more valuable or appropriate to address a potential mechanistic link (2, 3). Therefore, to yield provocative insights, cutting-edge platform technologies must be employed for studying the gene-environmental interactions in complex reproductive tract ailments that include early or delayed puberty, menstrual irregularities, infertility, sub-fertility, early pregnancy loss, fetal death, impaired fetal growth, low birth weight, premature birth, structural or functional birth defects, polycystic ovarian syndrome, endometriosis, uterine fibroids, reproductive tract infections, sexually transmitted diseases, and reproductive tract cancers. Given that developmental basis is apparently linked to adult disease outcome, there is a greater need to change our focus from treating diseases after they are detected to prevention and from risk assessment to early disease diagnosis. Environmental stress-induced deformities-evidence from human studies: A differentiating tissue that is actively proliferating to generate additional cells will respond differently to an insult as compared to a tissue than a fully differentiated tissue that has already generated many of the required cells after molecular reprogramming. Evidence from both epidemiological and mechanistic studies has not only established a potential link of environmental pollutants with impaired human fertility, but also shown that they possess the ability to alter placental function and hamper fetal development. While some of these pollutants act as an endocrine disruptor, others activate a cascade of events which significantly disturbs the intact reproductive system (4). A wide range of female reproductive tract disorders like polycystic ovarian syndrome (5), placental abnormalities and aneuploidy (6) are reported to be closely associated with the environmental chemicals results. Available reports also indicate that exposure of pregnant women to air pollutants results in increased risk of different abnormalities specifically related to heart, brain and lungs. Air pollution affects the normal developmental mechanisms of fetal brain and is related to the different diseases of the central nervous system (7). The expression of two vital genes, brain-derived neurotropic factor (BDNF) and syndecan-1 (SYN1), required for normal fetal brain development decreases significantly with the increasing particulate matter 2.5 (PM2.5) exposure in utero (8). In addition, pre-natal toxic exposure interferes with fetal lung development and is associated with the higher risk of developing pulmonary disorders including asthma (9). Breton et al. demonstrated that prenatal exposure to PM10 and PM2.5 is associated with the increased carotid arterial stiffness (10). Interestingly, exposed mothers are at higher risk of giving birth to low weight babies (11). In addition to the developmental artefacts, environmental stress signals can insinuate activation of ion channels, trigger pro-inflammatory cytokine response, induce oxidative stress, and affect cellular proliferation and differentiation orchestrating myriad abnormal changes which are transferred to the daughter progenitor cells. Links between pre-conceptual, peri-conceptual, and prenatal toxic exposure with adult onset of non-communicable diseases such as obesity, auto-immunity, type 2 diabetes, cardiovascular disorders, cancers, neuro-degenerative and mental sickness suggests that epigenetic mechanisms such as DNA methylation, histone modifications, and micro-RNA expression might be intricately involved, however, a thorough validation in human tissue samples remains sparse. Biomarkers: ray of hope?: Much of the excitement surrounding biomarkers today relates to identification of an ongoing change (genetic/epigenetic) and early disease diagnosis. For example, measuring appropriate biomarker in paternal blood and semen samples may provide early clues for well-timed and proper intervention. As significant amount of maternal chemical burden is shared with the developing fetus and infants, sampling of maternal blood or urine samples at different times of pregnancy allows an evaluation of the exposure of the fetus at different times of development, elucidating the chemicals that cross the placenta. A biomarker in clinical reproductive medicine may be useful to better understand and predict ovarian reserve, gamete quality, embryo viability and euploidy, as well as endometrial receptivity and pregnancy outcome, including miscarriage, ectopic pregnancy and obstetric complications, e.g. pre-eclampsia or preterm labor. Also, for effective management of in vitro fertilization (IVF) protocols, specific biomarkers could be used to discriminate between suitable and unsuitable embryos to be transferred. Some of the widely assessed biomarkers like serum progesterone, hCG and estrogen not only help to identify viable pregnancies but also provide crucial functional information about the disorders that affect testes, ovaries or adrenal glands. Similarly inhibin A is suggested to be beneficial in identification of ectopic pregnancies (12). Other proteins like CRP, placenta growth factor, fms-like tyrosine kinase-1(s-1FLT), leptin, transforming growth factor-a1 and plasminogen activator inhibitor may act as predictive biomarkers for different disorders including pre-eclampsia (13). Yet, these biomarkers have limited clinical exploitation due to poor sensitivity and specificity of the available methods for their detection. Innovative strategies: Several thousands of environmental contaminants penetrate daily into our environment and exert various kinds of stress response on reproductive health (2). Included in the mixture of exposures are the billions of naturally occurring and man-made chemicals (e.g., heavy metals, persistent organic pollutants, etc.); physical agents such as noise, vibration, temperature, etc.; macro level factors like population density, sanitation, etc.; and a spectrum of lifestyle factors that includes diet, physical activity and sleep. Assessment of cumulative risks for any given biological end-point will involve analysis, characterization, and possible quantification of the combined risks from multiple environmental stressors. When a pollutant enters our body, it either accumulates, or is processed metabolically and excreted. For real-time monitoring, it could be the concentration of the parental compound, its metabolite or conjugated derivative with endogenous molecules via enzymatically catalyzed transformations which can be studied using mass spectroscopy techniques. On the other hand, for understanding the molecular repercussion of the exposure the mainstay of research will have to be on a combined "omics-based approach" involving bio-molecules such as DNA, RNA, proteins, and metabolites. Large scale quantification of genes coding for proteins, regulatory elements and non-coding sequences (genomics), RNA and gene expression (transcriptomics), protein expression (proteomics), metabolites and metabolic pathways (metabolomics) will enable the identification of important genes, pathways, and protein expression signatures in suitable biological matrix of sizeable cohorts of men and women (2). Previous in vitro and in vivo studies have shown that environmental exposure results in the altered metabolic profile, is vital for xenobiotic clearance thereby exposing individuals and upcoming offspring to an increased risk of different disorders including type 1 and type 2 diabetes (14). Significant changes in the chromosomal region 11p15 are reported to be associated with Beckwith Wiedemann syndrome, fetal over growth, or Silver-Russell syndrome (SRS) under growth (15). It also disturbs epigenetic mechanism which includes DNA methylation, histone modifications, and mirco RNAs (miRNAs). Earlier studies have also reported that the altered methylation of guanine nucleotide-binding protein G(s) subunit alpha isoforms short (GNASAS) and insulin (INS) is associated with the increased risk of developing coronary heart disease (16). Exposure to tobacco smoke was reported to be significantly associated with the increasing miR-223 levels in both maternal and cord blood which further co-related with the rising cotinine concentrations in maternal urine (17). Similarly, a significant down-regulation of miR-146a was observed after nicotine and benzopyrene exposure further signifying the utility of epigenetic profile in assessing exposure associated dysregulations (18). Converging lines of evidence support the possibility that epigenetics may be a causal link between the genotype and environment, and hence, between the phenotype and disease which further substantiates that the changes incurred during in utero development can be transmitted trans-generationally. Recent advances in high-throughput methylated DNA analysis through whole-genome bisulfite sequencing and RNA-Seq, epigenome-wide association studies, epigenome editing approaches are more likely to provide novel insights to developmental origins of adult diseases (2). Although the cost of these technologies might be substantially high for large-scale application at the moment, these techniques can be used for more niche questions on limited samples to gain biological insight for further exploration. Risk prediction, early detection and prevention: Because of diversities in chemical nature, dose- response relationship and factors associated with susceptibility and vulnerability, design of risk assessment strategy is challenging (19). It is very likely that low and relatively innocuous concentration of contaminants often produce deleterious and reproductive health effect, which are hard to be predicted, because measurable effects are expressed only after prolonged exposure. When these incipient effects are expressed, it might be too late to take corrective actions or steps to reduce risk. Therefore, it is essential to develop biomarkers that convincingly reflect adverse exposure-response relationship. Novel biomarkers might offer vital clues for environmental-associated reproductive system diseases and thus facilitate (i) early diagnosis of a disease; (ii) recurrence or progression of a disease; (iii) identification of individuals for disease prevention; (iv) as a potential target for drugs; (v) as a marker for a drug response. Delineating the molecular signatures of environmental-associated reproductive illness requires comprehensive knowledge of the entire cascade of events from the release of an environmental contaminant through absorption, actions and damage within the body and the development of disease (20). Defining the extent and impact of exposure is a central element for understanding a complex disease form. While ascertaining the possible implication of any exogenous moiety, the precise amount that is available (internal dose) after it is absorbed via ingestion, inhalation, in utero, and dermal routes is only physiologically relevant. Once inside the body, the entity is transformed and either stored or eliminated, traversing through various metabolic pathways (2). Therefore, before validating a biomarker associated with any kind of environmental exposure (acute/chronic/occupational), it is necessary to discern where in this chemico-biological process the measured index comes from - that is whether it is a biomarker of exposure, susceptibility or effect? A potential biomarker can facilitate better identification of exposure, measure both susceptibility and vulnerability, and increase prediction of outcome. The scientific impact of development and validation of biomarkers in environmental-associated reproductive system diseases is highly significant as it opens the road to the exploitation, using modern-omics technologies, of thousands of biological matrices currently housed in existing bio-banks of several medical institutes. Bodily fluids have emerged as an important source of information in several acute and chronic environmentally associated pathologies (20). A number of investigators have attempted to use circulating bio-entities found in plasma, saliva, urine, milk, seminal plasma, tears, and amniotic fluid as disease biomarkers for reproductive tract ailments. These circulating entities capable of predicting the disease course include high molecular weight complexes, membrane fragments, extracellular vesicles, lipid rafts, exosomes, microvesicles, DNA, non-coding RNA and proteins. Detection of these novel entities in plasma or serum can act as a "liquid biopsy", which can be useful for a number of biomarker applications. Clinical translation: While identifying and characterizing the significant consequences of these associated factors on human reproduction and development, two defined clusters of population might be the most affected: (i) susceptible and; (2) vulnerable populations. Whereas, "susceptibility" refers to inherent biological factors, "vulnerability" indicates population at higher risk due to personal factors. Population with both susceptibility and vulnerability may together be referred as "sensitive" population. How environmental exposures affect reproductive function and development, and how this knowledge can be translated to reduce associated morbidities and enhance quality of life is precisely warranted. Recently, a large number of environmental and host risk factors have been identified that are associated with reproductive health risk resulting in dramatic fold increase in number of biomarkers reaching for clinical validation. However, the translation of these for use in the population-level screening in such a way as to have a significant impact on clinical practice poses a major challenge. Often the use of a predictive biomarker has poorer test characteristics when it is validated in two separate populations. If validated in a low disease prevalence setting, the predictive value may be low; on the other hand, in high disease prevalence setting, the same biomarker could have enough potential clinical utility. Therefore, the process of identification and validation for clinical application among the large number of purported biomarkers associated with environmental illness is a critical step in the translation process. Key to this process is to understand the differences between evaluating biomarkers and risk factors for prevention versus disease risk prediction and early detection. A robust indulgence in analysing these differences will be necessary to facilitate the translational process. The challenges are enormous but a cutting-edge tailored approach may help to set priorities for future reproductive health research, monitoring, and surveillance activities and for potential risk assessment or risk management follow-up efforts. Such strategies might pave the way to further understand the etiologic processes underlying the exposure-outcome relationship and offer possibilities for risk prediction, early detection and prevention. Acknowledgement The authors are thankful to the Department of Science & Technology, Department of Biotechnology, Council of Scientiﬁc and Industrial Research, and the University Grants Commission, Government of India, New Delhi for providing necessary funding assistance to the laboratory of Prof. Pradyumna Kumar Mishra. Conflict of Interest The authors report no conflicts of interest. 336 341 Arpit A Bhargava School of Biological Sciences, Dr. Harisingh Gour Central University School of Biological Sciences, Dr. Harisingh Gour Central University India Neelam N Pathak School of Biological Sciences, Dr. Harisingh Gour Central University School of Biological Sciences, Dr. Harisingh Gour Central University India Radhey RS Sharma Division of Reproductive Biology, Maternal and Child Health, Indian Council of Medical Research Division of Reproductive Biology, Maternal and Child Health, Indian Council of Medical Research India Nirmal NK Lohiya Centre for Advanced Studies in Zoology, University of Rajasthan Centre for Advanced Studies in Zoology, University of Rajasthan India Pradyumna PK Mishra School of Biological Sciences, Dr. Harisingh Gour Central University School of Biological Sciences, Dr. Harisingh Gour Central University India pkm_8bh@yahoo.co.uk No Keyword 709.pdf Mishra PK, Dabadghao S, Modi GK, Desikan P, Jain A, Mittra I, et al. 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