Oocytes/Embryos Banking: A Vague Hope for Poor Responder Women 2 1 2 One of the main challenges in management of female factor infertility is poor responders and low response to stimulation in aged and even younger women. Usually, it is not infrequent and varies between 9 to 24% in different reports (1). This wide range of incidence is due to the absence of a obvious report in literature. But in most articles, it is defined as suboptimal response of stimulation protocols for recruitment of sufficient numbers of follicles which are associated with diminution of retrieved oocytes, cycle cancellation and significantly lower pregnancy rate. In spite of difficulty in prediction, awareness of its occurrence is extremely important for individualization of treatment protocol according to each patient’s condition (2). There are different sterategies in the managment of poor responder patients to obtain a maximum number of oocyte with best quality. Different stimulation protocols for poor responder women using wide doses and types of gonadotropins have been recommended over the past three decads; in fact, none of them have been successful and hence, the old question still remains which investigates the best strategy for management of poor responders. These protocoles include high doses of gonadotropins against the standard dose for normal responders, short and ultrashort, mini- and microdose flareup regimen of GnRH agonists, and GnRH anntagonists. In addition, further approches have been applied to potentiate the effect of the above mentioned protcoles like administration of estradiol in luteal phase of cycle, administration of recombinant LH during gonadotropin stimulation, administration of growth hormone (GH), oral administration of dehydroepiandrosterone (DHEA) as an androgen, improvement of ovarian blood flow and vascularity through administration of asprin, natural IVF cycle as a simple and inexpensive protocol, and also oocyte and embryo banking (1). There are many contradictory results on advantages or rejection/acceptance and even the null effect of these protocols; some of which are overruled and some others are still commonly used to manage these patients. Introduction of vitrification technique to IVF clinics during the past decade revolutionizes all aspects of reproductive sciences especially fertility preservation for women at risk of diminishing their ovarian reserve over the time. Accumulation of oocytes or embryos from consecutive stimulation cycles is currently applied to increase the success rate of poor responders. Theoretically, accumulation of oocytes/embryos improves the chances of pregnancy by simulation of poor responders with normoresponder women status (3). However, this hypothesis may increase the rate of patients drop-out for continuing successive cycles and also deleterious effects of vitrification–warming on supernumerary oocytes/embryos. The vitrification-thawing procedure for oocyte/embryo is highly effective, safe and easy to apply. The results are highly related to expertise of embryologist so that in well designed laboratory with expert embryologist, survival rate is near to 100% and fertilization, cleavage and blastocyst rates of the thawed oocytes are similar to fresh ones. Therefore, the effect of freezing-thawing on oocytes and especially embryos is not significant and negligible. Other reasons to use this procdure for poor responders is increasing the chances of pregnancy, reducing the costs and also reducing dropout of patients for continuing treatment (4). Since the chance of fertilization and development of each oocyte is independent of other, when the oocytes do not have the necessary potential to develop to blastocyst stage, increasing their number during successive cycles would not affect the success rate, especially regarding the fact that most IVF clinics perform elective single embryo transfer. Perhaps the only oocyte banking advantage is reduction in the cost of fertilization and embryo transfer for multiple cycles, although the cost of oocyte freezing in successive cycles and ultimately, their thawing compensate this cost reduction. The other advantage of oocytes/embryos banking in poor responders is for preimplantation genetics screening (PGS) cycles. It is confirmed that the increase of aneuploidy rate in oocytes and resulting embryos is correlated with aging in women (5). However, the application of PGS to improve pregnancy rate in late reproduction age and also youger couples is uncertain and questionable. The focus of IVF clinics on PGS has waxed and waned during the last dacade due to its technical insufficiency, but it has risen again following introduction of next generation sequencing (NGS) technology and trophectoderm biopsy of blastocyst at the begining of current decade. However, increasing the number of embryos in techniques such as FISH and CGH array will reduce the cost of screening and increase the chance to find an euploid embryo, but at recent, the cost of NGS of each embryo is independent and finding euploid embryo among low number of embryos at one cycle will reduce the cost of further embryo screening and further IVF cycles. Regarding oocytes/embryos banking to avoid poor responders dropout, it should be noted that the practice seems to be so selfish and a type of distraint in IVF clinics for future referral of patients. Whenever a physician explains clearly the treatment process and chance of success at any stage, the patient will surely trust his physician and will accompany as long as the doctor advises them to continue further cycles. Overall, the hopeful result of an IVF cycle is at least two embryos with at least 8 cells at cleavage stage or one top quality blastocyst, so we must understand this concept of success at each cycle before starting another cycle. Currently, oocytes/embryos banking is advised and used in poor responder cycles as an effective procedure to increase pregnancy rate, but there is limited evidence of the triumph of this method in poor responders, and even in some cases, its effectiveness has been questioned. Therefore, prescribing oocytes/embryos banking to couples requires further studies and providing strong evidence for increasing pregnancy rate following consecutive cycles and oocytes/embryos storage. 123 125 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 30030.pdf Ubaldi F, Vaiarelli A, D'Anna R, Rienzi L. Management of poor responders in IVF: is there anything new? Biomed Res Int. 2014;2014:352098.##Cobo A, Garrido N, Crespo J, José R, Pellicer A. Accumulation of oocytes: a new strategy for managing low-responder patients. Reprod Biomed Online. 2012;24(4):424-32.##Kushnir VA, Barad DH, Albertini DF, Darmon SK, Gleicher N. Effect of Embryo Banking on U.S. National Assisted Reproductive Technology Live Birth Rates. PLoS One. 2016;11(5):e0154620.##Chatziparasidou A, Nijs M, Moisidou M, Chara O, Ioakeimidou C, Pappas C, et al. Accumulation of oocytes and/or embryos by vitrification: a new strategy for managing poor responder patients undergoing pre implantation diagnosis. Version 2. F1000Res. 2013 Nov 12 [revised 2014 Mar 3];2:240.##Cedars MI. Assisted reproductive technology: moving forward--or just moving? Fertil Steril. 2016;105(3):588-9.##

Female Fertility Preservations, Clinical and Experimental Options 2 1 2 Recently, due to tremendous progress in prognosis, diagnosis, and treatment of different kinds of malignancies, demands on fertility preservation were raised significantly in developed countries. Fertility failure is one of the most detrimental consequences of radio/cytotoxic treatment procedures in women who could overcome their cancer disease. For women who are involved in cancer diseases, there are multiple options regarding their fertility preservation and those could be selected according to patient’s age, the risk of ovarian involvement, the available time and the type of cancer with different levels of advantages and disadvantages. Although there are multiple options, but embryo cryopreservation and ovarian tissue cryopreservation are the most reliable methods for pre-mature and post-mature puberty, respectively. In addition, other approaches like artificial ovary, isolation and cryopreservation of follicles and mature and immature oocyte preservation are under investigations and the success rate of oocyte vitrification is increasing. Therefore, the techniques have the potential to be used in clinic in near future. The presence of comprehensive consultation, before the onset of any kind of cancer treatment procedures, is an indispensable issue which would help patients to make up their mind in choosing the immediate and the best available fertility preservation option. 125 133 Zahra Z Rajabi Department of Biomedical Engineering, University of Virginia Department of Biomedical Engineering, University of Virginia USA Fereshteh F Aliakbari Infertility and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences Infertility and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences Iran Hossein H Yazdekhasti Department of Anatomy, School of Medicine, Tehran University of Medical Sciences Department of Anatomy, School of Medicine, Tehran University of Medical Sciences Iran HY3U@virginia.edu Cancer treatmentCryopreservationEmbryoFertility preservationFreezingOocyteOvarian tissueTransplantation 30027.pdf Horner M, Ries LAG, Krapcho M, Neyman N, Aminou R, Howlader N, et al. 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Effect of CatSper and Hv1 Channel Inhibition on Progesterone Stimulated Human Sperm 2 1 2 Background: Intracellular calcium and proton concentrations are important factors for activating human sperm. Calcium ion (Ca2+) enters sperm through voltage-dependent calcium channel of sperm (CatSper). Proton was extruded from sperm through voltage-gated proton channel (Hv1). In the present study, the selective inhibitors of the CatSper and Hv1 channels, NNC 55-0396 (NNC) and zinc ion, respectively, were used to investigate functions of these channels. Methods: Normal semen samples (n=24) were washed and diluted to 20×106 sperm/ml. The diluted sample was divided into 8 groups, containing Ham’s F-10 (the control group), 2 µM NNC, 1 mM ZnCl2 and NNC+Zn. The other 4 groups were the same as above, except that they contained 1 µM progesterone. The computer assisted analysis was done by VT-Sperm 3.1 to determine the percentage of motile sperm and sperm velocity. Acrosomal status was monitored by FITC-PSA and viability assessed by Eosin–Y staining. Statistical comparisons were made using ANOVA followed by Tukey post hoc test. The p<0.05 was considered significant. Results: The percentage of viable and motile sperm, curvilinear velocity and other parameters of motility was reduced in all groups containing NNC, zinc and NNC+zinc. Progesterone–induced acrosome reaction was abolished by each of these inhibitors. The combination effect of NNC plus zinc on motility and progesterone–induced acrosome reaction was not stronger than NNC by itself. Conclusion: CatSper and Hv1 channels play a critical role in human sperm function and viability. It seems that a functional relationship exists between CatSper and Hv1 channels. 133 140 Sara S Keshtgar Department of Physiology, School of Medicine, Shiraz University of Medical Sciences Department of Physiology, School of Medicine, Shiraz University of Medical Sciences Iran keshtgar@sums.ac.ir Hamideh H Ghanbari Department of Physiology, Faculty of Medicine, Hormozgan University of Medical Sciences Department of Physiology, Faculty of Medicine, Hormozgan University of Medical Sciences Iran Esmaeel E Ghani Department of Physiology, Faculty of Medicine, Hormozgan University of Medical Sciences Department of Physiology, Faculty of Medicine, Hormozgan University of Medical Sciences Iran Seyed Mostafa SM Shid Moosavi Department of Physiology, School of Medicine, Shiraz University of Medical Sciences Department of Physiology, School of Medicine, Shiraz University of Medical Sciences Iran Acrosome reactionCatSper channelHv1 channelProgesteroneSperm motility 10026.pdf Suarez SS, Varosi SM, Dai X. Intracellular calcium increases with hyperactivation in intact, moving hamster sperm and oscillates with the flagellar beat cycle. Proc Natl Acad Sci USA. 1993;90(10):4660-4.##Ho HC, Suarez SS. Characterization of the intracellular calcium store at the base of the sperm flagellum that regulates hyperactivated motility. Biol Reprod. 2003;68(5):1590-6.##Ho HC, Suarez SS. An inositol 1,4,5-trisphosphate receptor-gated intracellular Ca(2 ) store is involved in regulating sperm hyperactivated motility. Biol Reprod. 2001;65(5):1606-15.##Alasmari W, Costello S, Correia J, Oxenham SK, Morris J, Fernandes L, et al. Ca2 signals generated by CatSper and Ca2 stores regulate different behaviors in human sperm. J Biol Chem. 2012;288(9):6248-58.##Castellano LE, Trevino CL, Rodriguez D, Serrano CJ, Pacheco J, Tsutsumi V, et al. Transient receptor potential (TRPC) channels in human sperm: expression, cellular localization and involvement in the regulation of flagellar motility. FEBS Lett. 2003;541(1-3):69-74.##Jungnickel MK, Marrero H, Birnbaumer L, Lémos JR, Florman HM. Trp2 regulates entry of Ca2 into mouse sperm triggered by egg ZP3. Nat Cell Biol. 2001;3(5):499-502.##Ren D, Xia J. Calcium signaling through CatSper channels in mammalian fertilization. Physiology (Bethesda). 2010;25(3):165-75.##Wennemuth G, Westenbroek RE, Xu T, Hille B, Babcock DF. CaV2.2 and CaV2.3 (N- and R-type) Ca2 channels in depolarization-evoked entry of Ca2 into mouse sperm. J Biol Chem. 2000;275(28):21210-7.##Kirichok Y, Lishko PV. Rediscovering sperm ion channels with the patch-clamp technique. Mol Hum Reprod. 2011;17(8):478-99.##Marquez B, Suarez SS. Bovine sperm hyperactivation is promoted by alkaline-stimulated Ca2 influx. Biol Reprod. 2007;76(4):660-5.##Lishko PV, Botchkina IL, Fedorenko A, Kirichok Y. Acid extrusion from human spermatozoa is mediated by flagellar voltage-gated proton channel. Cell. 2010;140(3):327-37.##Tombola F, Ulbrich MH, Isacoff EY. The voltage-gated proton channel Hv1 has two pores, each controlled by one voltage sensor. Neuron. 2008;58(4):546-56.##Suarez SS. Control of hyperactivation in sperm. Hum Reprod Update. 2008;14(6):647-57.##Darszon A, Acevedo JJ, Galindo BE, Hernandez-Gonzalez EO, Nishigaki T, Trevino CL, et al. Sperm channel diversity and functional multiplicity. Reproduction. 2006;131(6):977-88.##Lishko PV, Kirichok Y. The role of Hv1 and CatSper channels in sperm activation. J Physiol. 2010;588(Pt 23):4667-72.##Baldi E, Luconi M, Muratori M, Marchiani S, Tamburrino L, Forti G. Nongenomic activation of spermatozoa by steroid hormones: facts and fictions. Mol Cell Endocrinol. 2009;308(1-2):39-46.##Lishko PV, Botchkina IL, Kirichok Y. Progesterone activates the principal Ca2 channel of human sperm. Nature. 2011;471(7338):387-91.##Alasmari W, Barratt CLR, Publicover SJ, Whalley KM, Foster E, Kay V, et al. The clinical significance of calcium-signalling pathways mediating human sperm hyperactivation. Hum Reprod. 2013;28(4):866-76.##Mendoza C, Carreras A, Moos J, Tesarik J. Distinction between true acrosome reaction and degenerative acrosome loss by a one-step staining method using Pisum sativum agglutinin. J Reprod Fertil. 1992;95(3):755-63.##Contreras HR, Llanos MN. Detection of progesterone receptors in human spermatozoa and their correlation with morphological and functional properties. Int J Androl. 2001;24(4):246-52.##Sagare-Patil V, Vernekar M, Galvankar M, Modi D. Progesterone utilizes the PI3K-AKT pathway in human spermatozoa to regulate motility and hyperactivation but not acrosome reaction. Mol Cell Endocrinol. 2013;374(1-2):82-91.##Sagare-Patil V, Galvankar M, Satiya M, Bhandari B, Gupta SK, Modi D. Differential concentration and time dependent effects of progesterone on kinase activity, hyperactivation and acrosome reaction in human spermatozoa. Int J Androlo. 2012;35(5):633-44.##Jaiswal BS, Tur-Kaspa I, Dor J, Mashiach S, Eisenbach M. Human sperm chemotaxis: is progesterone a chemoattractant? Biol Reprod. 1999;60(6):1314-9.##Calogero AE, Hall J, Fishel S, Green S, Hunter A, D'Agata R. Effects of gamma-aminobutyric acid on human sperm motility and hyperactivation. Mol Hum Reprod. 1996;2(10):733-8.##Tamburrino L, Marchiani S, Minetti F, Forti G, Muratori M, Baldi E. The CatSper calcium channel in human sperm: relation with motility and involvement in progesterone-induced acrosome reaction. Hum Reprod. 2014;29(3):418-28.##Luconi M, Francavilla F, Porazzi I, Macerola B, Forti G, Baldi E. Human spermatozoa as a model for studying membrane receptors mediating rapid nongenomic effects of progesterone and estrogens. Steroids. 2004;69(8-9):553-9.##Strünker T, Goodwin N, Brenker C, Kashikar ND, Weyand I, Seifert R, et al. The CatSper channel mediates progesterone-induced Ca2 influx in human sperm. Nature. 2011;471(7338):382-6.##Quill TA, Sugden SA, Rossi KL, Doolittle LK, Hammer RE, Garbers DL. 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Ca2 channel inhibitor NNC 55-0396 inhibits voltage-dependent K channels in rabbit coronary arterial smooth muscle cells. J Pharmacol Sci. 2014;125(3):312-9.##

Activity of Matrix Metalloproteinase 2 and 9 in Follicular Fluid and Seminal Plasma and Its Relation to Embryo Quality and Fertilization Rate 2 1 2 Background: The purpose of this study was to evaluate the activity of matrix metalloproteinase 2 (MMP-2) and 9 (MMP-9) in follicular fluid and seminal plasma and the correlation of their activities with parameters that are important in successful intracytoplasmic sperm injection (ICSI). Methods: Seventy-four infertile couples admitted to the Research Center for Endometrium and Endometriosis to carry out ICSI method were enrolled in this study. Follicular fluid was collected after retrieving the oocyte. In addition, semen samples were collected and seminal plasma was used for determination of MMP2 and MMP-9 activity. Gelatin zymography electrophoresis was applied to measure MMPs activities in follicular fluid and seminal plasma. Results: In follicular fluid, there was a positive correlation between MMP-2 activity with oocyte (r=0.27, p=0.021) or embryo quality (r=0.30, p=0.014), but no correlation was observed between MMP-2 activity and oocyte count or fertilization. Activity of MMP-9 showed positive correlation with oocyte morphology (r=0.29, p=0.014). In addition, MMP-2 activity of seminal plasma had positive correlation with sperm count (r=0.28, p=0.015), fertilization (r=0.28, p=0.02), and embryo quality (r=0.28, r=0.026). Conclusion: MMP2 and MMP9 activities in seminal plasma have a positive effect on sperm count and motility. MMP-2 and MMP-9 activity in follicular fluid and seminal plasma could be important factors in embryo quality in patients undergoing ICSI and may affect the outcome of ICSI. 140 146 Mojgan M Atabakhsh Department of Clinical Biochemistry, School of Medicine, Hamadan University of Medical Sciences Department of Clinical Biochemistry, School of Medicine, Hamadan University of Medical Sciences Iran Iraj I Khodadadi Department of Clinical Biochemistry, School of Medicine, Hamadan University of Medical Sciences Department of Clinical Biochemistry, School of Medicine, Hamadan University of Medical Sciences Iran Iraj I Amiri ایرج امیری Endometrium and Endometriosis Research Center, Fatemieh Hospital, Hamadan University of Medical Sciences Endometrium and Endometriosis Research Center, Fatemieh Hospital, Hamadan University of Medical Sciences Iran Hossain H Mahjub Social Determinants of Health Research Center and Department of Epidemiology, School of Public Health, Hamadan University of Medical Sciences Social Determinants of Health Research Center and Department of Epidemiology, School of Public Health, Hamadan University of Medical Sciences Iran Haidar H Tavilani Gene targeting Lab, John Curtin School of Medical Research, The Australian National University Gene targeting Lab, John Curtin School of Medical Research, The Australian National University Iran tayebinia@umsha.ac.ir, tavilani@gmail.com FertilizationFollicular fluidMatrix metalloproteinase 2Matrix metalloproteinase 9Semen 30029.pdf Curry TE Jr, Osteen KG. The matrix metalloproteinase system: changes, regulation, and impact throughout the ovarian and uterine reproductive cycle. Endocr Rev. 2003;24(4):428-65.##Fanjul-Fernández M, Folgueras AR, Cabrera S, López-Otín C. Matrix metalloproteinases: evolution, gene regulation and functional analysis in mouse models. Biochim Biophys Acta. 2010;1803(1):3-19.##Baumgart E, Lenk SV, Loening SA, Jung K. Quantitative differences in matrix metalloproteinase (MMP)-2, but not in MMP-9, tissue inhibitor of metalloproteinase (TIMP)-1 or TIMP-2, in seminal plasma of normozoospermic and azoospermic patients. Hum Reprod. 2002;17(11):2919-23.##Ferrer M, Rodriguez H, Zara L, Yu Y, Xu W, Oko R. MMP2 and acrosin are major proteinases associated with the inner acrosomal membrane and may cooperate in sperm penetration of the zona pellucida during fertilization. Cell Tissue Res. 2012;349(3):881-95.##Chen H, Fok KL, Yu S, Jiang J, Chen Z, Gui Y, et al. CD147 is required for matrix metalloproteinases-2 production and germ cell migration during spermatogenesis. Mol Hum Reprod. 2011;17(7):405-14.##Smith MF, Ricke WA, Bakke LJ, Dow MP, Smith GW. Ovarian tissue remodeling: role of matrix metalloproteinases and their inhibitors. Mol Cell Endocrinol. 2002;191(1):45-56.##Goldman S, Shalev E. MMPS and TIMPS in ovarian physiology and pathophysiology. Front Biosci. 2004;1;9:2474-83.##Liu D, Zhu C. Regulation of ovarian function by the matrix metalloproteinase system. Chin Sci Bull. 2002;47(14):1145-9.##Hashemitabar M, Bahmanzadeh M, Mostafaie A, Orazizadeh M, Farimani M, Nikbakht R. A proteomic analysis of human follicular fluid: comparison between younger and older women with normal FSH levels. Int J Mol Sci. 2014;29;15(10):17518-40.##Magli MC, Jones GM, Lundin K, van den Abbeel E. Atlas of human embryology: from oocytes to preimplantation embryos. Preface. Hum Reprod. 2012;27 Suppl 1:i1.##WHO. WHO laboratory manual for the examination and processing of human semen. 5th ed. Geneva, CH: World Health Organization. 2010. 287 p.##Kruger NJ. The Bradford method for protein quantitation. In: Walker JM, editor. Basic protein and peptide protocols. Totowa, NJ: Humana Press; 1994. p. 9-15.##Ranjbaran JF, Farimani M, Tavilani H, Ghorbani M, Karimi JF, Poormonsefi F, et al. Matrix metalloproteinases 2 and 9 and MMP9/NGAL complex activity in women with PCOS. Reproduction. 2016;151(4):305-11.##Buchman-Shaked O, Kraiem Z, Gonen Y, Goldman S. Presence of matrix metalloproteinases and tissue inhibitor of matrix metalloproteinase in human sperm. J Androl. 2002;23(5):702-8.##Wiener-Megnazi Z, Vardi L, Lissak A, Shnizer S, Zeev Reznick A, Ishai D, et al. Oxidative stress indices in follicular fluid as measured by the thermochemiluminescence assay correlate with outcome parameters in in vitro fertilization. Fertil Steril. 2004;82 Suppl 3:1171-6.##Gottsch ML, Van Kirk EA, Murdoch WJ. Role of matrix metalloproteinase 2 in the ovulatory folliculo-luteal transition of ewes. Reproduction. 2002;124(3):347-52.##Rienzi L, Balaban B, Ebner T, Mandelbaum J. The oocyte. Hum Reprod. 2012;27 Suppl 1:i2-21.##D'Ascenzo S, Giusti I, Millimaggi D, Marci R, Tatone C, Cardigno Colonna R, et al. Intrafollicular expression of matrix metalloproteinases and their inhibitors in normally ovulating women compared with patients undergoing in vitro fertilization treatment. Eur J Endocrinol. 2004;151(1):87-91.##Horka P, Malickova K, Jarosova R, Janatkova I, Zima T, Kalousova M. Matrix metalloproteinases in serum and the follicular fluid of women treated by in vitro fertilization. J Assist Reprod Genet. 2012;29(11):1207-12.##Baka S, Zourla K, Malamitsi-Puchner A, Makrakis E, Kaparos G, Demeridou S, et al. Intrafollicular levels of matrix metalloproteinases-2 and -9 in patients with polycystic ovaries are not associated with pregnancy rate during IVF cycle. In Vivo. 2009;23(1):89-92.##Prados FJ, Debrock S, Lemmen JG, Agerholm I. The cleavage stage embryo. Hum Reprod. 2012;27 Suppl 1:i50-71.##Lee DM, Lee TK, Song HB, Kim CH. The expression of matrix metalloproteinase-9 in human follicular fluid is associated with in vitro fertilisation pregnancy. BJOG. 2005;112(7):946-51.##Miller JE, Smith TT. The effect of intracytoplasmic sperm injection and semen parameters on blastocyst development in vitro. Hum Reprod. 2001;16(5):918-24.##

2D and 3D Trans-vaginal Sonography to Determine Cut-offs for Ovarian Volume and Follicle Number per Ovary for Diagnosis of Polycystic Ovary Syndrome in Indian Women 2 1 2 Background: The purpose of the study was to determine cut-off values for ovarian volume (OV) and follicle number per ovary (FNPO) in Indian women with polycystic ovary syndrome (PCOS). Methods: Eighty six PCOS women (Rotterdam criteria) and forty five matched ovulatory and normo-androgenic women were recruited. A detailed 2D and 3D trans-vaginal scan was carried out in early follicular phase (D2-D5) in all patients. Ovarian volume, follicle number per ovary, stromal volume, vascularization index (VI), vascularization flow index (VFI) and flow index (FI) were measured in PCOS and controls. Mann-Whitney test and logistic analysis using PROC LOGISTIC function of SAS® (Version 9.3) were used to calculate the best cut-offs for the diagnosis of PCOS. Results: Mean ovarian volume was 13.7±5.89 and 5.06±2.44 (p<0.0001), FNPO was 19.18±6.89 and 7.13±3.51 (p<0.0001) in PCOS and controls, respectively. The cut-offs for the diagnosis of PCOS were 2D OV=6.15 cm³, 2D FNPO=12. By 3D scan, OV=7 cm³, FNPO=10, stromal volume=6 cm³, VI=4.546, VFI=2.925 and FI=19.266. Youden’s Index (To select optimal predicted probability cut-off) was the highest for 2D FNPO (0.88786). 2D FNPO showed the highest specificity and sensitivity (AUC), 0.95238 and 0.93548, for the diagnostic accuracy of PCOS. Conclusion: 2D and 3D trans-vaginal scans are equally accurate for assessment of ovarian morphology. FNPO has better diagnostic accuracy for PCOS compared to ovarian volume. Cut-off for FNPO and OV in Indian PCOS women is 12 and 6.15 cm³ by 2D, 10 and 7 cm³ by 3D trans-vaginal scan. 146 152 Sujata S Kar Department of Obstetrics and Gynaecology, Kar Clinic and Hospital Department of Obstetrics and Gynaecology, Kar Clinic and Hospital India suju2463@gmail.com Swoyam S Samparna Department of Radiology, Dnyandeo Yashwantrao, Patil Hospital Department of Radiology, Dnyandeo Yashwantrao, Patil Hospital India Ovarian volumePCOSPolycystic ovaryRotterdam criteriaThree dimensional ultrasound 30028.pdf 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.##Rotterdam ESHRE-ASRM-Sponsored PCOS Consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod. 2004;19(1):41-7.##Franks S. Controversy in clinical endocrinology: diagnosis of polycystic ovarian syndrome: in defense of the Rotterdam criteria. J Clin Endocrinol Metab. 2006;91(3):786-9.##Jonard S, Robert Y, Cortet-Rudelli C, Pigny P, Decanter C, Dewailly D. Ultrasound examination of polycystic ovaries: is it worth counting the follicles? Hum Reprod. 2003;18(3):598-603.##Duijikers IJ, Klipping C. Polycystic ovaries, as defined by the 2003 Rotterdam consensus criteria, are found to be very common in young health women. Gynecol Endocrinol. 2010;26(3):152-60.##Johnstone EB, Rosen MP, Neril R, Trevithick D, Sternfeld B, Murphy R, et al. The polycystic ovary post-rotterdam: a common, age-dependent finding in ovulatory women without metabolic significance. J Clin Endocrinol Metab. 2010;95(11):4965-72.##Kristensen SL, Ramlau-Hansen CH, Ernst E, Olsen SF, Bonde JP, Vested A, et al. A very large proportion of young Danish women have polycystic ovaries: is a revision of the Rotterdam criteria needed? Hum Reprod. 2010;25(12):3117-22.##Alsamarai S, Adams JM, Murphy MK, Post MD, Hayden Dl, Hall JE, et al. Criteria for polycystic ovarian morphology in polycystic ovary syndrome as a function of age. J Clin Endocrinol Metab. 2009;94(12):4961-70.##Chen Y, Li L, Chen X, Zhang Q, Wang W, Li Y, et al. Ovarian volume and follicle number in the diagnosis of polycystic ovary syndrome in Chinese women. Ultrasound Obstet Gynecol. 2008;32(5):700-3.##Köşüş N, Köşüş A, Turhan NÖ, Kamalak Z. Do threshold values of ovarian volume and follicle number for diagnosing polycystic ovarian syndrome in Turkish women differ from western countries? Eur J Obstet Gynecol Reprod Biol. 2011;154(2):177-81.##Azziz R, Carmina E, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Futterweit W, et al. The androgen excess and PCOS society criteria for the polycystic ovary syndrome: the complete task force report. Fertil Steril. 2009;91(2):456-88.##Deb S, Campbell BK, Clewes JS, Raine-Fenning NJ. Quantitative analysis of antral follicle number and size: a comparision of two-dimensional and automated three dimensional ultrasound techniques. Ultrasound Obstet Gynecol. 2010;35(3):354-60.##Jayaprakasan K, Walker KF, Clewes JS, Johnson IR, Raine-Fenning NJ. The interobserver reliability of off-line antral follicle counts made from stored three-dimensional ultrasound data: a comparative study of different measurement techniques. Ultrasound Obstet Gynecol. 2007;29(3):335-41.##Scheffer GJ, Broekmans FJ, Bancsi LF, Habbema JD, Looman CW, Te Velde ER. Quantitative transvaginal two and three-dimensional sonography of the ovaries: reproducibility of antral follicle counts. Ultrasound Obstet Gynecol. 2002;20(3):270-5.##Battaglia C, Battaglia B, Morotti E, Paradisi R, Aanetti I, Meriggiola MC, et al. Two- and three-dimensional sonographic and color Doppler technieques for diagnosis of polycystic ovary syndrome. The stormal/Ovarian volume ratio as a new diagnostic criterion. J Ultrasound Med. 2012;31(7):1015-24.##Dewailly D. Diagnostic criteria for PCOS: is there a need for a rethink? Best Pract Res Clin Obstet Gynaecol. 2016;37:5-11.##Dewailly D, Gronier H, Poncelet E, Robin G, Leroy M, Pigny P, et al. Diagnosis of polycystic ovary syndrome (PCOS): revisiting the threshold values of follicle count on ultrasound and of the serum AMH level for the definition of polycystic ovaries. Hum Reprod. 2011;26(11):3123-9.##Lujan ME, Jarrett BY, Brooks ED, Reines JK, Peppin AK, Muhn N, et al. Updated ultrasound criteria for polycystic ovary syndrome: reliable thresholds for elevated follicle population and ovarian volume. Hum Reprod. 2013;28(5):1361-8.##Han YS, Lee AR, Song HK, Choi JI, Kim JH, Kim MR, et al. Ovarian volume in Korean women with PCOS and its related factors. J Menopausal Med. 2017;23(1):25-31.##Celik Cem. Ovarian volume in Turkish women with normal and polycystic ovaries. J Clin Anal Med. 2013;5(95):406-8.##Lam P, Raine-Fenning N, Cheung L, Haines C. Three-dimensional ultrasound features of the Polycystic ovary in Chinese women. Ultrasound Obstet Gynecol. 2009;34(2):196-200.##Lam PM, Johnson IR, Raine-fenning NJ. Three-dimensional ultrasound features of the polycystic ovary and the effect of different phenotypic expressions on this parameters. Hum Reprod. 2007;22(12):3116-23.##

Safety Profile of Levonorgestrel: A Disproportionality Analysis of Food and Drug Administration Adverse Event Reporting System (FAERS) Database 2 1 2 Background: Levonorgestrel is most commonly utilized as an emergency oral contraceptive. Little is known and/or studied about the adverse effects of levonorgestrel, therefore, current investigation was aimed to generate signal for unreported adverse drug reactions of levonorgestrel using disproportionality analysis in food and drug administration adverse events reporting system database. Methods: In FDA Adverse Events Reporting System (FAERS) database, all adverse event reports for levonorgestrel between January 2006 to June 2015 were identified and disproportionality analysis was conducted for selected adverse events of levonorgestrel using Reporting Odds Ratio, Proportional Reporting Ratio and Information Component with 95% confidence interval. Results: A disproportionality analysis was done for 15 adverse events of levonorgestrel; out of these, signal for 10 adverse events was found and among them menstruation delayed was reported maximum (1791), followed by pregnancy after post-coital contraception (942), breast tenderness (901), metrorrhagia (899), dysmenorrhea (822), menorrhagia (541), nipple disorder (141), breast enlargement (77), ectopic pregnancy (61) and premenstrual syndrome (35). Pregnancy after post-coital contraception showed the highest signal having the Information Component value of 129.2, Reporting Odds Ratio value of 6.51 and Proportional Reporting Ratio value of 6.49. Conclusion: In this paper, ten novel AEs were identified that were disproportionately reported with the use of LNG by using data mining techniques. Although a causal relationship cannot be established, the number of cases reported suggests that there might be an association. If confirmed by epidemiologic studies, the findings from this study would have potential implications for the use of LNG and patient management in clinical practice. 152 157 Anitha A Kurian Department of Pharmacy Practice, Faculty of Pharmacy, M.S. Ramaiah University of Applied Sciences Department of Pharmacy Practice, Faculty of Pharmacy, M.S. Ramaiah University of Applied Sciences India Kanika K Kaushik Department of Pharmacy Practice, Faculty of Pharmacy, M.S. Ramaiah University of Applied Sciences Department of Pharmacy Practice, Faculty of Pharmacy, M.S. Ramaiah University of Applied Sciences India Subeesh SK Viswam Department of Pharmacy Practice, Faculty of Pharmacy, M.S. Ramaiah University of Applied Sciences Department of Pharmacy Practice, Faculty of Pharmacy, M.S. Ramaiah University of Applied Sciences India subeeshkviswam@gmail.com Eswaran E Maheswari Department of Pharmacy Practice, Faculty of Pharmacy, M.S. Ramaiah University of Applied Sciences Department of Pharmacy Practice, Faculty of Pharmacy, M.S. Ramaiah University of Applied Sciences India Radhika R Kunnavil Department of Community Medicine, M.S. Ramaiah Medical College Department of Community Medicine, M.S. Ramaiah Medical College India ContraceptiveData miningLevonorgestrel 20027.pdf El Maghraby HA, Nafee T, Guiziry D, Elnashar A. Randomized controlled trial of the effects of metformin versus combined oral contraceptives in adolescent PCOS women through a 24 month follow up period. Middle East Fertil Soc J. 2015;20(3):131-7.##Ozgoli G, Sheikhan Z, Dolatian M, Simbar M, Bakhtyari M, Nasiri M. Comparison of sexual dysfunction in women using depo-medroxyprogesterone acetate (DMPA) and cyclofem. J Reprod Infertil. 2015;16(2):102-8.##Hedayati-Moghaddam MR, Eftekharzadeh-Mashhadi I, Fathimoghadam F, Pourafzali SJ. Sexual and reproductive behaviors among undergraduate university students in Mashhad, a city in northeast of Iran. J Reprod Infertil. 2015;16(1):43-9.##Ibrahim ZM, Ahmed MR, Shaaban MM. Knowledge, attitude and practice of emergency contraception among health care providers in Ismailia, Egypt. Middle East Fertil Soc J. 2013;18(4):246-52.##Cwiak C, Howard B, Hsieh J, Ricciotti N, Sucato GS. Sexual and contraceptive behaviors among adolescents requesting emergency contraception. J Pediatr Adolesc Gynecol. 2016;29(6):643-7.##Provenzano-Castro B, Oizerovich S, Stray-Pedersen B. LNG-emergency contraceptive pills: what do Argentinean healthcare students know? Sex Reprod Healthc. 2017;12:93-9.##Alshammari TM, AlMutairi EN. Use of an entacapone-containing drug combination and risk of death: analysis of the FDA AERS (FAERS) database. Saudi Pharm J. 2015;23(1):28-32.##Strom BL. Pharmacoepidemiology. 4th ed. England: John Wiley & Sons; 2007. 889 p.##Poluzzi E, Piccinni C, Raschi E, De Ponti F. Data mining techniques in pharmacovigilance: analysis of the publicly accessible FDA adverse event reporting system (AERS). UK: Intech Open Access Publisher; 2012.##Hauben M, Hung E, Wood J, Soitkar A, Reshef D. The impact of database restriction on pharmacovigilance signal detection of selected cancer therapies. Ther Adv Drug Saf. 2017;8(5):145-56.##Shohel M, Rahman MM, Zaman A, Uddin MM, Al-Amin MM, Reza HM. A systematic review of effectiveness and safety of different regimens of levonorgestrel oral tablets for emergency contraception. BMC Womens Health. 2014;14:54.##Shamloo BK, Chhabra P, Freedman AN, Potosky A, Malin J, Weiss Smith S. Novel adverse events of bevacizumab in the US FDA adverse event reporting system database. Drug Saf. 2012;35(6):507-18.##Deshpande G, Gogolak V, Smith S. Data mining in drug safety. Pharm Med. 2010;24(1):37-43.##Graham JD, Clarke CL. Physiological action of progesterone in target tissues. Endocr Rev. 1997;18(4):502-19.##Rothman KJ, Lanes S, Sacks ST. The reporting odds ratio and its advantages over the proportional reporting ratio. Pharmacoepidemiol Drug Saf. 2004;13(8):519-23.##Evans SJ, Waller PC, Davis S. Use of proportional reporting ratios (PRRs) for signal generation from spontaneous adverse drug reaction reports. Pharmacoepidemiol Drug Saf. 2001;10(6):483-6.##Barry M. Nipple Discharge. In: Walker HK, Hall WD, Hurst JW, editors. Clinical methods: the history, physical, and laboratory examinations. Boston: Butterworths; 1990.##Gülay H, Bora S, Kìlìçturgay S, Hamaloğlu E, Göksel H. Management of nipple discharge. J Am Coll Surg. 1994;178(5):471-4.##Sasaki KJ. Menstruation Disorders in Adolescents [Internet]. New York: Medscape; 2016 [cited: 2017 Dec 22]. Available from: http://emedicine.medscape.com/article/953945-overview#a6.##Bégaud B. Dictionary of pharmacoepidemiology. 1st ed. UK: John Wiley & Sons, Ltd; 2002; p. 15-22.##Pariente A, Gregoire F, Fourrier-Reglat A, Haramburu F, Moore N. Impact of safety alerts on measures of disproportionality in spontaneous reporting databases: the notoriety bias. Drug Saf. 2007;30(10):891-8.##Calis KA, Rivlin ME. Dysmenorrhea Medication [Internet]. New York: Medscape; 2016 [cited: 2017 Dec 22]. Available from: https://emedicine.medscape.com/article/253812-medication.##Ekström P, Akerlund M, Forsling M, Kindahl H, Laudanski T, Mrugacz G. Stimulation of vasopressin release in women with primary dysmenorrhoea and after oral contraceptive treatment--effect on uterine contractility. Br J Obstet Gynaecol. 1992;99(8):680-4.##Wallenstein EJ, Fife D. Temporal patterns of NSAID spontaneous adverse event reports: the Weber effect revisited. Drug saf. 2001;24(3):233-7.##Pereira PP, Cabar FR, Raiza LC, Roncaglia MT, Zugaib M. Emergency contraception and ectopic pregnancy: report of 2 cases. Clinics (Sao Paulo). 2005;60(6):497-500.##

"Ambivalence Perception" the Consequence of Exposure to Pregnancy in Iranian Adolescent Women: A Qualitative Study 2 1 2 Background: Adolescent pregnancy is an important health problem, significantly related to negative effects on the health of both adolescent mothers and their babies. Little is known about adolescent pregnancy from the perspective of the adolescents, especially in developing countries. The present study aimed to explore the perception of response to pregnancy in Iranian adolescent women. Methods: This conventional content analysis was conducted from November 2015 to October 2016 in Guilan Province (In the north of Iran). Data were collected through unstructured interview with 24 married women aged between 14 and 18 years old. The participants were recruited using a purposive sampling method. Interviews began with a general question and were followed with some probing questions, and were continued till data saturation was reached. Results: "Ambivalence perception" was the main theme that merged in this study. Two other categories comprised the content of interviews: "Improving positive effects of pregnancy" and, "Diminishing negative effects of pregnancy" which were merged from nine sub-categories. Conclusion: The experiences of pregnancy were not completely undesired and negative as the teenage mothers expressed a feeling of satisfaction with the birth of their children. This finding will help health educators to develop cultural sensitive programs, activities, and educational interventions that assist adolescent mothers to deal with this ambivalent perception of pregnancy. 157 167 Maryam M Moridi Department of Health Education and Health Promotion, Faculty of Medical Sciences, Tarbiat Modares University Department of Health Education and Health Promotion, Faculty of Medical Sciences, Tarbiat Modares University Iran Farkhondeh F Amin Shokravi Department of Health Education and Health Promotion, Faculty of Medical Sciences, Tarbiat Modares University Department of Health Education and Health Promotion, Faculty of Medical Sciences, Tarbiat Modares University Iran aminsh_f@modares.ac.ir AdolescentPregnancyWomen’s health 10024.pdf Oner S, Yapici G, Kurt AO, Sasmaz T, Bugdayci R. The sociodemographic factors related with the adolescent pregnancy. Asian Pac J Reprod. 2012;1(2):135-41.##Rowbottom S, Laski L, Wong S, Singer A. Giving girls today and tomorrow. Breaking the cycle of adolescent pregnancy [Internet]. New York: UNFPA; 2007 [updated 2009 Feb 17; cited 2017 Nov 22]. Available from: https://www.unfpa.org/sites/default/files/pub-pdf/giving_girls.pdf##World Health Organization. Adolescent pregnancy. Fact sheet No. 364 [Internet]. Geneva: WHO; 2014 [updated 2018 Feb 23; cited 2018 Jan 06]. Available from: http://www.who.int/mediacentre/factsheets/fs364/en##Dehlendorf C, Rodriguez MI, Levy K, Borrero S, Steinauer J. Disparities in family planning. Am J Obstet Gynecol. 2010;202(3):214-20.##Ventura SJ, Hamilton BE, Matthews T. National and state patterns of teen births in the United States, 1940-2013. Natl Vital Stat Syst Rep. 2014;63(4):1-34.##Kariman N, Simbar M, Ahmadi F, Vedadhir AA. Socioeconomic and Emotional Predictors of Decision Making for Timing Motherhood Among Iran-ian Women in 2013. Iran Red Crescent Med J. 2014;16(2):e13629.##Mohammadi N, Montazeri S, Alaghband Rad J, Ardabili HE, Gharacheh M. Iranian pregnant teenage women tell the story of "fast development": A phenomenological study. Women Birth. 2016;29(4):303-9.##Herrman JW, Nandakumar R. Development of a survey to assess adolescent perceptions of teen parenting. J Nurs Meas. 2012;20(1):3-20.##Rocca CH, Harper CC. Do racial and ethnic differences in contraceptive attitudes and knowledge explain disparities in method use?. Perspect Sex Reprod Health. 2012;44(3):150-8.##Spear HJ, Lock S. Qualitative research on adolescent pregnancy: a descriptive review and analysis. J Pediatr Nurs. 2003;18(6):397-408.##Hertfelt WE. Teenage childbearing in Sweden: Support from social network and midwife [dissertation]. [Stockholm, Sweden]: Karolinska Institute; 2007. 61 p.##Dehghan-Nayeri N, Tajvidi M. Experiences of pregnancy among Iranian adolescents: A qualitative study. Iran J Nurs Midwifery Res. 2014;19(7 Suppl1):S7-S12.##Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105-12.##Carvalho GM, Merighi MA, Jesus MC. The experience of repeated fatherhood during adolescence. Midwifery. 2010;26(4):469-74.##Kaye DK. Negotiating the transition from adolescence to motherhood: coping with prenatal and parenting stress in teenage mothers in Mulago hospital, Uganda. BMC Public Health. 2008;8:83.##Word Health Organization. Maternal, newborn, child and adolescent health: Adolescent development [Internet]. Geneva: WHO; 2016 [updated 2018 Jan 23; cited 2018 Jun 06]. Available from: http://www.who.int/maternal_child_adolescent/topics/adolescence/development/en/##Maputle MS. Becoming a mother: teenage mothers' experiences of first pregnancy. Curationis. 2006;29(2):87-95.##Devries KM, Free CJ. “It’s not something you have to be scared about”: attitudes towards pregnancy and fertility among Canadian aboriginal young people. J Aborig Health. 2011;7(1):8-15.##Loke AY, Lam PL. Pregnancy resolutions among pregnant teens: termination, parenting or adoption? BMC Pregnancy Childbirth. 2014;14:421.##Sadler LS, Novick G, Meadows-Oliver M. "Having a baby changes everything" reflective functioning in pregnant adolescents. J Pediatr Nurs. 2016; 31(3):e219-31.##Higginbottom GM, Mathers N, Marsh P, Kirkham M, Owen JM, Serrant-Green L. Young people of minority ethnic origin in England and early parenthood: views from young parents and service providers. Soc Sci Med. 2006;63(4):858-70.##McMichael C. Unplanned but not unwanted? Teen pregnancy and parenthood among young people with refugee backgrounds. J Youth Stud. 2013;16(5):663-78.##Ngum Chi Watts MC, Liamputtong P, McMichael C. Early motherhood: a qualitative study exploring the experiences of African Australian teenage mothers in greater Melbourne, Australia. BMC Public Health. 2015;15:873.##Seamark CJ, Lings P. Positive experiences of teenage motherhood: a qualitative study. Br J Gen Pract. 2004;54(508):813-8.##Gyesaw NY, Ankomah A. Experiences of pregnancy and motherhood among teenage mothers in a suburb of Accra, Ghana: a qualitative study. Int J Womens Health. 2013;5:773-80.##Afable-Munsuz A, Speizer I, Magnus JH, Kendall C. A positive orientation toward early motherhood is associated with unintended pregnancy among New Orleans youth. Matern Child Health J. 2006;10(3):265-76.##Liamputtong P. Motherhood and “moral career”: discourses of good motherhood among southeast Asian immigrant women in Australia. Qual Soc. 2006;29(1):25-53.##Benza S, Liamputtong P. Pregnancy, childbirth and motherhood: a meta-synthesis of the lived experiences of immigrant women. Midwifery. 2014;30 (6):575-84.##Abbaspoor Z, Moghaddam-Banaem L, Ahmadi F, Kazemnejad A. Iranian mothers' selection of a birth method in the context of perceived norms: a content analysis study. Midwifery. 2014;30(7):804-9.##Atuyambe L, Mirembe F, Tumwesigye NM, Annika J, Kirumira EK, Faxelid E. Adolescent and adult first time mothers' health seeking practices during pregnancy and early motherhood in Wakiso dis-trict, central Uganda. Reprod Health. 2008;5:13.##Ryan RG. Age differences in personality: Adolescents and young adults. Pers Individ Dif. 2009;47(4):331-5.##Najarkolaei FR, Niknami S, Aminshokravi F, Tavafian SS, Joneidi Jafari NA, Golabchi A. Promoting sexual abstinence intention among female university students: A quasi-experimental study. J Res Med Sci. 2013;18(1):37-43.##

Infertile Couples Prefer Twins: Analysis of Their Reasons and Clinical Characteristics Related to This Preference 2 1 2 Background: The number of multiple pregnancies has been significantly increased in the last decades due to assisted reproduction techniques development. Compared to singleton, twins and multiple pregnancies are associated to more complications and risks for both mother and children. The objective of this study was to examine the proportion of patients preferring a multiple birth over a singleton after an IVF/ICSI attempt, their reasons and the influence of socio-demographic and clinical parameters on their preference. Methods: A prospective study was conducted in two different Spanish centers in 2014; a public university hospital and a private clinic, with different populations and embryo transfer policies. In order to evaluate patients and partners attitudes towards twins and singletons, an anonymous 10-question survey was conducted and 399 were invited to participate. Results: 58.2% of participants preferred having twins to having one child at a time and 4.8% preferred triplets. Primary reasons for preferring twins were "avoiding a new IVF/ICSI attempt" (61.6%), "I like the idea of having twins" (27.3%), "avoiding the waiting list" (5.8%), and "in my opinion with the latest technology, the rate and severity of complications in multiple pregnancies are low" (5.2%). The multivariate analysis showed that the only significant parameter related to a preference for multiplets was the transfer of women’s own fresh embryos (OR=3.31). Conclusion: Twin pregnancy risks are not perceived as important by the majority of IVF/ICSI couples, and many of them specifically prefer twins. In our opinion, much more information is needed highlighting the multiple pregnancy risks and that information should come from medical sources besides general media. 167 174 Rosario R Mendoza Human Reproduction Unit, Cruces University Hospital Human Reproduction Unit, Cruces University Hospital Spain Teresa T Jáuregui Human Reproduction Unit, Cruces University Hospital Human Reproduction Unit, Cruces University Hospital Spain Maria M Diaz-Nuñez Human Reproduction Unit, Cruces University Hospital Human Reproduction Unit, Cruces University Hospital Spain maria.diaznunez@osakidetza.eus Mariana M de la Sota Centro de Psicología Mariana de la Sota Centro de Psicología Mariana de la Sota Spain Alaitz A Hidalgo IVI Bilbao IVI Bilbao Spain Marcos M Ferrando IVI Bilbao IVI Bilbao Spain Lorea L Martínez-Indart Clinical Epidemiology Unit, Cruces University Hospital Clinical Epidemiology Unit, Cruces University Hospital Spain Antonia A Expósito Human Reproduction Unit, Cruces University Hospital Human Reproduction Unit, Cruces University Hospital Spain Roberto R Matorras Human Reproduction Unit, Cruces University Hospital Human Reproduction Unit, Cruces University Hospital Spain IVFQuestionnaireTwins 10017.pdf Martin JA, Park MM. Trends in twin and triplet births: 1980-97. Natl Vital Stat Rep. 1999;47(24):1-16.##Borkenhagen A, Brähler E, Kentenich H. Attitudes of German infertile couples towards multiple births and elective embryo transfer. Hum Reprod. 2007;22(11):2883-7.##Cain JM; Committee for the Ethical Aspects of Human Reproduction and Women's Health. Ethical guidelines in the prevention of iatrogenic multiple pregnancy. Int J Gynaecol Obstet. 2000;71(3):293-4.##Kinzler WL, Ananth CV, Vintzileos AM. Medical and economic effects of twin gestations. J Soc Gynecol Investig. 2000;7(6):321-7.##Spanish Act on Assisted Human Reproduction, Pub. L. 14/2006, BOE 126: 19947-19956 (May 26, 2006).##Boulot P, Vignal J, Vergnes C, Dechaud H, Faure JM, Hedon B. Multifetal reduction of triplets to twins: a prospective comparison of pregnancy outcome. Hum Reprod. 2000;15(7):1619-23.##Vilska S, Tiitinen A, Hydén-Granskog C, Hovatta O. Elective transfer of one embryo results in an acceptable pregnancy rate and eliminates the risk of multiple births. Hum Reprod. 1999;14(9):2392-5.##McLernon DJ, Harrild K, Bergh C, Davies MJ, de Neubourg D, Dumoulin JC, et al. Clinical effectiveness of elective single versus double embryo transfer: methanalisis of individual patient data from randomised trials. BMJ. 2010;341:c6945.##European IVF-monitoring Consortium (EIM); European Society of Human Reproduction and Embryology (ESHRE), Calhaz-Jorge C, De Geyter C, Kupka MS, de Mouzon J, et al. Assisted reproductive technology in Europe, 2013: results generated from European registers by ESHRE. Hum Reprod. 2017;32(10):1957-73.##Practice comittee of the society for assisted reproductive technology, Practice committee of the American society for reproductive medicine. Fertil Steril. 2012;97(4):835-42.##de la Fuente A, Boada M, Romeu A, Ballescá JL, Reche A, Muñoz M, et al. [Manual de buena Práctica clínica en Reproducción Asistida]. Madrid: Grupo de Interés de Ética y Buena Práctica de la Sociedad Española de Fertilidad (SEF); 2016. 144 p. Spanish.##Bhattacharya S, Kamath MS. Reducing multiple births in assisted reproduction technology. Best Pract Res Clin Obstet Gynaecol. 2014;28(2):191-9.##Ryan GL, Zhang SH, Dokras A, Syrop CH, Van Voorhis BJ. The desire of infertile patients for multiple births. Fertil Steril. 2004;81(3):500-4.##Højgaard A, Ottosen LDM, Kesmodel U, Ingerslev HJ. Patients attitudes towards twin pregnancies and single embryo transfer- a questionnaire study. Hum Reprod. 2007;22(10):2673-8.##Pinborg A, Loft A, Schmidt L, Andersen AN. Attitudes of IVF/ICSI-twin mothers towards twins and single embryo transfer. Hum Reprod. 2003;18:621-7.##Child TJ, Henderson AM, Tan SL. The desire for multiple pregnancy in male and female infertility patients. Hum Reprod. 2004;19(3):558-61.##Ferrera M. [Los estados de bienestar del sur en la Europa social]. In: Fernández LM, Urdiola SS, editors. [El estado de bienestar en la Europa del Sur]. Madrid: Instituto de estudios sociales avanzados; 1995. P. 85-112. Spanish.##Kalra SK, Milad MP, Klock SC, Grobman WA. Infertility patients and their partners: differences in the desire for twin gestations. Obstet Gynecol. 2003;102(1):152-5.##Frank DI. Gender differences in decision making about infertility treatment. Appl Nurs Res. 1990;3(2):56-62.##Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159-74.##Murray S, Shetty A, Rattray A, Taylor V, Bhattacharya B. A randomized comparison of alternative methods of information provision on the acceptability of elective single embryo transfer. Hum Reprod. 2004;19(4):911-6.##Mansour R, Ishihara O, Adamson GD, Dyer S, de Mouzon J, Nygren KG, et al. International committee for monitoring assisted reproductive technologies world report: Assisted reproductive technology 2006. Hum Reprod. 2014;29(7):1536-51.##DeDominicis GM. No Duty at any speed? Determining the responsibility of the automobile manufacturer in speed-related accidents. Hofstra Law Rev. 1986;14(2):403-32.##Ferraretti AP, Goossens V, Kupka M, Bhattacharya S, de Mouzon J, Castilla JA, et al. Assisted reproductive technology in Europe, 2009: results generated from European registers by ESHRE. Hum Reprod. 2013;28(9):2318-31.##Md Latar IL, Razali N. The desire for multiple pregnancy among patients with infertility and their partners. Int J Reprod Med. 2014;2014:301452.##Prados N, Quiroga R, Caligara C, Ruiz M, Blasco V, Pellicer A, et al. Elective single versus double embryo transfer: live birth outcome and patient acceptance in a prospective randomised trial. Reprod Fertil Dev. 2015;27(5):794-800.##

Ultrasound-guided Ex-vivo Retrieval of Mature Oocytes for Fertility Preservation During Laparoscopic Oophorectomy: A Case Report 2 1 2 Background: Cryopreservation of oocytes is an efficient method of fertility preservation (FP) that can be applied in women suffering from gynecologic conditions that menace their reproductive future. Collection of oocytes becomes challenging in some scenarios, like the possibility of an ovarian cancer, the "ex-vivo" harvest of oocytes for FP, aspirating follicles directly from the ovarian specimen already excised by laparotomy or laparoscopy and it is an option for these cases. Case Presentation: In the present case report, the case of a patient with an adnexal mass suspected to be a recurrent teratoma was described who referred to our Assisted Reproduction Unit in Hospital Quironsalud Malaga for FP counseling. After controlled ovarian hyperstimulation, followed by laparoscopic abdominal examination and oophorectomy, an ex-vivo follicular aspiration for oocyte retrieval was performed on the specimen, using a standard ultrasound-guided procedure to ease and improve the process. All the follicles were aspirated and 5 metaphase II oocytes were obtained. Conclusion: This is to our knowledge, the first communication describing the ex-vivo ovarian aspiration of mature oocytes for FP using standard ultrasound guidance. Although this ultrasound guidance is not completely necessary, as other authors demonstrated previously, such a procedure permitted an easy and complete harvest of oocytes in a rare tumor with bizarre cystic formations, which made follicle recognition very difficult. 174 182 Enrique EP de la Blanca Department of Assisted Reproduction, Hospital Quironsalud Malaga Department of Assisted Reproduction, Hospital Quironsalud Malaga Spain gharesifb@sums.ac.ir Maria MF Fernandez-Perez Department of Assisted Reproduction, Hospital Quironsalud Malaga Department of Assisted Reproduction, Hospital Quironsalud Malaga Spain Elena ED Martin-Diaz Department of Assisted Reproduction, Hospital Quironsalud Malaga Department of Assisted Reproduction, Hospital Quironsalud Malaga Spain Manuel M Lozano Department of Gynecology, Hospital Quironsalud Malaga Department of Gynecology, Hospital Quironsalud Malaga Spain Marta M Garcia-Sanchez Department of Assisted Reproduction, Hospital Quironsalud Malaga Department of Assisted Reproduction, Hospital Quironsalud Malaga Spain Carolina C Monedero Department of Assisted Reproduction, Hospital Quironsalud Malaga Department of Assisted Reproduction, Hospital Quironsalud Malaga Spain CryopreservationEx-vivo oocyte retrievalFertility preservationLaparascopyOvarian neoplasmsOvarian teratomaStruma ovariiVitrification 10018.pdf American College of Obstetricians and Gynecologists. ACOG practice bulletin. management of adnexal masses. Obstet Gynecol. 2007;110(1):201-14.##Royal College of Obstetricians and Gynaecologists (RCOG). Management of Suspected Ovarian Masses in Premenopausal Women. London: Royal College of obstetrician and gynaecologists (RCOG); 2011 Nov. 14 p. Green Top Guidelines No. 62.##Dadoun Y, Azaïs H, Keller L, d´Oracio E, Collinet P, Decanter C. [Systematic proposal of fertility preservation by mature oocyte cryopreservation for recurrent benign ovarian tumors]. Gynecol Obstet Fertil Senol. 2017;45(6):356-65. French.##Prasath EB, Chan ML, Wong WH, Lim CJ, Tharmalingam MD, Hendricks M, et al. First pregnancy and live birth resulting from cryopreserved embryos obtained from in vitro matured oocytes after oophorectomy in an ovarian cancer patient. Hum Reprod. 2014;29(2):276-8.##Alvarez M, Sole M, Devesa M, Fabregas R, Boada M, Tur R, et al. Live birth using vitrified--warmed oocytes in invasive ovarian cancer: case report and literature review. Reprod Biomed Online. 2014;28(6):663-8.##Sinha A, Ewies AA. Ovarian mature cystic teratoma: Challenges of surgical management. Obstet Gynecol Int. 2016;2016:2390178.##Wang W, Lai YC. Evidence of metachronous development of ovarian teratomas: a case report of bilateral mature cystic teratomas of the ovaries and systematic literature review. J Ovarian Res. 2017;10(1):17.##Park SB, Kim JK, Kim KR, Cho KS. Imaging findings of complications and unusual manifestations of ovarian teratomas. Radiographics. 2008;28(4):969-83.##Fatemi HM, Kyrou D, Al-Azemi M, Stoop D, De Sutter P, Bourgain C, et al. Ex-vivo oocyte retrieval for fertility preservation. Fertil Steril. 2011;95(5):1787.e15-7.##Revel A, Safran A, Benshushan A, Shushan A, Laufer N, Simon A. In vitro maturation and fertilization of oocytes from an intact ovary of a surgically treated patient with endometrial carcinoma: Case report. Hum Reprod. 2004;19(7):1608-11.##Huang JY, Buckett WM, Gilbert L, Tan SL, Chian RC. Retrieval of immature oocytes followed by in vitro maturation and vitrification: a case report on a new strategy of fertility preservation in women with borderline ovarian malignancy. Gynecol Oncol. 2007;105(2):542-4.##Bocca S, Dedmond D, Jones E, Stadtmauer L, Oehninger S. Successful extracorporeal mature oocyte harvesting after laparoscopic oophorectomy following controlled ovarian hyperstimulation for the purpose of fertility preservation in a patient with borderline ovarian tumor. J Assist Reprod Genet. 2011;28(9):771-2.##Kuwayama M, Vajta G, Kato O, Leibo SP. Highly efficient vitrification method for cryopreservation of human oocytes. Reprod Biomed Online. 2005;11(3):300-8.##Savelli L, Testa AC, Timmerman D, Paladini D, Ljungberg O, Valentin L. Imaging of gynecological disease (4): clinical and ultrasound characteristics of struma ovarii. Ultrasound Obstet Gynecol. 2008;32(2):210-9.##Matsushita H, Tani H. Successful infertility treatment following fertility-sparing surgery and chemotherapy for ovarian immature teratoma: a case report and a literature review. Reprod Med Biol. 2011;10(3):193-8.##Oliveira FG, Dozortsev D, Diamond MP, Fracasso A, Abdelmassih S, Abdelmassih V, et al. Evidence of parthenogenetic origin of ovarian teratoma: case report. Hum Reprod. 2004;19(8):1867-70.##Caspi B, Weissman A, Zalel Y, Barash A, Tulandi T, Shoham Z. Ovarian stimulation and in vitro fertilization in women with mature cystic teratomas. Obstet Gynecol. 1998;92(6):979-81.##Segers I, Mateizel I, Van Moer E, Smitz J, Tournaye H, Verheyen G, et al. In vitro maturation (IVM) of oocytes recovered from ovariectomy specimens in the laboratory: a promising ‘ex vivo’ method of oocyte cryopreservation resulting in the first report of an ongoing pregnancy in Europe. J Assist Reprod Genet. 2015;32(8):1221-31.##Gremeau AS, Andreadis N, Fatum M, Craig J, Turner K, McVeigh E, et al. In vitro maturation or in vitro fertilization for women with polycystic ovaries? a case-control study of 194 treatment cycles. Fertil Steril. 2012;98(2):355-60.##Shirasawa H, Terada Y. In vitro maturation of human immature oocytes for fertility preservation and research material. Reprod Med Biol. 2017;16(3):258-67.##Darai E, Fauvet R, Uzan C, Gouy S, Duvillard P, Morice P. Fertility and borderline ovarian tumor: a systematic review of conservative management, risk of recurrence and alternative options. Hum Reprod Update. 2013;19(2):151-66.##Whyte JS, Hawkins E, Rausch M, Hershlag A. In vivo oocyte retrieval in a young woman with ovarian cancer. Obstet Gynecol. 2014;124(2 Pt 2 Suppl 1):484-6.##Nielsen AP, Korsholm AS, Lemmen J, Sylvest R, Sopa N, Andersen AN. Selective use of corifollitropin for controlled ovarian stimulation for IVF in patients with low anti-Müllerian hormone. Gynecol Endocrinol. 2016;32(8);625-8.##Sztein JM, O’Brien MJ, Farley JS, Mobraaten LE, Eppig JJ. Rescue of oocytes from antral follicles of cryopreserved mouse ovaries: competence to undergo maturation, embryogenesis, and development to term. Hum Reprod. 2000;15(3):567-71.##De Sutter P, Dozortsev D, Verhoeff A, Coetsier T, Jansen CA, Van Os HC, et al. Transport intracytoplasmic sperm injection (ICSI): a cost-effective alternative. J Assist Reprod Genet. 1996;13(3):234-7.##Pereira N, Hubschmann AG, Lekovich JP, Schattman GL, Rosenwaks Z. Ex vivo retrieval and cryopreservation of oocytes from oophorectomized specimens for fertility preservation in a BRCA1 mutation carrier with ovarian cancer. Fertil Steril. 2017;108(2):357-60.##Doyle JO, Richter KS, Lim J, Stillman RJ, Graham JR, Tucker MJ. Successful elective and medically indicated oocyte vitrification and warming for autologous in vitro fertilization, with predicted birth probabilities for fertility preservation according to number of cryopreserved oocytes and age at retrieval. Fertil Steril. 2016;105(2):459-66.e2.##