PGS and the Critical Decision on Transfer of Defective Embryos 2 1 2 Today, pre-implantation genetic diagnosis/screening (PGD/PGS) tests are a key part of reproductive medicine in most countries. These techniques have been designed for a variety of purposes, including identification of embryos affected or carriers of monogenic diseases, identification of aneuploid embryos or selection of embryos with specific gender. Technical updates and improvements of PGD/PGS were done over time. According to CDC statistics, about 4-6% of ART cycles are candidates for PGS annually and there is evidence on the increase in request (1). Insomuch that the first use of the FISH technique in 1900 created new hopes for elimination of aneuploid embryos in the IVF cycles. For twenty years, the FISH technique was the undeniable method for PGS of embryos in IVF centers. But a large number of studies in the first years of recent decade failed to show the benefits of FISH/PGS for improvement of pregnancy rate in IVF cycles. At the beginning of recent decade, new tools and technologies of CGH array, SNP array, quantitative PCR and more recently NGS were developed and utilized for improvement of PGS results. This replacement has many advantages over older tools. Certain features of recent PGS techniques allow simultaneous evaluation of 23 pairs of chromosomes, the use of trophectoderm biopsy and more cells for evaluation and also the possibility of verifying biopsied blastomeres. Despite the development and effectiveness of new techniques and their ability to identify the maximum euploid embryos, a limited number of embryos is reported with chromosomal mosaicism due to using just 5-10 cells for genetic assessment (2). The rate of mosaicism in the new technologies is significantly reduced in comparison with FISH (3-5% versus 50%). If mosaic embryos at day 3 are cultured to day 5, approximately 50% of them would be self-corrected to euploid blastocysts, but a number of embryos are still reported as mosaic in PGS results. The mosaicism reports have formed a challenge in application of genetic testing of IVF embryos and subsequently patients counseling. It is always difficult to make decisions about the transfer of these embryos, particularly in cases where all embryos are reported mosaic or aneuploid and the couple cannot try for another cycle (3). The current practices predominantly transfer euploid embryos; however, a lot of data support the birth of healthy babies from mosaic embryos. Therefore, gynecologists, embryologists, geneticists, and patients applying for PGD/PGS in IVF clinics are faced with new challenges for mosaicism in genetic counseling. Therefore, it is imperative that all specialties related to the provision of these services collaborate to plan a comprehensive patient consultation protocol pre and post PGS. The counseling strategy and providing the correct information has a critical role in patient’s decision and avoidance of undesired outcomes for couples and service providers in the future. One of the main duties of pre-PGS counseling is to set realistic expectations for couples about PGS. Counseling sessions should include discussions on the challenges associated with PGS, the frequency of mosaicism regarding couple’s age, the false positive/negative results and patients should be brief-ed on the limited data about its effectiveness and also the interpretation of PGS results. Precise and comprehensive counseling may dissuade the couples who have little information or misconceptions about potentials of PGS (4). But in cases where couples inevitably request the transfer of mosaic embryos, the importance of post PGS consultation is more critical. The data discussed at this level should be different from pre-PGS counseling. The couples should be aware of the potential risks encountered with implantation of mosaic embryos, their lower implantation rate and higher abortion rate, the risk of fetal demise or uniparental disomy, the emotional and financial risk and also the couples should be informed that most of associated risks following mosaic embryos transfer are still unknown. Therefore, pregnancies following transfer of mosaic embryos should be referred for prenatal screening to detect any aneuploidy in the fetus (4). Recently, the International Preimplantation Genetics Association has issued a guideline for the transfer of mosaic embryos. According to this guideline, transfer of euploid embryos should be preferred to mosaic ones and mosaic monosomies to mosaic trisomies. If we have to transfer a mosaic trisomy embryo, mosaic trisomies of 1, 3, 4, 5, 6, 8, 9, 10, 11, 12, 17, 19, 20, 22, X, and Y are preferred over mosaic trisomies of 2, 7, 13, 14, 15, 16, 18, and 21 (3). In addition to the challenge of mosaic in PGS, there is a similar and even more important challenge for PGD in which due to economic, ethical, religious issues or couples' request, physcians are forced to transfer carrier embryos or the ones affected with single-gene disorders. There are several considerations on the request for transfer of genetically defective embryos; the couple’s reproductive autonomy and liberty, physician’s professional conscience, professional norms, laws, and practices, health of born children and psychological and medical consequences for pregnant spouse are the typical issues. Therefore, making decisions on transfer of prob-ably defective embryos is not so simple and straightforward and consequently before the final decision, all the above considerations should be taken into consideration (1). In addition, acoording to the recent committee opinion of American Society for Reproductive Medicine (ASRM) and the Society for Assisted Reproductive Technology (SART) the value of PGS for preimplantation screening of euploid and aneuploid embryos are not conclusive, because the previuose studies have important limitations and more studies need to be perform in future (5). Since transfer of defective embryos is associated with numerous medical, psychological, and socio-economic consequences, until obtaining further information in this area, it is recommended the couples try another cycle to find healthy euploid embryos instead of tranfer of mosaic or genetically defective embryos. 183 185 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 30038.pdf Dear J. A clash at the petri dish: transferring embryos with known genetic anomalies. J Law Biosci. 2018;5(2):219-61.##Brezina PR, Anchan R, Kearns WG. Preimplantation genetic testing for aneuploidy: what technology should you use and what are the differences? J Assist Reprod Genet. 2016;33(7):823-32.##Sachdev NM, Maxwell SM, Besser AG, Grifo JA. Diagnosis and clinical management of embryonic mosaicism. Fertil Steril. 2017;107(1):6-11.##Besser AG, Mounts EL. Counselling considerations for chromosomal mosaicism detected by preimplantation genetic screening. Reprod Biomed Online. 2017;34(4):369-74.##Gleicher N, Kushnir VA, Barad DH. How PGS/PGT-A laboratories succeeded in losing all credibility. Reprod Biomed Online. 2018;37(2):242-5.##

Male Infertility, Precision Medicine and Systems Proteomics 2 1 2 Precision medicine (PM) is an approach that has the power to create the best effect and safety of medicine and treatment with the least side effects for each person. PM is very helpful as sometimes due to inaccurate or late diagnosis or toxicities of the drugs irreversible side effect for patient's health are generated. This seemingly new and emerging science is also effective in preventing disease, due to differences in the genes, environment, and lifestyles of any particular person. PM can be a prominent criterion in infertility research. To achieve this goal, there should be information from a healthy human body, including genetic and molecular information. A PM is an evolution in health care, which is very helpful even economically. The guarantor of the PM success is the examination of the molecular profile of the patient, including genes, proteins, metabolites, etc. Therefore, genomics, proteomics, and metabolomics-based techniques are very important in this regard. Unfortunately, despite extensive studies on PM practice in various fields, male infertility has remained unresponsive. Given that around 20% of couples around the world suffer from infertility, and almost half of them are related to men's problems, the PM approach has a high potential for male infertility. In this study, with the help of proteomics and metabolomics, PM information on male infertility was explored. 185 193 Niloofar N Agharezaee Department of Genetics, Faculty of Advanced Science and Technology, Tehran Medical Sciences, Islamic Azad University Department of Genetics, Faculty of Advanced Science and Technology, Tehran Medical Sciences, Islamic Azad University Iran Mehrdad M Hashemi Department of Genetics, Faculty of Advanced Science and Technology, Tehran Medical Sciences, Islamic Azad University Department of Genetics, Faculty of Advanced Science and Technology, Tehran Medical Sciences, Islamic Azad University Iran Minoo M Shahani Faculty of Advanced Science and Technology, Tehran Medical Sciences, Islamic Azad University Faculty of Advanced Science and Technology, Tehran Medical Sciences, Islamic Azad University Iran 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 InfertilityMalePrecision medicineProteomics 30031.pdf Ziegelstein RC. 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Healthc Manage Forum. 2016;29(4):158-61.##Latosinska A, Frantzi M, Vlahou A, Merseburger AS, Mischak H. Clinical proteomics for precision medicine: the bladder cancer case. Proteomics Clin Appl. 2017;12(2).##Boersema PJ, Kahraman A, Picotti P. Proteomics beyond large-scale protein expression analysis. Curr Opin Biotechnol. 2015;34:162-70.##James P. Protein identification in the post-genome era: the rapid rise of proteomics. Q Rev Biophys. 1997;30(4):279-331.##Minai-Tehrani A, Jafarzadeh N, Gilany K. Metabolomics: a state-of-the-art technology for better understanding of male infertility. Andrologia. 2016;48(6):609-16.##Milardi D, Grande G, Vincenzoni F, Castagnola M, Marana R. Proteomics of human seminal plasma: identification of biomarker candidates for fertility and infertility and the evolution of technology. Mol Reprod Dev. 2013;80(5):350-7.##Lehmann S, Brede C, Lescuyer P, Cocho JA, Vialaret J, Bros P, et al. Clinical mass spectrometry proteomics (cMSP) for medical laboratory: what does the future hold? Clin Chim Acta. 2017;467:51-8.##Duarte TT, Spencer CT. Personalized proteomics: the future of precision medicine. Proteomes. 2016;4(4). pii: 29.##Anderson NL. The clinical plasma proteome: a survey of clinical assays for proteins in plasma and serum. Clin Chem. 2010;56(2):177-85.##Gilany K, Minai-Tehrani A, Savadi-Shiraz E, Rezadoost H, Lakpour N. Exploring the human seminal plasma proteome: an unexplored gold mine of biomarker for male infertility and male reproduction disorder. J Reprod Infertil. 2015;16(2):61-71.##Gilany K, Moazeni-Pourasil RS, Jafarzadeh N, Savadi-Shiraz E. Metabolomics fingerprinting of the human seminal plasma of asthenozoospermic patients. Mol Reprod Dev. 2014;81(1):84-6.##Gilany K, Mani-Varnosfaderani A, Minai-Tehrani A, Mirzajani F, Ghassempour A, Sadeghi MR, et al. Untargeted metabolomic profiling of seminal plasma in nonobstructive azoospermia men: a noninvasive detection of spermatogenesis. Biomed Chromatogr. 2017;31(8).##Gilany K, Pouracil RS, Sadeghi MR. Fourier transform infrared spectroscopy: a potential technique for noninvasive detection of spermatogenesis. Avicenna J Med Biotechnol. 2014;6(1):47-52.##Jafarzadeh N, Mani-Varnosfaderani A, Minai-Tehrani A, Savadi-Shiraz E, Sadeghi MR, Gilany K. Metabolomics fingerprinting of seminal plasma from unexplained infertile men: a need for novel diagnostic biomarkers. Mol Reprod Dev. 2015;82(3):150.##Jacobsen R, Bostofte E, Engholm G, Hansen J, Olsen JH, Skakkebaek NE, et al. Risk of testicular cancer in men with abnormal semen characteristics: cohort study. BMJ. 2000;321(7264):789-92.##Jensen TK, Jacobsen R, Christensen K, Nielsen NC, Bostofte E. Good semen quality and life expectancy: a cohort study of 43,277 men. Am J Epidemiol. 2009;170(5):559-65.##Eisenberg ML, Li S, Cullen MR, Baker LC. Increased risk of incident chronic medical conditions in infertile men: analysis of United States claims data. Fertil Steril. 2016;105(3):629-36.##Eisenberg ML. Improving the precision of the male fertility evaluation. Eur Urol. 2016;70(6):924-5.##Asero P, Calogero AE, Condorelli RA, Mongioi L, Vicari E, Lanzafame F, et al. Relevance of genetic investigation in male infertility. J Endocrinol Invest. 2014;37(5):415-27.##Bieniek JM, Drabovich AP, Lo KC. Seminal biomarkers for the evaluation of male infertility. Asian J Androl. 2016;18(3):426-33.##Majzoub A, Agarwal A. Antioxidant therapy in idiopathic oligoasthenoteratozoospermia. Indian J Urol. 2017;33(3):207-14.##Ghorbani M, Vatannejad A, Khodadadi I, Amiri I, Tavilani H. Protective effects of glutathion supplementation against oxidative stress during cryopreservation of human spermatozoa. Cryo letters. 2016;37(1):34-40.##Bisht S, Faiq M, Tolahunase M, Dada R. Oxidative stress and male infertility. 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Analysis of Apoptosis in Cultured Human Vitrified Ovarian Tissue in the Presence of Leukemia Inhibitory Factor 2 1 2 Background: For improving the human ovarian tissue culture, this study was designed to assess the incidence of apoptosis in this tissue following vitrification and in vitro culture in the presence of leukemia inhibitory factor (LIF) as an anti-apoptotic factor. Methods: After collecting the ovarian tissue samples they were divided into non-vitrified and vitrified groups and cultured for 14 days in the presence and absence of LIF then morphological, ultrastructural and steroidogenesis studies, TUNEL and caspase-3/7 assays, and apoptosis analysis by real time RT-PCR were done in all groups. The data were analyzed by independent t-tests and the real time RT-PCR results were compared by one-way ANOVA (p-values of <0.05 were considered significant). Results: No significant difference was observed between non-vitrified and vitrified groups in normality rate of follicles, the levels of hormones, TUNEL positive cells and caspase-3/7 activity. But in all LIF-treated groups, the levels of 17-β estradiol and progesterone were higher and TUNEL signals and caspase-3/7 activity were lower than non-LIF treated groups. The expression of Fas and FasL genes was higher in vitrified group in comparison with non-vitrified group but the expression of other genes was not significantly different. In LIF- treated groups, the expression of pro-apoptotic genes was significantly lower and the expression of anti-apoptotic genes was higher than non-LIF treated group. Conclusion: The vitrification of human ovarian tissue did not increase the incidence of apoptosis at the morphological and molecular levels during long term culture and LIF improves the survival and development of cultured follicles. 193 203 Maasoume M Abdollahi Department of Anatomical Sciences, Medical Sciences Faculty, Tarbiat Modares University Department of Anatomical Sciences, Medical Sciences Faculty, Tarbiat Modares University Iran Mojdeh M Salehnia مژده صالح نیا Department of Anatomical Sciences, Medical Sciences Faculty, Tarbiat Modares University Department of Anatomical Sciences, Medical Sciences Faculty, Tarbiat Modares University Iran salehnim@modares.ac.ir, mogdeh@dr.com Saghar S Salehpour ساغر صالحپور Infertility and Reproductive Health Research Center (IRHRC), Shahid Beheshti University of Medical Sciences Infertility and Reproductive Health Research Center (IRHRC), Shahid Beheshti University of Medical Sciences Iran Shahram Sh Pour Beiranvand Department of Anatomical Sciences, Medical Sciences Faculty, Tarbiat Modares University Department of Anatomical Sciences, Medical Sciences Faculty, Tarbiat Modares University Iran ApoptosisCaspase-3/7In vitro cultureLeukemia inhibitory factorOvarian tissueVitrification 30036.pdf Chaput L, Grémeau AS, Vorilhon S, Pons H, Chabrot C, Grèze V, et al. 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Neurotrophic effects of leukemia inhibitory factor on neural cells derived from human embryonic stem cells. Stem Cells. 2012;30(11):2387-99.##Nilsson EE, Kezele P, Skinner MK. Leukemia inhibitory factor (LIF) promotes the primordial to primary follicle transition in rat ovaries. Mol Cell Endocrinol. 2002;188(1-2):65-73.##Haidari K, Salehnia M, Valoujerdi MR. The effects of different concentrations of leukemia inhibitory factor on the development of isolated preantral follicles from fresh and vitrified mouse ovaries. Iran Biomed J. 2006;10(4):185-90.##Zhou XH, Wu YJ, Shi J, Zheng SS. Cryopreservation of human ovarian tissue: Comparison of novel direct cover vitrification and conventional vitrification. Cryobiology. 2010;60(2):101-5.##Chang HJ, Moon JH, Lee JR, Jee BC, Suh CS, Kim SH. Optimal condition of vitrification method for cryopreservation of human ovarian cortical tissues. J Obstet Gynaecol Res. 2011;37(8):1092-101.##Xiao Z, Wang Y, Li L, Luo S, Li SW. 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Quantification strategies in real-time PCR. In: Bustin SA, editor. AZ of quantitative PCR. USA: International University Line; 2004. p. 89-113.##Gandolfi F, Paffoni A, Papasso Brambilla E, Bonetti S, Brevini TA, Ragni G. Efficiency of equilibrium cooling and vitrification procedures for the cryopreservation of ovarian tissue: comparative analysis between human and animal models. Fertil Steril. 2006;85 Suppl 1:1150-6.##Rahimi G, Isachenko V, Todorov P, Tawadros S, Mallmann P, Nawroth F, et al. Apoptosis in human ovarian tissue after conventional freezing or vitrification and xenotransplantation. Cryo Lett. 2009;30(4):300-9.##Dalman A, Deheshkar Gooneh Farahani NS, Totonchi M, Pirjani R, Ebrahimi B, Rezazadeh Valojerdi M. Slow freezing versus vitrification technique for human ovarian tissue cryopreservation: an evaluation of histological changes, WNT signaling pathway and apoptotic genes expression. Cryobiology. 2017;79:29-36.##Brodowska A, Laszczyńska M, Starczewski A. Apoptosis in ovarian cells in postmenopausal women. Folia Histochem Cytobiol. 2007;45(2):99-105.##Abir R, Fisch B, Jin S, Barnnet M, Freimann S, Van den Hurk R, Feldberg D, et al. Immunocytochemical detection and RT–PCR expression of leukaemia inhibitory factor and its receptor in human fetal and adult ovaries. Mol Hum Reprod. 2004;10(5):313-9.##Da Nóbrega JE, Gonçalves PBD, Chaves RN, Magalhaes DdM, Rossetto R, Lima-Verde IB, et al. Leukemia inhibitory factor stimulates the transition of primordial to primary follicle and supports the goat primordial follicle viability in vitro. Zygote-The Biology of Gametes and Early Embryos. 2012;20(1):73-8.##Haidari K, Salehnia M, Rezazadeh Valojerdi M. The effect of leukemia inhibitory factor and coculture on the in vitro maturation and ultrastructure of vitrified and nonvitrified isolated mouse preantral follicles. Fertil Steril. 2008;90(6):2389-97.##Kong HS, Kim EJ, Youm HW, Kim SK, Lee JR, Suh CS, et al. 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Evaluating the Potential of Three Sperm Surface Antigens as Egg-adhesion Biomarkers for Human Sperm Selection 2 1 2 Background: The selection of sperm with good genomic integrity and surface antigens is suggested for improving assisted reproductive technology (ART) outcome. The aim of this study was evaluating the heat shock protein (HSPA2), Dj-1 and serum amyloid P compound (SAP) three sperm surface proteomes as biomarkers for this purpose. Methods: In this study, semen samples were obtained from 114 men who presented at Avicenna Fertility Clinic for their treatment. The semen characteristics, DNA fragmentation Index (DFI), chromatin maturation index (CMI), biomarker levels, and their embryo quality were considered. The paired-samples t-test and independent-samples t-test were used for analyzing the data and p-values<0.05 were considered significant. Results: Outcomes exhibited the major reduction in HSPA2, DJ-1 and SAP following reduction in sperm quality and DNA integrity (p<0.001) with cut-off value of 14% (HSPA2), 12% (DJ-1) and 10% (SAP). The specificity of these three biomarkers was 95.2, 73.8 and 88.1%, respectively. Also, DFI (p<0.001), CMI (p<0.05), cleavage (p<0.05), and embryos quality (p<0.001) decreased significantly in abnormal spermiogram (ANS) group in compared with normal spermiogram (¬NS) group. It was shown that DFI was 97.1% in HSPA2, 76.5% in DJ-1 and 94.1% in SAP, and CMI was 95.0%, 75.50% and 87.5%, respectively. The significant correlation was found between of the three biomarkers and CMI (p<0.001), DFI (p<0.001) and embryos quality (p<0.001). Conclusion: By comparing the efficiency of these three biomarkers for selecting sperm with the lowest level of chromatin damages, it seems that selection based on HSPA2 has significance over others. 203 211 Mahnaz M Heidari مهناز حیدری Department of Embryology and Andrology, Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Department of Embryology and Andrology, Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Sara S Darbandi Department of Embryology and Andrology, Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Department of Embryology and Andrology, Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Mahsa M Darbandi Department of Embryology and Andrology, Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Department of Embryology and Andrology, Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Naser N Amirjanati Department of Andrology, Avicenna Fertility Clinic Department of Andrology, Avicenna Fertility Clinic Iran Mahmood M Bozorgmehr محمود بزرگمهر Department of Monoclonal Antibody Research Center, Avicenna Research Institute (ARI), ACERCR Department of Monoclonal Antibody Research Center, Avicenna Research Institute (ARI), ACERCR Iran Hojjat H Zeraati حجت زراعتی Department of Epidemiology and Biostatistics, Tehran University of Medical Sciences, TUMS Department of Epidemiology and Biostatistics, Tehran University of Medical Sciences, TUMS Iran Mohammad Mehdi MM Akhondi محمدمهدی آخوندی Department of Embryology and Andrology, Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Department of Embryology and Andrology, Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR Iran Mohammad Reza MR Sadeghi محمدرضا صادقی Monoclonal Antibody Research Center, Avicenna Research Institute, ACERCR Monoclonal Antibody Research Center, Avicenna Research Institute, ACERCR Iran DJ-1Heat shock protein A2Serum amyloid P componentSperm DNA 30037.pdf Seli E, Sakkas D. 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Investigation of the association between the outcomes of sperm chromatin condensation and decondensation tests, and assisted reproduction techniques. Andrologia. 2015;47(4):438-47.##Naaby-Hansen S, Herr JC. Heat shock proteins on the human sperm surface. J Reprod Immunol. 2010;84(1):32-40.##Berteli TS, Da Broi MG, Martins WP, Ferriani RA, Navarro PA. Magnetic-activated cell sorting before density gradient centrifugation improves recovery of high-quality spermatozoa. Andrology. 2017;5(4):776-82.##Erberelli RF, Salgado RM, Pereira DH, Wolff P. Hyaluronan-binding system for sperm selection enhances pregnancy rates in ICSI cycles associated with male factor infertility. JBRA Assist Reprod. 2017;21(1):2-6.##Razavi S, Nasr‐Esfahani M, Deemeh M, Shayesteh M, Tavalaee M. Evaluation of zeta and HA‐binding methods for selection of spermatozoa with normal morphology, protamine content and DNA integrity. Andrologia. 2010;42(1):13-9.##Simon L, Ge SQ, Carrell DT. 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Free Radic Res. 2001;35(6):885-93.##Taira T, Saito Y, Niki T, Iguchi‐Ariga SM, Takahashi K, Ariga H. DJ‐1 has a role in antioxidative stress to prevent cell death. EMBO Rep. 2004;5(2):213-8.##Takahashi K, Taira T, Niki T, Seino C, Iguchi-Ariga SM, Ariga H. DJ-1 positively regulates the androgen receptor by impairing the binding of PIASx alpha to the receptor. J Biol Chem. 2001;276(40):37556-63.##Bickerstaff M, Botto M, Hutchinson W, Herbert J, Tennent G, Bybee A, et al. Serum amyloid P component controls chromatin degradation and prevents antinuclear autoimmunity. Nat Med. 1999;5(6):694-7.##World Health Organization. WHO laboratory manual for the examination and processing of human semen. 5th ed. Geneva: World Health Organization. 2010. 286 p.##Torki-Boldaji B, Tavalaee M, Bahadorani M, Nasr-Esfahani MH. Selection of physiological spermatozoa during intracytoplasmic sperm injection. Andrologia. 2017;49(1).##Shamsi MB, Imam SN, Dada R. Sperm DNA integrity assays: diagnostic and prognostic challenges and implications in management of infertility. J Assist Reprod Genet. 2011;28(11):1073-85.##Evenson DP, Larson KL, Jost LK. Sperm chromatin structure assay: its clinical use for detecting sperm DNA fragmentation in male infertility and comparisons with other techniques. J Androl. 2002;23(1):25-43.##Wu YM, Xia XY, Pan LJ, Shao Y, Jin BF, Huang YF, et al. [Evaluation of sperm mitochondrial function using Rh123/PI dual fluorescent staining]. Zhonghua Nan Ke Xue. 2006;12(9):803-6. Chinese.##Kim JY, Kim JH, Jee BC, Lee JR, Suh CS, Kim SH. Can intracytoplasmic sperm injection prevent total fertilization failure and enhance embryo quality in patients with non-male factor infertility? Eur J Obstet Gynecol Reprod Biol. 2014;178:188-91.##Spinaci M, Volpe S, Bernardini C, De Ambrogi M, Tamanini C, Seren E, et al. Immunolocalization of heat shock protein 70 (Hsp 70) in boar spermatozoa and its role during fertilization. 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The Study of Association Between Polymorphism of TNF-α Gene’s Promoter Region and Recurrent Pregnancy Loss 2 1 2 Background: According to the literature review, polymorphisms of tumor necrosis factor alpha’s (TNF-α) promoter region are probably the genetic risk factors of recurrent pregnancy loss. This study has investigated five single nucleotide polymorphisms in the TNF-α gene’s promoter region to evaluate their relationship with recurrent pregnancy loss disorder. Methods: Blood samples were taken from 65 women with recurrent pregnancy loss (Case group) and 65 healthy women with a history of successful pregnancy (Control group). Polymerase chain reaction with high resolution melting (PCR-HRM) analysis was done to determine the promoter region of -308G/A, -850T/C, -238G/A, -1031T/C and -863A/C TNF-α polymorphisms. The data were assessed using logistic regression models. P values less than 0.05 were considered statistically significant. Results: Significant associations were found between recurrent pregnancy loss and -863C/A (p=0.000), -308G/A (p=0.045), and -238G/A (p=0.034) polymorphisms. TNF-α polymorphisms of -863C and -238G may be susceptible factors of recurrent pregnancy loss cases. The -308G polymorphism has an important role in maintaining pregnancy. Conclusion: The -863C/A and -238G/A TNF-α polymorphisms are possible genetic risk factors of recurrent pregnancy loss and might be its predictive markers. 211 219 Roshanak R Aboutorabi روشنک ابوترابی Infertility Laboratory, Beheshti Hospital, School of Medicine, Isfahan University of Medical Sciences Infertility Laboratory, Beheshti Hospital, School of Medicine, Isfahan University of Medical Sciences Iran Ehsan E Behzadi School of Medicine, Isfahan University of Medical Sciences School of Medicine, Isfahan University of Medical Sciences Iran Mohammad Javad MJ Sadegh School of Medicine, Isfahan University of Medical Sciences School of Medicine, Isfahan University of Medical Sciences Iran Seyed Pooriya SP Fatehi School of Medicine, Isfahan University of Medical Sciences School of Medicine, Isfahan University of Medical Sciences Iran Soroosh S Semsarzadeh School of Medicine, Isfahan University of Medical Sciences School of Medicine, Isfahan University of Medical Sciences Iran Yasaman Y Zarrin School of Medicine, Isfahan University of Medical Sciences School of Medicine, Isfahan University of Medical Sciences Iran Mohammad M Kazemi Department of Genetics, School of Medicine, Isfahan University of Medical Sciences Department of Genetics, School of Medicine, Isfahan University of Medical Sciences Iran Laleh L Rafiee Applied Physiology Research Center, Isfahan University of Medical Sciences Applied Physiology Research Center, Isfahan University of Medical Sciences Iran Fatemeh Sadat FS Mostafavi Infertility Laboratory, Beheshti Hospital, School of Medicine, Isfahan University of Medical Sciences Infertility Laboratory, Beheshti Hospital, School of Medicine, Isfahan University of Medical Sciences Iran fs.mostafavi@gmail.com PolymorphismRecurrent Pregnancy LossTumor necrosis factor alpha 30033.pdf Cohn D, Goddijn M, Middeldorp S, Korevaar J, Dawood F, Farquharson R. Recurrent miscarriage and antiphospholipid antibodies: prognosis of subsequent pregnancy. J Thromb Haemost. 2010;8(10):2208-13.##Wilcox AJ, Weinberg CR, O'Connor JF, Baird DD, Schlatterer JP, Canfield RE, et al. Incidence of early loss of pregnancy. N Engl J Med. 1988;319(4):189-94.##Coulam CB, Clark DA, Beer AE, Kutteh WH, Silver R, Kwak J, et al. Current clinical options for diagnosis and treatment of recurrent spontaneous abortion. Am J Reprod Immunol. 1997;38(2):57-74.##Jauniaux E, Farquharson RG, Christiansen OB, Exalto N. Evidence-based guidelines for the investigation and medical treatment of recurrent miscarriage. Hum Reprod. 2006;21(9):2216-22.##Louis JF, Thoma ME, Sørensen DN, McLain AC, King RB, Sundaram R, et al. The prevalence of couple infertility in the United States from a male perspective: evidence from a nationally representative sample. Andrology. 2013;1(5):741-8.##Jaslow CR, Carney JL, Kutteh WH. Diagnostic factors identified in 1020 women with two versus three or more recurrent pregnancy losses. Fertil Steril. 2010;93(4):1234-43.##American Society for Reproductive Medicine. Patient’s fact sheet: recurrent pregnancy loss. Birmingham, Alabama: American Society for Reproductive Medicine, 2008.##Sierra S, Stephenson M. Genetics of recurrent pregnancy loss. Semin Reprod Med. 2006;24(1):17-24.##Practice Committee of the American Society for Reproductive Medicine. Evaluation and treatment of recurrent pregnancy loss: a committee opinion. Fertil Steril. 2012;98(5):1103-11.##Royal college of obstetricians and gynaecologists. The investigation and treatment of couples with recurrent miscarriage. UK: Royal college of obstetricians and gynaecologists. Scientific Advisory Committee. 2011. Guideline No.:17.##Parveen F, Agrawal S. A study of forty‐seven single nucleotide polymorphisms among recurrent miscarriage using classification and regression tree analysis. Am J Reprod Immunol. 2013;70(6):529-37.##Choudhury SR, Knapp LA. Human reproductive failure I: immunological factors. Hum Reprod Update. 2001;7(2):113-34.##Bansal AS. Joining the immunological dots in recurrent miscarriage. Am J Reprod Immunol. 2010;64(5):307-15.##Saini V, Arora S, Yadav A, Bhattacharjee J. Cytokines in recurrent pregnancy loss. Clin Chim Acta. 2011;412(9-10):702-8.##Niederkorn JY. See no evil, hear no evil, do no evil: the lessons of immune privilege. Nat Immunol. 2006;7(4):354-9.##Challis JR, Lockwood CJ, Myatt L, Norman JE, Strauss JF 3rd, Petraglia F. Inflammation and pregnancy. Reprod Sci. 2009;16(2):206-15.##Piccinni MP, Beloni L, Livi C, Maggi E, Scarselli G, Romagnani S. Defective production of both leukemia inhibitory factor and type 2 T-helper cytokines by decidual T cells in unexplained recurrent abortions. Nat Med. 1998;4(9):1020-4.##Raghupathy R. Th1-type immunity is incompatible with successful pregnancy. Immunol Today. 1997;18(10):478-82.##Chaouat G, Lédée‐Bataille N, Zourbas S, Ostojic S, Dubanchet S, Martal J, et al. Cytokines, implantation and early abortion: re‐examining the Th1/Th2 paradigm leads to question the single pathway, single therapy concept. Am J Reprod Immunol. 2003;50(3):177-86.##Daher S, de Arruda Geraldes Denardi K, Blotta MH, Mamoni RL, Reck AP, Camano L, et al. Cytokines in recurrent pregnancy loss. J Reprod Immunol. 2004;62(1):151-7.##Wegmann TG, Lin H, Guilbert L, Mosmann TR. Bidirectional cytokine interactions in the maternal-fetal relationship: is successful pregnancy a TH2 phenomenon? Trends Immunol. 1993;14(7):353-6.##Saito S, Nakashima A, Shima T, Ito M. Th1/Th2/Th17 and regulatory T‐cell paradigm in pregnancy. Am J Reprod Immunol. 2010;63(6):601-10.##Moller DE. Potential role of TNF-α in the pathogenesis of insulin resistance and type 2 diabetes. Trends Endocrinol Metab. 2000;11(6):212-7.##Giannubilo SR, Landi B, Pozzi V, Sartini D, Cecati M, Stortoni P, et al. The involvement of inflammatory cytokines in the pathogenesis of recurrent miscarriage. Cytokine. 2012;58(1):50-6.##Kolte AM, Nielsen HS, Moltke I, Degn B, Pedersen B, Sunde L, et al. A genome-wide scan in affected sibling pairs with idiopathic recurrent miscarriage suggests genetic linkage. Mol Hum Reprod. 2011;17(6):379-85.##Hehlgans T, Pfeffer K. The intriguing biology of the tumour necrosis factor/tumour necrosis factor receptor superfamily: players, rules and the games. Immunology. 2005;115(1):1-20.##Hanna J, Goldman-Wohl D, Hamani Y, Avraham I, Greenfield C, Natanson-Yaron S, et al. Decidual NK cells regulate key developmental processes at the human fetal-maternal interface. Nat Med. 2006;12(9):1065-74.##Weng L, Macciardi F, Subramanian A, Guffanti G, Potkin SG, Yu Z, et al. SNP-based pathway enrichment analysis for genome-wide association studies. BMC Bioinformatics. 2011;12:99.##Babbage SJ, Arkwright PD, Vince GS, Perrey C, Pravica V, Quenby S, et al. Cytokine promoter gene polymorphisms and idiopathic recurrent pregnancy loss. J Reprod Immunol. 2001;51(1):21-7.##Jang HG, Choi Y, Kim JO, Jeon YJ, Rah H, Cho SH, et al. Polymorphisms in tumor necrosis factor-alpha (-863C>A, -857C>T and 488G>A) are associated with idiopathic recurrent pregnancy loss in Korean women. Hum Immunol. 2016;77(6):506-11.##Sariban E, Imamura K, Luebbers R, Kufe D. Transcriptional and posttranscriptional regulation of tumor necrosis factor gene expression in human monocytes. J Clin Invest. 1988;81(5):1506-10.##Abutorabi R, Baradaran A, Mostafavi FS, Zarrin Y, Mardanian F. Evaluation of tumor necrosis factor alpha polymorphism frequencies in endometriosis. Int J Fertil Steril. 2015;9(3):329-37.##Lee BE, Jeon YJ, Shin JE, Kim JH, Choi DH, Jung YW, et al. Tumor necrosis factor-α gene polymorphisms in Korean patients with recurrent spontaneous abortion. 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Plasma TNF‐α levels are higher in early pregnancy in patients with secondary compared with primary recurrent miscarriage. Am J Reprod Immunol. 2013;70(5):347-58.##Daher S, Shulzhenko N, Morgun A, Mattar R, Rampim GF, Camano L, et al. Associations between cytokine gene polymorphisms and recurrent pregnancy loss. J Reprod Immunol. 2003;58(1):69-77.##Prigoshin N, Tambutti M, Larriba J, Gogorza S, Testa R. Cytokine gene polymorphisms in recurrent pregnancy loss of unknown cause. Am J Reprod Immunol. 2004;52(1):36-41.##Finan RR, Al-Irhayim Z, Mustafa FE, Al-Zaman I, Mohammed FA, Al-Khateeb GM, et al. Tumor necrosis factor-α polymorphisms in women with idiopathic recurrent miscarriage. J Reprod Immunol. 2010;84(2):186-92.##Liu RX, Wang Y, Wen LH. Relationship between cytokine gene polymorphisms and recurrent spontaneous abortion. Int J Clin Exp Med. 2015;8(6):9786-92.##Zammiti W, Mtiraoui N, Finan RR, Almawi WY, Mahjoub T. Tumor necrosis factor α and lymphotoxin α haplotypes in idiopathic recurrent pregnancy loss. Fertil Steril. 2009;91(5):1903-8.##

Association of Growth Factors Genes with Miscarriage 2 1 2 Background: The study was aimed to investigate the association of VEGFA gene polymorphic variants -2578C>A (rs699947) and -634G>C (rs2010963) and TGFB1 gene 915G>C (rs1800471) and gene expression level with miscarriage in the first trimester. Methods: 288 women with different courses of pregnancy and 61 chorionic tissue samples were involved in case-control study. Allele-specific polymerase chain reaction in real time was used for genotyping. Next, gene-gene interactions were analyzed using the multifactor dimensionality reduction method. VEGFA and TGFВ1 genes expression levels were determined by RT-PCR. Results: It was found that SNP rs699947 was associated with the miscarriage risk change (p=0.05). The CC genotype was associated with reduced risk of abortion in the first trimester, and the CA genotype with increased risk. Genotypes VEGFA -2578CС/VEGFА -634CG, VEGFA -2578AА/VEGFА -634CG, and VEGFA -2578CС/VEGFА -634CG/TGFВ1 936CC were associated with lowered risk of miscarriage in the first trimester. mRNA level of TGFВ1 was significantly higher in decidual tissue compared to chorionic tissue in normally progressing pregnancy (p=0.003). VEGFA gene expression level was directly correlated with the TGFВ1 mRNA level (R=0.60; р=0.038). In pregnancy loss, an inverse relationship was observed (R=-0.76; р=0.028). Conclusion: The SNP rs699947 is associated with pregnancy loss in the first trimester. The MDR analysis data showed the significant relationship between VEGFA and TGFB1 genes in two-locus and three-locus models. A change in the ratio of the concentrations of growth factors can disrupt the processes of cell division, apoptosis and angiogenesis processes. 219 229 Tatiana TA Marakhovskaya Department of Genetics, Southern Federal University Department of Genetics, Southern Federal University Russia tmarakhovskaya@mail.ru Elena EV Butenko Department of Genetics, Southern Federal University Department of Genetics, Southern Federal University Russia Konstantin KA Kovalenko Department of Genetics, Southern Federal University Department of Genetics, Southern Federal University Russia Elena EV Mashkina Department of Genetics, Southern Federal University Department of Genetics, Southern Federal University Russia Chorionic tissueDeciduaGene expressionGene polymorphic variantsGrowth factorsMiscarriage 30035.pdf Graham СН, Lysiak JJ, McCrae KR, Lala PK. Localization of transforming growth factor-beta at the human fetal-maternal interface: role in trophoblast growth and differentiation. 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Development and Psychometric Properties of Menstrual Health Seeking Behaviors Questionnaire (MHSBQ-42) in Female Adolescents 2 1 2 Background: Lack of accurate menstrual knowledge, attitude, and practices leave female adolescents ignorant of the necessary health behaviors during menstruation. This study aimed to develop a menstrual health-seeking behavior questionnaire based on the theory of planned behavior to evaluate its psychometric properties in female adolescents in Tehran. Methods: This study was conducted on 578 female adolescents aged 12-15 years in Tehran. The first draft of the menstrual health-seeking behavior questionnaire containing 52 items was developed based on the theory of planned behavior (TPB). The content and face validity of the questionnaire was assessed by a panel of experts. Construct validity was also assessed using exploratory factor analysis (KMO=0.73) with varimax rotation. Cranach's alpha and test-retest were used to examine the reliability of the questionnaire. All statistical analysis was performed using SPSS 23.0 and AMOS 23.0. Results: The content and face validity of the 42 items were finally confirmed. Content validity index was greater than 0.73 for all six TPB constructs. Explanatory factor analysis yielded an acceptable fit for the six-factor model (RMSE=0.053, 95% CI 0.042-0.064). These factors jointly explained 65% of the variance in the outcome variables. Cranach's alpha coefficients ranged from 0.79 to 0.91, demonstrating an excellent internal consistency and high reliability of the questionnaire. Test-retest reliability was also satisfactory for all items (ICC=0.86-0.94). Conclusion: The results illustrate that the menstrual health-seeking behavior questionnaire is psychometrically adequate and highly reliable. This theoretically grounded questionnaire can be well applied in future interventions for female adolescents to assess their menstrual health-related knowledge, attitude, and practices. 229 237 Fatemeh F Darabi Department of Public Health, Asadabad School of Medical Sciences Department of Public Health, Asadabad School of Medical Sciences Iran Mehdi M Yaseri Department of Epidemiology and Biostatistics, Tehran University of Medical Sciences, TUMS Department of Epidemiology and Biostatistics, Tehran University of Medical Sciences, TUMS Iran Alireza AR Rohban Department of Rehabilitation Management, School of Rehabilitation Sciences, Iran University of Medical Sciences Department of Rehabilitation Management, School of Rehabilitation Sciences, Iran University of Medical Sciences Iran Farideh F Khalajabadi-Farahani Department of Population & Health, National Population Studies & Comprehensive Management Institute Department of Population & Health, National Population Studies & Comprehensive Management Institute Iran faridehfarahani2@gmail.com; farideh.farahani@psri.ac.ir Female adolescentsMenstrual healthPsychometricQuestionnaireTehran 30032.pdf McGrory A. Education for the menarche. Pediatr Nurs. 1995;21(5):439-40; 43.##Bahrami N, Soleimani MA, Chan YH, Ghojazadeh M, Mirmiran P. Menarche age in Iran: A meta-analysis. Iran J Nurs Midwifery Res. 2014;19(5):444-50.##Alavi M, Poushaneh K, Khosravi A. Puberty health: knowledge, attitude and practice of the adolescent girls in Tehran, Iran. 2009;8(1):59-65.##Mosavi SA, Babazadeh R, Najmabadi KM, Shariati M. Assessing Iranian adolescent girls' needs for sexual and reproductive health information. J Adolesc Health. 2014;55(1):107-13.##Chrisler JC. Teaching taboo topics: menstruation, menopause, and the psychology of women. Psychol Women Q. 2013;37(1):128-32.##Costos D, Ackerman R, Paradis L. Recollections of menarche: Communication between mothers and daughters regarding menstruation. Sex Roles. 2002;46(1-2):49-59.##Dasgupta A, Sarkar M. Menstrual hygiene: how hygienic is the adolescent girl? Indian J Community Med. 2008;33(2):77-80.##Delaney J, Lupton MJ, Toth E. 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Veiled Truths: Iranian Women and Risky Sexual Behavior in the Context of Substance Use 2 1 2 Background: Substance use disorders and risky sexual behavior coexist for some women. Explanatory models of women's sexuality in the context of substance use are under study. This study aimed to explore how women’s sexual behavior can become risky in the context of substance use. Methods: In this ethnographic inquiry, 25 women with substance use disorders (SUDs) were included at two Drop-In-Centers (DICs) in South Tehran. Observation, semi-structured interviews and field notes were used to collect data. Qualitative content analysis was used to attain the explanatory model of women’s sexual behaviors in the context of substance use. Results: Three major themes emerged from the data analysis regarding their lives in the context of substance use; 1) life in the context of drug abuse, 2) negative self-perception, and 3) strive to survive. Subthemes were identified as loss of contact with family, social stigma, self-forgetfulness, worthlessness, low self-efficacy, and unsafe sexual context. Conclusion: Findings suggest that women with SUDs are highly interwoven with women’s sexual health, facilitating a shift towards risky behaviors. Integration of safe sexual skills building programs with substance use treatment is needed. 237 247 Effat E Merghati Khoei Iranian National Center for Addiction Studies (INCAS), Institution of Risk Behavior Reduction, Tehran University of Medical Sciences Iranian National Center for Addiction Studies (INCAS), Institution of Risk Behavior Reduction, Tehran University of Medical Sciences Iran Mansoureh M Jamshidimanesh School of Nursing and Midwifery, Iran University of Medical Sciences School of Nursing and Midwifery, Iran University of Medical Sciences Iran jamshidimanesh@yahoo.com Mohammad Hassan MH Emamian Center for Health Related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences Center for Health Related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences Iran Fatemeh F Sheikhan Department of Midwifery, Khalkhal Branch, Islamic Azad University Department of Midwifery, Khalkhal Branch, Islamic Azad University Iran Kate K Dolan National Drug and Alcohol Research Centre, University of NSW National Drug and Alcohol Research Centre, University of NSW Australia Kathleen K Brady Department of Psychiatry and Behavioral Sciences, The Medical University of South Carolina (MUSC) Department of Psychiatry and Behavioral Sciences, The Medical University of South Carolina (MUSC) USA Drug abuseEthnographyIranian womenQualitative inquirySexual risk behaviors 30034.pdf Evans EA, Grella CE, Washington DL, Upchurch DM. 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An Unusual Presentation of Endometriosis as an Ileocolic Intussusception with Cecal Mass: A Case Report 2 1 2 Background: Bowel endometriosis affects about 3.8-37% of women with endometriosis diagnosis. Most of the time endometriosis involves the recto-sigmoid .Right colon involvement is not common in endometriosis and also a few studies have reported obstructive endometriosis of bowel. Here, a case of endometriosis was reported with the ileocolic intussusception and cecal mass. Case Presentation: A 32y old woman was referred to Yas hospital due to severe low abdominal pain and vomiting. Ultrasonographic examination of her pelvis revealed bilateral ovarian cysts. Abdominal erect X-ray showed dilatation of small bowel segments. Diagnostic colonoscopy showed one small ulcer with the pressure effect of mass like lesion at cecum. The patient was taken to the operating room for excision of the mass; as a result the ileocolic intussusception was seen. After reduction, a firm mass was recognized at cecum so the ileocecal resection was performed. In pathologic examination of mass, endometriosis was reported. The postoperative period was uneventful. Conclusion: The diagnosis of bowel endometriosis is sometimes difficult. The case of bowel obstructive endometriosis is rare. Surgical excision of bowel endometriosis is necessary for symptomatic patients with bowel obstruction. Bowel endometriotic nodules are excised by nodulectomy or segmental resection. 247 250 Neda N Nozari Gastrointestinal Ward, Yas Hospital, Tehran University of Medical Sciences Gastrointestinal Ward, Yas Hospital, Tehran University of Medical Sciences Iran nozari_neda@yahoo.com Maryam M Shafiei Department of Surgery, Yas Hospital, Tehran University of Medical Sciences Department of Surgery, Yas Hospital, Tehran University of Medical Sciences Iran Soheila S Sarmadi Department of Pathology, Yas Hospital, Tehran University of Medical Sciences Department of Pathology, Yas Hospital, Tehran University of Medical Sciences Iran BowelEndometriomaEndometriosisIntestinal obstruction 10025.pdf Kim KJ, Jung SS, Yang SK, Yoon SM, Yang DH, Ye BD, et al. Colonoscopic findings and histologic diagnostic yield of colorectal endometriosis. J Clin Gastroenterol. 2011;45(6):536-41.##Eljuga D, Klarić P, Grbavac I, Kuna K. Abdominal wall endometriosis: case report. Acta Clin Croat. 2012;51(2):261-3.##Paramythiotis D, Stavrou G, Panidis S, Panagiotou D, Chatzopoulos K, Papadopoulos VN, et al. Concurrent appendiceal and umbilical endometriosis: a case report and review of the literature. J Med Case Rep. 2014;8:258.##Ferrero S, Camerini G, Maggiore UL, Venturini PL, Biscaldi E, Remorgida V. Bowel endometriosis: recent insights and unsolved problems. World J Gastrointest Surg. 2011;3(3):31-8.##Ono H, Honda S, Danjo Y, Nakamura K, Okabe M, Kimura T, et al. Rectal obstruction due to endometriosis: A case report and review of the Japanese literature. Int J Surg Case Rep. 2014;5(11):845-8.##Soumekh A, Nagler J. Gastrointestinal endometriosis causing subacute intestinal obstruction with gradual development of weight loss and misdiagnosed as irritable bowel syndrome. Case Rep Gastroenterol. 2014;8(1):51-5.##Ling CM, Lefebvre G. Extrapelvic endometriosis: a case report and review of the literature. J Soc Obstet Gynaecol Can. 2000;22(2):97-100.##Seaman H, Ballard K, Wright J, de Vries C. Endometriosis and its coexistence with irritable bowel syndrome and pelvic inflammatory disease: findings from a national case control study Part 2. BJOG. 2008;115(11):1392-6.##Hsu AL, Khachikyan I, Stratton P. Invasive and non-invasive methods for the diagnosis of endometriosis. Clin Obstet Gynecol. 2010;53(2):413-9.##Milone M, Mollo A, Musella M, Maietta P, Sosa Fernandez LM, Shatalova O, et al. Role of colonoscopy in the diagnostic work-up of bowel endometriosis. World J Gastroenterol. 2015;21(16):4997-5001.##Redwine DB. Ovarian endometriosis: a marker for more extensive pelvic and intestinal disease. Fertil Steril. 2015;72(2):310-5.##Remorgida V, Ferrero S, Fulcheri E, Ragni N, Martin DC. Bowel endometriosis: presentation, diagnosis, and treatment. Obstet Gynecol Surv. 2007;62(7):461-70.##