Do We Have the Right to Challenge the Rules of Nature Using Science and Technology Tools? 2 1 2 This month, newspapers and websites released the news referring to the birth of twin girls by the world's oldest mother. A 74-year-old Indian woman and an 82-year-old Indian man, who have been married for 57 years were treated after 30 years of postmenopause. She became pregnant using donated eggs at an infertility clinic in Guntur, India. This treatment resulted in delivery of twin girls (1). This news disseminated confusion and received blame from medical policy makers, ethicists, lawyers and physicians, that why third-party infertility treatment should be ordered to such aged couple and debates about the future of children. Interestingly, and perhaps unfortunately, the report states that one day after the birth of these babies, her husband had heart attack, admitted to intensive care unit, besides the mother who was at special care in this unit due to the complications of pregnancy and twin delivery. In addition, numerous extremely old cases have been reported to give birth to live babies previously; for example, in 2008, a pregnant woman, named Omkari Panwar, in India aged 70 or 72 years had live birth. However, her age was not confirmed due to the lack of a formal birth certificate. In 2016, another Indian woman, Daljinder Kaur, delivered a boy at the age of 72 (1). According to literature, an egg donation pregnancy resulted in multiple gestations at age 50. Immediately following delivery, hypertension was observed with nausea and vomiting. A few hours later, the case was diagnosed with HELLP syndrome and died of cerebral hemorrhage (2). Similar to the above case, in most of these cases, the mothers died shortly after delivery due to pregnancy and delivery complications or even other illnesses such as cancer. Nature has restricted the life span of a woman's reproduction, but advances in science and technology can improve chances of getting pregnant through hormone replacement therapy and eggs or embryos donation, or even the preservation of the eggs or embryos of mothers at younger age. Furthermore, human pregnancy beyond the biological barriers is unnatural. The fact that some grandparents successfully take care of their grandchildren is not essentially sufficient to justify the use of reproductive technologies for pregnancy in post-menopausal women after 50 (3). In fact, these grandparents, who are now parents of children, are unable to supply the psychological, economic, and physical demands of these children and maintain long-term parenting relationships. In addition, in most cases reported these children lost one or both parents before they reached adolescence which is the most stressful event of life that is beyond the endurance of children and adolescents. In addition, another problem with these pregnancies is the advanced paternal age, which is associated with increased birth anomalies and congenital disabilities due to genetic defects, as well as an increased risk of autism and schizophrenia (3). Therefore, egg and embryo donations should be discouraged for older women who are also suffering from medical problems by providing extensive counseling that these risks are exacerbated by pregnancy and childbirth. Since the large numbers of medical problems are pregnancy-related, especially following multiple pregnancies, elective single embryo transfer (eSET) should be an unchanging rule for all ART services for pregnancy at advanced age. The menopausal practitioner and obstetricians should provide more realistic insights about the evidence-based facts of maternal, fetal and neonate risks in pregnancy at advanced age. Clinicians should also advise the couples that you are at risk of not having a baby whenever you decide to delay your pregnancy and childbirth. There is no comprehensive guideline for maternal health of over aged candidates for pregnancy, although the American Society for Reproductive Medicine (ASRM) has stated that healthy women over 50 who have conceived through egg donation are at high gestational risks. Therefore, it is recommended that over aged women be prohibited from receiving this service (4). Although we recognize the obvious complications of pregnancy and childbirth of very old mothers as well as some of complications in their infants, we have no knowledge or prognosis of the long-term health consequences of these children at adulthood and geriatric era. Finally, in the creation of universe, the restriction of women’s reproductive period provided wisdom and rational reasons, but we have come to the war of nature with the tools of science and technology. However, we must consider the fact that in similar cases, such as damaging the nature and environment ecology, we have witnessed the consequences of such activities for a long time which make us to contemplate and regret for all previous deed. Thus we need to respect the rules of nature and limit our challenges. 199 201 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 60063.pdf Rhys Blakely. World’s oldest new mother has twins at the age of 74 in India. The Times. 2019 Sept 7.##Schutte JM, Schuitemaker NW, Steegers EA, van Roosmalen J; Dutch Maternal Mortality Committee. Maternal death after oocyte donation at high maternal age: case report. Reprod Health. 2008;5:12.##Ethics committee of the American society for reproductive medicine. Oocyte or embryo donation to women of advanced reproductive age: an Ethics Committee opinion. Fertil Steril. 2016;106(5):e3-e7.##Sauer MV. Reproduction at an advanced maternal age and maternal health. Fertil Steril. 2015;103(5):1136-43.##

Fertility Preservation in Benign Gynecological Diseases: Current Approaches and Future Perspectives 2 1 2 Although fertility preservation is a growing topic in the management of oncological diseases, different benign gynecological pathologies are able to compromise the ovarian reserve due to mechanisms related to the pathology itself or secondary to the performed treatments. Endometriosis, benign ovarian tumors, adnexal torsion, familiarity and genetic syndromes are all benign conditions that can compromise the ovarian reserve. Endometriosis and particularly endometriomas provide a direct damage to ovarian reserve, with different mechanisms, and an indirect damage related to surgery. Similarly, benign ovarian tumors can provide a detrimental effect on ovarian reserve for the surgical treatment, especially for bilateral or recurrent tumors, and in case of secondary adnexal torsion with late diagnosis. Different fertility preservation options are available and should be considered particularly in cases with bilateral or recurrent pathology and/or surgery. In general, the identification of patients at risk of early ovarian failure, for benign gynecological disease or based on known genetic causes or familiarity, is of paramount importance in order to apply fertility preservation techniques before the complete depletion of ovarian reserve. 201 209 Zaki Z Sleiman Lebanese American University, Department of Obstetrics and Gynecology Lebanese American University, Department of Obstetrics and Gynecology Lebanon Erbil E Karaman Department of Obstetrics and Gynecology, Medical Faculty, Yuzuncu Yil University Department of Obstetrics and Gynecology, Medical Faculty, Yuzuncu Yil University Turkey Milan M Terzic Department of Obstetrics and Gynecology, National Research Center of Mother and Child Health, University Medical Center Department of Obstetrics and Gynecology, National Research Center of Mother and Child Health, University Medical Center Turkey Sanja S Terzic Department of Medicine, Nazarbayev University, School of Medicine Department of Medicine, Nazarbayev University, School of Medicine Kazakhstan Giovanni G Falzone Obstetrics and Gynaecology Unit, Umberto I Hospital Obstetrics and Gynaecology Unit, Umberto I Hospital Italy gio.falzone@alice.it Simone S Garzon Department of Obstetrics and Gynecology, Filippo Del Ponte Hospital, University of Insubria Department of Obstetrics and Gynecology, Filippo Del Ponte Hospital, University of Insubria Italy Benign ovarian tumorsCounselingEndometriosisFertility preservation 60056.pdf Donnez J, Dolmans MM. Fertility preservation in women. N Engl J Med. 2017;378(4):400-1.##Yasmin E, Balachandren N, Davies MC, Jones GL, Lane S, Mathur R, et al. Fertility preservation for medical reasons in girls and women: British fertility society policy and practice guideline. Hum Fertil (Camb). 2018;21(1):3-26.##Practice committee of the american society for reproductive medicine. testing and interpreting measures of ovarian reserve: a committee opinion. Fertil Steril. 2015;103(3):e9-e17.##Wallace WH, Kelsey TW. Human ovarian reserve from conception to the menopause. PLoS One. 2010;5(1):e8772.##Chiofalo B, Palmara V, Laganà AS, Triolo O, Vitale SG, Conway F, et al. Fertility sparing strategies in patients affected by placental site trophoblastic tumor. Curr Treat Options Oncol. 2017;18(10):58.##Vitale SG, Rossetti D, Tropea A, Biondi A, Laganà AS. Fertility sparing surgery for stage IA type I and G2 endometrial cancer in reproductive-aged patients: evidence-based approach and future perspectives. Updates Surg. 2017;69(1):29-34.##de Ziegler D, Borghese B, Chapron C. Endometriosis and infertility: pathophysiology and management. Lancet. 2010;376(9742):730-8.##Maniglio P, Ricciardi E, Meli F, Vitale SG, Noventa M, Vitagliano A, et al. Catamenial pneumothorax caused by thoracic endometriosis. Radiol Case Rep. 2017;13(1):81-5.##Burney RO, Giudice LC. Pathogenesis and pathophysiology of endometriosis. Fertil Steril 2012;98 (3):511-9.##Laganà AS, Vitale SG, Salmeri FM, Triolo O, Ban Frangež H, Vrtačnik-Bokal E, et al. Unus pro omnibus, omnes pro uno: a novel, evidence-based, unifying theory for the pathogenesis of endometriosis. Med Hypotheses. 2017;103:10-20.##Laganà AS, La Rosa VL, Rapisarda AMC, Valenti G, Sapia F, Chiofalo B, et al. Anxiety and depression in patients with endometriosis: impact and management challenges. Int J Womens Health. 2017;9:323-30.##Pope CJ, Sharma V, Sharma S, Mazmanian D. A systematic review of the association between psychiatric disturbances and endometriosis. J Obstet Gynaecol Can. 2015;37(11):1006-15.##Chen LC, Hsu JW, Huang KL, Bai YM, Su TP, Li CT, et al. Risk of developing major depression and anxiety disorders among women with endometriosis: a longitudinal follow-up study. J Affect Disord. 2016;190:282-5.##Vitale SG, La Rosa VL, Rapisarda AMC, Laganà AS. Impact of endometriosis on quality of life and psychological well-being. J Psychosom Obstet Gynaecol. 2017;38(4):317-9.##Duffy JM, Arambage K, Correa FJ, Olive D, Farquhar C, Garry R, et al. Laparoscopic surgery for endometriosis. Cochrane Database Syst Rev. 2014;(4):CD011031.##Raffaelli R, Garzon S, Baggio S, Genna M, Pomini P, Laganà AS, et al. Mesenteric vascular and nerve sparing surgery in laparoscopic segmental intestinal resection for deep infiltrating endometriosis. Eur J Obstet Gynecol Reprod Biol. 2018; 231:214-9.##Laganà AS, Vitale SG, Trovato MA, Palmara VI, Rapisarda AMC, Granese R, et al. Full-thickness excision versus shaving by laparoscopy for intestinal deep infiltrating endometriosis: rationale and potential treatment options. Biomed Res Int. 2016;2016:3617179.##Laganà AS, Garzon S, Franchi M, Casarin J, Gullo G. Translational animal models for endometriosis research: a long and windy road. Ann Transl Med. 2018;6(22):431.##Laganà AS, Salmeri FM, Vitale SG, Triolo O, Götte M. Stem cell trafficking during endometriosis: may epigenetics play a pivotal role? Reprod Sci. 2018;25(7):978-9.##Kitajima M, Defrre S, Dolmans MM, Colette S, Squifflet J, Van Langendonckt A, et al. Endometriomas as a possible cause of reduced ovarian reserve in women with endometriosis. Fertil Steril. 2011;96(3):685-91.##Skinner MK. Regulation of primordial follicle assembly and development. Hum Reprod Update. 2005;11(5):461-71.##Kitajima M, Dolmans MM, Donnez O, Masuzaki H, Soares M, Donnez J. Enhanced follicular recruitment and atresia in cortex derived from ovaries with endometriomas. Fertil Steril. 2014;101 (4):1031-7.##David A, Van Langendonckt A, Gilliaux S, Dolmans MM, Donnez J, Amorim CA. Effect of cryopreservation and transplantation on the expression of kit ligand and anti-Mllerian hormone in human ovarian tissue. Hum Reprod. 2012;27(4):1088-95.##Bina F, Soleymani S, Toliat T, Hajimahmoodi M, Tabarrai M, Abdollahi M, et al. Plant-derived medicines for treatment of endometriosis: a comprehensive review of molecular mechanisms. Pharmacol Res. 2019;139:76-90.##Vetvicka V, Laganà AS, Salmeri FM, Triolo O, Palmara VI, Vitale SG, et al. Regulation of apoptotic pathways during endometriosis: from the molecular basis to the future perspectives. Arch Gynecol Obstet. 2016;294(5):897-904.##Vitale SG, Laganà AS, Nigro A, La Rosa VL, Rossetti P, Rapisarda AM, et al. Peroxisome proliferator-activated receptor modulation during metabolic diseases and cancers: master and minions. PPAR Res. 2016;2016:6517313.##Laganà AS, Vitale SG, Nigro A, Sofo V, Salmeri FM, Rossetti P, et al. Pleiotropic actions of peroxisome proliferator-activated receptors (PPARs) in dysregulated metabolic homeostasis, inflammation and cancer: current evidence and future perspectives. Int J Mol Sci. 2016;17(7). pii: E999.##de Barros IBL, Malvezzi H, Gueuvoghlanian-Silva BY, Piccinato CA, Rizzo LV, Podgaec S. "What do we know about regulatory T cells and endometriosis? a systematic review". J Reprod Immunol. 2017;120:48-55.##Gogacz M, Bogusiewicz M, Putowski L, Adamiak A, Wertel I, Jakowicki JA, et al. [Expression of tumor necrosis factor-alpha (TNF-alpha) on peritoneal fluid mononuclear cells in women with endometriosis]. Ginekol Pol. 2008;79(1):31-5.##Sturlese E, Salmeri FM, Retto G, Pizzo A, De Do-minici R, Ardita FV, et al. Dysregulation of the Fas/FasL system in mononuclear cells recovered from peritoneal fluid of women with endometriosis. J Reprod Immunol. 2011;92(1-2):74-81.##Vitale SG, Capriglione S, Peterlunger I, La Rosa VL, Vitagliano A, Noventa M, et al. The role of oxidative stress and membrane transport systems during endometriosis: a fresh look at a busy corner. Oxid Med Cell Longev. 2018;2018:7924021.##Hamdan M, Dunselman G, Li TC, Cheong Y. The impact of endometrioma on IVF/ICSI outcomes: A systematic review and meta-analysis. Hum Reprod Update. 2015;21(6):809-25.##Somigliana E, Viganò P, Filippi F, Papaleo E, Be-naglia L, Candiani M, et al. Fertility preservation in women with endometriosis: For all, for some, for none? Hum Reprod. 2015;30(6):1280-6.##Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D’Hooghe T, De Bie B, et al. ESHRE guideline: management of women with endometriosis. Hum Reprod. 2014;29(3):400-12.##Somigliana E, Berlanda N, Benaglia L, Viganò P, Vercellini P, Fedele L. Surgical excision of endometriomas and ovarian reserve: A systematic review on serum antimüllerian hormone level modifications. Fertil Steril. 2012;98(6):1531-8.##Benaglia L, Somigliana E, Vighi V, Ragni G, Vercellini P, Fedele L. Rate of severe ovarian damage following surgery for endometriomas. Hum Reprod. 2010;25(3):678-82.##Somigliana E, Benaglia L, Vigano P, Candiani M, Vercellini P, Fedele L. Surgical measures for endometriosis-related infertility: a plea for research. Placenta. 2011;32 Suppl 3:S238-42.##Coccia ME, Rizzello F, Mariani G, Bulletti C, Pa-lagiano A, Scarselli G. Ovarian surgery for bilateral endometriomas influences age at menopause. Hum Reprod. 2011;26(11):3000-7.##Muzii L, Di Tucci C, Di Feliciantonio M, Marchetti C, Perniola G, Panici PB. The effect of surgery for endometrioma on ovarian reserve evaluated by antral follicle count: a systematic review and meta-analysis. Hum Reprod. 2014;29(10):2190-8.##Ata B, Turkgeldi E, Seyhan A, Urman B. Effect of hemostatic method on ovarian reserve following laparoscopic endometrioma excision; comparison of suture, hemostatic sealant, and bipolar dessication. a systematic review and meta-analysis. J Minim Invasive Gynecol. 2015;22(3):363-72.##Vercellini P, Viganò P, Somigliana E, Fedele L. Endometriosis: pathogenesis and treatment. Nat Rev Endocrinol. 2014;10(5):261-75.##Guo SW. Recurrence of endometriosis and its control. Hum Reprod Update. 2009;15(4):441-61.##Carrillo L, Seidman DS, Cittadini E, Meirow D. The role of fertility preservation in patients with endometriosis. J Assist Reprod Genet. 2016;33(3):317-23.##Rienzi L, Gracia C, Maggiulli R, LaBarbera AR, Kaser DJ, Ubaldi FM, et al. Oocyte, embryo and blastocyst cryopreservation in ART: systematic review and meta-analysis comparing slow-freezing versus vitrification to produce evidence for the development of global guidance. Hum Reprod Update. 2017;23(2):139-55.##Rienzi L, Ubaldi FM. Oocyte versus embryo cryopreservation for fertility preservation in cancer patients: guaranteeing a women’s autonomy. J Assist Reprod Genet. 2015;32(8):1195-6.##Stoop D. Oocyte vitrification for elective fertility preservation: Lessons for patient counseling. Fertil Steril. 2016;105(3):603-4.##Wallace WH, Smith AG, Kelsey TW, Edgar AE, Anderson RA. Fertility preservation for girls and young women with cancer: population-based validation of criteria for ovarian tissue cryopreservation. Lancet Oncol. 2014;15(10):1129-36.##Donnez J, Dolmans MM, Diaz C, Pellicer A. Ovarian cortex transplantation: Time to move on from experimental studies to open clinical application. Fertil Steril. 2015;104(5):1097-8.##Oktay K, Oktem O. Ovarian cryopreservation and transplantation for fertility preservation for medical indications: report of an ongoing experience. Fertil Steril. 2010;93(3):762-8.##Brosens I, Gordts S, Benagiano G. Endometriosis in adolescents is a hidden, progressive and severe disease that deserves attention, not just compassion. Hum Reprod. 2013;28(8):2026-31.##Nelson SM, Telfer EE, Anderson RA. The ageing ovary and uterus: New biological insights. Hum Reprod Update. 2013;19(1):67-83.##Hvidman HW, Petersen KB, Larsen EC, Macklon KT, Pinborg A, Andersen AN. Individual fertility assessment and pro-fertility counselling; Should this be offered to women and men of reproductive age? Hum Reprod. 2015;30(1):9-15.##Garzon S, Laganà AS, Pomini P, Raffaelli R, Ghe-zzi F, Franchi M. Laparoscopic reversible occlusion of uterine arteries and cornuostomy for advanced interstitial pregnancy. Minim Invasive Ther Allied Technol. 2018:1-4.##Garzon S, Raffaelli R, Montin U, Ghezzi F. Primary hepatic pregnancy: report of a case treated with laparoscopic approach and review of the literature. Fertil Steril. 2018;110(5):925-31.##Vercellini P, De Matteis S, Somigliana E, Buggio L, Frattaruolo MP, Fedele L. Long-term adjuvant therapy for the prevention of postoperative endometrioma recurrence: A systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2013;92 (1):8-16.##Frydman R. Introduction: Gynecology surgery and preservation of fertility. Fertil Steril. 2014;101(3):607.##Laganà AS, Sofo V, Salmeri FM, Palmara VI, Triolo O, Terzić MM, et al. Oxidative stress during ovarian torsion in pediatric and adolescent patients: changing the perspective of the disease. Int J Fertil Steril. 2016;9(4):416-23.##Nur Azurah AG, Zainol ZW, Zainuddin AA, Lim PS, Sulaiman AS, Ng BK. Update on the manage-ment of ovarian torsion in children and adolescents. World J Pediatr. 2014;11(1):35-40.##Wang Z, Zhang D, Zhang H, Guo X, Zheng J, Xie H. Characteristics of the patients with adnexal torsion and outcomes of different surgical procedures: a retrospective study. Medicine (Baltimore). 2019;98(5):e14321.##Bertozzi M, Esposito C, Vella C, Briganti V, Zam-pieri N, Codrich D, et al. Pediatric ovarian torsion and its recurrence: a multicenter study. J Pediatr Adolesc Gynecol. 2017;30(3):413-17.##Kaur N, Reid F, Ma K. Ovarian ectopic pregnancy: laparoscopic excision and ovarian conservation. J Minim Invasive Gynecol. 2019;26(6):1006.##Melcer Y, Maymon R, Vaknin Z, Pansky M, Men-dlovic S, Barel O, et al. Primary Ovarian ectopic pregnancy: still a medical challenge. J Reprod Med. 2016;61(1-2):58-62.##Andrade AG, Rocha S, Marques CO, Simões M, Martins I, Biscaia I, et al. Ovarian ectopic pregnancy in adolescence. Clin Case Rep. 2015;3(11):912-5.##Feit H, Leibovitz Z, Kerner R, Keidar R, Sagiv R. Ovarian pregnancy following in vitro fertilization in a woman after bilateral salpingectomy: a case report and review of the literature. J Minim Invasive Gynecol. 2015;22(4):675-7.##Di Paola R, Garzon S, Giuliani S, Laganà AS, Noventa M, Parissone F, et al. Are we choosing the correct FSH starting dose during controlled ovarian stimulation for intrauterine insemination cycles? potential application of a nomogram based on woman’s age and markers of ovarian reserve. Arch Gynecol Obstet. 2018;298(5):1029-35.##Vitale SG, Rossetti P, Corrado F, Rapisarda AM, La Vignera S, Condorelli RA, et al. How to achieve high-quality oocytes? the key role of myo-inositol and melatonin. Int J Endocrinol. 2016;2016:4987436.##Papaleo E, Zaffagnini S, Munaretto M, Vanni VS, Rebonato G, Grisendi V, et al. Clinical application of a nomogram based on age, serum FSH and AMH to select the FSH starting dose in IVF/ICSI cycles: a retrospective two-centres study. Eur J Obstet Gynecol Reprod Biol. 2016;207:94-9.##Artini PG, Di Berardino OM, Papini F, Genazzani AD, Simi G, Ruggiero M, et al. Endocrine and clinical effects of myo-inositol administration in polycystic ovary syndrome. a randomized study. Gynecol Endocrinol. 2013;29(4):375-9.##Laganà AS, Garzon S, Casarin J, Franchi M, Ghe-zzi F. Inositol in polycystic ovary syndrome: restoring fertility through a pathophysiology-based approach. Trends Endocrinol Metab. 2018;29(11):768-80.##Sortino MA, Salomone S, Carruba MO, Drago F. Polycystic ovary syndrome: insights into the therapeutic approach with inositols. Front Pharmacol. 2017;8:341.##Cozzolino M, Vitagliano A, Di Giovanni MV, Laganà AS, Vitale SG, Blaganje M, et al. Ultrasound-guided embryo transfer: summary of the evidence and new perspectives. a systematic review and meta-analysis. Reprod Biomed Online. 2018; 36(5):524-42.##Vitagliano A, Noventa M, Saccone G, Gizzo S, Vitale SG, Laganà AS, et al. Endometrial scratch injury before intrauterine insemination: is it time to re-evaluate its value? evidence from a systematic review and meta-analysis of randomized controlled trials. Fertil Steril. 2018;109(1):84-96.e4.##Nandi A, Sinha N, Ong E, Sonmez H, Poretsky L. Is there a role for vitamin D in human reproduction? Horm Mol Biol Clin Investig. 2016;25(1):15-28.##Laganà AS, Vitale SG, Ban Frangež H, Vrtačnik-Bokal E, D’Anna R. Vitamin D in human reproduction: the more, the better? An evidence-based critical appraisal. Eur Rev Med Pharmacol Sci. 2017;21(18):4243-51.##Reyes-Muñoz E, Sathyapalan T, Rossetti P, Shah M, Long M, Buscema M, et al. Polycystic ovary syndrome: implication for drug metabolism on assisted reproductive techniques-a literature review. Adv Ther. 2018;35(11):1805-15.##Donnez O, Roman H. Choosing the right surgical technique for deep endometriosis: shaving, disc excision, or bowel resection? Fertil Steril. 2017;108(6):931-42.##European society for human reproduction and embryology (ESHRE) guideline group on POI, Webber L, Davies M, Anderson R, Bartlett J, Braat D, et al. ESHRE guideline: management of women with premature ovarian insufficiency. Hum Reprod. 2016;31(5):926-37.##Qin Y, Jiao X, Simpson JL, Chen ZJ. Genetics of primary ovarian insufficiency: New developments and opportunities. Hum Reprod Update. 2015;21(6):787-808.##Grynberg M, Bidet M, Benard J, Poulain M, Sonigo C, Cédrin-Durnerin I, et al. Fertility preservation in Turner syndrome. Fertil Steril. 2016;105(1):13-9.##

Can We Prepare IVF Culture Media Two Days Before Ovum Pick up Without Affecting Embryological Parameters? A Retrospective Case-Matched Study 2 1 2 Background: According to several laboratory protocols and specific conditions, in vitro fertilization (IVF) dishes with culture media can be prepared 24 hr in advance compared to routine protocols. However, it is not clear if this procedure can affect embryological outcomes. Methods: A nested case-control study was done in a cohort of couples undergoing IVF at the Infertility Unit of the ASST Lariana from August 2016 to July 2018. Cases were patients undergoing ovum pick up after a laboratory day off. Controls were patients undergoing ovum pick up after working days from Monday to Thursday. Culture media for oocyte culture and insemination were prepared about 42 and 18 hr before oocyte retrieval for cases and controls, respectively. Cases and controls were matched with a 1:2 ratio (for age, inseminated oocytes, length of stimulation). The "Good-Quality-Index" (GQI) was the main outcome to be compared between the two groups and was defined as good quality transferred or cryopreserved embryos on day 2 or 3+number of good quality blastocysts/inseminated oocytes. Results: A total of 76 cases and 152 matched controls were enrolled. The median GQI was equal to 33.0% (IQR: 20.0-50.0%) and 33.0% (IQR: 25.0-50.0%), in cases and controls, respectively (p=0.40). Study groups and GQI were not significantly correlated (correlation coefficient r=0.047, p=0.48). Main embryological parameters and cumulative pregnancy rates were similar between the two groups. Conclusion: Our data support the vision that culture media can be prepared 24 hr in advance compared to routine protocols without affecting embryological outcomes. 209 218 Alessio A Paffoni ASST Lariana, Infertility Unit ASST Lariana, Infertility Unit Italy alessio.paffoni@alice.it Elisabetta E Ballabio ASST Lariana, Infertility Unit ASST Lariana, Infertility Unit Italy Sabrina S Cesana ASST Lariana, Infertility Unit ASST Lariana, Infertility Unit Italy Stefania S Ferrari Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Italy Hilda H Wyssling ASST Lariana, Infertility Unit ASST Lariana, Infertility Unit Italy Marco MC Bianchi ASST Lariana, Infertility Unit ASST Lariana, Infertility Unit Italy Culture mediumEmbryoEmbryologyIVF 60058.pdf Zorn JR, Boyer P, Guichard A. Never on asunday: programming for IVF-ETand gift. Lancet. 1987;(8529):385-6.##Conaghan J, Dimitry ES, Mills M, Margara RA, Winston RM. Delayed human chorionic gonadotropin administration for in-vitro fertilisation. Lancet. 1989;(8650):1323-4.##Dimitry ES, Bates SA, Oskarsson T, Margara R, Winston RM. Programming in vitro fertilization for a 5- or 3-day week. Fertil Steril. 1991;55(5):934-8.##Abdalla H, Baber RJ, Leonard T, Kirkland A, Mitchell A, Power M,et al. Timed oocyte collection in an assisted conception programme using GnRH analogue. Hum Reprod. 1989;4(8):927-30.##Tan SL, Balen A, Hussein EE, el Hussein E, Mills C, Campbell S, et al. A prospective randomized study of the optimum timing of human chorionic gonadotropin administration after pituitary desensitization in in vitro fertilization. Fertil Steril. 1992;57(6):1259-64.##Mochtar MH, Custers IM, Koks CA, Bernardus RE, Verhoeve HR, Mol BW,et al. Timing oocyte collection in GnRH agonists down-regulated IVF and ICSI cycles: a randomized clinical trial. Hum Reprod. 2011;26(5):1091-6.##Kolibianakis EM, Albano C, Camus M, Tournaye H, Van Steirteghem AC, Devroey P. Prolongation of the follicular phase in in vitro fertilization results in a lower ongoing pregnancy rate in cycles stimulated with recombinant follicle-stimulating hormone and gonadotropin-releasing hormone antagonists. Fertil Steril. 2004;82(1):102-7.##Feichtinger M, Karlström PO, Olofsson JI, Rodriguez-Wallberg KA. Weekend-free scheduled IVF/ICSI procedures and single embryo transfer do not reduce live-birth rates in a general infertile population. Acta Obstet Gynecol Scand. 2017;96(12):1423-9.##Tremellen KP, Lane M. Avoidance of weekend oocyte retrievals during GnRH antagonist treatment by simple advancement or delay of hCG administration does not adversely affect IVF live birth outcomes. Hum Reprod. 2010;25(5):1219-24.##Morley L, Tang T, Yasmin E, Hamzeh R, Rutherford AJ, Balen AH. Timing of human chorionic gonadotrophin (hCG) hormone administration in IVF protocols using GnRH antagonists: a randomized controlled trial. Hum Fertil. 2012;15(3):134-9.##Glujovsky D, Farquhar C, Quinteiro Retamar AM,Alvarez Sedo CR,Blake D. Cleavage stage versus blastocyst stage embryo transfer in assisted reproductive technology. Cochrane Database Syst Rev. 2016;(6):CD002118.##Brown J, Daya S, Matson P. Day three versus day two embryo transfer following in vitro fertilization or intracytoplasmic sperm injection. Cochrane Database Syst Rev. 2016;12:CD004378.##Costa-Borges N, Bellés M, Meseguer M, Galliano D, Ballesteros A, Calderón G. Blastocyst development in single medium with or without renewal on day 3: a prospective cohort study on sibling donor oocytes in a time-lapse incubator. Fertil Steril. 2016;105(3):707-13.##Aparicio-Ruiz B, Romany L, Meseguer M. Selection of preimplantation embryos using time-lapse microscopy in in vitro fertilization: state of the technology and future directions. Birth Defects Res. 2018;110(8):648-53.##Reed ML, Hamic A, Thompson DJ, Caperton CL. Continuous uninterrupted single medium culture without medium renewal versus sequential media culture: a sibling embryo study. Fertil Steril. 2009;92(5):1783-6.##Wiemer KE. Setup procedures for optimizing performance in the IVF laboratory.In: Montag MH, Morbeck DE, editors. Principles of IVF laboratory practice. Cambridge university press: New York; 2017. p. 88-96.##Swain J, Cabrera L, Xu X, Smith GD. Microdrop preparation factors influence culture-media osmolality, which can impair mouse embryo preimplantation development. Reprod Biomed Online. 2012;24(2):142-7.##Kleijkers SH, van Montfoort AP, Bekers O, Coonen E, Derhaag JG, Evers JL, et al. Ammonium accumulation in commercially available embryo culture media and protein supplements during storage at 2-8°C and during incubation at 37°C. Hum Reprod. 2016;31(6):1192-9.##Kuwayama M. Highly efficient vitrification for cryopreservation of human oocytes and embryos: the Cryotop method. Theriogenology. 2007;67(1):73-80.##Alpha scientists in reproductive medicine and ESHRE special interest group of embryology. The Istanbul consensus workshop on embryo assessment: proceedings of an expert meeting. Hum Reprod. 2011;26(6):1270-83.##De Geyter C, Calhaz-Jorge C, Kupka MS, Wyns C, Mocanu E, Motrenko T, et al. ART in Europe, 2014: results generated from European registries by ESHRE: the European IVF-monitoring consortium (EIM) for the European society of human reproduction and embryology (ESHRE). Hum Reprod. 2018;33(9):1586-1601.##Stewart-Savage J, Bavister BD. Deterioration of stored culture media as monitored by a sperm motility bioassay. J In Vitro Fert Embryo Transf. 1988;5(2):76-80.##Weathersbee PS, Francis MM, Macaso TM, Sauer MV, Paulson RJ. A new long shelf life formulation of modified Ham's F-10 medium: biochemical and clinical evaluation. J Assist Reprod Genet. 1995;12(3):175-9.##Piette C, Mouzon JD, Bachelot A, Spira A. In-vitro fertilization: influence of women's age on pregnancy rates. Hum Reprod. 1990;5(1):56-9.##Ziebe S, Loft A, Petersen JH, Andersen A-G, Lindenberg S, Petersen K, et al. Embryo quality and developmental potential is compromised by age. Acta Obstet Gynecol Scand. 2001;80(2):169-74.##Bartolacci A, Pagliardini L, Makieva S, Salonia A, Papaleo E, Viganò P. Abnormal sperm concentration and motility as well as advanced paternal age compromise early embryonic development but not pregnancy outcomes: a retrospective study of 1266 ICSI cycles. J Assist Reprod Genet. 2018;35(10):1897-903.##Chapuis A, Gala A, Ferrières-Hoa A, Mullet T, Bringer-Deutsch S, Vintejoux E, et al. Sperm quality and paternal age: effect on blastocyst formation and pregnancy rates. Basic Clin Androl. 2017;27:2.##Simon L, Murphy K, Shamsi M, Liu L, Emery B, Aston KI, et al. Paternal influence of sperm DNA integrity on early embryonic development. Hum Reprod. 2014;29(11):2402-12.##Nelissen EC, Van Montfoort AP, Coonen E, Derhaag JG, Geraedts JP, Smits LJ, et al. Further evidence that culture media affect perinatal outcome: findings after transfer of fresh and cryopreserved embryos. Hum Reprod. 2012;27(7):1966-76.##

Evaluation of the Prevalence of Exons 1 And 10 Polymorphisms of LHCGR Gene and Its Relationship with IVF Success 2 1 2 Background: Luteinizing hormone receptor gene shows four nonsynonymous polymorphisms within the exons. Three of these polymorphisms, i.e. rs4539842 (an insertion of 6bp CTGCAG at nucleotide position 54), rs12470652 (c.827A>G/p.Asn291Ser), and rs2293275 (c.935G>A/p.Ser312Asn) have been studied more frequently. Beside other hormones, LH and FSH have an important role in production of competent oocyte and female fertility. Therefore, the objective of the current study was to investigate the prevalence of exons 1(rs4539842) and 10(rs12470652, rs2293275) polymorphisms of the LHCGR gene and its relationship with successful IVF in Iranian infertile women. Methods: SNPs in exons 1 and 10 were analyzed in 100 women of two equally sized groups of IVF failure and IVF success women using genomic DNA. For polymorphisms in exon 10, PCR and direct sequencing were used and for the polymorphism in exon 1, RFLP technique was used. The RFLP technique is confirmed by sequencing. Results: Our results showed significant difference in allelic frequency of SNP rs2293275 among IVF successful and IVF failure groups (p=0.001). For this variation, AA genotype (A allele) was shown to have protective effect against IVF failure (p=0.03 and OR=0.04), while GG genotype (G allele) was a susceptive genotype to IVF failure (p=0.003 and OR=3.88).Allelic frequency of SNP rs4539842 also showed significant difference between the two groups (p=0.0025). For this SNP, subjects with no 6bp insertion (homozygote deletion genotype) were susceptible to be Failure in IVF (p=0.009 and OR=2.93). Conclusion: It has been revealed that two common SNPs (rs4539842 and rs2293275) in the LHCGR gene are associated with the outcome of IVF in Iranian infertile women. Thus, these two SNPs can be suggested to be used as predictors for IVF outcome in Iranian population. 218 225 Maliheh M Javadi-Arjmand Department of Medical Genetics, School of Medicine, Tehran University of Medical Sciences Department of Medical Genetics, School of Medicine, Tehran University of Medical Sciences Iran Elia D Damavandi Specialized Medical Genetic Center of Academic Center for Education, Culture and Research (ACECR), Tehran University of Medical Sciences Branch Specialized Medical Genetic Center of Academic Center for Education, Culture and Research (ACECR), Tehran University of Medical Sciences Branch Iran Hamid H Choobineh School of Allied Medicine, Tehran University of Medical Sciences School of Allied Medicine, Tehran University of Medical Sciences Iran Fereshteh F Sarafrazi-Esfandabadi Specialized Medical Genetic Center of Academic Center for Education, Culture and Research (ACECR), Tehran University of Medical Sciences Branch Specialized Medical Genetic Center of Academic Center for Education, Culture and Research (ACECR), Tehran University of Medical Sciences Branch Iran Majid M Kabuli Department of Medical Genetics, School of Medicine, Tehran University of Medical Sciences Department of Medical Genetics, School of Medicine, Tehran University of Medical Sciences Iran Atoosa A Mahdavi Department of Obstetrics and Gynecology, Dr. Shariati Hospital, Tehran University of Medical Sciences Department of Obstetrics and Gynecology, Dr. Shariati Hospital, Tehran University of Medical Sciences Iran Mohsen M Ghadami Department of Medical Genetics, School of Medicine, Tehran University of Medical Sciences Department of Medical Genetics, School of Medicine, Tehran University of Medical Sciences Iran mghadami@tums.ac.ir In vitro fertilizationInfertilityLHCGR genePolymorphism 60061.pdf Vander Borght M, Wyns C. Fertility and infertility: definition and epidemiology. Clin Biochem. 2018;62:2-10.##Akhondi MM, Ranjbar F, Shirzad M, Behjati Ardakani Z, Kamali K, Mohammad K. Practical difficulties in estimating the prevalence of primary infertility in Iran. Int J Fertil Steril. 2019;13(2):113-7.##Teoh PJ, Maheshwari A. Low-cost in vitro fertilization: current insights. Int J Womens Health. 2014;6:817-27.##Kissin DM, Zhang Y, Boulet SL, Fountain C, Bearman P, Schieve L, et al. Association of assisted reproductive technology (ART) treatment and parental infertility diagnosis with autism in ART-conceived children. Hum Reprod. 2014;30(2):454-65.##Filicori M, Cognigni GE, Pocognoli P, Ciampaglia W, Bernardi S. Current concepts and novel applications of LH activity in ovarian stimulation. Trends Endocrinol Metab. 2003;14(6):267-73.##Alviggi C, Clarizia R, Mollo A, Ranieri A, De Placido G. Who needs LH in ovarian stimulation? Reprod Biomed Online. 2006;12(5):599-607.##Paterson ND, Foong SC, Greene CA. Improved pregnancy rates with luteinizing hormone supplementation in patients undergoing ovarian stimulation for IVF. J Assist Reprod Genet. 2012;29(7):579-83.##Jeppesen JV, Kristensen SG, Nielsen ME, Humaidan P, Dal Canto M, Fadini R, et al. LH-receptor gene expression in human granulosa and cumulus cells from antral and preovulatory follicles. J Clin Endocrinol Metab. 2012;97(8):E1524-31.##Maman E, Yung Y, Kedem A, Yerushalmi GM, Konopnicki S, Cohen B, et al. High expression of luteinizing hormone receptors messenger RNA by human cumulus granulosa cells is in correlation with decreased fertilization. Fertil Steril. 2012;97(3):592-8.##Yung Y, Aviel-Ronen S, Maman E, Rubinstein N, Avivi C, Orvieto R, et al. Localization of luteinizing hormone receptor protein in the human ovary. Mol Hum Reprod. 2014;20(9):844-9.##Themmen APN, Huhtaniemi IT. Mutations of gonadotropins and gonadotropin receptors: elucidating the physiology and pathophysiology of pituitary-gonadal function. Endocr Rev. 2000;21(5):551-83.##Rousseau-Merck MF, Misrahi M, Atger M, Loosfelt H, Milgrom E, Berger R. Localization of the human luteinizing hormone/ choriogonadotropin receptor gene (LHCGR) to chromosome 2p21. Cytogenet Cell Genet. 1990;54(1-2):77-9.##Atger M, Misrahi M, Sar S, Le Flem L, Dessen P, Milgrom E. Structure of the human luteinizing hormone-choriogonadotropin receptor gene: unusual promoter and 5′ non-coding regions. Mol Cell Endocrinol. 1995;111(2):113-23.##Minegish T, Nakamura K, Takakura Y, Miyamoto K, Hasegawa Y, Ibuki Y, et al. Cloning and sequencing of human LH/hCG receptor cDNA. Biochem Biophys Res Commun. 1990;172(3):1049-54.##Müller T, Gromoll Jr, Simoni M. Absence of exon 10 of the human luteinizing hormone (LH) receptor impairs LH, but not human chorionic gonadotropin action. J Clin Endocrinol Metab. 2003;88(5):2242-9.##Simoni M, Tuttelmann F, Michel C, Bockenfeld Y, Nieschlag E, Gromoll J. Polymorphisms of the luteinizing hormone/chorionic gonadotropin receptor gene: association with maldescended testes and male infertility. Pharmacogenet Genomics. 2008;18(3):193-200.##Piersma D, Berns EM, Verhoef-Post M, Uitterlinden AG, Braakman I, Pols HA, et al. A common polymorphism renders the luteinizing hormone receptor protein more active by improving signal peptide function and predicts adverse outcome in breast cancer patients. J Clin Endocrinol Metab. 2006;91(4):1470-6.##Lindgren I, Baath M, Uvebrant K, Dejmek A, Kjaer L, Henic E, et al. Combined assessment of polymorphisms in the LHCGR and FSHR genes predict chance of pregnancy after in vitro fertilization. Hum Reprod. 2016;31(3):672-83.##Lei ZM, Mishra S, Zou W, Xu B, Foltz M, Li X, et al. Targeted disruption of luteinizing hormone/human chorionic gonadotropin receptor gene. Mol Endocrinol. 2001;15(1):184-200.##Zhang FP, Poutanen M, Wilbertz J, Huhtaniemi I. Normal prenatal but arrested postnatal sexual development of luteinizing hormone receptor knockout (LuRKO) mice. Mol Endocrinol. 2001;15(1):172-83.##Valkenburg O, Uitterlinden A, Piersma D, Hofman A, Themmen A, De Jong F, et al. Genetic polymorphisms of GnRH and gonadotrophic hormone receptors affect the phenotype of polycystic ovary syndrome. Hum Reprod. 2009;24(8):2014-22.##Capalbo A, Sagnella F, Apa R, Fulghesu A, Lanzone A, Morciano A, et al. The 312 N variant of the luteinizing hormone/choriogonadotropin receptor gene (LHCGR) confers up to 2 7‐fold increased risk of polycystic ovary syndrome in a S ardinian population. Clin Endocrinol. 2012;77(1):113-9.##Thathapudi S, Kodati V, Erukkambattu J, Addepally U, Qurratulain H. Association of luteinizing hormone chorionic gonadotropin receptor gene polymorphism (rs2293275) with polycystic ovarian syndrome. Genet Test Mol Biomarkers. 2015;19(3):128-32.##Piersma D, Verhoef-Post M, Look MP, Uitterlinden AG, Pols HA, Berns EM, et al. Polymorphic variations in exon 10 of the luteinizing hormone receptor: functional consequences and associations with breast cancer. Mol Cell Endocrinol. 2007;276(1-2):63-70.##Powell BL, Piersma D, Kevenaar ME, Van Staveren I, Themmen A, Iacopetta B, et al. Luteinizing hormone signaling and breast cancer: polymorphisms and age of onset. J Clin Endocrinol Metab. 2003;88(4):1653-7.##

NUCB2/Nesfatin-1 in the Blood and Follicular Fluid in Patients with Polycystic Ovary Syndrome and Poor Ovarian Response 2 1 2 Background: Failure to respond adequately to standard protocols and to recruit adequate follicles is called ‘poor ovarian response’. The relationships between metabolic alterations and NUCB2/Nesfatin-1 levels were explored in patients with polycystic ovary syndrome (PCOS) undergoing in vitro fertilization/intracytoplasmic sperm injection. Methods: This case-control study involved 20 infertile women with PCOS and 20 control women diagnosed as poor ovarian responders stimulated with a GnRH antagonist. Blood samples were taken during ovum pick-up and follicular fluids (FF) were obtained from a dominant follicle from the subjects. Samples were analyzed by using ELISA. Statistical analysis was performed with SPSS version 20. Data are expressed as means ± standard deviation (SD). Results: Blood NUCB2/Nesfatin-1 levels in PCOS were significantly lower (p=0.011) while the NUCB2/Nesfatin-1 levels of FF in poor ovarian response (POR) were higher, but not statistically significant. Insulin, total testosterone, fasting glucose, homeostasis model assessment, and insulin resistance index in women with POR decreased when compared with PCOS. Blood NUCB2/Nesfatin-1 levels were significantly higher than FF NUCB2/Nesfatin-1 levels in both groups (p<0.001). Moreover, a positive correlation was detected between blood NUCB2/Nesfatin-1 and testosterone (p=0.602, r=0.304), HOMA-IR (p=0.252, r=0.384), BMI (p=0.880, r=0.44) in PCOS, but it was not significant. Conclusion: NUCB2/Nesfatin-1 levels might be important in follicular growth in PCOS subjects undergoing IVF/ICSI with an antagonist protocol and NUCB2/Nesfatin-1 level could reliably help to predict poor ovarian response. 225 231 Zekiye Z Catak Department of Clinical Biochemistry, University of Health Sciences, Elazig Fethi Sekin City Hospital Department of Clinical Biochemistry, University of Health Sciences, Elazig Fethi Sekin City Hospital Turkey Seyda S Yavuzkir Department of Obstetrics and Gynecology, School of Medicine, Firat University Department of Obstetrics and Gynecology, School of Medicine, Firat University Turkey Esra E Kocdemir Department of Clinical Biochemistry, Kovancilar State Hospital Department of Clinical Biochemistry, Kovancilar State Hospital Turkey Kader K Ugur Department of Internal Medicine (Endocrinology and Metabolism Diseases), School of Medicine, Firat University Department of Internal Medicine (Endocrinology and Metabolism Diseases), School of Medicine, Firat University Turkey Meltem M Yardim Department of Medical Biochemistry and Clinical Biochemistry (Firat Hormones Research Group), Medical School, Firat University Department of Medical Biochemistry and Clinical Biochemistry (Firat Hormones Research Group), Medical School, Firat University Turkey İbrahim İ Sahin Department of Medical Biology, Medical School, Erzincan Binali Yildirim University Department of Medical Biology, Medical School, Erzincan Binali Yildirim University Turkey Esra EP Agirbas School of Medicine, Medical School Student, Firat University School of Medicine, Medical School Student, Firat University Turkey Suleyman S Aydin Department of Medical Biochemistry and Clinical Biochemistry (Firat Hormones Research Group), Medical School, Firat University Department of Medical Biochemistry and Clinical Biochemistry (Firat Hormones Research Group), Medical School, Firat University Turkey saydin1@hotmail.com PCOSInfertilityNesfatin-1Follicular fluidGlucose metabolismPregnancy 60060.pdf Deniz R, Gurates B, Aydin S, Celik H, Sahin İ, Baykus Y, et al. Nesfatin-1 and other hormone alterations in polycystic ovary syndrome. Endocrine. 2012;42(3):694-9.##Gault JM, Davis R, Cascella NG, Saks ER, Corripio-Collado I, Anderson WS, et al. Approaches to neuromodulation for schizophrenia. J Neurol Neurosurg Psychiatry. 2018;89(7):777-87.##Alp E, Görmüş U, Güdücü N, Bozkurt S. Nesfatin-1 levels and metabolic markers in polycystic ovary syndrome. Gynecol Endocrinol. 2015;31(7):543-7.##Azziz R. PCOS in 2015: New insights into the genetics of polycystic ovary syndrome. Nat Rev Endocrinol. 2016;12(2):74-5.##Legro RS, Castracane VD, Kauffman RP. Detecting insulin resistance in polycystic ovary syndrome: purposes and pitfalls. Obstet Gynecol Surv. 2004;59(2):141-54.##Ayada C, Toru Ü, Korkut Y. Nesfatin-1 and its effects on different systems. Hippokratia. 2015;19(1):4-10.##García-Galiano D, Navarro VM, Roa J, Ruiz-Pino F, Sánchez-Garrido MA, Pineda R, et al. The anorexigenic neuropeptide, nesfatin-1, is indispensable for normal puberty onset in the female rat. J Neurosci. 2010;30(23):7783-92.##Chung Y, Kim H, Im E, Kim P, Yang H. Th 17 cells and nesfatin-1 are associated with spontaneous abortion in the CBA/j× DBA/2 mouse model. Dev Reprod. 2015;19(4):243-52.##Feng R, Sang Q, Zhu Y, Fu W, Liu M, Xu Y, et al. MiRNA-320 in the human follicular fluid is associated with embryo quality in vivo and affects mouse embryonic development in vitro. Sci Rep. 2015;5:8689.##Ademoglu EN, Gorar S, Carlıoglu A, Dellal FD, Berberoglu Z, Akdeniz D, et al. Plasma nesfatin-1 levels are increased in patients with polycystic ovary syndrome. J Endocrinol Invest. 2014;37(8):715-9.##Zamah AM, Hsieh M, Chen J, Vigne JL, Rosen MP, Cedars MI, et al. Human oocyte maturation is dependent on LH-stimulated accumulation of the epidermal growth factor-like growth factor, amphiregulin. Hum Reprod. 2010;25(10):2569-78.##Aydin S. A short history, principles, and types of ELISA, and our laboratory experience with peptide/protein analyses using ELISA. Peptides. 2015;72:4-15.##Dore R, Levata L, Lehnert H, Schulz C. Nesfatin-1: functions and physiology of a novel regulatory peptide. J Endocrinol. 2017;232(1):R45-65.##Seon S, Jeon D, Kim H, Chung Y, Choi N, Yang H. Testosterone regulates NUCB2 mRNA expression in male mouse hypothalamus and pituitary gland. Dev Reprod. 2017;21(1):71-8.##Aslan M, Celik O, Celik N, Turkcuoglu I, Yilmaz E, Karaer A, et al. Cord blood nesfatin-1 and apelin-36 levels in gestational diabetes mellitus. Endocrine. 2012;41(3):424-9.##Li QC, Wang HY, Chen X, Guan HZ, Jiang ZY. Fasting plasma levels of nesfatin-1 in patients with type 1 and type 2 diabetes mellitus and the nutrient-related fluctuation of nesfatin-1 level in normal humans. Regul Pept. 2010;159(1-3):72-7.##Haider D, Schaller G, Kapiotis S, Maier C, Luger A, Wolzt M. The release of the adipocytokine visfatin is regulated by glucose and insulin. Diabetologia. 2006;49(8):1909-14.##Su Y, Zhang J, Tang Y, Bi F, Liu JN. The novel function of nesfatin-1: anti-hyperglycemia. Biochem Biophys Res Commun. 2010;391(1):1039-42.##Gao X, Zhang K, Song M, Li X, Luo L, Tian Y, et al. Role of nesfatin-1 in the reproductive axis of male rat. Sci Rep. 2016;6:32877.##Xu Y, Zhang H, Li Q, Lao K, Wang Y. The role of nesfatin-1 expression in letrozole-induced polycystic ovaries in the rat. Gynecol Endocrinol. 2017;33(6):438-41.##Celik O, Yesilada E, Hascalik S, Celik N, Sahin I, Keskin L, et al. Angiotensin-converting enzyme gene polymorphism and risk of insulin resistance in PCOS. Reprod Biomed Online. 2010;20(4):492-8.##Llaneza-Suarez D, Llaneza P, González C, De-La-Fuente P, García-Ochoa C, Garrido P, et al. Assessment of follicular fluid leptin levels and insulin resistance as outcome predictors in women undergoing in vitro fertilization–intracytoplasmic sperm injection. Fertil Steril. 2014;102(6):1619-25.##Blüher M, Mantzoros CS. From leptin to other adipokines in health and disease: facts and expectations at the beginning of the 21st century. Metabolism. 2015;64(1):131-45.##Mantzoros CS, Cramer DW, Liberman RF, Barbieri RL. Predictive value of blood and follicular fluid leptin concentrations during assisted reproductive cycles in normal women and in women with the polycystic ovarian syndrome. Hum Reprod. 2000;15(3):539-44.##Catak Z, Aydin S, Sahin İ, Kuloglu T, Aksoy A, Dagli AF. Regulatory neuropeptides (ghrelin, obestatin and nesfatin-1) levels in blood and reproductive tissues of female and male rats with fructose-induced metabolic syndrome. Neuropeptides. 2014;48(3):167-77.##Fedorcsák P, Dale PO, Storeng R, Tanbo T, Abyholm T. The impact of obesity and insulin resistance on the outcome of IVF or ICSI in women with polycystic ovarian syndrome. Hum Reprod. 2001;16(6):1086-91.##Broughton DE, Moley KH. Obesity and female infertility: potential mediators of obesity's impact. Fertil Steril. 2017;107(4):840-7.##Crosignani PG, Ragni G, Parazzini F, Wyssling H, Lombroso G, Perotti L. Anthropometric indicators and response to gonadotrophin for ovulation induction. Hum Reprod. 1994;9(3):420-3.##Wass P, Waldenström U, Rössner S, Hellberg D. An android body fat distribution in females impairs the pregnancy rate of in-vitro fertilization-embryo transfer. Hum Reprod. 1997;12(9):2057-60.##Wang JX, Davies MJ, Norman RJ. Polycystic ovarian syndrome and the risk of spontaneous abortion following assisted reproductive technology treatment. Hum Reprod. 2001;16(12):2606-9.##

Malignant Mixed Germ Cell Tumors of the Ovary: A Series of Rare Cases 2 1 2 Background: Malignant mixed germ cell tumors of ovary are rare aggressive cancers affecting young adolescent girls. The commonest combination reported in literature is dysgerminoma and endodermal sinus tumors but in our study the most common combination was immature teratoma and endodermal sinus tumor which is exteremely rare. Preservation of future fertility is a concern. Fertility sparing surgery followed by combination chemotherapy is the current treatment of choice but treatment must be individualized depending upon the nature of the tumor. Methods: A retrospective study on five patients with these tumors was conducted on patients at Guru Gobind Singh Medical College and Hospital (Punjab, India) between September 2009 to January 2018. Results: Median age of patients was 15.6 years. Histopathological combination was immature teratoma and endodermal sinus tumor (n=3), endodermal sinus tumor and embryonal carcinoma (n=1), and mature and immature teratoma (n=1). Tumor markers AFP, beta HCG and LDH were raised in all except the patient with mature and immature teratoma. All patients underwent surgery followed by combination chemotherapy. Three patients developed metastasis within six months of treatment and died. In the remaining two, no reccurrence was reported till date. Conclusion: Malignant mixed germ cell tumors of ovary are extremely rare tumors and have poor prognosis. Fertility preservation is a concern as these patients are usually young adolescent girls but fertility sparing treatment must be individualized on the basis of tumor type, surgical staging, and availability of combination chemotherapy. Considering high recurrence rate and mortality, total hysterectomy with bilateral salpingo-oophorectomy with complete surgical staging followed by combination chemotherapy should be perfomed at advanced stage and aggressive tumor biology. Preservation of fertility must be held secondary. 231 237 Lajya LD Goyal Department of Obstetrics and Gynaecology, Guru Gobind Singh Medical College and Hospital, Faridkot Department of Obstetrics and Gynaecology, Guru Gobind Singh Medical College and Hospital, Faridkot India Balpreet B Kaur Department of Obstetrics and Gynaecology, Guru Gobind Singh Medical College and Hospital, Faridkot Department of Obstetrics and Gynaecology, Guru Gobind Singh Medical College and Hospital, Faridkot India bdhaliwal199@gmail.com Rama RK Badyal Department of Pathology, Guru Gobind Singh Medical College and Hospital, Faridkot Department of Pathology, Guru Gobind Singh Medical College and Hospital, Faridkot India Alfa feto proteinEndodermal sinus tumorMalignant mixed germ cell tumor 60059.pdf Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer. 2010;127(12):2893-917.##Bhurgri Y, Shaheen Y, Kayani N, Nazir K, Ahmed R, Usman A,et al. Incidence, trends and morphology of ovarian cancer in Karachi (1995-2002). Asian Pac J Cancer Prev. 2011;12(6):1567-71.##Pectasides D, Pectasides E, Kassanos D. Germ cell tumors of ovary. Cancer Treat Rev. 2008;34(5):427-41.##Koshy M, Vijayananthan A, Vadiveloo V. Malignant ovarian mixed germ cell tumour: a rare combination. Biomed Imaging Interv J. 2005;1(2):e10.##Munemane A, Munemane M. Malignant mixed germ cell tumours of the ovary- A report of 2 cases. Int J Med Sci Public Health. 2014;3(1):105-7.##Tiwary B, Sinha H, Pandey V. Malignant mixed germ cell tumour of ovary: a rare case report. Int J Reprod Contracept Obstet Gynecol. 2015;4(2):511-3.##Moniaga NC, Randall LM. Malignant mixed ovarian germ cell tumour with embryonal component. J Paediatr Adolesc Gynecol. 2011;24(1):e1-3.##Bailey J, Church D. Management of germ cell tumours of the ovary. Rev Gynaecol Pract. 2005;5:201.##Goyal LD, Kaur S, Kawatra K. Malignant mixed germ cell tumour of the ovary- an unusual combination and review of literature. J Ovarian Res. 2014;7:91.##Malignant ovarian germ cell tumours. Royal College of Obstetricians and Gynaecologists. Scientific impact paper No. 2016;11:1-10.##Mazumdar M, Bajorin DF, Bacik J, Higgins G, Motzer RJ, Bosl GJ. Predicting outcome to chemotherapy in patients with germ cell tumors: the value of the rate of decline of human chorionic gonadotrophin and alpha-fetoprotein during therapy. J Clin Oncol. 2001;19(9):2534-41.##Gershensom DM. Treatment of ovarian cancer in young women. Clin Obstet Gynecol. 2012;55(1):65-74.##Parkinson CA, Hatcher HM, Ajithkumar TV. Management of malignant ovarian germ cell tumors. Obstet Gynecol Surv. 2011;66(8):507-14.##Nishio S, Ushijima K, Fukui A, Fujiyoshi N, Kawano K, Komai K, et al. Fertility-preserving treatment for patients with malignant germ cell tumors of the ovary. J Obstet Gynaecol Res. 2006;32(4):416-21.##Vazquez I, Rustin GJ. Current controversies in the management of germ cell tumours. Curr Opin Oncol. 2013;25(5):539-45.##Lai CH, Chang TC, Hsueh S, Wu TI, Chao A, Chou HH, et al. Outcome and prognostic factors in ovarian germ cell malignancies. Gynecol Oncol. 2005;96(3):784-91.##Kumar S, Shah JP, Bryant CS, Imudia AN, Cote ML, Ali-Fehmi R. The prevalence and prognostic impact of lymph node metastasis in malignant germ cell tumors of the ovary. Gynecol Oncol. 2008;110(2):125-32.##Smith JP, Rutledge F, Sutow WW. Mixed gynecologic tumors in children. current approaches to treatment. Am J Obstet Gynecol. 1973;116(2):261-70.##Mangili G, Sigismondi C, Gadducci A, Cormio G, Scollo P, Tateo S, et al. Outcome and risk factors for recurrence in malignant ovarian germ cell tumours: a MITO-9 retrospective study. Int J Gynecol Cancer. 2011;21(8):1414-21.##Zhao T, Zhang H, Liu Y, Jiang H, Wang X, Lu Y The role of staging surgery in the treatment of apparent early-stage malignant ovarian germ cell tumours. Aust N Z J Obstet Gynaecol. 2016;56(4):398-402.##Mahdi H, Swensen RE, Hanna R, Kumar S, Ali-Fehmi R, Semaan A. Prognostic impact of pelvis lymphadenectomy in clinically early stage malignant germ cell tumour of the ovary. Brit J Cancer. 2011;105(4):493-7.##Reddihalli PV, Subbian A Umadevi K, Rathod PS, Krishnappa S, Nanaiah SP, et al. Immature teratoma of ovary--outcome following primary and secondary surgery: study of a single institution cohort. Eur J Obstet Gynecol Reprod Biol. 2015;192:17-21.##Cicin I, Saip P, Guney N, Eralp Y, Ayan I, Kebudi R, et al. Yolk sac tumours of the ovary: evaluation of clinicopathological features and prognostic factors. Eur J Obstet Gynecol Reprod Biol. 2009;146(2):210-4.##Lee KH, Lee IH, Kim BG, Nam JH, Kim WK, Kang SB, et al. Clinicopathologic characteristics of malignant germ cell tumors in the ovaries of Korean women; A Korean Gynecologic Oncology Group Study. Int J Gynecol Cancer. 2009;19(1):84-7.##

Evaluation of IL-17 and IL-35 Serum Levels in Patients with Preeclampsia 2 1 2 Background: Pre-eclampsia (PE) is the most common pregnancy complication affecting 2-8% of all pregnancies. PE could lead to maternal and prenatal morbidity. Imbalanced cytokine network and altered levels of several inflammatory and anti-inflammatory cytokines have been reported in PE. Because of scare information regarding the roles of IL-17 and IL-35 in PE, the current study aimed to investigate the serum level of these cytokines in a group of Iranian women suffering from PE. Methods: Serum samples were collected from 100 pre-eclamptic and 100 healthy pregnant women. Patients and controls were matched for age, ethnicity and body mass index. The level of IL-35 and IL-17 were evaluated by ELISA technique. T test and one-way ANOVA with Tukey Post-Hoc test were used for analysis and p<0.05 were assumed significant. Results: The serum level of IL-35 was increased in pre-eclamptic subjects as compared with healthy pregnant women (p<0.001). There was no significant difference in the serum level of IL-17 between pre-eclamptic and healthy pregnant women (p=0.73). Moreover, the results of the present study also showed that the pregnant women with severe pre-eclampsia had higher level of IL-35 in their sera when compared to those with mild form of the disease (p<0.001). In addition, the serum level of IL-35 was significantly elevated in women with higher proteinuria (p<0.001). Conclusion: Based on the our results, it seems that elevated levels of IL-35 in sera of pre-eclamptic women might work as a marker to evaluate the severity of the pre-eclampsia. 237 244 Atefeh A Batebi Department of Gynecology and Obstetrics, School of Medicine, Shiraz University of Medical Sciences Department of Gynecology and Obstetrics, School of Medicine, Shiraz University of Medical Sciences Iran Bahia B Namavar-Jahromi Department of Gynecology and Obstetrics, School of Medicine, Shiraz University of Medical Sciences Department of Gynecology and Obstetrics, School of Medicine, Shiraz University of Medical Sciences Iran namavarb@sums.ac.ir, gharesifb@sums.ac.ir Mohammad M Ali-Hassanzadeh Department of Immunology, School of Medicine, Shiraz University of Medical Sciences Department of Immunology, School of Medicine, Shiraz University of Medical Sciences Iran Moslem M Ahmadi Department of Immunology, School of Medicine, Shiraz University of Medical Sciences Department of Immunology, School of Medicine, Shiraz University of Medical Sciences Iran Mahsa M Sadat Hosseini Department of Immunology, School of Medicine, Shiraz University of Medical Sciences Department of Immunology, School of Medicine, Shiraz University of Medical Sciences Iran Behrouz B Gharesi-Fard Infertility Research Center, School of Medicine, Shiraz University of Medical Sciences Infertility Research Center, School of Medicine, Shiraz University of Medical Sciences Iran Interleukin-17Interleukin-35Pre-eclampsiaPregnancyProteinuria 60057.pdf English FA, Kenny LC, McCarthy FP. Risk factors and effective management of preeclampsia. Integr Blood Press Control. 2015;8:7-12.##August P and Sibai BM. Preeclampsia: Clinical features and diagnosis [Internet]. Waltham, MA; 2014 [updated 2019 Apr 25; cited 2019 Apr 29]. Available from: https://www.uptodate.com/contents/preeclampsia-clinical-features-and-diagnosis##Cotechini T, Komisarenko M, Sperou A, Macdonald-Goodfellow S, Adams MA, Graham CH. Inflammation in rat pregnancy inhibits spiral artery remodeling leading to fetal growth restriction and features of preeclampsia. J Exp Med. 2014;211(1):165-79.##Racicot K, Kwon JY, Aldo P, Silasi M, Mor G. Understanding the complexity of the immune system during pregnancy. Am J Reprod Immunol. 2014;72(2):107-16.##Vargas-Rojas MI, Solleiro-Villavicencio H, Soto-Vega E. Th1, Th2, Th17 and treg levels in umbilical cord blood in preeclampsia. J Matern Fetal Neonatal Med. 2016;29(10):1642-5.##Perez-Sepulveda A, Torres MJ, Khoury M, Illanes SE. Innate immune system and preeclampsia. Front Immunol. 2014;5:244.##Raghupathy R. Cytokines as key players in the pathophysiology of preeclampsia. Med Princ Pract. 2013;22 Suppl 1:8-19.##Redman CW, Sargent IL, Taylor RN. Immunology of normal pregnancy and preeclampsia. In: Taylor RN, Roberts JM, Cunningham FG, Lindheimer MD, editors. Chesley's hypertensive disorders in pregnancy. USA: Elsevier; 2015. p. 161-79.##Teymouri M, Pirro M, Fallarino F, Gargaro M, Sahebkar A. IL-35, a hallmark of immune‐regulation in cancer progression, chronic infections and inflammatory diseases. Int J Cancer. 2018;143(9):2105-15.##Keijsers RR, Joosten I, van Erp PE, Koenen HJ, van de Kerkhof PC. Cellular sources of IL-17 in psoriasis: a paradigm shift? Exp Dermatol. 2014;23(11):799-803.##Monin L, Gaffen SL. Interleukin 17 family cytokines: signaling mechanisms, biological activities, and therapeutic implications. Cold Spring Harb Perspect Biol. 2018;10(4). pii: a028522.##Pongcharoen S, Somran J, Sritippayawan S, Niumsup P, Chanchan P, Butkhamchot P, et al. Interleukin-17 expression in the human placenta. Placenta. 2007;28(1):59-63.##Fu B, Tian Z, Wei H. TH17 cells in human recurrent pregnancy loss and pre-eclampsia. Cell Mol Immunol. 2014;11(6):564-70.##Martínez-García EA, Chávez-Robles B, Sánchez-Hernández PE, Núñez-Atahualpa L, Martín-Máquez BT, Muñoz-Gómez A, et al. IL-17 increased in the third trimester in healthy women with term labor. Am J Reprod Immunol. 2011;65(2):99-103.##Cornelius DC, Wallace K, Scott JD, Campbell N, Thomas A, Hogg JP, Moseley J, LaMarca B. [35-OR]: A role for TH17 cells and IL-17 in mediating the pathophysiology associated with preeclampsia. Pregnancy Hypertens. 2015;5(1):17.##Molvarec A, Czegle I, Szijártó J, Rigó J Jr. Increased circulating interleukin-17 levels in preeclampsia. J Reprod Immunol. 2015;112:53-7.##Li X, Fang P, Yang WY, Wang H, Yang X. IL-35, as a newly proposed homeostasis-associated molecular pattern, plays three major functions including anti-inflammatory initiator, effector, and blocker in cardiovascular diseases. Cytokine. 2019;122:154076.##Mao H, Gao W, Ma C, Sun J, Liu J, Shao Q, et al. Human placental trophoblasts express the immunosuppressive cytokine IL-35. Hum Immunol. 2013;74(7):872-7.##Yue Cy, Zhang B, Ying CM. Elevated serum level of IL-35 associated with the maintenance of maternal-fetal immune tolerance in normal pregnancy. PloS one. 2015;10(6):e0128219.##Cao W, Wang X, Chen T, Zhu H, Xu W, Zhao S, et al. The expression of notch/notch ligand, IL-35, IL-17, and Th17/Treg in preeclampsia. Dis Markers. 2015;2015:316182.##Ozkan ZS, Simsek M, Ilhan F, Deveci D, Godekmerdan A, Sapmaz E. Plasma IL-17, IL-35, interferon-γ, SOCS3 and TGF-β levels in pregnant women with preeclampsia, and their relation with severity of disease. J Matern Fetal Neonatal Med. 2014;27(15):1513-7.##Saito S, Nakashima A. A review of the mechanism for poor placentation in early-onset preeclampsia: the role of autophagy in trophoblast invasion and vascular remodeling. J Reprod Immunol. 2014;101-102:80-8.##Mor G, Cardenas I, Abrahams V, Guller S. Inflammation and pregnancy: the role of the immune system at the implantation site. Ann N Y Acad Sci. 2011;1221(1):80-7.##Niedbala W, Wei XQ, Cai B, Hueber AJ, Leung BP, McInnes IB, et al. IL-35 is a novel cytokine with therapeutic effects against collagen‐induced arthritis through the expansion of regulatory T cells and suppression of Th17 cells. Eur J Immunol. 2007;37(11):3021-9.##Gharesi-Fard B, Mobasher-Nejad F, Nasri F. The expression of T-helper associated transcription factors and cytokine genes in pre-eclampsia. Iran J Immunol. 2016;13(4):296-308.##Anvari F, Dabagh-Gorjani F, Soltani-Zangbar MS, Kamali-Sarvestani E, Malek-Hosseini Z, Gharesi-Fard B. Investigating the association of IL-17A and IL-17F with susceptibility to pre-eclampsia in Iranian women. Iran J Immunol. 2015;12(2):117-28.##Prins JR, van der Hoorn MLP, Keijser R, Ris-Stalpers C, van Beelen E, Afink GB, et al. Higher decidual EBI3 and HLA-G mRNA expression in preeclampsia: Cause or consequence of preeclampsia. Hum Immunol. 2016;77(1):68-70.##Espes D, Singh K, Sandler S, Carlsson PO. Increased interleukin-35 levels in patients with type 1 diabetes with remaining C-peptide. Diabetes Care. 2017;40(8):1090-5.##Fonseca-Camarillo G, Furuzawa-Carballeda J, Yamamoto-Furusho JK. Interleukin 35 (IL-35) and IL-37: intestinal and peripheral expression by T and B regulatory cells in patients with inflammatory bowel disease. Cytokine. 2015;75(2):389-402.##Madazli R, Aydin S, Uludag S, Vildan O, Tolun N. Maternal plasma levels of cytokines in normal and preeclamptic pregnancies and their relationship with diastolic blood pressure and fibronectin levels. Acta Obstet Gynecol Scand. 2003;82(9):797-802.##Szarka A, Rigó J Jr, Lázár L, Beko G, Molvarec A. Circulating cytokines, chemokines and adhesion molecules in normal pregnancy and preeclampsia determined by multiplex suspension array. BMC Immunol. 2010;11:59.##Makris A, Xu B, Yu B, Thornton C, Hennessy A. Placental deficiency of interleukin-10 (IL-10) in preeclampsia and its relationship to an IL10 promoter polymorphism. Placenta. 2006;27(4-5):445-51.##Cemgil Arikan D, Aral M, Coskun A, Ozer A. Plasma IL-4, IL-8, IL-12, interferon-γ and CRP levels in pregnant women with preeclampsia, and their relation with severity of disease and fetal birth weight. J Matern Fetal Neonatal Med. 2012;25(9):1569-73.##He D, Liu M, Liu B. Interleukin-35 as a new biomarker of renal involvement in lupus nephritis patients. Tohoku J Exp Med. 2018;244(4):263-70.##Myatt L, Redman CW, Staff AC, Hansson S, Wilson ML, Laivuori H, et al. Strategy for standardization of preeclampsia research study design. Hypertension. 2014;63(6):1293-301.##

The Contingent Prenatal Screening Test for Down’s Syndrome and Neural Tube Defects in West of Iran 2 1 2 Background: The purpose of the study was to evaluate the use of contingent prenatal screening for the detection of Down’s syndrome and neural tube defects (NTDs) in west of Iran. Methods: A prospective study was conducted on 653 pregnant women referred to a medical diagnostic laboratory (Imam Reza Clinic, Kermanshah, Iran) for contingent prenatal screening tests between October 2016 to September 2017. Results: Among 651 women screened in the first trimester, 8 (1.22%) pregnancies were screen-positive for Down’s syndrome. In the second trimester, among 605 women, 25 (4.13%) had a positive result and all of these women voluntarily underwent amniocentesis. Overall, five pregnancies were complicated with chromosomal abnormalities, including five cases of Down’s syndrome. Conclusion: In a nutshell, the contingent prenatal screening tests were found to be useful for estimation of Down’s syndrome as well as NTDs in both young and older mothers in west of Iran. These tests should be performed for pregnant women before an invasive test for Down’s syndrome. 244 252 Faranak F Aghaz Fertility and Infertility Research Center, Health Technology Institute, Kermanshah University of Medical Sciences Fertility and Infertility Research Center, Health Technology Institute, Kermanshah University of Medical Sciences Iran Seyyedeh Zeinab SZ Ojagh Imamreza Clinic Imamreza Clinic Iran Saber S Khanjari 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 Asad A Vaisi-Raygani Asad Vaisi-Raygani Fertility and Infertility Research Center, Health Technology Institute, Kermanshah University of Medical Sciences Fertility and Infertility Research Center, Health Technology Institute, Kermanshah University of Medical Sciences Iran avaisiraygani@gmail.com Mozaffar M Khazaei مظفر خزاعی Fertility and Infertility Research Center, Health Technology Institute, Kermanshah University of Medical Sciences Fertility and Infertility Research Center, Health Technology Institute, Kermanshah University of Medical Sciences Iran Mitra M Bakhtiari Fertility and Infertility Research Center, Health Technology Institute, Kermanshah University of Medical Sciences Fertility and Infertility Research Center, Health Technology Institute, Kermanshah University of Medical Sciences Iran Contingent prenatal screening testDown syndromeIranNeural tube defects 60055.pdf Margaret Chan.World Health Organization. 2nd rev. ed. Geneva, Switzerland: Elsiveier; 2015; 267 p.##Askarpour S, Ostadian N, Javaherizadeh H, Chabi S. Omphalocele, gastroschisis: epidemiology, survival, and mortality in Imam Khomeini hospital, Ahvaz-Iran. Pol Przegl Chir. 2012;84(2):82-5.##Sitkin NA, Ozgediz D, Donkor P, Farmer DL. Congenital anomalies in low-and middle-income countries: the unborn child of global surgery. World J Surg. 2015;39(1):36-40.##Goetzinger KR, Shanks AL, Odibo AO, Macones GA, Cahill AG. Advanced maternal age and the risk of major congenital anomalies. Am J Perinatol. 2017;34(3):217-22.##Nicolaides KH. Screening for fetal chromosomal abnormalities: need to change the rules. Ultrasound Obstet Gynecol. 1994;4(5):353-4.##Mujezinovic F, Alfirevic Z. Procedure-related complications of amniocentesis and chorionic villous sampling: a systematic review. Obstet Gynecol. 2007;110(3):687-94.##Wald N, Rodeck C, Hackshaw AK, Walters J, Chitty L, Mackinson AM. First and second trimester antenatal screening for Down's syndrome: the results of the serum, uUrine and ultrasound screening study (SURUSS). J Med Screen. 2003;10(2):56-104.##Diamandopoulos K, Green J. Down syndrome: an integrative review. J Neonatal Nurs. 2018;24(5):235-41.##Wald NJ, Hackshaw AK. Combining ultrasound and biochemistry in first-trimester screening for Down's syndrome. Prenat Diagn. 1997;17(9):821-9.##Wanapirak C, Piyamomgkol W, Sirichotiyakul S, Tongprasert F, Srisupundit K, Luewan S, et al. Second trimester maternal serum screening for fetal down syndrome: as a sreening test for hemoglobin Bart's disease: a prospective population-based study. Prenat Diagn. 2018;38(9):700-5.##Lee FK, Chen LC, Cheong ML, Chou CY, Tsai MS. First trimester combined test for Down syndrome screening in unselected pregnancies - a report of a 13-year experience. Taiwanese J Obstet Gynecol. 2013;52(4):523-6.##Behzadmehr R, Keikhaie KR, Soltan Pour N. Investigating the attitude of pregnant women on the efficacy of ultrasound in diagnosing pregnancy based on level of education and number of pregnancies in Zabol Amiral-momenin Hospital during 2015-2016. Int J Pharm Life Sci. 2017;8(1);5559-63.##Alldred SK, Takwoingi Y, Guo B, Pennant M, Deeks JJ, Neilson JP, et al. First and second trimester serum tests with and without first trimester ultrasound tests for Down's syndrome screening. Cochrane Database Syst Rev. 2017;3:CD012599.##Driscoll DA, Gross SJ; Professional practice guidelines committee. Screening for fetal aneuploidy and neural tube defects. Genet Med. 2009;11(11):818-21.##Mersy E, Smits LJ, van Winden LA, de Die-Smulders CE; South-East Netherlands NIPT Consortium, Paulussen AD, et al. Noninvasive detection of fetal trisomy 21: systematic review and report of quality and outcomes of diagnostic accuracy studies performed between 1997 and 2012. Hum Reprod Update. 2013;19(4):318-29.##Robinson HP, Fleming JE. A critical evaluation of sonar “crown-rump length” measurements. Br J Obstet Gynaecol. 1975;82(9):702-10.##Christianson A, Howson CP, Modell B. March of dimes: global report on birth defects, the hidden toll of dying and disabled children. 1st ed. USA: March of Dimes Birth Defects Found. 2005. 84 p.##Ali A, Zahad S, Masoumeh A, Azar A. Congenital malformations among live births at Arvand hospital, Ahwaz, Iran- a prospective study. Pakistan J Med Sci. 2008;24(1):33.##Samadirad B, Khamnian Z, Hosseini MB, Dastgiri S. Congenital anomalies and termination of pregnancy in Iran. J Pregnancy. 2012;2012:574513.##Zahed Pasha Y, Vahedi A, Zamani M, Alizadeh-Navaei R, Zahed Pasha E. Prevalence of birth defects in Iran: a systematic review and meta-analysis. Arch Iran Med. 2017;20(6):376-85.##Canfield MA, Mai CT, Wang Y, O’halloran A, Marengo LK, Olney RS, et al. The association between race/ethnicity and major birth defects in the United States, 1999-2007. Am J Public Health. 2014;104(9):e14-23.##Carmichael JB, Liu HP, Janik D, Hallahan TW, Nicolaides KH, Krantz DA. Expanded conventional first trimester screening. Prenat Diagn. 2017;37(8):802-7.##Tu S, Rosenthal M, Wang D, Huang J, Chen Y. Performance of prenatal screening using maternal serum and ultrasound markers for Down syndrome in Chinese women: a systematic review and meta-analysis. BJOG. 2016;123 Suppl 3:12-22.##The selection and use of essential medicines. World Health Organ Tech Rep Ser. 2015;(994):vii-xv, 1-546.##Seyyed Kavoosi E, Younessi S, Farhud DD. Screening of fetal chromosome aneuploidies in the first and second trimester of 125,170 Iranian pregnant women. Iran J Public Health. 2015;44(6):791-6.##Kaewsuksai P, Jitsurong S. Prospective study of the feasibility and effectiveness of a second-trimester quadruple test for Down syndrome in Thailand. Int J Gynecol Obstet. 2017;139(2):217-21.##Phadke SR, Puri RD, Ranganath P. Prenatal screening for genetic disorders: Suggested guidelines for the Indian Scenario. Indian J Med Res. 2017;146(6):689-99.##

Eculizumab-Related Abortion in a Woman with Paroxysmal Nocturnal Hemoglobinuria: A Case Report 2 1 2 Background: The use of eculizumab during pregnancy has generally been discouraged. Published data on related studies provides conflicting information and establishing a benefit-risk relationship proves to be a complicated task. Miscarriage rates, concomitant medications, and the stages of pregnancy when eculizumab treatment was initiated varied among the patients included in the case series. The aim of this report is to discuss eculizumab use during pregnancy. Case Presentation: A case of a woman diagnosed with Paroxysmal Nocturnal Hemoglobinuria (PNH) and treated with eculizumab, who expressed desire for pregnancy is presented. Six months after her eculizumab treatment, the patient experienced spontaneous abortion in her first trimester. The direct relation between eculizumab and the miscarriage is not clear. Other factors may have influenced this case, thus demonstrating the difficulty of managing pregnancy in women with PNH. Conclusion: Controversy on eculizumab risk during pregnancy encourages further review on its use, highlighting the importance to assess each case individually. 252 256 Adrián A Rodríguez-Ferreras Pharmacy Department, Hospital Universitario Central de Asturias Pharmacy Department, Hospital Universitario Central de Asturias Spain adrianrf7@gmail.com Lucia L Velasco-Roces Pharmacy Department, Hospital Universitario Central de Asturias Pharmacy Department, Hospital Universitario Central de Asturias Spain AbortionComplement activationEculizumabMiscarriagePregnancy 60062.pdf Patel A, Unnikrishnan A, Murphy M, Egerman R, Wheeler S, Richards A, et al. Paroxysmal nocturnal hemoglobinuria in pregnancy: a dilemma in treatment and thromboprophylaxis. Case Rep Hematol. 2017;2017:7289126.##Almeida AM, Bedrosian C, Cole A, Muus P, Schrezenmeier H, Szer J, et al. Clinical benefit of eculizumab in patients with no transfusion history in the international paroxysmal nocturnal haemoglobinuria registry. Int Med J. 2017;47(9):1026-34.##Kelly R, Arnold L, Richards S, Hill A, Bomken C, Hanley J, et al. The management of pregnancy in paroxysmal nocturnal haemoglobinuria on long term eculizumab. Br J Haematol. 2010;149(3):446-50.##Kelly RJ, Höchsmann B, Szer J, Kulasekararaj A, de Guibert S, Röth A, et al. Eculizumab in pregnant patients with paroxysmal nocturnal hemoglobinuria. N Engl J Med. 2015;373(11):1032-9.##de Guibert S, Peffault de Latour R, Varoqueaux N, Labussière H, Rio B, Jaulmes D et al. Paroxysmal nocturnal hemoglobinuria and pregnancy before the eculizumab era: the French experience. Haematologica. 2011;96(9):1276-83.##Parker CJ. Update on the diagnosis and management of paroxysmal nocturnal hemoglobinuria. Hematology Am Soc Hematol Educ Program. 2016;2016(1):208-16.##Hallstensen RF, Bergseth G, Foss S, Jæger S, Gedde-Dahl T, Holt J, et al. Eculizumab treatment during pregnancy does not affect the complement system activity of the newborn. Immunobiology. 2015;220(4):452-9.##European Medicines Agency. Summary of product charecteristics [Internet]. Eculizumab (Soliris®); [cited 2018 Nov 5]. 55 p. Available from: http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/000791/WC500054208.pdf9.##Bjørge L, Ernst P, Haram KO. Paroxysmal nocturnal hemoglobinuria in pregnancy. Acta Obstet Gynecol Scand. 2003;82(1):1067-71.##Villegas A, Arrizabalaga B, Bonanad S, Colado E, Gaya A, González A, et al. [Spanish consensus statement for diagnosis and treatment of paroxysmal nocturnal haemoglobinuria]. Med Clin (Barc). 2016;146(6):278.e1-7. Spanish.##Fieni S, Bonfanti L, Gramellini D, Benassi L, Delsignore R. Clinical management of paroxysmal nocturnal hemoglobinuria in pregnancy: a case report and updated review. Obstet Gynecol Surv. 2006;61(9):593-601.##Sasano T, Tomimatsu T, Nishimura J, Matsumura I, Kanakura Y, Kimura T. Two consecutive pregnancies in a patient with paroxysmal nocturnal haemoglobinuria treated with anticoagulant therapy at different doses. Blood Coagul Fibrinolysis. 2016;27(1):109-12.##Morita Y, Nishimura J, Shimada T, Tanaka H, Serizawa K, Taniguchi Y, et al. Successful anticoagulant therapy for two pregnant PNH patients, and prospects for the eculizumab era. Int J Hematol. 2013;97(4):491-7.##Miyasaka N, Miura O, Kawaguchi T, Arima N, Morishita E, Usuki K, et al. Pregnancy outcomes of patients with paroxysmal nocturnal hemoglobinuria treated with eculizumab: a Japanese experience and updated review. Int J Hematol. 2016;103(6):703-12.##Sicre de Fontbrune F, Peffault de Latour R. Ten years of clinical experience with eculizumab in patients with paroxysmal nocturnal hemoglobinuria. Semin Hematol. 2018;55(3):124-9.##