Health Problems and Financial Burdens in Mislabeling IVF Failures as RIF 2 1 2 As an embryologist dealing with infertility problems, every day I witness many infertile couples are referred by gynecologists and infertility specialists or sometimes based on their direct request for advice on the cause of their previous IVF failures and decision on the future treatment plan. The common feature of these couples is that in cases with two or more failures and even in cases with a single cycle failure, regardless of the quality of the transferred embryos and characteristics of endometrium, repeated implantation failure (RIF) is the common diagnosis for them. Therefore, specialists and frequently the couples themselves make a request to take advantage of advanced techniques or other add-on interventions so that their next cycle would be successful without repeating the failure. Therefore, unsuccessful IVF treatment is a main problem for infertile couples and healthcare providers; in fact, there are fewer surgical and medical interventions with a failure rate of more than 50% through application of advanced treatments. The reason for certain number of unsuccessful IVF treatments can be attributed to low efficiency of human reproduction and impaired fecundity in some cases, and the explanation for the rest is associated with lack of knowledge regarding this complex process, which has become more obvious during the last half century with extensive advances in science and technology (1). Now one of the main undiscovered issues for embryologists is determining the exact difference between IVF cycle failures and repeated implantation failure of embryos. Does replacing one term with another cause problems in the treatment procedures of infertile couples? In studies on RIF, the first attempt should be determining whether the cause of RIF is related to embryo or endometrium. Moreover, establishing the number and conditions of failed cycles is of secondary importance. Despite enormous data and discussion on this subject, RIF remains a mystery in ART. As a phenomenon without an agreed definition, there are roughly 76 different definitions of RIF in literature reviews (2). Possible causes of RIF include unhealthy habits (such as smoking and obesity), poor gamete quality, thrombophilia, and uterine abnormalities (such as congenital uterine anomalies, polyps, fibroids, intrauterine pathology, and hydrosalpinx). However, many unknown causes require further research on RIF (3). The most important criterion in defining RIF is the number of embryos transferred in previous failed cycles. Initially, RIF was defined as failure of IVF cycles following transfer of at least 10 embryos. More recent definitions consider RIF as lack of conception after transfer of at least four top quality embryos. However, based on some definitions, the number of embryos and cycles may be adjusted by taking into account the embryo euploidy and women age. Today, most specialists declare RIF after at least four failed cycles with good quality embryos (2). The exact label of RIF is when there are three or four consecutive cycles of euploid embryo transfer with good preparation of a normal endometrium, though the occurrence of such condition is very rare (<5%). Even if we accept controversies and concur with multiple viewpoints and definitions of RIF, the next question is what additional and potentially ineffective treatments will be imposed on couples if the RIF is incorrectly applied instead of failed IVF cycles. Currently, there are various therapies and interventions for RIF which fall into the following five general categories (3): 1. Uterine interventions such as endometrial scratching, diagnostic and operative hysteroscopy, fertiloscopy and laparoscopy, endometrial biopsy for histological and microbiological evaluation and endometritis treatment, laser irradiation pretreatment of endometrium, and copper IUD insertion. 2. Embryological interventions and treatment add-ons including sequential embryo transfer (at the cleavage and blastocyst stage), co-culture of embryos with autologous cumulus cells, using intracytoplasmic morphologically selected sperm injection (IMSI), enrichment of embryo transfer medium with hyaluronic acid (Embryo Glue), extending embryo culture to the blastocyst stage, zygote intrafallopian transfer (ZIFT), assisted hatching (AH), preimplantation genetic testing for aneuploidy (PGT-A), and embryo selection using time-lapse microscopy (TLM). 3. Immune-modulating interventions including prescription of intravenous immunoglobulin (IVIG), intrauterine administration of peripheral blood mononuclear cells (PBMCs), intrauterine injection of pretreated menstrual blood stem cells, prescribing immunosuppressive drugs, administration of subcutaneous or intrauterine granulocyte colony stimulating factor (G-CSF), intrauterine injection of autologous platelet-rich plasma (PRP), intrauterine injection of human chorionic gonadotropin (hCG), administration of low molecular weight heparin (LMWH), aspirin, prednisolone, and intravenous intralipid. 4. Enhancing endometrial receptivity using human growth hormone (GH), vaginal sildenafil, or technologies aimed at identifying the window of implantation (WOI) such as the endometrial receptivity array (ERA). 5. A group of partially approved therapeutic interventions of alternative medicine, including traditional Chinese medicine (TCM) and acupuncture. As it can be seen, a wide range of expensive interventions for the success of IVF and ongoing pregnancy are prescribed by healthcare providers for RIF patients, and therefore, misdiagnosing a couple with RIF inflicts a heavy financial burden on the individuals, wastes their golden time to receive proper treatment, and even in some cases, irreparable physical injury would be the final outcome. On the other hand, even if couples are properly selected and each of these interventions is prescribed accurately, many of them have questionable efficacy or the studies provide weak supporting evidences for their use which ultimately implies uncertainty in their application (4). Unfortunately, these interventions are now in common use around the world. Their popularity is not limited to one country, one region or a few selected clinics. For example, IVF clinics in the UK prescribed one or more of these add-ons to 74% of their patients in 2018. Like IVIG, it is an expensive treatment, costing between 2,000-14,000$ per IVF cycle, and the UK Department of Health and Social Care does not recommend IVIG for the treatment of RIF (4). PGT-A can cost anywhere from 4,000-10,000$ depending on the fertility clinic and the number of tested embryos; PGT-A has been red rated by Human Fertilisation and Embryology Authority (HFEA) due to poor evidence from RCTs to show its effectiveness in improving the chances of pregnancy in RIF. However, limited studies have reported that PGT-A can significantly increase live birth rates when applied at blastocyst-stage embryos of women older than 35 years (5). Successful pregnancy, in addition to a top quality blastocyst, requires a receptive endometrium. According to available data, suboptimal endometrial receptivity is the main cause of 2/3 of implantation failures. A report on the relationship between age and implantation rate has shown that with increasing female age, the degree of asynchrony between the embryo and the endometrium increases. Based on these findings, 50% of embryo transfers in women under 35 years were asynchronous, while this rate is 68.1% in women over 35 years (2). In a large retrospective study on 4429 patients who achieved three consecutive euploid single embryo transfers, the results demonstrated that the true prevalence of RIF is <5%. In patients who performed three euploid single blastocyst transfers, clinical pregnancy was achieved in 95.2% of cases. Such results in women with normal uterus cast doubt on the etiology of RIF due to endometrial disorders. It again emphasizes the need for comprehensive clinical trials on the causes and etiology of RIF and also RCTs for each of these already routinely used IVF add-ons (6). Therefore, before labeling couples with RIF, a careful investigation should be carried out to find the reasons for the failure of previous cycles, and the selection of any add-ons for increasing success rate in future cycles should be based on obtained evidence of previous cycles. In addition, consultation of the treatment team, including gynecologists, andrologists, embryologists, and other specialists is necessary for selection of the best treatment plan for every RIF patient. 229 231 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 140170.pdf Lubinsky M. Evolutionary justifications for human reproductive limitations. J Assist Reprod Genet. 2018;35(12):2133-9.##Pirtea P, de Ziegler D, Ayoubi JM. Recurrent implantation failure-is it the egg or the chicken? Life (Basel). 2021;12(1):39.##Busnelli A, Somigliana E, Cirillo F, Baggiani A, Levi-Setti PE. Efficacy of therapies and interventions for repeated embryo implantation failure: a systematic review and meta-analysis. Sci Rep. 2021;11(1):1747.##Lensen S, Shreeve N, Barnhart KT, Gibreel A, Ng EH, Moffett A. In vitro fertilization add-ons for the endometrium: it doesn't add-up. Fertil Steril. 2019;112(6):987-93.##Simopoulou M, Sfakianoudis K, Maziotis E, Tsioulou P, Grigoriadis S, Rapani A, et al. PGT-A: who and when? a systematic review and network meta-analysis of RCTs. J Assist Reprod Genet. 2021;38(8):1939-57.##Pirtea P, De Ziegler D, Tao X, Sun L, Zhan Y, Ayoubi JM, et al. Rate of true recurrent implantation failure is low: Results of three successive frozen euploid single embryo transfers. Fertil Steril. 2021;115(1):45-53.##

The Effects of Preimplantation Genetic Testing for Aneuploidy (PGT-A) on Patient-Important Outcomes in Embryo Transfer Cases: A Meta-Analysis 2 1 2 Background: The aim of this study was to evaluate the effect of preimplantation genetic testing for aneuploidy (PGT‐A) on patient-important reproductive outcomes after in vitro fertilization (IVF). Methods: Randomized and non-randomized studies have been sought in Ovid, MEDLINE, EMBASE, Web of Science, Scopus, and Cochrane Central Register of Controlled Trials since each database’s inception through May 2021. Main keywords used for the search strategy included "Embryo transfer", "In vitro fertilization", "DNA sequencing", and "Comparative genome hybridization". Studies were screened independently and in duplicate. Results: Ten studies were finally analyzed, representing a total of 2630 embryo transfers. The pooled OR for live birth rates were 1.45 (95%CI 0.24-8.78, I2 96%) and 1.66 (95%PI 0.15-18.01, 95%CI 0.98-2.83, I2 81%) derived from the NRSIs and the RCTs, respectively, in which the miscarriage rate were 1.25 (95%CI 0.19-8.33, I2 70%) and 0.57 (95%PI 0.06-5.34, 95%CI 0.27-1.21, I2 53%), and clinical pregnancy rates were 3.08 (95%CI 2.22-4.29, I2 0%) and 1.43 (95%PI 0.38-5.42, 95%CI 0.96-2.13, I2 68%). Influence analyses showed a greater treatment effect when excluding studies without patients at advanced maternal age. Conclusion: There seems to be no significant difference in reproductive outcomes when using PGT-A in the general population; however, the procedure seems advantageous for patients at advanced maternal age. Nevertheless, this warrants caution when recommending the procedure to all couples seeking ART, as the current possible benefits may not justify the additional costs for all groups of patients. 231 250 Luis H LH Sordia-Hernandez University Center of Reproductive Medicine, Universidad Autónoma de Nuevo León University Center of Reproductive Medicine, Universidad Autónoma de Nuevo León Mexico drsordia@gmail.com Felipe A FA Morales-Martinez University Center of Reproductive Medicine, Universidad Autónoma de Nuevo León University Center of Reproductive Medicine, Universidad Autónoma de Nuevo León Mexico Fernando Díaz FD González-Colmenero Plataforma Invest Medicina UANL Ker Unit Mayo Clinic (Ker Unit Mexico), Universidad Autónoma de Nuevo León Plataforma Invest Medicina UANL Ker Unit Mayo Clinic (Ker Unit Mexico), Universidad Autónoma de Nuevo León Mexico Andrea A Flores-Rodriguez Plataforma Invest Medicina UANL Ker Unit Mayo Clinic (Ker Unit Mexico), Universidad Autónoma de Nuevo León Plataforma Invest Medicina UANL Ker Unit Mayo Clinic (Ker Unit Mexico), Universidad Autónoma de Nuevo León Mexico Paloma C PC Leyva-Camacho Plataforma Invest Medicina UANL Ker Unit Mayo Clinic (Ker Unit Mexico), Universidad Autónoma de Nuevo León Plataforma Invest Medicina UANL Ker Unit Mayo Clinic (Ker Unit Mexico), Universidad Autónoma de Nuevo León Mexico Maria Ofelia MO Sordia-Piñeyro University Center of Reproductive Medicine, Universidad Autónoma de Nuevo León University Center of Reproductive Medicine, Universidad Autónoma de Nuevo León Mexico Otto H OH Valdés-Martínez University Center of Reproductive Medicine, Universidad Autónoma de Nuevo León University Center of Reproductive Medicine, Universidad Autónoma de Nuevo León Mexico Selene M SM García-Luna University Center of Reproductive Medicine, Universidad Autónoma de Nuevo León University Center of Reproductive Medicine, Universidad Autónoma de Nuevo León Mexico René R Rodríguez-Guajardo University Center of Reproductive Medicine, Universidad Autónoma de Nuevo León University Center of Reproductive Medicine, Universidad Autónoma de Nuevo León Mexico Luis H LH Sordia-Piñeyro University Center of Reproductive Medicine, Universidad Autónoma de Nuevo León University Center of Reproductive Medicine, Universidad Autónoma de Nuevo León Mexico Assisted reproductive techniquesComparative genomic hybridizationEmbryo transferIn vitro fertilizationPreimplantation genetic diagnosis 140160.pdf Solim ZNN, Stavers KC, Mustafa F, Lim R. Assessing characteristics which influence the success rate of in vitro fertilization. J Basic Clin Reprod Sci. 2021;10(3).##Eskew AM, Jungheim ES. A history of developments to improve in vitro fertilization. Mo Med. 2017;114(3):156-9.##Theobald R, SenGupta S, Harper J. The status of preimplantation genetic testing in the UK and USA. Hum Reprod. 2020;35(4):986-98.##Harper JC, Boelaert K, Geraedts J, Harton G, Kearns WG, Moutou C, et al. ESHRE PGD consortium data collection V: cycles from january to december 2002 with pregnancy follow-up to october 2003. Hum Reprod. 2006;21(1):3-21.##Nagaoka SI, Hassold TJ, Hunt PA. Human aneuploidy: mechanisms and new insights into an age-old problem. Nat Rev Genet. 2012;13(7):493-504.##Hassold T, Hunt P. To err (meiotically) is human: the genesis of human aneuploidy. Nat Rev Genet. 2001;2(4):280-91.##Verlinsky Y, Cieslak J, Freidine M, Ivakhnenko V, Wolf G, Kovalinskaya L, et al. Pregnancies following pre-conception diagnosis of common aneuploidies by fluorescent in-situ hybridization. Hum Reprod. 1995;10(7):1923-7.##Forman EJ, Hong KH, Ferry KM, Tao X, Taylor D, Levy B, et al. In vitro fertilization with single euploid blastocyst transfer: a randomized controlled trial. Fertil Steril. 2013;100(1):100-7.e1.##Sermon K, Capalbo A, Cohen J, Coonen E, De Rycke M, De Vos A, et al. The why, the how and the when of PGS 2.0: current practices and expert opinions of fertility specialists, molecular biologists, and embryologists. Mol Hum Reprod. 2016;22(8):845-57.##Cornelisse S, Zagers M, Kostova E, Fleischer K, van Wely M, Mastenbroek S. Preimplantation genetic testing for aneuploidies (abnormal number of chromosomes) in in vitro fertilisation. Cochrane Database Syst Rev. 2020;9(9):CD005291.##Capalbo A, Rienzi L, Cimadomo D, Maggiulli R, Elliott T, Wright G, et al. Correlation between standard blastocyst morphology, euploidy and implantation: an observational study in two centers involving 956 screened blastocysts. Hum Reprod. 2014;29(6):1173-81.##Scott RTJ, Upham KM, Forman EJ, Zhao T, Treff NR. Cleavage-stage biopsy significantly impairs human embryonic implantation potential while blastocyst biopsy does not: a randomized and paired clinical trial. Fertil Steril. 2013;100(3):624-30.##Fiorentino F, Spizzichino L, Bono S, Biricik A, Kokkali G, Rienzi L, et al. PGD for reciprocal and Robertsonian translocations using array comparative genomic hybridization. Hum Reprod. 2011;26(7):1925-35.##Schoolcraft WB, Treff NR, Stevens JM, Ferry K, Katz-Jaffe M, Scott RTJ. Live birth outcome with trophectoderm biopsy, blastocyst vitrification, and single-nucleotide polymorphism microarray-based comprehensive chromosome screening in infertile patients. Fertil Steril. 2011;96(3):638-40.##Wells D. Next-generation sequencing: the dawn of a new era for preimplantation genetic diagnostics. Fertil Steril. 2014;101(5):1250-1.##Scott RTJ, Upham KM, Forman EJ, Hong KH, Scott KL, Taylor D, et al. Blastocyst biopsy with comprehensive chromosome screening and fresh embryo transfer significantly increases in vitro fertilization implantation and delivery rates: a randomized controlled trial. Fertil Steril. 2013;100(3):697-703.##Coetsier T, Dhont M. Avoiding multiple pregnancies in in-vitro fertilization: who’s afraid of single embryo transfer? Hum Reprod. 1998;13(10):2663-4.##Maxwell SM, Grifo JA. Should every embryo undergo preimplantation genetic testing for aneuploidy? A review of the modern approach to in vitro fertilization. Best Pract Res Clin Obstet Gynaecol. 2018;53:38-47.##Mantravadi Sr. K, Debnath S, Sanjay Relekar NR, Rao Sr. DG. PGT-A doesn’t seem to benefit recurrent implantation failure couples to optimize live births. Fertil Steril. 2020;114(3):e436.##Sciorio R, Dattilo M. PGT-A preimplantation genetic testing for aneuploidies and embryo selection in routine ART cycles: Time to step back? Clin Genet. 2020;98(2):107-15.##Neumann K, Sermon K, Bossuyt P, Goossens V, Geraedts J, Traeger-Synodinos J, et al. An economic analysis of preimplantation genetic testing for aneuploidy by polar body biopsy in advanced maternal age. BJOG. 2020;127(6):710-8.##Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535.##McGinn T, Wyer PC, Newman TB, Keitz S, Leipzig R, For GG. Tips for learners of evidence-based medicine: 3. Measures of observer variability (kappa statistic). CMAJ. 2004;171(11):1369-73.##Duffy JMN, Bhattacharya S, Bhattacharya S, Bofill M, Collura B, Curtis C, et al. Standardizing definitions and reporting guidelines for the infertility core outcome set: an international consensus development study. Fertil Steril. 2021;115(1):201-12.##Sterne JA, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898.##Sterne JAC, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:i4919.##Schünemann H, Brożek J, Guyatt G, Oxman A. GRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013. The GRADE Working Group, 2013.; 2013.##Mcmaster university. GRADEpro GDT: GRADEpro guideline development tool [Software] [Internet]. Evidence Prime, Inc.; 2020. Available from: gradepro.org##Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.handbook.cochrane.org##Viechtbauer W, Cheung MWL. Outlier and influence diagnostics for meta-analysis. Res Synth Methods. 2010;1(2):112-25.##Harrer M, Cuijpers P, Furukawa TA, Ebert DD. Doing meta-analysis with R: A hands-on guide. 1st ed. New York: Prot Lab Erlangen; 2019. 500 p.##Higgins JPT, Thompson SG, Spiegelhalter DJ. A re‐evaluation of random‐effects meta‐analysis. J R Stat Soc Ser A Stat Soc. 2009;172(1):137-59.##Schoolcraft WB, Fragouli E, Stevens J, Munne S, Katz-Jaffe MG, Wells D. Clinical application of comprehensive chromosomal screening at the blastocyst stage. Fertil Steril. 2010;94(5):1700-6.##Liss J, Pastuszek E, Pukszta S, Hoffmann E, Kuczynski W, Lukaszuk A, et al. Effect of next-generation sequencing in preimplantation genetic testing on live birth ratio. Reprod Fertil Dev. 2018;30(12):1720-7.##Ozgur K, Berkkanoglu M, Bulut H, Yoruk GDA, Candurmaz NN, Coetzee K. Single best euploid versus single best unknown-ploidy blastocyst frozen embryo transfers: a randomized controlled trial. J Assist Reprod Genet. 2019;36(4):629-36.##Sato T, Sugiura-Ogasawara M, Ozawa F, Yamamoto T, Kato T, Kurahashi H, et al. Preimplantation genetic testing for aneuploidy: a comparison of live birth rates in patients with recurrent pregnancy loss due to embryonic aneuploidy or recurrent implantation failure. Hum Reprod. 2019;34(12):2340-8.##Munné S, Kaplan B, Frattarelli JL, Child T, Nakhuda G, Shamma FN, et al. Preimplantation genetic testing for aneuploidy versus morphology as selection criteria for single frozen-thawed embryo transfer in good-prognosis patients: a multicenter randomized clinical trial. Fertil Steril. 2019;112(6):1071-9.e7.##Greco E, Bono S, Ruberti A, Lobascio AM, Greco P, Biricik A, et al. Comparative genomic hybridization selection of blastocysts for repeated implantation failure treatment: a pilot study. Biomed Res Int. 2014;2014:457913.##Yang Z, Liu J, Collins GS, Salem SA, Liu X, Lyle SS, et al. Selection of single blastocysts for fresh transfer via standard morphology assessment alone and with array CGH for good prognosis IVF patients: results from a randomized pilot study. Mol Cytogenet. 2012;5(1):24.##Sui YL, Lei CX, Ye JF, Fu J, Zhang S, Li L, et al. In vitro fertilization with single-Nucleotide polymorphism microarray-based preimplantation genetic testing for aneuploidy significantly improves clinical outcomes in infertile women with recurrent pregnancy loss: A randomized controlled trial. Reprod Dev Med. 2020;4(1):32-41.##Munné S, Alikani M, Tomkin G, Grifo J, Cohen J. Embryo morphology, developmental rates, and maternal age are correlated with chromosome abnormalities. Fertil Steril. 1995;64(2):382-91.##Rubio C, Simón C, Vidal F, Rodrigo L, Pehlivan T, Remohí J, et al. Chromosomal abnormalities and embryo development in recurrent miscarriage couples. Hum Reprod. 2003;18(1):182-8.##Practice committees of the American society for reproductive medicine and the society for assisted reproductive technology. The use of preimplantation genetic testing for aneuploidy (PGT-A): a committee opinion. Fertil Steril. 2018;109(3):429-36.##Dahdouh EM, Balayla J, García-Velasco JA. Comprehensive chromosome screening improves embryo selection: a meta-analysis. Fertil Steril. 2015;104(6):1503-12.##Lee E, Illingworth P, Wilton L, Chambers GM. The clinical effectiveness of preimplantation genetic diagnosis for aneuploidy in all 24 chromosomes (PGD-A): systematic review. Hum Reprod. 2015;30(2):473-83.##Griesinger G. Beware of the ’implantation rate’! Why the outcome parameter “implantation rate” should be abandoned from infertility research. Hum Reprod. 2016;31(2):249-51.##Simopoulou M, Sfakianoudis K, Maziotis E, Tsioulou P, Grigoriadis S, Rapani A, et al. PGT-A: who and when? a systematic review and network meta-analysis of RCTs. J Assist Reprod Genet. 2021;38(8):1939-57.##Mochizuki L, Gleicher N. The PGS/PGT-A controversy in IVF addressed as a formal conflict resolution analysis. J Assist Reprod Genet. 2020;37(3):677-87.##Gleicher N, Patrizio P, Brivanlou A. Preimplantation Genetic Testing for Aneuploidy – a Castle Built on Sand. Trends Mol Med. 2021;27(8):731-42.##McArthur SJ, Leigh D, Marshall JT, de Boer KA, Jansen RPS. Pregnancies and live births after trophectoderm biopsy and preimplantation genetic testing of human blastocysts. Fertil Steril. 2005;84(6):1628-36.##Kokkali G, Traeger-Synodinos J, Vrettou C, Stavrou D, Jones GM, Cram DS, et al. Blastocyst biopsy versus cleavage stage biopsy and blastocyst transfer for preimplantation genetic diagnosis of beta-thalassaemia: a pilot study. Hum Reprod. 2007;22(5):1443-9.##Dekel-Naftali M, Aviram-Goldring A, Litmanovitch T, Shamash J, Yonath H, Hourvitz A, et al. Chromosomal integrity of human preimplantation embryos at different days post fertilization. J Assist Reprod Genet. 2013;30(5):633-48.##

A Homogeneous Ensemble of Robust Pre-defined Neural Network Enables Automated Annotation of Human Embryo Morphokinetics 2 1 2 Background: The purpose of the current study was to reduce the risk of human bias in assessing embryos by automatically annotating embryonic development based on their morphological changes at specified time-points with convolutional neural network (CNN) and artificial intelligence (AI). Methods: Time-lapse videos of embryo development were manually annotated by the embryologist and extracted for use as a supervised dataset, where the data were split into 14 unique classifications based on morphological differences. A compilation of homogeneous pre-trained CNN models obtained via TensorFlow Hub was tested with various hyperparameters on a controlled environment using transfer learning to create a new model. Subsequently, the performances of the AI models in correctly annotating embryo morphologies within the 14 designated classifications were compared with a collection of AI models with different built-in configurations so as to derive a model with the highest accuracy. Results: Eventually, an AI model with a specific configuration and an accuracy score of 67.68% was obtained, capable of predicting the embryo developmental stages (t1, t2, t3, t4, t5, t6, t7, t8, t9+, tCompaction, tM, tSB, tB, tEB). Conclusion: Currently, the technology and research of artificial intelligence and machine learning in the medical field have significantly and continuingly progressed in an effort to develop computer-assisted technology which could potentially increase the efficiency and accuracy of medical personnel’s performance. Nonetheless, building AI models with larger data is required to properly increase AI model reliability. 250 257 Gunawan B GB Danardono IRSI Research and Training Center IRSI Research and Training Center Indonesia gunawanbondan@gmail. com Alva A Erwin IRSI Research and Training Center IRSI Research and Training Center Indonesia James J Purnama Faculty of Engineering and Information Technology, Swiss German University Faculty of Engineering and Information Technology, Swiss German University Indonesia Nining N Handayani IRSI Research and Training Center IRSI Research and Training Center Indonesia Arie A AA Polim IRSI Research and Training Center IRSI Research and Training Center Indonesia Arief A Boediono IRSI Research and Training Center IRSI Research and Training Center Indonesia Ivan IR Sini IRSI Research and Training Center IRSI Research and Training Center Indonesia Artificial intelligenceAutomationComputer-assisted image processingEmbryonic developmentIn vitro fertilizationMachine learningNeural networks 140161.pdf Kanakasabapathy MK, Thirumalaraju P, Bormann CL, Kandula H, Dimitriadis I, Souter I, et al. Development and evaluation of inexpensive automated deep learning-based imaging systems for embryology. Lab Chip. 2019;19(24):4139-45.##Chavez-Badiola A, Flores-Saiffe-Farías A, Mendizabal-Ruiz G, Drakeley AJ, Cohen J. Embryo ranking intelligent classification algorithm (ERICA): artificial intelligence clinical assistant predicting embryo ploidy and implantation. Reprode Biomed Online. 2020;41(4):585-93.##Lee CI, Su YR, Chen CH, Chang TA, Kuo EE, Zheng WL, et al. End-to-end deep learning for recognition of ploidy status using time-lapse videos. J Assist Reprod Genet. 2021;38(7):1655-63.##Huang B, Tan W, Li Z, Jin L. An artificial intelligence model (euploid prediction algorithm) can predict embryo ploidy status based on time-lapse data. Reprod Biol Endocrinol. 2021;19(1):185.##Kanakasabapathy MK, Thirumalaraju P, Bormann CL, Gupta R, Pooniwala R, Kandula H, et al. Deep learning mediated single time-point image-based prediction of embryo developmental outcome at the cleavage stage. arXiv preprint arXiv:2006.08346. 2020 May 21.##Huang B, Zheng S, Ma B, Yang Y, Zhang S, Jin L. Using deep learning to predict the outcome of live birth from more than 10,000 embryo data. BMC Pregnancy Childbirth. 2022;22(1):36.##Miyagi Y, Habara T, Hirata R, Hayashi N. Feasibility of artificial intelligence for predicting live birth without aneuploidy from a blastocyst image. Reprod Med Biol. 2019;18(2):204-11.##Malmsten J, Zaninovic N, Zhan Q, Rosenwaks Z, Shan J. Automated cell stage predictions in early mouse and human embryos using convolutional neural networks. In2019 IEEE EMBS international conference on biomedical & health informatics (BHI) 2019 May 19 (pp. 1-4). IEEE.##Liu Z, Huang B, Cui Y, Xu Y, Zhang B, Zhu L, et al. Multi-task deep learning with dynamic programming for embryo early development stage classification from time-lapse videos. IEEE Access. 2019;7:122153-63.##Khan A, Gould S, Salzmann M. Deep convolutional neural networks for human embryonic cell counting. InEuropean conference on computer vision 2016 Oct 8 (pp. 339-348). Springer, Cham.##Gingold JA, Ng NH, McAuley J, Lipton Z, Desai N. Predicting embryo morphokinetic annotations from time-lapse videos using convolutional neural networks. Fertil Steril. 2018;110(4):e220.##Thirumalaraju P, Kanakasabapathy MK, Bormann CL, Gupta R, Pooniwala R, Kandula H, et al. Evaluation of deep convolutional neural networks in classifying human embryo images based on their morphological quality. Heliyon. 2021;7(2):e06298.##VerMilyea M, Hall JM, Diakiw SM, Johnston A, Nguyen T, Perugini D, et al. Development of an artificial intelligence-based assessment model for prediction of embryo viability using static images captured by optical light microscopy during IVF. Hum Reprod. 2020;35(4):770-84.##Chen TJ, Zheng WL, Liu CH, Huang I, Lai HH, Liu M. Using deep learning with large dataset of microscope images to develop an automated embryo grading system. Fertil Reprod. 2019;1(1):51-6.##Louis CM, Erwin A, Galinium M. Automated annotation of in vtrio fertilization time-lapse using deep neural network [dissertation]: Swiss German University; 2020. 105 p##Palermo GD, O’Neill CL, Chow S, Cheung S, Parrella A, Pereira N, et al. Intracytoplasmic sperm injection: state of the art in humans. Reproduction. 2017;154(6):F93-F110.##Pribenszky C, Nilselid AM, Montag M. Time-lapse culture with morphokinetic embryo selection improves pregnancy and live birth chances and reduces early pregnancy loss: a meta-analysis. Reprod Biomed Online. 2017;35(5):511-20.##Raudonis V, Paulauskaite-Taraseviciene A, Sutiene K, Jonaitis D. Towards the automation of early-stage human embryo development detection. Biomed Eng Online. 2019;18(1):120.##O'Shea K, Nash R. An introduction to convolutional neural networks. arXiv preprint arXiv:1511.08458. 2015 Nov 26.##Gu J, Wang Z, Kuen J, Ma L, Shahroudy A, Shuai B, et al. Recent advances in convolutional neural networks. Pattern Recognition. 2018;77:354-77.##Albawi S, Mohammed TA, Al-Zawi S. Understanding of a convolutional neural network. In2017 international conference on engineering and technology (ICET) 2017 Aug 21 (pp. 1-6). Ieee.##Abadi M, Agarwal A, Barham P, Brevdo E, Chen Z, Citro C, et al. Tensorflow: Large-scale machine learning on heterogeneous distributed systems. arXiv preprint arXiv:1603.04467. 2016 Mar 14.##Abadi M, Barham P, Chen J, Chen Z, Davis A, Dean J, et al. {TensorFlow}: A system for {Large-Scale} machine learning. In12th USENIX symposium on operating systems design and implementation (OSDI 16) 2016 (pp. 265-283).##Dillon JV, Langmore I, Tran D, Brevdo E, Vasudevan S, Moore D, Patton B, Alemi A, Hoffman M, Saurous RA. Tensorflow distributions. arXiv preprint arXiv:1711.10604. 2017 Nov 28.##Chollet F, others. Keras [Internet]. San Francisco: GitHub; 2015 [cited 2021 Apr 16]. Available from: https://github.com/fchollet/keras##

Estimation of Serum and Seminal Plasma Levels of Glactin-1 in Non-Obstructive Azoospermia Cases and Their Correlations with the Rate of Sperm Retrieval: A Comparative Prospective Study 2 1 2 Background: Remarkably, the current study is one of the first to deploy galectin-1 (Gal-1) in determining the degree of impairment of spermatogenesis among cases with non-obstructive azoospermia (NOA) as well as utilizing it as a biomarker to predict the rate of sperm retrieval in these patients. The purpose of the study was to evaluate the seminal plasma and serum levels of Gal-1 in NOA patients as well as their correlations with Johnsen’s tubular biopsy scoring (JTBS). Methods: The current case control study included totally 48 patients with NOA whose ages ranged from 24 to 46 years old and 50 age matched healthy controls. Gal-1 levels were measured in both seminal plasma and serum of all subjects by the enzyme-linked immunosorbent assay (ELISA). Results: A significant negative correlation between seminal plasma levels of Gal-1 and JTBS was detected (r=-0.281, p=0.048) in the NOA cases. Interestingly, the receiver operating characteristic (ROC) curve had demonstrated that the cutoff value of seminal plasma levels of Gal-1 in determining azoospermia was >0.735 ng/ml and the area under the curve (AUC) was 0.858. The sensitivity, specificity, positive predictive, and negative predictive values for seminal plasma levels of Gal-1 were 76, 92, 90.5, and 79.3, respectively. In addition, sensitivity, specificity, positive predictive, and negative predictive values for serum levels of Gal-1 were 38, 66, 52.8, and 51.6, respectively. Conclusion: Seminal plasma levels of Gal-1 are higher in NOA men versus healthy controls. Interestingly, negative correlation of seminal plasma levels of Gal-1 with JTBS was determined. Thus, it can be used as a good predictor for NOA cases. 257 264 Sameh Fayek SF GamalEl Din Department of Andrology and STDs, Faculty of Medicine Kasralainy, Cairo University Department of Andrology and STDs, Faculty of Medicine Kasralainy, Cairo University Egypt samehfayek@kasralainy.edu.eg Khadiga Kh Abougabal Department of Clinical and Chemical Pathology, Faculty of Medicine, Beni-Suef University Department of Clinical and Chemical Pathology, Faculty of Medicine, Beni-Suef University Egypt Hany Mohammed HM Saad Department of Andrology, Faculty of Medicine, Suez Canal University Department of Andrology, Faculty of Medicine, Suez Canal University Egypt Mohamed MS Mohamed Department of Andrology and STDs, Faculty of Medicine Kasralainy, Cairo University Department of Andrology and STDs, Faculty of Medicine Kasralainy, Cairo University Egypt Amira Mahmoud MA Mohamed Ali Egyptian Ministry of Health and Population Egyptian Ministry of Health and Population Egypt Ahmed A Abo Sief Department of Andrology and STDs, Faculty of Medicine, Beni-Suef University Department of Andrology and STDs, Faculty of Medicine, Beni-Suef University Egypt Non-obstructive azoospermiaSeminal plasma levels of Gal-1Serum levels of Gal-1 140162.pdf Agarwal A, Mulgund A, Hamada A, Chyatte MR. A unique view on male infertility around the globe. Reprod Biol Endocrinol. 2015;13:37.##Barratt CLR, Björndahl L, De Jonge CJ, Lamb DJ, Osorio Martini F, McLachlan R, et al. The diagnosis of male infertility: an analysis of the evidence to support the development of global WHO guidance-challenges and future research opportunities. Hum Reprod Update. 2017;23(6):660-80.##Skakkebaek NE, Rajpert-De Meyts E, Buck Louis GM, Toppari J, Andersson AM, Eisenberg ML, et al. Male reproductive disorders and fertility trends: influences of environment and genetic susceptibility. Physiol Rev. 2016;96(1):55-97.##Babakhanzadeh E, Nazari M, Ghasemifar S, Khodadadian A. Some of the factors involved in male infertility: a prospective review. Int J Gen Med. 2020;5:13:29-41.##Minhas S, Bettocchi C, Boeri L, Capogrosso P, Carvalho J, Cilesiz NC, et al. European association of urology guidelines on male sexual and reproductive health: 2021 update on male infertility. Eur Urol. 2021;80(5):603-20.##Gudeloglu A, Parekattil SJ. Update in the evaluation of the azoospermic male. Clinics (Sao Paulo). 2013;68 Suppl 1(Suppl 1):27-34.##Lee JY, Dada R, Sabanegh E, Carpi A, Agarwal A. Role of genetics in azoospermia. Urology. 2011;77:598-601.##Barondes SH, Cooper DN, Gitt MA, Leffler H. Galectins. Structure and function of a large family of animal lectins. J Biol Chem. 1994;269(33):20807-10.##Özbek M, Hitit M, Yıldırım N, Özgenç Ö, Ergün E, Ergün L, et al. Expression pattern of galectin-1 and galectin-3 in rat testes and epididymis during postnatal development. Acta Histochem. 2018;120(8):814-27.##Cummings RD, Liu FT. Galectins. In: Varki AC, Cummings RD, Esko JD, Freeze HH, Stanley P, Bertozzi CR, et al, editors. Essentials of glycobiology cold spring harbor. New York: Cold spring harbor laboratory press, 2009. Chapter 33.##Baum LG, Pang M, Perillo NL, Wu T, Delegeane A, Uittenbogaart CH, et al. Human thymic epithelial cells express an endogenous lectin, galectin-1, which binds to core 2 O‐glycans on thymocytes and T lymphoblastoid cells. J Exp Med. 1995;181(3):877-87.##Ahmed H, Fink NE, Pohl J, Vasta GR. Galectin-1 from bovine spleen: biochemical characterization, carbohydrate specificity and tissue-specific isoform profiles. J Biochem. 1996;120(5):1007-19.##Moiseeva EP, Javed Q, Spring EL, de Bono DP. Galectin 1 is involved in vascular smooth muscle cell proliferation. Cardiovasc Res. 2000;45(2):493-502.##Hittelet A, Legendre H, Nagy N, Bronckart Y, Pector JC, Salmon I, et al. Upregulation of galectins-1 and -3 in human colon cancer and their role in regulating cell migration. Int J Cancer. 2003;103(3):370-9.##Van den Brule F, Califice S, Garnier F, Fernandez PL, Berchuck A, Castronovo V. Galectin-1 accumulation in the ovary carcinoma peritumoralstroma is induced by ovary carcinoma cells and affects both cancer cell proliferation and adhesion to laminin-1 and fibronectin. Lab Invest. 2003;83(3):377-86.##Akazawa C, Nakamura Y, Sango K, Horie H, Kohsaka S. Distribution of the galectin-1 mRNA in the rat nervous system: its transient upregulation in rat facial motor neurons after facial nerve axotomy. Neuroscience. 2004;125(1):171-8.##Biron VA, Iglesias MM, Troncoso MF, Besio-Moreno M, Patrignani ZJ, Pignataro OP, et al. Galectin-1: biphasic growth regulation of Leydig tumor cells. Glycobiology. 2006;16(9):810-21.##Johnsen SG. Testicular biopsy score count - a method for registration of spermatogenesis in human testes: normal values and results in 335 hypogonadal males. Hormones. 1970;1(1):2-25.##World medical association. World medical association declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191-4.##Menkhorst EM, Gamage T, Cuman C, Kaitu'u-Lino TJ, Tong S, Dimitriadis E. Galectin-7 acts as an adhesion molecule during implantation and increased expression is associated with miscarriage. Placenta. 2014;35(3):195-201.##Menkhorst E, Koga K, Van Sinderen M, Dimitriadis E. Galectin-7 serum levels are altered prior to the onset of pre-eclampsia. Placenta. 2014;35(4):281-5.##Davalieva K, Kiprijanovska S, Noveski P, Plaseski T, Kocevska B, Broussard C, et al. Proteomic analysis of seminal plasma in men with different spermatogenic impairment. Andrologia. 2012;44(4):256-64.##Dettin L, Rubinstein N, Aoki A, Rabinovich GA, Maldonado CA. Regulated expression and ultrastructural localization of galectin-1, a proapoptotic beta-galactoside-binding lectin, during spermatogenesis in rat testis. Biol Reprod. 2003;68(1):51-9.##Chui K, Trivedi A, Cheng CY, Cherbavaz DB, Dazin PF, Huynh AL, et al. Characterization and functionality of proliferative human sertoli cells. Cell Transplant. 2011;20(5):619-35.##Kim H, Lee J, Hyun JW, Park JW, Joo HG, Shin T. Expression and immunohistochemical localization of galectin-3 in various mouse tissues. Cell Biol Int. 2007;31(7):655-62.##Kim M, Kim S, Kim H, Kim H, Joo HG, Shin T. Immunohistochemical localization of galectin-3 in the reproductive organs of the cow. Acta Histochem. 2008;110(6):473-80.##Khorsandi L, Orazizadeh M. Immunolocalization of galectin-3 in mouse testicular tissue. Iran J Basic Med Sci. 2011;14(4):349-53.##Ellerhorst J, Troncoso P, Xu XC, Lee J, Lotan R. Galectin-1 and galectin-3 expression in human prostate tissue and prostate cancer. Urol Res. 1999;27(5):362-7.##

Testicular Sperm Extraction and Intracytoplasmic Sperm Injection in Management of Obstructive Azoospermia: A Two-Year Multicenter Review in Ghana 2 1 2 Background: The objective of this study was to evaluate treatment outcomes and assess predictors of clinical pregnancy in obstructive azoospermia cases treated with testicular sperm extraction (TESE) and intracytoplasmic sperm injection (ICSI) in Ghana. Methods: This study was a retrospective study conducted on 67 men seeking treatment for obstructive azoospermia at two study sites in Ghana from January 2018 to December 2019. First, archived data were reviewed and treatment outcomes of cases of obstructive azoospermia from the hospital records were evaluated. Infertile men who met the inclusion criteria were recruited. Descriptive data were expressed in the form of frequencies and percentages. The dependent and independent variables were analyzed using multiple logistic regression and reported as odds ratios (ORs). The confidence interval (CI) was set at 95% and a p-value <0.05 was considered significant. Results: The mean age of male participants was 42.43±9.11 years (mean±SD) while the mean age of their partners was 32.89±5.73 years (mean±SD). The average duration of infertility before intervention was 5.01±3.60 years (mean±SD). Successful pregnancy was observed in 52.2% (35/67) of the participants. After adjusting for confounders, the rate of a successful clinical pregnancy was 0.07 lower for every additional year increase in the male’s age [AOR=0.93 (95%CI=0.87 - 0.99), p=0.02]. Conclusion: Overall the rate of clinical pregnancy following TESE/ICSI from our study was 52.2%. A man’s age was a strong predictor of successful clinical pregnancy among couples treated with TESE-ICSI for obstructive azoospermia in Ghana. 264 271 Promise E PE Sefogah Department of Obstetrics and Gynaecology, College of Health Sciences, University of Ghana Medical School Department of Obstetrics and Gynaecology, College of Health Sciences, University of Ghana Medical School Ghana Alim A Swarray-Deen Department of Obstetrics and Gynaecology, College of Health Sciences, University of Ghana Medical School Department of Obstetrics and Gynaecology, College of Health Sciences, University of Ghana Medical School Ghana asdeen8@gmail.com Edem K EK Hiadzi Department of Obstetrics and Gynaecology, Lister Hospital and Fertility Centre Department of Obstetrics and Gynaecology, Lister Hospital and Fertility Centre Ghana Rudolph K RK Adageba Department of Obstetrics and Gynaecology, Ruma Fertility and Specialist Hospital Department of Obstetrics and Gynaecology, Ruma Fertility and Specialist Hospital Ghana Nana NE Oduro Department of Obstetrics and Gynaecology, Korle Bu Teaching Hospital Department of Obstetrics and Gynaecology, Korle Bu Teaching Hospital Ghana Hanson G HG Nuamah Department of Epidemiology and Disease Control, School of Public Health, University of Ghana Department of Epidemiology and Disease Control, School of Public Health, University of Ghana Ghana Mercy A MA Nuamah Department of Obstetrics and Gynaecology, College of Health Sciences, University of Ghana Medical School Department of Obstetrics and Gynaecology, College of Health Sciences, University of Ghana Medical School Ghana AzoospermiaIntracytoplasmic sperm injectionMale infertilityTesticular sperm retrieval 140163.pdf Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, Stevens GA. National, regional, and global trends in infertility prevalence since 1990: a systematic analysis of 277 health surveys. PLoS Med. 2012;9(12):e1001356.##Dupree JM. Insurance coverage for male infertility care in the United States. Asian J Androl. 2016;18(3):339-41.##Mehta A, Nangia AK, Dupree JM, Smith JF. Limitations and barriers in access to care for male factor infertility. Fertil Steril. 2016;105(5):1128-37.##Tüttelmann F, Werny F, Cooper TG, Kliesch S, Simoni M, Nieschlag E. Clinical experience with azoospermia: aetiology and chances for spermatozoa detection upon biopsy. Int J Androl. 2011;34(4):291-8.##Gyasi-Sarpong CK, Manu Maison PO, Koranteng AK. The pattern of male infertility in Kumasi, Ghana. Afr J Infertil Assist Concept. 2017;2:3-5.##Esteves SC, Lee W, Benjamin DJ, Seol B, Verza S, Agarwal A. Reproductive potential of men with obstructive azoospermia undergoing percutaneous sperm retrieval and intracytoplasmic sperm injection according to the cause of obstruction. J Urol. 2013;189(1):232-7.##Jungwirth A, Giwercman A, Tournaye H, Diemer T, Kopa Z, Dohle G, et al. European association of urology guidelines on male infertility: The 2012 update. Eur Urol. 2012;62(2):324-32.##Abdulwahed SR, Mohamed EEM, Taha EA, Saleh MA, Abdelsalam YM, Elganainy EO. Sensitivity and specificity of ultrasonography in predicting etiology of azoospermia. Urology. 2013;81(5):967-71.##Lee HS, Seo JT. Advances in surgical treatment of male infertility. World J Mens Health. 2012;30(2):108-13.##Abdel Raheem A, Garaffa G, Rushwan N, De Luca F, Zacharakis E, Abdel Raheem T, et al. Testicular histopathology as a predictor of a positive sperm retrieval in men with non-obstructive azoospermia. BJU Int. 2013;111(3):492-9.##Bernie AM, Ramasamy R, Schlegel PN. Predictive factors of successful microdissection testicular sperm extraction. Basic Clin Androl. 2013;23:5.##Caroppo E, Colpi EM, Gazzano G, Vaccalluzzo L, Scroppo FI, D’Amato G, et al. Testicular histology may predict the successful sperm retrieval in patients with non-obstructive azoospermia undergoing conventional TESE: a diagnostic accuracy study. J Assist Reprod Genet. 2017;34(1):149-54.##Sartorius GA, Nieschlag E. Paternal age and reproduction. Hum Reprod Update. 2010;16(1):65-79.##Hammiche F, Laven JSE, Boxmeer JC, Dohle GR, Steegers EAP, Steegers-Theunissen RPM. Sperm quality decline among men below 60 years of age undergoing IVF or ICSI treatment. J Androl. 2011;32(1):70-6.##Enatsu N, Miyake H, Chiba K, Fujisawa M. Predictive factors of successful sperm retrieval on microdissection testicular sperm extraction in Japanese men. Reprod Med Biol. 2016;15(1):29-33.##Gnessi L, Scarselli F, Minasi MG, Mariani S, Lubrano C, Basciani S, et al. Testicular histopathology, semen analysis and FSH, predictive value of sperm retrieval: supportive counseling in case of reoperation after testicular sperm extraction (TESE). BMC Urol. 2018;18(1):63.##Busch AS, Tüttelmann F, Cremers JF, Schubert M, Nordhoff V, Schüring AN, et al. FSHB −211 G>T polymorphism as predictor for TESE success in patients with unexplained azoospermia. J Clin Endocrinol Metab. 2019;104(6):2315-24.##Belloc S, Cohen-Bacrie M, Amar E, Izard V, Benkhalifa M, Dalléac A, et al. High body mass index has a deleterious effect on semen parameters except morphology: results from a large cohort study. Fertil Steril. 2014;102(5):1268-73.##Eisenberg ML, Kim S, Chen Z, Sundaram R, Schisterman EF, Buck Louis GM. The relationship between male BMI and waist circumference on semen quality: Data from the LIFE study. Hum Reprod. 2015;30(2):493-4.##Klonoff-Cohen HS, Natarajan L. The effect of advancing paternal age on pregnancy and live birth rates in couples undergoing in vitro fertilization or gamete intrafallopian transfer. Am J Obstet Gynecol. 2004;191(2):507-14.##Mehta A, Bolyakov A, Schlegel PN, Paduch DA. Higher pregnancy rates using testicular sperm in men with severe oligospermia. Fertil Steril. 2015;104(6):1382-7.##Tsai YR, Lan KC, Kung FT, Lin PY, Chiang HJ, Lin YJ, et al. The effect of advanced paternal age on the outcomes of assisted reproductive techniques among patients with azoospermia using cryopreserved testicular spermatozoa. Taiwan J Obstet Gynecol. 2013;52(3):351-5.##Kavoussi PK, West BT, Chen SH, Hunn C, Gilkey MS, MacHen GL, et al. A comprehensive assessment of predictors of fertility outcomes in men with non-obstructive azoospermia undergoing microdissection testicular sperm extraction. Reprod Biol Endocrinol. 2020;18(1):90.##Cameron NJ, Bhattacharya S, McLernon DJ. Cumulative live birth rates following blastocyst- versus cleavage-stage embryo transfer in the first complete cycle of IVF: a population-based retrospective cohort study. Hum Reprod. 2020;35(10):2365-74.##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.##Blake DA, Proctor M, Johnson NP. The merits of blastocyst versus cleavage stage embryo transfer: A Cochrane review. Hum Reprod. 2004;19(4):795-807.##Rehnitz J, Rösner S, Harsch J, Dietrich J, Bruckner T, Capp E, et al. Factors influencing success rate of intracytoplasmic sperm injection with azoospermic male patients. Geburtshilfe Frauenheilkd. 2020;80(7):713-22.##Kamath MS, Mascarenhas M, Kirubakaran R, Bhattacharya S. Number of embryos for transfer following in vitro fertilisation or intra-cytoplasmic sperm injection. Cochrane Database Syst Rev. 2020;8(8):CD003416.##Pandian Z, Marjoribanks J, Ozturk O, Serour G, Bhattacharya S. Number of embryos for transfer following in vitro fertilisation or intra-cytoplasmic sperm injection. Cochrane Database Syst Rev. 2013(7):CD003416.##

The Diagnostic Accuracy of Galectin-9 for Diagnosis of Endometriosis in Comparison with Laparoscopy 2 1 2 Background: Endometriosis is a common devastating gynecological disease with severe complications. Researches on noninvasive diagnostic tests with acceptable accuracy are still ongoing. The purpose of the present study was to evaluate the diagnostic value of serum Galectin-9 (Gal-9) level in comparison with laparoscopic results in endometriosis patients. Methods: Sixty-one patients, referred to Booali, Rasool-e-Akram, and Pars Hospitals affiliated to Islamic Azad University of Medical Sciences, were recruited. Patients laparoscopically diagnosed with endometriosis were assigned to the case (n=32) and who diagnosed with other diseases were assigned to the control group (n=29). In general, 56 patients (30 in case and 26 in control group) completed the study. The serum level of Galectin-9 was measured using ELISA method before laparoscopy and was compared between the groups. Next, categorical variables were compared using Chi square and quantitative variables using independent samples t-test or Mann-Whitney U test. The Gal-9 cut-off was calculated using the Youden’s index and ROC curve; then, sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratio of Gal-9 were reported. The p<0.05 were considered statistically significant. Results: Mean serum level of Galectin-9 was 669.3±416.50 pg/ml in the case group and 265.42±492.30 pg/ml in the control group (p=0.001). Considering a cut-off value of 138 pg/ml, Galectin-9 had a sensitivity of 100% and specificity of 88.46% for diagnosis of endometriosis (p<0.001). Conclusion: Galectin-9 measurement is helpful in diagnosis of endometriosis. Future studies are recommended for investigating the generalizability of these results. 271 279 Sahar S Jarollahi Islamic Azad University of Medical Sciences Islamic Azad University of Medical Sciences Iran Shahla Sh Chaichian Shahla Chaichian Islamic Azad University of Medical Sciences Islamic Azad University of Medical Sciences Iran shchaichian@gmail.com Ali a Jarollahi Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences Iran Roya R Hajmohammadi Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences Iran Reza R Mashayekhi Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences Iran Fereshteh F Shahmohammadi Islamic Azad University of Medical Sciences Islamic Azad University of Medical Sciences Iran Mohammad M Eslamivaghar Islamic Azad University of Medical Sciences Islamic Azad University of Medical Sciences Iran Ziba Z Ghasemi Islamic Azad University of Medical Sciences Islamic Azad University of Medical Sciences Iran BiomarkersDiagnostic testsEndometriosisGalectin-9Laparascopy 140164.pdf Parasar P, Ozcan P, Terry KL. Endometriosis: epidemiology, diagnosis and clinical management. Curr Obstet Gynecol Rep. 2017;6(1):34-41.##Riazi H, Tehranian N, Ziaei S, Mohammadi E, Hajizadeh E, Montazeri A. Clinical diagnosis of pelvic endometriosis: a scoping review. BMC Womens Health. 2015;15:39.##Vitale SG, La Rosa VL, Rapisarda AMC, Laganà AS. Endometriosis and infertility: the impact on quality of life and mental health. J Endometr Pelvic Pain Dis. 2017;9(2):112-5.##Mehdizadeh Kashi A, Moradi Y, Chaichian S, Najmi Z, Mansori K, Salehin F, et al. Application of the world health organization quality of life instrument, short form (WHOQOL-BREF) to patients with endometriosis. Obstet Gynecol Sci. 2018;61(5):598-604.##Mehedintu C, Plotogea M, Ionescu S, Antonovici M. Endometriosis still a challenge. J Med Life. 2014;7(3):349-57.##Zhang S, Gong TT, Wang HY, Zhao YH, Wu QJ. Global, regional, and national endometriosis trends from 1990 to 2017. Ann N Y Acad Sci. 2021;1484(1):90-101.##Malvezzi H, Marengo EB, Podgaec S, de Azevedo Piccinato C. Endometriosis: current challenges in modeling a multifactorial disease of unknown etiology. J Transl Med. 2020;18(1):311.##Rolla E. Endometriosis: advances and controversies in classification, pathogenesis, diagnosis, and treatment. F1000Res. 2019;8:F1000 Faculty Rev-529.##Chaichian S. Surgical management of endo-metriosis. Ann Bariatric Surg. 2013;2(4):100-10.##Dana PM, Taghavipour M, Mirzaei H, Yousefi B, Moazzami B, Chaichian S, et al. Circular RNA as a potential diagnostic and/or therapeutic target for endometriosis. Biomark Med. 2020;14(13):1277-87.##Taghavipour M, Sadoughi F, Mirzaei H, Yousefi B, Moazzami B, Chaichian S, et al. Apoptotic functions of microRNAs in pathogenesis, diagnosis, and treatment of endometriosis. Cell Biosci. 2020;10:12.##Kamili NA, Arthur CM, Gerner‐Smidt C, Tafesse E, Blenda A, Dias‐Baruffi M, et al. Key regulators of galectin–glycan interactions. Proteomics. 2016;16(24):3111-25.##Sciacchitano S, Lavra L, Morgante A, Ulivieri A, Magi F, De Francesco GP, et al. Galectin-3: one molecule for an alphabet of diseases, from A to Z. Int J Mol Sci. 2018;19(2):379.##Yilmaz H, Celik H, Ozdemir O, Kalkan D, Namuslu M, Abusoglu S, et al. Serum galectin-3 levels in women with PCOS. J Endocrinol Invest. 2014;37(2):181-7.##Hisrich BV, Young RB, Sansone AM, Bowens Z, Green LJ, Lessey BA, et al. Role of human galectins in inflammation and cancers associated with endometriosis. Biomolecules. 2020;10(2):230.##Menkhorst EM, Gamage T, Cuman C, Kaitu'u-Lino T, Tong S, Dimitriadis E. Galectin-7 acts as an adhesion molecule during implantation and increased expression is associated with miscarriage. Placenta. 2014;35(3):195-201.##Noël JC, Chapron C, Borghese B, Fayt I, Anaf V. Galectin-3 is overexpressed in various forms of endometriosis. Appl Immunohistochem Mol Morphol. 2011;19(3):253-7.##de Mattos RM, Machado DE, Perini JA, Alessandra-Perini J, da Costa NdOM, de Oliveira AFdR, et al. Galectin-3 plays an important role in endometriosis development and is a target to endometriosis treatment. Mol Cell Endocrinol. 2019;486:1-10.##Chen HL, Liao F, Lin TN, Liu FT. Galectins and neuroinflammation. In: Yu R, Schengrund, CL, editors. Glycobiology of the nervous system. New York: Springer; 2014. p. 517-42.##Yang H, Yin J, Ficarrotta K, Hsu S, Zhang W, Cheng C. Aberrant expression and hormonal regulation of Galectin-3 in endometriosis women with infertility. J Endocrinol Invest. 2016;39(7):785-91.##Bastón JI, Barañao RI, Ricci AG, Bilotas MA, Olivares CN, Singla JJ, et al. Targeting galectin‐1‐induced angiogenesis mitigates the severity of endometriosis. J Pathol. 2014;234(3):329-37.##Popovici RM, Krause MS, Germeyer A, Strowitzki T, von Wolff M. Galectin-9: a new endometrial epithelial marker for the mid-and late-secretory and decidual phases in humans. J Clin Endocrinol Metab. 2005;90(11):6170-6.##Shimizu Y, Kabir-Salmani M, Azadbakht M, Sugihara K, Sakai K, Iwashita M. Expression and localization of galectin-9 in the human uterodome. Endocr J. 2008;55(5):879-87.##Brubel R, Bokor A, Pohl A, Schilli GK, Szereday L, Bacher-Szamuel R, et al. Serum galectin-9 as a noninvasive biomarker for the detection of endometriosis and pelvic pain or infertility-related gynecologic disorders. Fertil Steril. 2017;108(6):1016-25.e2.##Canis M, Donnez JG, Guzick DS, Halme JK, Rock JA, Schenken RS, et al. Revised american society for reproductive medicine classification of endometriosis: 1996. Fertil Steril. 1997;67(5):817-21.##Flores I, Waelkens E, D'Hooghe T. Noninvasive diagnosis of endometriosis: review of current peripheral blood and endometrial biomarkers. Best Pract Res Clin Obstet Gynaecol. 2018;50:72-83.##Nisenblat V, Bossuyt PM, Shaikh R, Farquhar C, Jordan V, Scheffers CS, et al. Blood biomarkers for the non‐invasive diagnosis of endometriosis. Cochrane Database Syst Rev. 2016;2016(5): CD012179.##Rokhgireh S, Mehdizadeh Kashi A, Chaichian S, Delbandi AA, Allahqoli L, Ahmadi-Pishkuhi M, et al. The diagnostic accuracy of combined enolase/Cr, CA125, and CA19-9 in the detection of endometriosis. Biomed Res Int. 2020;2020:5208279.##Hirsch M, Duffy JM, Deguara CS, Davis CJ, Khan KS. Diagnostic accuracy of Cancer Antigen 125 (CA125) for endometriosis in symptomatic women: a multicenter study. Eur J Obstet Gynecol Reprod Biol. 2017;210:102-7.##Hirsch M, Duffy J, Davis CJ, Nieves Plana M, Khan KS, International collaboration to harmonise outcomes and measures for endometriosis. Diagnostic accuracy of cancer antigen 125 for endometriosis: a systematic review and meta‐analysis. BJOG. 2016;123(11):1761-8.##Moar P, Tandon R. Galectin-9 as a biomarker of disease severity. Cell Immunol. 2021;361:104287.##Brooks AK, Lawson MA, Rytych JL, Yu KC, Janda TM, Steelman AJ, et al. Immunomodulatory factors galectin-9 and interferon-gamma synergize to induce expression of rate-limiting enzymes of the kynurenine pathway in the mouse hippocampus. Front Immunol. 2016;7:422.##Meggyes M, Szereday L, Bohonyi N, Koppan M, Szegedi S, Marics-Kutas A, et al. Different expression pattern of TIM-3 and Galectin-9 molecules by peripheral and peritoneal lymphocytes in women with and without endometriosis. Int Mol Sci. 2020;21(7):2343.##Ahn SH, Monsanto SP, Miller C, Singh SS, Thomas R, Tayade C. Pathophysiology and immune dysfunction in endometriosis. Biomed Res Int. 2015;2015:795976.##Králíčková M, Vetvicka V. Immunological aspects of endometriosis: a review. Ann Transl Med. 2015;3(11):153.##Kor E, Mostafavi SRS, Mazhin ZA, Dadkhah A, Kor A, Arvanagh SH, et al. Relationship between the severity of endometriosis symptoms (dyspareunia, dysmenorrhea and chronic pelvic pain) and the spread of the disease on ultrasound. BMC Res Notes. 2020;13(1):546.##

Frequency, Risk Factors, and Pregnancy Outcomes in Cases with Placenta Accreta Spectrum Disorder: A Case-Control Study 2 1 2 Background: Placenta accreta spectrum (PAS) disorder is an important life-threatening problem. The purpose of the current study was to determine the frequency, risk factors, and pregnancy outcomes of PAS in our population. Methods: This is a case-control study using the data from a main tertiary referral university hospital in Ahvaz, southwest of Iran. The sample included 187 cases diagnosed with placenta accreta spectrum from 2015 to 2019 and 552 controls without PAS. A multivariable logistic regression model was used to find independent risk factors with 95% confidence interval. Pregnancy outcomes were evaluated using chi-square, t-test, and Mann-Whitney U test and p<0.05 were considered statistically significant. Results: The frequency of PAS during the study period was 3.7/1000 deliveries (0.37%). It was found that multiparity (≥3 deliveries, OR=2.05: 95%CI:1.21-3.47) and multigravidity (≥3 deliveries, OR=2.98: 95%CI:1.55-5.72), prior cesarean delivery (OR=52.55: 95%CI:19.73-139.96), and placenta previa (OR=27.48: 95%CI:9.62-78.5) are the independent risk factors of PAS. Complications and morbidity associated with PAS included hysterectomy (60.4% vs. 0.7%, p<0.001), cystostomy (24.1% vs. 0.2%, p<0.001), the need for blood transfusion (73.7% vs. 1.4%, p<0.001), intensive care unit admission of mother (42.8% vs. 0.2%, p<0.001), duration of hospitalization (7.52±6.34 vs. 1.97±1.83, p<0.001), preterm birth <37 weeks (61.4% vs. 16.8%, p<0.001), and perinatal mortality (7.4% vs. 1.8%, p<0.001) which manifested statistically significant values. Conclusion: The frequency of PAS is similar to other populations. Prior cesarean delivery, placenta previa, multigravidity, and multiparity were independent risk factors and also perinatal hysterectomy and preterm birth were the most important complications. 279 288 Mitra M Tadayon Reproductive Health Promotion Research Center, Ahvaz Jundishapur University of Medical Sciences Reproductive Health Promotion Research Center, Ahvaz Jundishapur University of Medical Sciences Iran Nahid N Javadifar Reproductive Health Promotion Research Center, Ahvaz Jundishapur University of Medical Sciences Reproductive Health Promotion Research Center, Ahvaz Jundishapur University of Medical Sciences Iran nahidjavadifar_341@yahoo. com, Javadifar–n@ajums.ac.ir Maryam M Dastoorpoor Department of Epidemiology, Menopause-Andropause Research Center, Ahvaz Jundishapur University of Medical Sciences Department of Epidemiology, Menopause-Andropause Research Center, Ahvaz Jundishapur University of Medical Sciences Iran Nahid N Shahbazian Fertility, Infertility, and Perinatology Research Center, Ahvaz Jundishapur University of Medical Sciences Fertility, Infertility, and Perinatology Research Center, Ahvaz Jundishapur University of Medical Sciences Iran Cesarean deliveryPlacenta accreta spectrumPlacenta previa Endometrium 140165.pdf Jauniaux E, Ayres-de-Campos D, Langhoff-Roos J, Fox KA, Collins S; FIGO placenta accreta diagnosis and management expert consensus panel. FIGO classification for the clinical diagnosis of placenta accreta spectrum disorders. Int J Gynaecol Obstet. 2019;146(1):20-4.##Abuhamad A. Morbidly adherent placenta. Semin Perinatol. 2013;37(5):359-64.##Bartels HC, Postle JD, Downey P, Brennan DJ. Placenta accreta spectrum: a review of pathology, molecular biology, and biomarkers. Dis Markers. 2018;2018:1507674.##Farquhar CM, Li Z, Lensen S, McLintock C, Pollock W, Peek MJ, et al. Incidence, risk factors and perinatal outcomes for placenta accreta in Australia and New Zealand: a case–control study. BMJ Open. 2017;7(10):e017713.##Jauniaux E, Chantraine F, Silver RM, Langhoff-Roos J; FIGO placenta accreta diagnosis and management expert consensus panel. FIGO consensus guidelines on placenta accreta spectrum disorders: Epidemiology. Int J Gynaecol Obstet. 2018;140(3):265-73.##Fitzpatrick KE, Sellers S, Spark P, Kurinczuk JJ, Brocklehurst P, Knight M. Incidence and risk factors for placenta accreta/increta/percreta in the UK: a national case-control study. PLoS One. 2012;7(12):e52893.##Eshkoli T, Weintraub AY, Sergienko R, Sheiner E. Placenta accreta: risk factors, perinatal outcomes, and consequences for subsequent births. Am J Obstet Gynecol. 2013;208(3):219.e1-7.##Garmi G, Salim R. Epidemiology, etiology, diagnosis, and management of placenta accreta. Obstet Gynecol Int. 2012;2012:873929.##Jauniaux E, Collins S, Burton G. Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging. Am J Obstet Gynecol. 2017;218(1):75-87.##Lu T, Song B, Pu H, Li KD, Huang MW, Mei J, et al. Prognosticators of intravoxel incoherent motion (IVIM) MRI for adverse maternal and neonatal clinical outcomes in patients with placenta accreta spectrum disorders. Transl Androl Urol. 2020;9(2):258-66.##Publications committee. Society for maternal-fetal medicine, Belfort MA. Placenta accreta. Am J Obstet Gynecol. 2010;203(5):430-9.##Baughman WC, Corteville JE, Shah RR. Placenta accreta: spectrum of US and MR imaging findings. Radiographics. 2008;28(7):1905-16.##Berhan Y, Urgie T. A literature review of placenta accreta spectrum disorder: The place of expectant management in Ethiopian setup. Ethiop J Health Sci. 2020;30(2):277-92.##Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol. 2005;192(5):1458-61.##Carusi DA. The placenta accreta spectrum: Epidemiology and risk factors. Clin Obstet Gynecol. 2018;61(4):733-42.##El Gelany S, Mosbeh MH, Ibrahim EM, Mohammed M, Khalifa EM, Abdelhakium AK, et al. Placenta accreta spectrum (PAS) disorders: incidence, risk factors and outcomes of different management strategies in a tertiary referral hospital in Minia, Egypt: a prospective study. BMC Pregnancy Childbirth. 2019;19(1):313.##Garmi G, Goldman S, Shalev E, Salim R. The effects of decidual injury on the invasion potential of trophoblastic cells. Obstet Gynecol. 2011;117(1):55-9.##Cheng HC, Pelecanos A, Sekar R. Review of peripartum hysterectomy rates at a tertiary Australian hospital. Aust N Z J Obstet Gynaecol. 2016;56(6):614-8.##Imtiaz R, Masood Z, Husain S, Husain S, Izhar R, Hussain S. A comparison of antenatally and intraoperatively diagnosed cases of placenta accreta spectrum. J Turk Ger Gynecol Assoc. 2020;21(2):84-9.##Piñas Carrillo A, Chandraharan E. Placenta accreta spectrum: Risk factors, diagnosis and management with special reference to the Triple P procedure. Womens Health (Lond). 2019;15:1745506519878081.##Slaoui A, Talib S, Nah A, El Moussaoui K, Benzina I, Zeraidi N, et al. Placenta accreta in the department of gynaecology and obstetrics in Rabat, Morocco: case series and review of the literature. Pan Afr Med J. 2019;33:86.##

Prevalence of Polycystic Ovary Syndrome in Iranian Adolescent Girls Based on Adults and Adolescents’ Diagnostic Criteria in Mashhad City 2 1 2 Background: PCOS is a common endocrine disorder of reproductive age with high morbidity that its prevalence ranging from 5.6% to 26%. The aim of this study was to evaluate the prevalence of PCOS in Iranian adolescent girls aged 14-19 years based on adults and adolescents’ criteria. Methods: This cross-sectional study was carried out with 650 high school adolescent girls in Mashhad city, north-east of Iran. PCOS was defined as the presence of three or two of the three features including oligo/amenorrhea, clinical or biochemical hyperandrogenism, and polycystic ovaries. Descriptive statistics, chi-square, and t-test were used to analyze the data through SPSS vs 22 (SPSS Inc., USA) and the significance level was set at p≤0.05. Results: The mean age of adolescent girls was 16.73±3.4 years. The prevalence of PCOS using Rotterdam, National Institutes of Health (NIH), Androgen Excess– PCOS Society (AES), European Society of Human Reproduction and Embryology (ESHRE)/American Society for Reproductive Medicine (ASRM) (2012), and Endocrine Society Clinical Practice (2013) criteria was 4.2%, 3.6%, 3.6%, 0.7%, and 3.6%, respectively. Conclusion: The rate for prevalence of PCOS calculated based on Rotterdam, NIH, AES, and Endocrine Society (2013) criteria was higher in comparison to ESHRE/ ASRM (2012) criteria. According to the results of our study, in order to prevent overestimation of this syndrome’s prevalence in the adolescents due to its overlap with signs of pubertal development, all above-mentioned three criteria should be considered together, which is in line with the recommendations proposed by Carmina et al. and ESHRE/ASRM working group. 288 296 Seyedeh Azam SA Pourhoseini Department of Obstetrics and Gynecology, School of Medicine, Mashhad University of Medical Sciences Department of Obstetrics and Gynecology, School of Medicine, Mashhad University of Medical Sciences Iran Raheleh R Babazadeh Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences Iran Babazadehr@mums.ac.ir Seyed Reza SR Mazlom Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences Iran Adolescent girlsIranPolycystic ovary syndromePrevalence 140159.pdf Christensen SB, Black MH, Smith N, Martinez MM, Jacobsen SJ, Porter AH, et al. Prevalence of polycystic ovary syndrome in adolescents. Fertil Steril. 2013;100(2):470-7.##Norman RJ, Dewailly D, Legro RS, Hickey TE. Polycystic ovary syndrome. Lancet. 2007;370(9588):685-97.##Tomislav P. Polycystic ovary syndrome in adolescence [Master Thesis]. Zagreb: University of Zagreb; 2015. 40 p.##Joshi B, Mukherjee S, Patil A, Purandare A, Chauhan S, Vaidya R. A cross-sectional study of polycystic ovarian syndrome among adolescent and young girls in Mumbai, India. Indian J Endocrinol Metabol. 2014;18(3):317-24.##March WA, Moore VM, Willson KJ, Phillips DI, Norman RJ, Davies MJ. The prevalence of polycystic ovary syndrome in a community sample assessed under contrasting diagnostic criteria. Hum Reprod. 2010;25(2):544-51.##Goodarzi MO, Dumesic DA, Chazenbal G, Azziz R. Polycystic ovary syndrome: etiology, pathogenesis and diagnosis. Nat Rev Endocrinol. 2011;7(4):219-31.##Diamanti-Kandarakis E. PCOS in adolescents. Best Pract Res Clin Obstet Gynaecol. 2010;24(2):173-83.##Hashemipour M, Faghihimani S, Zolfaghary B, Hovsepian S, Ahmadi F, Haghighi S. Prevalence of polycystic ovary syndrome in girls aged 14–18 years in Isfahan, Iran. Horm Res. 2004;62(6):278-82.##Nidhi R, Padmalatha V, Nagarathna R, Amritanshu R. Prevalence of polycystic ovarian syndrome in Indian adolescents. J Pediatr Adolesc Gynecol. 2011;24(4):223-7.##Lizneva D, Suturina L, Walker W, Brakta S, Gavrilova-Jordan L, Ricardo A. Criteria, prevalence, and phenotypes of polycystic ovary syndrome. Fertil Steril. 2016;106(1):6-15.##Peña AS, Witchel SF, Hoeger KM, Oberfield SE, Vogiatzi MG, Misso M, et al. Adolescent polycystic ovary syndrome according to the international evidence-based guideline. BMC Med. 2020;18(1):72.##Carmina E, Oberfield SE, Lobo RA. The diagnosis of polycystic ovary syndrome in adolescents. Am J Obstet Gynecol. 2010;203(3):201.e1-5.##Fauser BC, Tarlatzis BC, Rebar RW, Legro RS, Balen AH, Lobo R, et al. Consensus on women’s health aspects of polycystic ovary syndrome (PCOS): the Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus Workshop Group. Fertil Steril. 2012;97(1):28-38.e25.##Legro RS, Arslanian SA, Ehrmann DA, Hoeger KM, Murad MH, Pasquali Renato, et al. Diagnosis and treatment of polycystic ovary syndrome: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2013;98(12):4565-92.##Akbarzadeh M, Naderi T, Dabbagh Manesh M, Tabatabaee HR. The frequency of various phenotypes of polycystic ovarian syndrome in adolescents, based on rotterdam criteria. Int J School Health. 2015;2(3):e26512.##Yildiz BO, Bolour S, Woods K, Moore A, Azziz R. Visually scoring hirsutism. Hum Reprod Update. 2009;16(1):51-64.##Zawadzki JK, Dunaif A. Diagnostic criteria for polycystic ovary syndrome (a rational approach). Polycystic Ovary Syndrome. 1992;4:377-84.##Rotterdam ESHRE/ASRM-sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril. 2004;81(1):19-25.##Ricardo A, Carmina E, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Futterweit W, et al. The androgen excess and PCOS society criteria for the polycystic ovary syndrome: the complete task force report. Fertil Steril. 2009;91(2):456-88.##Witchel SF, Oberfield S, Rosenfield RL, Codner E, Bonny A, Ibáñez L, et al. The diagnosis of polycystic ovary syndrome during adolescence. Horm Res Paediatr. 2015;83(6):376-89.##Pochi PE, Shalita AR, Strauss JS, Webster SB, Cunliffe WJ, Katz HI, et al. Report of the consensus conference on acne classification: Washington, DC, March 24 and 25, 1990. J Am Acad Dermatol. 1991;24(3):495-500.##Tay CT, Hart RJ, Hickey M, Moran LJ, Earnest A, Doherty DA, et al. Updated adolescent diagnostic criteria for polycystic ovary syndrome: impact on prevalence and longitudinal body mass index trajectories from birth to adulthood. BMC Med. 2020;18(1):389.##Desai N, Tiwari R, Patel S. Prevalence of polycystic ovary syndrome and its associated risk factors among adolescent and young girls in ahmedabad region. Indian J Pharm Pract. 2018;11(3):119.##Asgharnia M, Mirblook F, Soltani MA. The prevalence of polycystic ovary syndrome (PCOS) in high school students in Rasht in 2009 according to NIH criteria. Int J Fertil Steril. 2011;4(4):156-9.##Esmaeilzadeh S, Delavar MA, Amiri M, Khafri S, Pasha NG. Polycystic ovary syndrome in Iranian adolescents. Int J Adolescent Med Health. 2014;26(4):559-65.##Kaewnin J, Vallibhakara O, Arj-Ong Vallibhakara S, Wattanakrai P, Butsripoom B, Somsook E, et al. Prevalence of polycystic ovary syndrome in Thai University adolescents. Gynecol Endocrinol. 2018;34(6):476-80.##Chae SJ, Kim JJ, Choi YM, Hwang KR, Jee BC, Ku SY, et al. Clinical and biochemical characteristics of polycystic ovary syndrome in Korean women. Hum Reprod. 2008;23(8):1924-31.##Salehpour S, Shirvani HE, Entezari A. Evaluation of the prevalence of polycystic ovarian syndrome among adolescent (15-18 Years Old) girls in Tehran during 2005-2006. Int J Fertil Steril. 2010;4(3):122-7.##Rashidi H, Tehrani FR, Khomami MB, Tohidi M, Azizi F. To what extent does the use of the Rotterdam criteria affect the prevalence of polycystic ovary syndrome? a community-based study from the Southwest of Iran. Eur J Obstet Gynecol Reprod Biol. 2014;174:100-5.##Ramezani Tehrani F, Simbar M, Tohidi M, Hosseinpanah F, Azizi F. The prevalence of polycystic ovary syndrome in a community sample of Iranian population: Iranian PCOS prevalence study. Reprod Biol Endocrinol. 2011;9:39.##Mehrabian F, Khani B, Kelishadi R, Ghanbari E. The prevalence of polycystic ovary syndrome in Iranian women based on different diagnostic criteria. Endokrynol Pol. 2011;62(3):238-42.##Rahmanpour H, Heidari R, Fekri S. The prevalence of polycystic ovarian syndrome in 14-18 year old girls of Zanjan High Schools, 2008. J Adv Med Biomed Res. 2009;17(67):79-88.##Roe AH, Dokras A. The diagnosis of polycystic ovary syndrome in adolescents. Rev Obstet Gynecol. 2011;4(2):45-51.##Van Hooff M, Voorhorst F, Kaptein M, Hirasing R, Koppenaal C, Schoemaker J. Endocrine features of polycystic ovary syndrome in a random population sample of 14-16 year old adolescents. Hum Reprod. 1999;14(9):2223-9.##Rachmiel M, Kives S, Atenafu E, Hamilton J. Primary amenorrhea as a manifestation of polycystic ovarian syndrome in adolescents: a unique subgroup? Arch Pediatr Adolesc Med. 2008;162(6):521-5.##Franks S. Polycystic ovary syndrome in adolescents. Int J Obesity. 2008;32(7):1035-41.##Fauser BC, Tarlatzis BC, Rebar RW, Legro RS, Balen AH, Lobo R, et al. Consensus on women’s health aspects of polycystic ovary syndrome (PCOS): the Amsterdam ESHRE/ASRM-sponsored 3rd PCOS Consensus workshop group. Fertil Steril. 2012;97(1):28-38.e25.##

Apparent Homozygosity for a gr/gr AZFc Deletion in A 47,XYY Man with Oligozoospermia and Secondary Infertility 2 1 2 Background: Approximately 1 in 1000 men have a 47,XYY karyotype. Previous publications have presented cases of infertile XYY men and have suggested that the additional Y chromosome may cause disrupted meiosis leading to sperm apoptosis. The purpose of the current study was to determine whether XYY men are over-represented in infertility cohorts. Methods: In this paper, an ongoing infertility cohort was evaluated for Y chromosome microdeletions using the MLPA technique and the data from the first 2000 referrals were recorded. Moreover, the MLPA technique detected 47,XYY karyotypes. Results: Four XYY individuals were identified within the cohort. One of the four XYY men was shown to have an apparent gr/gr partial AZFc deletion on both Y chromosomes while Sertoli cell only syndrome was detected in another case. The other two cases (out of 2000) might, therefore, represent an incidental finding. Conclusion: The gr/gr deletion is not detectable by the multiplex PCR method; therefore, there might be additional explanations for the fertility problems of infertile XYY men reported in previously published articles. It seems that among other cases, their XYY karyotype may be coincidental, rather than causative of their fertility issues. 296 303 David J DJ Bunyan Wessex Regional Genetics Laboratory, Salisbury District Hospital Wessex Regional Genetics Laboratory, Salisbury District Hospital UK dbunyan@nhs.net Mili M Saran Complete Fertility Limited, Princess Anne Hospital Complete Fertility Limited, Princess Anne Hospital UK James I JI Hobbs Wessex Regional Genetics Laboratory, Salisbury District Hospital Wessex Regional Genetics Laboratory, Salisbury District Hospital UK David J DJ Anderson Wessex Regional Genetics Laboratory, Salisbury District Hospital Wessex Regional Genetics Laboratory, Salisbury District Hospital UK Philippa J PJ Duncan-Flavell Wessex Regional Genetics Laboratory, Salisbury District Hospital Wessex Regional Genetics Laboratory, Salisbury District Hospital UK Rachel J RJ Howarth Wessex Regional Genetics Laboratory, Salisbury District Hospital Wessex Regional Genetics Laboratory, Salisbury District Hospital UK Jonathan L.A JLA Callaway Wessex Regional Genetics Laboratory, Salisbury District Hospital Wessex Regional Genetics Laboratory, Salisbury District Hospital UK James N JN MacPherson Wessex Regional Genetics Laboratory, Salisbury District Hospital Wessex Regional Genetics Laboratory, Salisbury District Hospital UK AzoospermiaChromosomal deletionInfertilityMenSex chromosome disordersXYY karyotype 140166.pdf Jacobs PA, Melville M, Ratcliffe S, Keay AJ, Syme J. A cytogenetic survey of 11,680 newborn infants. Ann Hum Genet. 1974;37(4):359-76.##Gekas J, Thepot F, Turleau C, Siffroi JP, Dadoune JP, Briault S, et al. Chromosomal factors of infertility in candidate couples for ICSI: an equal risk of constitutional aberrations in women and men. Hum Reprod. 2001;16(1):82-90.##Rives N, Milazzo JP, Miraux L, North MO, Sibert L, Macé B. From spermatocytes to spermatozoa in an infertile XYY male. Int J Androl. 2005;28(5):304-10.##Robinson DO, Jacobs PA. The origin of the extra Y chromosome in males with a 47,XYY karyotype. Hum Mol Genet. 1999;8(12):2205-9.##Moretti E, Anichini C, Sartini B, Collodel G. Sperm ultrastructure and meiotic segregation in an infertile 47,XYY man. Andrologia. 2007;39(6):229-34.##Wong EC, Ferguson KA, Chow V, Ma S. Sperm aneuploidy and meiotic sex chromosome configurations in an infertile XYY male. Hum Reprod. 2008;23(2):374-8.##El-Dahtory F, Elsheikha HM. Male infertility related to an aberrant karyotype, 47,XYY: four case reports. Cases J. 2009;2(1):28.##Zorrilla M, Yatsenko AN. The genetics of infertility: current status of the field. Curr Genet Med Rep. 2014;1(4):10.1007/s40142-013-0027-1.##Blanco J, Rubio C, Simon C, Egozcue J, Vidal F. Increased incidence of disomic sperm nuclei in a 47,XYY male assessed by fluorescent in situ hybridization (FISH). Hum Genet. 1997;99(3):413-6.##Chevret E, Rousseaux S, Monteil M, Usson Y, Cozzi J, Pelletier R, et al. Meiotic behaviour of sex chromosomes investigated by three-colour FISH on 35,142 sperm nuclei from two 47,XYY males. Hum Genet. 1997;99(3):407-12.##Lim AS, Fong Y, Yu SL. Analysis of the sex chromosome constitution of sperm in men with a 47,XYY mosaic karyotype by fluorescence in situ hybridization. Fertil Steril. 1999;72(1):121-3.##Shi Q, Martin RH. Multicolor fluorescence in situ hybridization analysis of meiotic chromosome segregation in a 47,XYY male and a review of the literature. Am J Med Genet. 2000;93(1):40-6.##Blanco J, Egozcue J, Vidal F. Meiotic behaviour of the sex chromosomes in three patients with sex chromosome anomalies (47,XXY, mosaic 46,XY/47,XXY and 47,XYY) assessed by fluorescence in-situ hybridization. Hum Reprod. 2001;16(5):887-92.##Gonzalez-Merino E, Hans C, Abramowicz M, Englert Y, Emiliani S. Aneuploidy study in sperm and preimplantation embryos from nonmosaic 47,XYY men. Fertil Steril. 2007;88(3):600-6.##Kim IW, Khadilkar AC, Ko EY, Sabanegh Jr ES. 47,XYY syndrome and male infertility. Rev Urol. 2013;15(4):188-96.##Tiepolo L, Zuffardi O. Localization of factors controlling spermatogenesis in the nonfluorescent portion of the human Y chromosome long arm. Hum Genet. 1976;34(2):119-24.##Bianchi NO, Richard SM, Peltomäki P, Bianchi MS. Mosaic AZF deletions and susceptibility to testicular tumors. Mutat Res. 2002;503(1-2):51-62.##Vogt PH, Edelmann A, Kirsch S, Henegariu O, Hirschmann P, Kiesewetter F, et al. Human Y chromosome azoospermia factors (AZF) mapped to different subregions in Yq11. Hum Mol Genet. 1996;5(7):933-43.##Navarro-Costa P, Gonçalves J, Plancha CE. The AZFc region of the Y chromosome: at the crossroads between genetic diversity and male infertility. Hum Reprod Update. 2010;16(5):525-42.##Noordam MJ, Westerveld GH, Hovingh SE, van Daalen SK, Korver CM, van der Veen F, et al. Gene copy number reduction in the azoospermia factor c (AZFc) region and its effect on total motile sperm count. Hum Mol Genet. 2011;20(12):2457-63.##Foresta C, Moro E, Ferlin A. Y chromosome microdeletions and alterations of spermatogenesis. Endocr Rev. 2001;22(2):226-39.##Kuroda-Kawaguchi T, Skaletsky H, Brown LG, Minx PJ, Cordum HS, Waterston RH, et al. The AZFc region of the Y chromosome features massive palindromes and uniform recurrent deletions in infertile men. Nat Genet. 2001;29(3):279-86.##Skaletsky H, Kuroda-Kawaguchi T, Minx PJ, Cordum HS, Hillier L, Brown LG, et al. The male-specific region of the human Y chromosome is a mosaic of discrete sequence classes. Nature. 2003;423(6942):825-37.##Reijo R, Lee TY, Salo P, Alagappan R, Brown LG, Rosenberg M, et al. Diverse spermatogenic defects in humans caused by Y chromosome deletions encompassing a novel RNA-binding protein gene. Nat Genet. 1995;10(4):383-93.##Oates RD, Silber S, Brown LG, Page DC. Clinical characterization of 42 oligospermic or azoospermic men with microdeletion of the AZFc region of the Y chromosome, and of 18 children conceived via ICSI. Hum Reprod. 2002;17(11):2813-24.##Repping S, Skaletsky H, Lange J, Silber S, Van Der Veen F, Oates RD, et al. Recombination between palindromes P5 and P1 on the human Y chromosome causes massive deletions and spermatogenic failure. Am J Hum Genet. 2002;71(4):906-22.##Saxena R, de Vries JW, Repping S, Alagappan RK, Skaletsky H, Brown LG, et al. Four DAZ genes in two clusters found in the AZFc region of the human Y chromosome. Genomics. 2000;67(3):256-67.##Fernandes S, Huellen K, Goncalves J, Dukal H, Zeisler J, Rajpert De Meyts E, et al. High frequency of DAZ1/DAZ2 gene deletions in patients with severe oligozoospermia. Mol Hum Reprod. 2002;8(3):286-98.##Repping S, Skaletsky H, Brown L, van Daalen SK, Korver CM, Pyntikova T, et al. Polymorphism for a 1.6-Mb deletion of the human Y chromosome persists through balance between recurrent mutation and haploid selection. Nat Genet. 2003;35(3):247-51.##Repping S, van Daalen SK, Korver CM, Brown LG, Marszalek JD, Gianotten J, et al. A family of human Y chromosomes has dispersed throughout northern Eurasia despite a 1.8-Mb deletion in the azoospermia factor c region. Genomics. 2004;83(6):1046-52.##Fernandes S, Paracchini S, Meyer LH, Floridia G, Tyler-Smith C, Vogt PH. A large AZFc deletion removes DAZ3/DAZ4 and nearby genes from men in Y haplogroup N. Am J Hum Genet. 2004;74(1):180-7.##Moro E, Ferlin A, Yen PH, Franchi PG, Palka G, Foresta C. Male infertility caused by a de novo partial deletion of the DAZ cluster on the Y chromosome. J Clin Endocrinol Metab. 2000;85(11):4069-73.##Bienvenu T, Patrat C, McElreavey K, de Almeida M, Jouannet P. Reduction in the DAZ gene copy number in two infertile men with impaired spermatogenesis. Ann Genet. 2001;44(3):125-8.##Ferlin A, Moro E, Rossi A, Foresta C. A novel approach for the analysis of DAZ gene copy number in severely idiopathic infertile men. J Endocrinol Invest. 2002;25(1):RC1-3.##de Vries JW, Hoffer MJ, Repping S, Hoovers JM, Leschot NJ, van der Veen F. Reduced copy number of DAZ genes in subfertile and infertile men. Fertil Steril. 2002;77(1):68-75.##de Vries JW, Repping S, van Daalen SK, Korver CM, Leschot NJ, van der Veen F. Clinical relevance of partial AZFc deletions. Fertil Steril. 2002;78(6):1209-14.##Ferlin A, Bettella A, Tessari A, Salata E, Dallapiccola B, Foresta C. Analysis of the DAZ gene family in cryptorchidism and idiopathic male infertility. Fertil Steril. 2004;81(4):1013-8.##Ferlin A, Tessari A, Ganz F, Marchina E, Barlati S, Garolla A, et al. Association of partial AZFc region deletions with spermatogenic impairment and male infertility. J Med Genet. 2005;42(3):209-13.##Mitra A, Dada R, Kumar R, Gupta NP, Kucheria K, Gupta SK. Y chromosome microdeletions in azoospermic patients with Klinefelter's syndrome. Asian J Androl. 2006;8(1):81-8.##Cetinkaya M, Kaba M, Çetin ES, Candan S. Case report: Y chromosome microdeletion in an infertile patient with mosaic Klinefelter syndrome. Int J Hum Genet. 2015;15(3):145-8.##Li LX, Dai HY, Ding XP, Zhang YP, Zhang XH, Ren HY, et al. Investigation of AZF microdeletions in patients with Klinefelter syndrome. Genet Mol Res. 2015;14(4):15140-7.##Pan Y, Zhang HG, Xi QI, Zhang H, Wang RX, Li LL, et al. Molecular microdeletion analysis of infertile men with karyotypic Y chromosome abnormalities. J Int Med Res. 2018;46(1):307-15.##Aydemir H, Karkucak M, Cimen HI, Halis F, Kumsar S, Sonbahar AE, et al. A rare combination of 45, X/46, XY mosaicism and Y chromosome microdeletion in an infertile man with azoospermia. Genet Couns. 2016;27(1):95-8.##Kim JW, Park SY, Ryu HM, Lee DE, Lee BY, Kim SY, et al. Molecular and clinical characteristics of 26 cases with structural Y chromosome aberrations. Cytogenet Genome Res. 2012;136(4):270-7.##Simoni M, Bakker E, Krausz C. EAA/EMQN best practice guidelines for molecular diagnosis of Y-chromosomal microdeletions. State of the art 2004. Int J Androl. 2004;27(4):240-9.##Schouten JP, McElgunn CJ, Waaijer R, Zwijnenburg D, Diepvens F, Pals G. Relative quantification of 40 nucleic acid sequences by multiplex ligation-dependent probe amplification. Nucleic Acids Res. 2002;30(12):e57.##Bunyan DJ, Callaway JLA, Laddach N. The detection of partial Y-chromosome AZFc deletions in infertile men using the Multiplex Ligation-dependent Probe Amplification assay. J Reprod Infertil. 2012;13(3):174-8.##Seabright M. A rapid banding technique for human chromosomes. Lancet. 1971;2(7731):971-2.##Rozen SG, Marszalek JD, Irenze K, Skaletsky H, Brown LG, Oates RD, et al. AZFc deletions and spermatogenic failure: A population-based survey of 20,000 Y chromosomes. Am J Hum Genet. 2012;91(5):890-6.##Krausz C, Hoefsloot L, Simoni M, Tüttelmann F, European academy of andrology; European molecular genetics quality network. EAA/EMQN best practice guidelines for molecular diagnosis of Y-chromosomal microdeletions: state-of-the-art 2013. Andrology. 2014;2(1):5-19.##Mokanszki A, Ujfalusi A, Gombos É, Balogh I. Examination of Y-chromosomal microdeletions and partial microdeletions in idiopathic infertility in East Hungarian patients. J Hum Reprod Sci. 2018;11(4):329-36.##Jedidi I, Ouchari M, Yinb Q. Autosomal single-gene disorders involved in human infertility. Saudi J Biol Sci. 2018;25(5):881-7.##Stouffs K, Gheldof A, Tournaye H, Vandermaelen D, Bonduelle M, Lissens W, et al. Sertoli cell-only syndrome: behind the genetic scenes. Biomed Res Int. 2016;2016:6191307.##

An Incidental Detection of a Cryptic Complex Chromosome Rearrangement Found During NGS Based PGT-SR: A Case Report 2 1 2 Background: Complex chromosome rearrangements (CCRs) involve more than 2 chromosomal breakpoints and cause the exchanges of chromosomal segments between two or more chromosomes. The carriers of CCRs have normal phenotypes, but they have a higher risk of reproductive failure. Case Presentation: This paper presents a couple with a history of two affected children, one spontaneous abortion, three in vitro fertilization (IVF) failures, and one healthy boy who were referred to our laboratory for preimplantation genetic testing (PGT). The wife had been evaluated as a carrier of 46,XX,t (2;6)(p21;p25); therefore, four IVF treatment cycles supported with PGT for this translocation had been performed in different IVF centers until the couple consulted our laboratory. Only one of these four IVF attempts had resulted in a healthy boy and this IVF study had been performed with fluorescence in situ hybridization (FISH)-based preimplantation genetic testing for structural chromosomal rearrangements (PGT-SR). The fifth IVF study with next-generation sequencing (NGS)-based PGT was performed by our laboratory and no healthy embryo was found in evaluated 6 embryos. During our NGS-based PGT, the cryptic involvement of 12p was firstly detected. FISH with chromosome 2,6, and 12 specific probes revealed that the mother was a carrier of a balanced 3-way translocation of 46,XX,t(2;6;12)(p21;p25;p13). Conclusion: NGS based PGT-SR method is an accurate method for detecting the copy number variations and is helpful to find out the cryptic CCRs. 303 310 Leyla L Özer Department of Medical Genetics, Faculty of Medicine, Yuksek İhtisas University Department of Medical Genetics, Faculty of Medicine, Yuksek İhtisas University Turkey leyla_ozer@yahoo.com Suleyman S Aktuna Department of Medical Genetics, Faculty of Medicine, Yuksek İhtisas University Department of Medical Genetics, Faculty of Medicine, Yuksek İhtisas University Turkey Evrim E Unsal Department of Medical Genetics, Faculty of Medicine, Yuksek İhtisas University Department of Medical Genetics, Faculty of Medicine, Yuksek İhtisas University Turkey Aysun A Baltaci Gen-Art IVF Center Gen-Art IVF Center Turkey Volkan V Baltaci Department of Medical Genetics, Faculty of Medicine, Yuksek İhtisas University Department of Medical Genetics, Faculty of Medicine, Yuksek İhtisas University Turkey Chromosomal translocationChromosomal abnormalitiesNext generation sequencingPreimplantation genetic testing 140167.pdf Pellestor F, Anahory T, Lefort G, Puechberty J, Liehr T, He´don B, et al. Complex chromosomal rearrangements: origin and meiotic behavior. Hum Reprod Update. 2011;17(4):476-94.##Madan K. Balanced complex chromosome rearrangements: reproductive aspects. a review. Am J Med Genet Part A. 2012;158A(4):947-63.##Madan K. What is a complex chromosome rearrangement? Am J Med Genet A. 2013;161A(5):1181-4.##Gorski JL, Kistenmacher ML, Punnett HH, Zackai EH, Emanuel BS. Reproductive risks for carriers of complex chromosome rearrangements: analysis of 25 families. Am J Med Genet. 1988;29(2):247-61.##Madan K, Nieuwint AW, Van Bever Y. Recombination in a balanced complex translocation of a mother leading to a balanced reciprocal translocation in the child. Review of 60 Cases of balanced complex translocations. Hum Genet. 1997;99(6):806-15.##Hu L, Wei Y, Luo K, Xie P, Gong F, Xiong B, et al. Clinical outcomes in carriers of complex chromosomal rearrangements: a retrospective analysis of comprehensive chromosome screening results in seven cases. Fertil Steril. 2018;109(3):486-92.##Scriven PN, Bint SM, Davies AF, Ogilvie CM. Meiotic outcomes of three-way translocations ascertained in cleavage-stage embryos: refinement of reproductive risks and implications for PGD. Eur J Hum Genet. 2014;22(6):748-53.##Harton G, Braude P, Lashwood A, Schmutzler A, Traeger-Synodinos J, Wilton L, et al. ESHRE PGD consortium best practice guidelines for organization of a PGD centre for PGD/preimplantation genetic screening. Hum Reprod. 2010;26(1):14-24.##ESHRE PGT consortium steering committee, Carvalho F, Coonen E, Goossens V, Kokkali G, Rubio C, et al. ESHRE PGT consortium good practice recommendations for the organisation of PGT. Hum Reprod Open. 2020;2020(3):hoaa021.##[No Authors listed]. Preimplantation genetic testing: ACOG committee opinion, Number 799. Obstet Gynecol. 2020;135(3):e133-e7.##Gregori MD, Ciccone R, Magini P, Pramparo T, Gimelli S, Messa J, et al. Cryptic deletions are a common finding in "balanced" reciprocal and complex chromosome rearrangements: A study of 59 patients. J Med Genet. 2007;44(12):750-62.##Escudero T, Estop A, Fischer J, Munne S. Preimplantation genetic diagnosis for complex chromosome rearrangements. Am J Med Genet A. 2008;146A(13):1662-9.##Vanneste E, Melotte C, Voet T, Robberecht C, Debrock S, Pexsters A, et al. PGD for a complex chromosomal rearrangement by array comparative genomic hybridization. Hum Reprod. 2011;26(4):941-9.##Nonaka T, Ooki I, Enomoto T, Takakuwa K. Complex chromosomal rearrangements in couples affected by recurrent spontaneous abortion. Int J Gynaecol Obstet. 2015;128(1):36-9.##Li G, Shi W, Niu W, Xu J, Guo Y, Su Y, et al. The influence of balanced complex chromosomal rearrangements on preimplantation embryonic development potential and molecular karyotype. BMC Genomics. 2020;21(1):326.##Athalye A, Sanap R, Madon P, Naik D, Warang D, Padyal P, et al. Preimplantation genetic testing for a complex chromosome rearrangement, case report of a cryptic translocation detected on pre-PGT workup. Obstet Gynecol Int J. 2018;9(2):138-41.##McKenzie LJ, Cisneros PL, Torsky S, Bacino CA, Buster JE, Carson SA, et al. Preimplantation genetic diagnosis for a known cryptic translocation: follow-Up clinical report and implication of segregation products. Am J Med Genet. 2003;121A(1):56-9.##Brunet B, Shen J, Cai L, Xie J, Cui Y, Liu J, et al. Preimplantation genetic testing for complex chromosomal rearrangement carriers by next-generation sequencing. Reprod Biomed Online. 2018;37(3):375-82.##Wang X, Wu C, Hao D, Zhang J, Tan C, Cheng D, et al. One healthy live birth after preimplantation genetic testing of a cryptic balanced translocation (9;13) in a family with cerebral palsy and glaucoma: a case report. BMC Med Genomics. 2021;14(1):82.##Frumkin T, Peleg S, Gold V, Reches A, Asaf S, Azem F, et al. Complex chromosomal rearrangement-a lesson learned from PGS. J Assist Reprod Genet. 2017;34(8):1095-1100.##

The Appropriate Criteria in Patients Selection for Myomectomy in the Era of Minimally Invasive Surgery: A Case Report 2 1 2 Background: Myoma is the most common benign monoclonal neoplasm of the uterus with increased frequency during reproductive years of women. Case Presentation: A twenty two year old female presented with abdomen lump, dysmenorrhoea, and heavy menstrual bleeding. Multiple myomas were diagnosed based on clinical and radiological findings. Abdominal myomectomy was performed and 75 myomas were enucleated followed by reconstruction of uterus. The second case was a 28 year old married woman presented with heavy menstrual bleeding and dysmenorrhoea. Ultrasound reported single posterior wall myoma of 8´6.3´5.8 cm in size. Laparoscopic myomectomy was performed. At follow-up visit, both cases were completely free of any symptoms. Conclusion: Myomectomy is a feasible and safe option and a uterine preserving surgery even in the presence of multiple myomas. Setting appropriate criteria in selecting patients for abdominal myomectomy rather than MIS is essential to avoid conversion and associated morbidity. 310 314 Sangam S Jha Department of Obstetrics and Gynecology, AIIMS Patna Department of Obstetrics and Gynecology, AIIMS Patna India sangam.jha78@gmail.com Sonia S Sonia Department of Obstetrics and Gynecology, AIIMS Patna Department of Obstetrics and Gynecology, AIIMS Patna India Hemali H Sinha Department of Obstetrics and Gynecology, AIIMS Patna Department of Obstetrics and Gynecology, AIIMS Patna India Upasna U Sinha Department of Radiodiagnosis, AIIMS Patna Department of Radiodiagnosis, AIIMS Patna India Heavy menstrual bleedingLaparascopyMyomaUterine myomectomy 140168.pdf Grube M, Neis F, Brucker SY, Kommoss S, Andress J, Weiss M, et al. Uterine fibroids-current trends and strategies. Surg Technol Int. 2019;34:257-63.##Saldana TM, Moshesh M, Baird DD. Self-reported family history of leiomyoma: not a reliable marker of high risk. Ann Epidemiol. 2013;23(5):286-90.##Munro MG, Critchley HOD, Fraser IS; FIGO menstrual disorders committee. Corrigendum to "The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions" [Int J Gynecol Obstet 143(2018) 393-408]. Int J Gynaecol Obstet. 2019;144(2):237.##Woźniak A, Woźniak S. Ultrasonography of uterine leiomyomas. Prz Menopauzalny. 2017;16(4):113-7.##Rakotomahenina H, Rajaonarison J, Wong L, Brun JL. Myomectomy: technique and current indications. Minerva Ginecol. 2017;69(4):357-69.##Vargas MV, Denny Larson K, Sparks A, Margulies SL, Marfori CQ, Moawad G, et al. The association of operative time with outcomes in minimally invasive and abdominal myomectomy. Fertil Steril. 2019;111(6):1252-8.e1.##Agdi M, Tulandi T. Endoscopic management of uterine fibroids. Best Pract Res Clin Obstet Gynecol. 2008;22(4):707-16.##Mallick R, Odejinmi F. Pushing the boundaries of laparoscopic myomectomy: a comparative analysis of peri-operative outcomes in 323 women undergoing laparoscopic myomectomy in a tertiary referral centre. Gynecol Surg. 2017;14(1):22.##Kongnyuy EJ, Wiysonge C. Interventions to reduce haemorrhage during myomectomy for fibroids. Cochrane Database Syst Rev. 2014;2014(8):CD005355.##Bekabil TT. Successful removal of 36 fibroids from a uterus: case report. Clin Case Rep Rev. 2015;1(2):25-6.##

Monkeypox and Male Fertility: Is There Any Looming Danger? 2 1 2 The current emergence of monkeypox virus infection, mainly reported from previously non-endemic regions, raised concerns about its transmission and possible implication on general health and wellbeing. The concern is spawned from the fact that the virus keeps spreading, and as of the 8 th September 2022, at least 88 countries have reported over 54191 cases globally (1). In the wake of the Covid-19 pandemic, this recent outbreak is mustering up thoughts of public panic, social disruption, severe illness, and comorbidities, including risks to fertility and offspring. Monkeypox virus is an enveloped linear double-stranded DNA virus that belongs to the Orthopoxvirus genus of the Poxviridae family. This genus also comprises viruses like horsepox virus, Uasin Gishu virus, camelpox virus, cowpox virus, ectromelia virus, raccoonpox virus, skunkpox virus, taterapox virus, vaccinia virus, variola virus, volepox virus, abatino macacapox virus, akhmeta virus, and alaskapox virus. Monkeypox is a zoonotic viral disease transmitted to humans from animals with symptoms similar to those seen in smallpox patients, although it is clinically less severe. It was first discovered in 1958 when two outbreaks of a pox-like disease occurred in colonies of monkeys kept for research. The first human case of monkeypox was recorded in 1970 in the Democratic Republic of the Congo during a period of intensified effort to eliminate smallpox. Monkeypox primarily occurs in Central and West Africa, often near tropical rainforests (2, 3). The viral replication of the monkeypox virus occurs in the cytoplasm. This virus enters the host cell by attaching viral proteins to the host plasma membrane glycosaminoglycans, which then mediate cellular endocytosis of the virus. The fusion of the viral proteins with the host cell plasma membrane causes the virus to release its viral core into the host cytoplasm. This process leads to an expression of intermediate genes, which will enhance genomic DNA replication by the viral DNA polymerase. Once replication begins, the production of genes and subsequently viral structural proteins continues, which enhances the maturation of virus particles into brick-shaped intracellular mature virions. These virions are either released upon cell lysis or can acquire a second membrane from the Golgi apparatus and bud as extracellular virions through transportation via microtubules (2). Therefore, the monkeypox virus can be transmitted through contact with the virus from an infected animal, virus-contaminated material, or infected person via body fluids (including vertical transmission), sores, respiratory droplets, respiratory secretions, skin lesions or plausibly through semen and vaginal fluids (2, 4). While close physical contact is a well-known risk factor for transmission, it is unclear if monkeypox can be explicitly transmitted through sexual activities. Out of the available studies reporting monkeypox infection, seven articles (Table 1) have shown the presence of the virus in human semen (5-11). However, it is still unclear if the presence of the virus in the semen led to transfection during intercourse or whether it is only related to close contact. Of interest is the study of Antinori et al, who reported the presence of human monkeypox virus in the seminal plasma of three of four Italian men evaluated. It was shown that these men had unprotected sexual intercourse with multiple partners during the first two weeks of May 2022 and were admitted to two different hospitals between 17 and 22 of May 2022. The semen samples were collected 5-7 days before onset of symptoms, and these samples were positive for the monkeypox virus, with a quantification cycle (Cq) value ranging from 27-30. Although the correlation between Cq value and infectious viral load of monkeypox virus is not yet known, the results showed possible viral shedding in the semen (5). Similar results were displayed in one Italian patient living in Portugal, with a Cq value of 31 (7). Another study reported that out of nine semen samples analyzed from monkeypox virus infected patients, seven were positive for monkeypox virus as early as day four from symptom onset with Cq values ranging from 25.5 to 40 across different days (8). Similarly, the semen sample of a man from Canada was positive for monkeypox virus on day ten after onset of symptom (11). Lapa et al. reported that the semen sample of an Italian man was positive for monkeypox virus from day five after symptom onset until day nineteen with a Cq range of 27.8 to 40.6. The viral DNA was isolated from the semen on day six after symptom onset and inoculated in Vero E6 cells. After 48 hr of inoculation, evident cytopathic features were observed in the cells until end of experiment (96 hr). This suggests that prolonged shedding of monkeypox virus DNA can occur in the semen of infected patients for weeks after symptoms onset and semen collected in the acute phase of infection (day 6 after symptom onset) might contain a replication-competent virus and hence represent a potential source of infection. Therefore, it was concluded that transmission of monkeypox virus during sexual activity might be a viable and recognized route (10). Additionally, Noe et al. reported that the semen samples of two German men who had unprotected sexual intercourse were positive for the monkeypox virus, with viral DNA concentrations comparable to blood (6). Recently, a group of clinicians retrospectively analyzed 528 cases of monkeypox infection diagnosed between April 27 and June 24, 2022, at 43 sites in 16 countries. They reported that 98% of the infected individuals were homosexual or bisexual men (median age was 38 years) and transmission was suspected to have occurred through sexual activity in 95% of these cases. In this study, monkeypox virus DNA was also detected in 29 of 32 semen samples analyzed (9). On the other hand, four additional studies from Australia, Portugal, Romania, and USA showed that men (27, 1, 1 and 1, respectively) who also had a history of risky sexual behavior (e.g. unprotected sexual intercourse) displayed viremia; however, their semen samples were not tested (12-15). The presence of the monkeypox virus in the semen could be just a consequence of the viremia, because the inflammation caused by the viral infection could alter the blood-testis barriers and allow the virus to enter the testes (5). The question remains if the presence of monkeypox in the seminal plasma would adversely affect overall male fecundity, either during or after monkeypox virus infection. Additionally, it is unclear whether this viral shedding causes transmission through the semen, knowing that semen as the potential route of transmission has been proposed for other viral infections that were previously considered unlikely to be transferred sexually, including Ebola virus, Zika virus, and SARs-CoV-2. There is evidence of the relationship between viral infection with members of the orthopoxvirus genus and orchitis in both humans and rodents. Of particular interest is the study of Phadke et al. who reported that infertile patients with smallpox infection had a higher incidence of azoospermia (42.57%) when compared to the control (17.87%), and that these patients with smallpox infection commonly presented with obstructive azoospermia (79.36%) (16). In patients with non-obstructive azoospermia, testicular lesions such as partial or complete arrest of spermatogenesis at various levels, germinal cell aplasia, severe tubular atrophy, and hyalinization of the tubules were encountered. However, whether the virus is present in the testicular epithelium, or whether the infection aggravated the infertility condition remains a matter of debate, because these patients were infertile even before contracting the smallpox infection. Additionally, studies have shown that men infected with SARS-CoV-2 displayed abnormal semen parameters, altered hormone profile, and disrupted spermatogenesis (17, 18). Furthermore, in 2017, 27 viruses were reported in semen, several of which were found to be involved in sexual transmission (19). In addition, during the last five years, the number of reports about viruses being present in the semen has increased such as monkeypox, Dengue virus, and Chapare virus, and undoubtedly this will negatively impact human fertility since the infection of the semen with other viruses has been shown to pose a danger to male fertility potential (20). The available findings cannot be used to substantiate whether infection with monkeypox virus could harm male fertility potential. Therefore, it is recommended that the generic guidance on viral infections be strongly considered and adhered to, until position statements are made. Additionally, prospective parents, assisted reproductive technology (ART) patients, gamete donors and gestational carriers, who meet the diagnostic criteria for viral infection should avoid becoming pregnant or participating in any fertility programs until there is a certainty regarding the effect of monkeypox virus infection on male fertility potential and on future offspring. Finally, it is advised that suitable precautions should be taken when engaging in sexual activities to minimize the potential risk of spreading and/or contracting monkeypox. Acknowledgement This study was partly supported by the Al Jalila Foundation. Conflict of Interest Authors declare no conflict of interest. 314 318 Stefan S SS du Plessis College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences United Arab Emirates Stefan.duplessis@mbru.ac.ae Walter D WD Cardona Maya Reproduction Group, Department of Microbiology and Parasitology, Faculty of Medicine, Universidad de Antioquia Reproduction Group, Department of Microbiology and Parasitology, Faculty of Medicine, Universidad de Antioquia Colombia Temidayo S TS Omolaoye College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences United Arab Emirates No Keyword 140169.pdf Statistics & Data [Internet]. Statistics & Data; c2022. Monkeypox–data–Live update; 2022 Jul 25 [cited 2022 Sep 8]; [about 4 screens]. Available from: https://statisticsanddata.org/monkeypox-dashboard-live##Damon IK. Fields Virology. 6th ed. Philadelphia: Oxford Academic-Lippincott Williams and Wilkins; 2013. Chapter 67, Poxviruses; p.2160–84.##WHO: Monkeypox [Internet]. Geneva, Switzerland: World Health Organization; c2022. Monkeypox Key facts; 2022 May 19[cited 2022 Jun 6]; [about 6 screens]. Available from: https://www.who.int/news-room/fact-sheets/detail/monkeypox##CDC: Monkeypox [Internet]. Atlanta Center for Disease Control and Prevention; Monkeypox Signs and Symptoms; updated 2022 Jun 1 [cited 2022 Jun 6]; [about 3 screens]. Available from: https://www.cdc.gov/poxvirus/monkeypox/index.html ##Antinori A, Mazzotta V, Vita S, Carletti F, Tacconi D, Lapini LE, et al. Epidemiological, clinical and virological characteristics of four cases of monkeypox support transmission through sexual contact, Italy, May 2022. Euro Surveill. 2022;27(22):2200421.##Noe S, Zange S, Seilmaier M, Antwerpen MH, Fenzl T, Schneider J, et al. Clinical and virological features of rst human Monkeypox cases in Germany. Infection. 2022:1-10.##Mileto D, Riva A, Cutrera M, Moschese D, Mancon A, Meroni L, et al. New challenges in human monkeypox outside Africa : a review and case report from Italy. Travel Med Infect Dis. 2022;49:102386.##Peiró-Mestres A, Fuertes I, Camprubí-Ferrer D, Ángeles Marcos M, Vilella A, Navarro M, et al. Frequent detection of monkeypox virus DNA in saliva, semen, and other clinical samples from 12 patients, Barcwlona, Spain, May to June 2022. Euro Surveill. 2022;27(28):2200503.##Thornhill JP, Barkati S, Walmsley S, Rockstroh J, Antinori A, Harrison LB, et al. Monkeypox virus infection in humans across 16 countries - April-June 2022. N Engl J Med. 2022;387(8):679-91.##Lapa D, Carletti F, Mazzotta V, Matusali G, Pinnetti C, Meschi S, et al. Monkeypox virus isolation from a semen sample collected in the early phase of infection in a patient with prolonged seminal viral shedding. Lancet Infect Dis. 2022;22(9):1267-9.##Tan DHS, Jaeranny S, Li M, Sukhdeo SS, Monge JC, Callejas MF, et al. Atypical clinical presentation of monkeypox complicated by myopericarditis. Open Forum Infect Dis. 2022;9 (8):ofac394.##Perez-Duque M, Ribeiro S, Martins JV, Casaca P, Leite PP, Tavares M, et al. Ongoing monkeypox virus outbreak, Portugal, 29 April to 23 May 2022. Euro Surveill. 2022;27(22):2200424.##Hammerschlag Y, Macleod G, Papadakis G, Sanchez AA, Druce J, Taiaroa G, et al. Monkeypox infection presenting as genital rash, Australia, May 2022. Euro Surveill. 2022;27(22):2200411.##Oprea C, Ianache I, Piscu S, Tardei G, Maria Nica EC, Popescu CP, et al. First report of monkeypox in a patient living with HIV from Romania. Travel Med Infect Dis. 2022;49:102395.##Ortiz-Martínez Y, Rodríguez-Morales AJ, Franco-Paredes C, Chastain DB, Gharamti AA, Vargas Barahona L, et al. Monkeypox - a description of the clinical progression of skin lesions: a case report from Colorado, USA. Ther Adv Infect Dis. 2022;9:20499361221117726.##Phadke AM, Samant NR, Dewal SD. Smallpox as an etiologic factor in male infertility. Fertil Steril. 1973;24(10):802-4.##Purpura LJ, Alukal J, Chong AM, Liu L, Cantos A, Shah J, et al. SARS-CoV-2 shedding in semen and oligozoospermia of patient with severe coronavirus disease 11 weeks after infection. Emerg Infect Dis. 2021;28(1):196-200.##Omolaoye TS, Adeniji AA, Cardona Maya WD, du Plessis SS. SARS-COV-2 (Covid-19) and male fertility: where are we? Reprod Toxicol. 2021;99:65-70.##Salam AP, Horby PW. The breadth of viruses in human semen. Emerg Infect Dis. 2017;23(11):1922-4.##Mons J, Mahé-Poiron D, Mansuy JM, Lheureux H, Nigon D, Moinard N, et al. Effects of acute dengue infection on sperm and virus clearance in body fluids of men. Emerg Infect Dis. 2022;28(6):1146-53.##