Unravelling the role of HAS2, GREM1, and PTGS2 gene expression in cumulus cells: implications for human oocyte development competency - a systematic review and integrated bioinformatic analysis

The leading indicator for successful outcomes in in-vitro fertilization (IVF) is the quality of gametes in oocytes and sperm. Thus, advanced research aims to highlight the parameter in assessing these qualities - DNA fragmentation in sperm and oocyte development capacity (ODC) via evaluation of microenvironments involving its maturation process. Regarding oocytes, most evidence reveals the role of cumulus cells as non-invasive methods in assessing their development competency, mainly via gene expression evaluation. Our review aims to consolidate the evidence of GDF-9 derivatives, the HAS2, GREM1, and PTGS2 gene expression in cumulus cells used as ODC markers in relevant publications and tailored to current IVF outcomes. In addition to that, we also added the bioinformatic analysis in our review to strengthen the evidence aiming for a better understanding of the pathways and cluster of the genes of interest - HAS2, GREM1, and PTGS2 in cumulus cell level. Otherwise, the current non-invasive method can be used in exploring various causes of infertility that may affect these gene expressions at the cumulus cell level. Nevertheless, this method can also be used in assessing the ODC in various cohorts of women or as an improvement of markers following targeted tools or procedures by evaluating the advancement of these gene expressions following the targeted intervention.

Piper sarmentosum Roxb. Inhibits Angiotensin-Converting Enzyme Activity in Phorbol 12-Myristate-13-Acetate-Induced Endothelial Cells

Angiotensin-converting enzyme (ACE) plays a crucial role in the pathogenesis of hypertension. Piper sarmentosum Roxb., an herb known for its antihypertensive effect, lacks a comprehensive understanding of the mechanism underlying its antihypertensive action. This study aimed to elucidate the antihypertensive mechanism of aqueous extract of P. sarmentosum leaves (AEPS) via its modulation of the ACE pathway in phorbol 12-myristate-13-acetate (PMA)-induced human umbilical vein endothelial cells (HUVECs). HUVECs were divided into five groups: control, treatment with 200 µg/mL AEPS, induction 200 nM PMA, concomitant treatment with 200 nM PMA and 200 µg/mL AEPS, and treatment with 200 nM PMA and 0.06 μM captopril. Subsequently, ACE mRNA expression, protein level and activity, angiotensin II (Ang II) levels, and angiotensin II type 1 receptor (AT1R) and angiotensin II type 2 receptor (AT2R) mRNA expression in HUVECs were determined. AEPS successfully inhibited ACE mRNA expression, protein and activity, and angiotensin II levels in PMA-induced HUVECs. Additionally, AT1R expression was downregulated, whereas AT2R expression was upregulated. In conclusion, AEPS reduces the levels of ACE mRNA, protein and activity, Ang II, and AT1R expression in PMA-induced HUVECs. Thus, AEPS has the potential to be developed as an ACE inhibitor in the future.

Unexplained subfertility: active or conservative management?

OBJECTIVES

Unexplained subfertility (UEI) describes a couple whose standard subfertility workout consider acceptable but unable to conceived.

METHODS

This retrospective study was conducted in the Advanced Reproductive Centre, UKM Hospital, Kuala Lumpur, from January 2016 to December 2019. The data of 268 UEI couples were obtained from the clinical database. Women aged 21-45 years old was included and further divided into four groups according to the female partner's age and subfertility duration: group A (age <35 years and subfertility <2 years), group B (age <35 years and subfertility >2 years), group C (age >35 years and subfertility <2 years), and group D (age >35 years and subfertility <2 years). All statistical analyses were performed using SPSS 22.0 for Windows.

RESULTS

A total of 255 cases were included in this study. The mean age of the women was 32.9 ± 4.04 years, and the mean subfertility duration was 5.04 ± 2.9 years. A total of 51 (20 %) cases underwent timed sexual intercourse, 147 (57.6 %) cases had intrauterine insemination (IUI), whereas 57 (22.4 %) cases opted for in vitro fertilization (IVF). A total of 204 cases underwent active management (IUI/IVF), which showed a significant difference (p<0.05). Out of eight clinical pregnancies, half of them were from group B.

CONCLUSIONS

Active management in younger women with a shorter subfertility duration revealed a better pregnancy outcome. Otherwise, individualized treatment should be considered in selecting a suitable treatment plan.

MicroRNAs in Endometriosis: Insights into Inflammation and Progesterone Resistance

Endometriosis, a non-malignant gynecological disorder influenced by estrogen, involves the growth of endometrial tissue outside the uterus. Its development includes processes such as inflammation, progesterone resistance, angiogenesis, and cell proliferation. Epigenetic factors, particularly the dysregulation of microRNAs (miRNAs), have emerged as key factors in these mechanisms in endometriosis. This review aims to unveil the intricate molecular processes that control inflammation, progesterone resistance, and miRNA functions in endometriosis. In addition, it provides a comprehensive overview of the current understanding regarding the involvement of miRNAs in the inflammatory aspects of this condition. This synthesis encompasses research investigating the molecular underpinnings of inflammation, along with the biogenesis and roles of miRNAs in endometriosis. Furthermore, it examines human studies and functional analyses to establish the intricate connection between miRNAs, inflammation, and progesterone resistance in the context of endometriosis. The results highlight the significant impact of dysregulated miRNAs on the inflammatory pathways and hormonal imbalances characteristic of endometriosis. Consequently, miRNAs hold promise as potential non-invasive biomarkers and targeted therapeutic agents aimed at addressing inflammation and enhancing the response to progesterone treatment in individuals with endometriosis.

Expression of HOXA10 Gene in Women with Endometriosis: A Systematic Review

The homeobox A10 (HOXA10) gene is known to be related to endometriosis; however, due to a lack of knowledge/evidence in the pathogenesis of endometriosis, the mechanisms that link HOXA10 to endometriosis still need to be clarified. This review addresses the difference in the expression of the HOXA10 gene in endometriotic women versus non-endometriotic women across populations by country and discusses its influences on women's fertility. An organized search of electronic databases was conducted in Scopus, ScienceDirect, PubMed, and Web of Science. The keywords used were (HOXA10 OR "homeobox A10" OR PL OR HOX1 OR HOX1H OR HOX1.8) AND ("gene expression") AND (endometriosis). The initial search resulted in 623 articles, 10 of which were included in this review. All ten papers included in this study were rated fair in terms of the quality of the studies conducted. The expression of the HOXA10 gene was found to be downregulated in most studies. However, one study provided evidence of the downregulation and upregulation of HOXA10 gene expression due to the localization of endometriotic lesions. Measuring the expression of the HOXA10 gene in women is clinically essential to predicting endometriosis, endometrial receptivity, and the development of pinopodes in the endometrium during the luteal phase.

Infertility and cortisol: a systematic review

Introduction

Stress and infertility form a complex relationship. In line with this, various stress-related biological markers have been investigated in infertility.

Methods

This systematic review was performed using PRISMA guidelines (i) to report whether cortisol is highly present in infertile patients compared to fertile control; (ii) to report whether there is any significant difference in the cortisol level in infertile subjects that conceive and those that didn't at the end of assisted reproduction treatments. Original articles involving human (male and female) as subjects were extracted from four electronic databases, including the list of references from the published papers. Sixteen original full-length articles involving male (4), female (11), and both genders (1) were included.

Results

Findings from studies that compared the cortisol level between infertile and fertile subjects indicate that (i) Male: three studies reported elevated cortisol level in infertile patients and one found no significant difference; (ii) Female: four studies reported increased cortisol level in infertile subjects and three studies found no significant difference. Findings from studies that measured the cortisol level from infertile patients that conceived and those that didn't indicate that (i) Male: one study reported no significant difference; (ii) Female: one study reported elevated cortisol in infertile patients that conceived, whereas two studies reported increased cortisol in infertile patients that was unable to conceive. Five studies found no significant difference between the groups.

Discussion

In the present review we only included the cortisol value that was measured prior to stimulation or IVF treatment or during natural or spontaneous cycles, despite this, there are still variations in the sampling period, assessment techniques and patients' characteristics. Hence, at present, we are still unable to conclude that cortisol is significantly elevated in infertile patients. We warrant future studies to standardize the time of biological sample collection and other limitations that were addressed in the review to negate the unwanted influencing factors.

The spectrum of in vitro maturation in clinical practice: the current insight

In vitro oocyte maturation (IVM) has been used worldwide. Despite the long-term implementation, the uptake of this procedure to complement current in vitro fertilization (IVF) remains low. The main reason is likely due to the non-synchronization of protocol and definition criteria, leading to difficulty in collective proper outcome data worldwide and, thus, lack of understanding of the exact IVM procedure. The review aims to consolidate the current clinical practice of IVM by dissecting relevant publications to be tailored for a current spectrum of clinical practice. Nevertheless, the background theories of oocyte maturation were also explored to provide a comprehensive understanding of the basis of IVM theories. Additional discussion of other potential uses of IVM in the future, such as in ovarian tissue cryopreservation known as OTO-IVM for fertility preservation and among women with diminished ovarian reserve, was also explored. Otherwise, future collaboration among all IVM centers is paramount for better collection of clinical data to provide valid recommendations for IVM in clinical practice, especially in molecular integrity and possible DNA alteration if present for IVM offspring outcome safety purposes.

Effects of Dehydroepiandrosterone (DHEA) Supplementation on Ovarian Cumulus Cells following In Vitro Fertilization (IVF)/Intra-Cytoplasmic Sperm Injection (ICSI) Treatment-A Systematic Review

Despite many studies exploring the effects of DHEA supplementation, its application in IVF procedure continues to be a subject of debate owing to the inconsistent findings and the lack of rigorously designed, large-scale, randomized trials. Our review aims to explore the effectiveness of DHEA supplementation in ovarian cumulus cells following IVF/ICSI treatment. We conducted a literature search of Pub-Med, Ovid MEDLINE, and SCOPUS (inception to June 2022) for all relevant articles, including the keywords of "dehydroepiandrosterone/DHEA", "oocyte", and "cumulus cells". From the preliminary search, 69 publications were identified, and following a thorough screening process, seven studies were ultimately incorporated into the final review. Four hundred twenty-four women were enrolled in these studies, with DHEA supplementation being administered exclusively to women exhibiting poor ovarian response/diminished ovarian reserve or belonging to an older age demographic. The intervention in the studies was DHEA 75-90 mg daily for at least 8-12 weeks. The only randomized controlled trial showed no difference in clinical or cumulus cell-related outcomes between the control and treatment groups. However, the remaining six studies (two cohorts, four case-controls) showed significant beneficial effects of DHEA in cumulus cell-related outcomes compared to the group (older age or POR/DOR) without DHEA supplementation. All studies revealed no significant difference in stimulation and pregnancy outcomes. Our review concludes that DHEA supplementation did show beneficial effect on ovarian cumulus cells in improving oocyte quality for women of advanced age or with poor ovarian responders.

HOXA10 DNA Methylation Level in the Endometrium Women with Endometriosis: A Systematic Review

Endometriosis is an inflammatory chronic systemic disease resulting in pelvic pain and infertility. However, despite a high prevalence of endometriosis, disease identification is still insufficient, and a high percentage of misdiagnosing was observed. Hence, a comprehensive study needs to be done to improve our understanding of the pathogenesis of endometriosis. Aberrant hypermethylation of HOXA10 has been reported to play a role in endometriosis. Thus, a comprehensive literature search was conducted to identify the DNA methylation level of HOXA10 among endometriosis patients across populations. The literature search was done using PubMed, Scopus, EBSCOhost, and Science Direct applying (HOXA10 OR "homeobox A10" OR "HOXA-10" OR HOX1) AND ("DNA methylation" OR methylation) AND (endometriosis OR endometrioma) as keywords. From 491 retrieved studies, five original articles investigating the DNA methylation level of HOXA10 from endometrium tissues among endometriosis women were included. All five included studies were classified as high-quality studies. High HOXA10 DNA methylation level was observed in the endometrium tissue of women with endometriosis in all the included studies. The secretory phase was identified as the best sampling time for HOXA10 DNA methylation study in endometriosis, and the most studied DNA methylation site is the promoter region of the HOXA10. However, more studies are needed to expose the HOXA10 mechanism in the pathogenesis of endometriosis.

Comparison of Treatment Outcomes among Sibling Oocytes Using Different Culture Systems-Conventional IVF versus INVOcell Device-And Evaluation of INVOcell User Satisfaction: The INVOcIVF Study

INVOcell is considered an alternative to conventional IVF proposed for intravaginal embryo culture; however, implementation is still low because evidence is scanty regarding its outcome and, most importantly, the device's user satisfaction. Thus, we aim to compare the embryo outcome of sibling oocytes following INVOcell culture with conventional IVF (cIVF) by assessing its clinical outcome (fertilization, blastulation rate, and good embryo quality) and the user satisfaction evaluation based on a local validation questionnaire. A prospective study was done at a university-setting hospital for 12 months (July 2021-2022). The oocytes collected were divided into INVOcell and cIVF groups equally. Inclusion criteria included <40 years old and body mass index (BMI) < 30 kg/m². The pre- and post-satisfaction questionnaires were assessed. In total, 23 women were included following standard controlled ovarian stimulation (COS). The mean age was 32.9, and the mean BMI was 24.9 kg/m². Most of them suffered from tubal factors. A total of 252 oocytes were collected and incubated accordingly (cIVF; 138, INVOcell; 114). The blastulation rate was superior in the INVOcell group (p = 0.16); otherwise, the fertilization rate and good embryo quality were not significantly different between both methods (p > 0.05). Overall, women were satisfied with the INVOcell device as they were adequately advised, follow-up was scheduled, and the lowest score was obtained for all side effects of the device. Although both methods produce similar fertilization rates and good-quality embryos, the blastulation rates were better in the INVOcell group. Functionally, it is a user-friendly device and tolerable. Therefore, INVOcell can be used as an alternative method for reproductive treatment in carefully selected patients without jeopardizing the IVF outcomes.

Single Dose Gonadotropin-Releasing Hormone Agonist Luteal Support in Fresh Embryo Transfer: Variation in Timing, Type, and Dosage

Objectives

To evaluate the effects of the addition of single-dose GnRH agonist to the routine progestogens use for luteal phase support on IVF outcome as compared to progestogens only.

Methods

This is a retrospective case-control study on selected patients who underwent IVF treatment with fresh embryo transfer (ET) under Medically Assisted Conception Unit, University Kebangsaan Malaysia Medical Center for the period of June 2015–June 2018. A higher dose of 0.2 mg subcutaneous Decapeptyl was administered 2 days before fresh ET concurrent with routine progestogen support. Patients with different luteal phase regimes, frozen embryo transfer and medical records with missing data were excluded. Their medical records were reviewed, and data analyzed. The pregnancy outcomes measured included biochemical pregnancy rates, clinical pregnancy rates, live birth rates and miscarriage rates.

Results

A total of 786 patients were analyzed. Four hundred forty-four patients were given luteal phase support with progestogens and GnRH agonist, whereas 342 patients served as control were given progestogens only. The study group showed higher biochemical pregnancy rate (47.7 vs. 44.4%,), clinical pregnancy rate (25.7 vs. 23.4%) and livebirth rate (24.3 vs. 22.2%), respectively but not statistically significant. The rate of miscarriage among the study group was lower (4.5% vs 9.4%) compared to the progestogen group alone. Nonetheless, the OHSS rate was slightly increased in the study group (4.5 vs. 3.5%) despite using a mild stimulation protocol.

Conclusions

New regime of GnRH agonist luteal support in addition to the standard progestogen support was found to be beneficial in overall IVF outcome.

A Systematic Review and Integrated Bioinformatic Analysis of Candidate Genes and Pathways in the Endometrium of Patients With Polycystic Ovary Syndrome During the Implantation Window

Polycystic ovary syndrome (PCOS) is a common disorder with wide-ranging clinical heterogeneity that causes infertility. However, the comprehensive molecular mechanisms of PCOS in causing infertility is remaining unclear. Hence, a comprehensive literature search was conducted using PubMed, Scopus, EBSCOhost, and Science Direct. Medical Subject Heading (MeSH) terms like PCOS, gene expression, implantation window and endometrium were used as the keywords. From 138 studies retrieved, original articles with RNA profiling on human endometrial tissues in PCOS women during the implantation window were included. Study design, sample size, sample type, method, and differentially expressed genes (DEGs) were identified from all publications. The DEGs were analyzed using the software packages DAVID, STRING, and Cytoscape. Three studies that met inclusion criteria were included, and 368 DEGs were identified. Twelve significant clusters from the protein-protein interaction network (PPI) complex were found, and cluster 1 showed very high intermolecular interactions. Five candidate genes (AURKA, CDC25C, KIF23, KIF2C, and NDC80) were identified from the systematic review and integrated bioinformatics analysis. It is concluded that cell cycle is the fundamental biological processes that were dysregulated in the endometrium of PCOS women, affecting decidualization progression in the endometrium during the implantation window.

Impact and Adaptation of Reproductive Training During COVID-19 Pandemic in Malaysia

The novel coronavirus (COVID-19) pandemic has affected the community at large. It has affected almost everyone and every aspect of social, economic and educational activities. Training in reproductive medicine has not been spared, as training in this field requires a combination of clinical interaction with patients, procedural experience, constant discussions and the element of research. The changes to numbers of new infections or active cases dictate the restrictions placed on the community and health care services alike. At the beginning of the pandemic, both the patients' fear of going to a health care facility and movement restrictions had caused a significant reduction in the number of COVID-19 cases. Furthermore, the Ministry of Health (MOH) Malaysia's recommendation to withhold all non-essential medical services, including those related to reproductive medicine, falls under this category. Therefore, it could negatively impact the quality of training and lead to an extension of training duration in reproductive medicine. Thus, the procedural experience could be supplemented with simulator training, teleconsultation could replace standard clinic sessions and online meeting platforms could replace routine academic meetings. Any modifications must be adaptable or flexible, as similar infectious pandemics and restrictions could recur from time to time.

A fine tuning of embryo loading technique by eliminating the air bubble in the outer sheath of embryo catheter among women undergoing IVF treatment

OBJECTIVES

The role of air bubbles in bracketing the embryo-containing medium in inner catheter during embryo transfer (ET) has already been established. However, the role of air bubbles in outer catheter (OC) during implantation is yet to be determined. This study aimed to compare the implantation rates between women who have undergone ET with or without ASP (Vitrolife^®; Sweden), a medium use for oocyte retrieval and rinsing in OC embryo catheter. The purpose of introducing the ASP medium to the OC was to eliminate air bubbles in that space during implantation.

METHODS

A total of 312 women were randomly divided into two groups with 156 participants each group. In Group A, ASP medium was used during ET, whereas in Group B, no ASP medium was utilized. Positive implantation was defined as serum beta-hCG level >5 mIU/mL taken on the 7th day following ET.

RESULTS

The average age of the majority of the participants was 30-39 years and had at least 4-5 years of subfertility. The unexplained subfertility was the prominent cause of ET failure in both groups. In most of the participants in both groups, ET was done using fresh embryo cycles with good to excellent embryo grades. After the ASP medium was manipulated in the OC in both groups, the positive implantation rate was not different in both groups (p>0.05).

CONCLUSIONS

The elimination of air bubbles in OC by using the ASP medium during ET did not confer an additional benefit nor exert a negative impact on implantation rate.

Oncofertility in Islam: The Malaysian Perspective

The implementation of oncofertility services is of great importance among cancer survivors of reproductive age to ensure a good quality of life. However, the uptake of this service among Muslim patients is very challenging because of inconclusive laws or evidence based on the Islamic perspective. Hence, we summarized the limited evidence available to consolidate current recommendations for oncofertility practices in the Muslim population in Malaysia. The available “fatwa” and “muzakarah” regarding reproductive procedures and gamete cryopreservation in Islam was searched from the recommendations of local and international bodies, including published and unpublished sources. The relevant information was then extracted according to the current understanding of dilemmas in oncofertility practices in Malaysia, tabulated, and consolidated. Most of the available “fatwa” has been revised by recent “muzakarah” to suit current oncofertility practices. Most Islamic organizations support the practice of oncofertility in Muslim hence indicates that oncofertility services are permissible. Therefore, proper recommendations and counseling are paramount to ensure understanding among Muslim patients.

The outcome of intra-cytoplasmic sperm injection (ICSI): do the sperm concentration and motility matter?

OBJECTIVES

The male-factor subfertility was reported to be 30% globally; thus, the intracytoplasmic sperm injection (ICSI) procedure was implemented to improve the overall in vitro fertilization (IVF) rates. Nevertheless, at least 10% of fertilization failure still occurs. Concerning this issue, we explored the association of sperm concentration and motility with the quality of embryo development and pregnancy outcome in IVF-ICSI cycles.

METHODS

Retrospective analysis of 109 couples with male factor were done over 14 months in a tertiary university hospital in Malaysia. The data were divided into four groups; Group I: normal sperm parameters, Group II: normal sperm concentration but reduced total sperm motility, Group III: reduced sperm concentration and motility, Group IV: reduced sperm concentration but normal sperm motility. Only fresh semen samples and fresh embryo transfers were included. The fertilization, cleavage rate, embryo quality and pregnancy outcome were assessed.

RESULTS

Overall, group I had the highest oocytes yield and ICSI attempted; (10.12 + 6.50), whereas the lowest was in group IV; (7.00 + 2.82). Group II revealed the highest fertilization and cleavage rates; (54.14 + 25.36), (55.16 + 26.06), thus not surprisingly resulting in the highest number of good embryos and highest clinical pregnancy rates. The lowest cleavage and pregnancy rates were seen in group IV. However, all the outcomes were not statically significant (p>0.05).

CONCLUSIONS

Similar fertilization rate and comparable pregnancy outcome was seen among couples with normal and reduced sperm concentration and motility.

The Effect of Surgical Intervention of Endometriosis to CA-125 and Pain

Endometriosis is an inflammatory condition characterised by the presence of endometrial growth beyond the uterine cavity. It is a debilitating disease requiring multiple modalities of treatment. In considering surgery as the option of treatment, the benefits should outweigh the risk. Besides direct surgical risk, intervention may lead to a reduction of ovarian reserve, in addition to premature menopause and low fecundity. To date, there is an inconclusive evidence to support any specific parameters in monitoring disease progression following surgical intervention. Serum cancer antigen (CA)-125 is expressed by coelomic epithelium and has been extensively studied as a biomarker for endometriosis. Elevated expression of CA-125 has been shown in endometrial tissues and the marker increased indirectly from peritoneal irritation that accompanies an extensive form of endometriosis. Additionally, the visual analogue scale (VAS) scores have been used as an objective measurement for measuring pain, especially in a complex disease such as endometriosis. This review aims to consolidate a series of clinical trials that utilised CA-125 level and VAS score as tools for monitoring patients undergoing surgery for endometriosis.

Comparison between Iberet Folic® and Zincofer® in treatment of iron deficiency anaemia in pregnancy

OBJECTIVES

To compare the effect of Iberet Folic^® and Zincofer^® on haemoglobin (Hb) and serum ferritin level; and its adverse effect.

METHODS

This randomised controlled trial conducted from January 2018 until December 2018. Pregnant women below 34 weeks of gestation, with Hb concentration less than 11 g/dL and serum ferritin level less than 12 ug/L were randomised to receive either one tablet Zincofer^® or one tablet Iberet Folate^® daily for four weeks. Both groups were compared in terms of effect on Hb level, serum ferritin level, and other haematological indices adverse effect related to treatment, and treatment cost.

RESULTS

Hundred and thirty patients were recruited in this study with 68 patients in Iberet Folic group and 62 patients in Zincofer group. The change in the Hb and serum ferritin level from baseline to day 30 did not differ significantly between treatment groups. The mean (±SD) change from baseline to day 30 was 2.15 (±0.59) g/dL in the Iberet Folic group, and 1.98 (±0.49) in the Zincofer (p value = 0.08). Mean serum ferritin at day 30 was 17.2 (±3.68) ug/L and 16.7 (±4.28) ug/L with 8.44 (±3.41) and 8.55 (±3.50) difference, respectively (p = 0.86). Adverse events were comparable in between groups, with p value >0.05. GI intolerance and constipation were among the common side effects, occurred in 34.6 and 29.2% cases, respectively.

CONCLUSIONS

Zincofer^® offers equivalent efficacy and side effect profile in comparison with Iberet Folic^® for the treatment of iron deficiency anaemia (IDA) during pregnancy, but with lower cost.

Pregnancy outcomes in systemic lupus erythematosus (SLE) women

Background Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory condition with multi-organ involvement predominantly affecting young women. There are very limited studies in pregnancy in Asian SLE patients and therefore we embarked on this study to identify pregnancy outcomes of Malaysian women with SLE. Materials and methods We performed a retrospective study of pregnancy outcomes in SLE patients in our institution from January 2007 to December 2014. A total of 71 pregnancies from 44 women were analysed. Results The mean age of our cohort was 30.5 ± 3.9 years. The rate of active disease at conception, antiphospholipid syndrome and lupus nephritis were 22.5%, 32.4% and 57.7% respectively. SLE flare occurred in 33 out of 71 pregnancies whereas 19 pregnancies were complicated with preeclampsia. The livebirth rate for our cohort was 78.9%, whilst preterm delivery was 42.9%. On univariate analysis, active disease and flare in pregnancy were both strongly associated with foetal loss and preterm delivery. Lupus nephritis (p = 0.011), SLE flare (p = 0.008) and antiphospholipid syndrome (p = 0.032) significantly increased the risk of preeclampsia. Aspirin and hydroxychloroquine were protective against foetal loss [odds ratio (OR) 0.12] and preeclampsia (OR 0.25), respectively. On multivariate analysis, active disease was a predictor of SLE flare (p = 0.002) and foetal loss (p = 0.018) and SLE flare was the main predictor of preterm delivery (p = 0.006). Conclusions Pregnancies in women with SLE should be planned and aspirin and HCQ use were beneficial in reducing adverse pregnancy outcomes.

Management Options and Outcome of Cerebral Arteriovenous Malformation in Pregnancy: Case Series

Cerebral arteriovenous malformation (AVM) is a rare entity with an estimated prevalence of 0.01-0.05% in the general population. We reviewed hospital obstetric records during 2010-2017 and reported a case series of six patients with cerebral AVM in pregnancy, of which five patients had successful pregnancy, and one maternal mortality.

Reviewing the role of progesterone therapy in endometriosis

Endometriosis is a benign, chronic inflammatory condition characterized by the presence and growth of endometrial implants outside the uterine cavity. The cause of endometriosis is multifactorial. It is due to the diversity of hypothesis and plausibility of hormonal alterations which could play a major role. Evidence has shown that progesterone resistance is a key factor for endometriosis sufferers. Medical therapy can avoid surgical intervention, which may lead to a reduced in ovarian reserve, and its effects of earlier menopause and reduced fecundity. Progesterone receptor isoform has provided new insight as the potential treatment. Progestin, anti-progestin and selective progesterone receptor modulators usage, which target these receptors, could avoid hypo-estrogenic side effects, which can be debilitating. Numerous types of these medications have been used on and off labeled to treat endometriosis with varying success. This review aims to consolidate series of clinical trials using progestins in endometriosis.

Knowledge, attitudes and practice regarding copper intrauterine contraceptive devices among doctors in Malaysia

BACKGROUND AND OBJECTIVE

Intrauterine contraceptive devices (IUDs) are an important method to reduce unmet need for family planning and for prevention of unintended pregnancy. However, IUD use in Malaysia is still low. Doctors play a major role in influencing IUD uptake among women. This study was designed to evaluate doctors' knowledge, attitudes and perceptions towards IUDs and factors associated with their current practice.

METHODS

A questionnaire was mailed to public and private contraceptive providers who practise in Kuala Lumpur, Malaysia.

RESULTS

A total of 400 doctors were invited and 240 (60%) of them responded to the survey. Of the respondents, 161 (65.9%) were from the public or government sector and 89 (34.1%) were from the private sector. The knowledge score of doctors was classed as 'average', and correlated well with their previous training level, working position, number of patients seen in a week and number of contraceptive methods available in their facilities. The age, gender, working duration, availability of IUDs in the premises and number of IUD insertions in a month were not statistically associated with the providers' knowledge. The use of IUDs was low, especially among private doctors, and was significantly related to their knowledge of the method. Knowledge scores, perception and practice were significantly lower in the private sector.

The World Health Organization (WHO) versus The International Association of Diabetes and Pregnancy Study Group (IADPSG) diagnostic criteria of gestational diabetes mellitus (GDM) and their associated maternal and neonatal outcomes

Background Gestational diabetes mellitus (GDM) is a common medical complication in pregnancy. The aim of this study was to compare the prevalence of GDM using the World Health Organization (WHO) criteria and the International Association of Diabetes and Pregnancy Study Group (IADPSG) criteria in our population. We further compared the incidence of adverse maternal and neonatal outcomes in women diagnosed with GDM using these criteria and determined whether the IADPSG criteria is suitable in our population. Methods This randomized controlled trial was conducted at our antenatal clinic involving 520 patients from 1st February 2015 until 30th September 2017. They were randomized into the WHO and the IADPSG groups. All eligible women underwent a standard oral glucose tolerance test with 75 g glucose, their fasting and 2 h post prandial glucose levels were taken. The primary outcome was the prevalence of GDM. The secondary outcomes were the incidence of primary cesarean section, gestational hypertension or preeclampsia, preterm delivery <37 weeks, fetal macrosomia, neonatal hypoglycemia and shoulder dystocia or birth injury. Results The prevalence of GDM in both groups were similar (37.9% vs. 38.6%). GDM women in the WHO group had a significantly higher incidence of gestational hypertension or preeclampsia (p = 0.004) and neonatal hypoglycemia (p = 0.042). In contrast, GDM women in the IADPSG group had a significantly higher incidence of fetal macrosomia (p = 0.027) and cesarean section (p = 0.012). Conclusion The IADPSG diagnostic criteria for GDM may not be suitable for use in our population as it resulted in women being diagnosed later and being undertreated, thus leading to adverse maternal and neonatal outcomes.

Back pain in pregnancy among office workers: risk factors and its impact on quality of life

Background Back pain is a common presenting complaint during pregnancy and it is often being considered as part of the pregnancy process. The purpose of the study is to investigate the prevalence of back pain in pregnancy, risk factors and its impact on the quality of life in pregnant women. Materials and methods Three hundred and fifty-eight pregnant women who attended the antenatal clinic in Universiti Kebangsaan Malaysia (UKM) Medical Centre were recruited in this cross-sectional study from October 2011 until April 2012. The back pain was further classified into lumbar pain and posterior pelvic pain. The severity of back pain was assessed using visual analoque scale (VAS) and the functional limitation was assessed using the Oswestry Disability Questionnaire (ODQ). Result The prevalence of back pain in pregnancy was 84.6%. Occupation and previous history of back pain were associated with back pain in pregnancy. In terms of functional limitation disability, total ODQ score was statistically significant correlate with severity of pain (VAS score). Personal care, sitting, standing, sex life and social life were significantly affected. Conclusion The risk factors for back pain in pregnancy were type of occupation and history of back pain. The higher VAS score, the more ODQ will be affected. Personal care, sitting, standing, sex life and social life were significantly affected.

Effect of an Educational Intervention on Knowledge of Human Papillomavirus Vaccination among Pre-University Students in Malaysia

BACKGROUND

Cervical cancer is the fourth most common cancer among women worldwide. Studies evaluating the effect of health education on knowledge and perception of cervical cancer have generated conflicting results. Thus, this study aimed to evaluate the effect of educational intervention towards knowledge of HPV vacccination for cervical cancer prevention among pre-university students in Malaysia.

MATERIALS AND METHODS

This was an experimental before and after study performed between October 2014 and March 2015. Five hundred and eighty students were randomly assigned into intervention and control groups. All were required to complete both pre-intervention and post-intervention questionnaires. Those in the intervention group were given an information leaflet to read before answering the post-intervention questionnaire.

RESULTS

Almost half (48.3%) of the students had poor knowledge, with a score less than 5, and only 51 (8.8%) exhibited good knowledge, with a score of 11 and above. After educational intervention, the number of students with poor knowledge was reduced to 177 (29.3%) and the number of students who exhibited good knowledge increased to 148 (25.5%). Students from the intervention group demonstrated significant higher total scores in knowledge regarding 'HPV infection and cervical cancer' (p=0.000) and 'HPV vaccination and cervical cancer prevention' (p=0.000) during post-intervention as compared to the control group.

CONCLUSIONS

Knowledge on HPV infection and vaccination is low among pre-university students. Educational intervention in the form of information leaflets appears effective in creating awareness and improving knowledge.

Use of hydroxyprogesterone caproate to prevent preterm labour in uterine didelphys: a case report

Congenital uterine anomalies have been associated with poor reproductive outcome, which include recurrent miscarriage, abruptio placenta, intra-uterine growth restriction and preterm delivery. Here, we report a case: 36 years old, G3P2, known case of uterine didelphys, with history of preterm birth, who successfully carried her pregnancy till term with weekly intramuscular injection of 250 mg hydroxyprogesterone caproate (®Proluton Depot, Zuellig Pharma).

Retained placenta: Do we have any option?

Retained placenta is a known cause of post-partum haemorrhage and maternal mortality. A recent systemic review has confirmed that the incidence of retained placenta had increased all over the world, which is more common in developed countries. Failure of retro-placental myometrium contraction is the main cause of retained placenta. Maternal age greater than 35 years, grandmultipara, preterm labor, history of previous retained placenta, and caesarean section were the risk factors for retained placenta. Manual removal of the placenta has been the treatment of choice. Attempts had been made by clinician and researchers to find a safe, effective and reliable method to avoid the need for surgical intervention. The efficacy and safety of prostaglandin, nitroglycerin or acupuncture in the management of retained placenta are yet to be further evaluated. Nonetheless, till date only intra-umbilical vein oxytocin has been studied extensively but with varied success. More randomized clinical trials are needed to address this issue. However, if immediate manual placenta removal service is unavailable, a trial of intra-umbilical vein oxytocin 100 IU at a total volume of at least 40 mL while preparing for transfer to a tertiary center or theatre may result in spontaneous expulsion of the placenta.

Case report of ruptured non-communicating right rudimentary horn pregnancy: an acute emergency

Ruptured pregnancy in the rudimentary horn of women who have had a vaginal delivery is rare and unpredictable. However, when undiagnosed, this condition could lead to maternal morbidity and mortality. We report a pregnancy at 19 weeks gestation presented with acute abdomen and hypovolemic shock. She was initially thought to have an intrauterine pregnancy with the provisional diagnosis of a ruptured uterus. Intraoperatively, a ruptured non-communicating right rudimentary horn with ex utero pregnancy was discovered.