O-292 Comparison of effect of two different trigger regimens; single (hCG) versus dual (hCG + Leuprolide) on outcome of fresh IVF cycles: A randomized controlled trial

Study question

Does adding gonadotropin-releasing hormone agonist (GnRHa) to hCG trigger increases the number of high-grade embryos in GnRH antagonist protocol in fresh non-donor IVF?

Summary answer

Final oocyte maturation triggered by dual trigger increases the number of MII oocytes thus transferring good-quality embryos and cryopreserving surplus embryos compared to hCG trigger.

What is known already

hCG has been conventionally used as a ‘faux’ LH surge to bring about final oocyte maturation due to structural similarity between the two. GnRH agonist, on the other hand, induces a more physiological gonadotropin surge for follicular maturation, but is associated with luteal phase deficiency. Recent studies have shown that combining GnRHa with hCG trigger improves oocyte maturation and embryo quality with the added benefit of a luteal phase support, thereby improving IVF outcomes in terms of both embryological and reproductive outcomes.

Study design, size, duration

A single-center, open labelled, randomized controlled trial including 100 normal responder patients between 21-38 years undergoing IVF using GnRH antagonist protocol between January 2020 to August 2021. The study excluded patients with the presence of other variables of adverse outcomes like diminished ovarian reserve (AFC < 5 or AMH < 1.2 ng/ml), endocrine disorders, thin endometrium (<6mm), previous history of uterine surgeries, and high responders.

Participants/materials, setting, methods

100 patients undergoing fresh IVF cycle using GnRH antagonist protocol were randomized after informed consent to receive either dual trigger (Leuprolide acetate 1 mg + rhCG 250 mcg, n = 50) or single hCG trigger (rhCG 250 mcg, n = 50). Oocyte retrieval was done 35-37 hours after trigger followed by IVF/ICSI, as indicated. Oocyte and embryo grading was done using Istanbul consensus. Analysis was done by ITT. Outcomes were analyzed using Independent t-test and Chi-square test.

Main results and the role of chance

The baseline characteristics were comparable in both arms. the number of MII oocytes retrieved (7.82 versus 5.92, p = 0.003) and the number of day-3 grade-1 embryos (4.24 versus 1.8, p < 0.001) were higher in the dual trigger group, whereas fertilization rates between the two groups (91.82% versus 88.51%, p=NS) were comparable. Consequently, the number of embryos cryopreserved (2.68 versus 0.94, p < 0.001) were significantly higher in the dual trigger group. However, the implantation rate between the two groups (21% versus 19.6%, p = 0.770) was comparable. The serum LH levels 12 hours post trigger were measured in both the arms and as expected, high serum LH values were documented in the dual trigger group (46.23 mIU/ml vs 0.93 mIU/ml, p < 0.0001).

Limitations, reasons for caution

Due to the impact of the Covid-19 pandemic causing an intermittent pause in IVF services at our center, a smaller sample size of 100 patients could be enrolled in the study, and reproductive outcomes in terms of live births and cumulative live births could not be assessed

Wider implications of the findings

This study, though small, has contributed to some evidence of redesigning the dual trigger in all antagonist cycles, with the exception of high responders and PCOS patients. The addition of GnRHa to hCG trigger has led to the possibility of cryopreserving surplus embryos thereby increasing the cumulative live births.

Trial registration number

CTRI/2020/08/027030

P-323 Should We Measure Oxidative Stress Biomarkers In Follicular Fluid Of Women With Endometriosis Undergoing IVF?

Study question

Do levels of Oxidative stress (OS) biomarkers differ in the follicular fluid of women with endometriosis compared to tubal factor infertility?

Summary answer

8-Isoprostane is a promising biomarker in diagnosing oxidative stress in women with endometriosis opening a window of opportunity for improving outcomes.

What is known already

A delicate balance between oxidants and antioxidants is required for oocyte development and maturation. Any perturbation in the oocyte microenvironment which is the follicular fluid results in hampered oocyte quality and further affects the embryo development. As endometriosis causes destruction of the oocyte milieu, various OS biomarkers have been explored with inconclusive results. The present study aimed to compare these biomarkers in follicular fluid of women with endometriosis and tubal factor infertility undergoing in-vitro fertilization and correlate with ART outcomes.

Study design, size, duration

In a cross sectional study conducted at the assisted conception unit at a tertiary care hospital from 2017-2018 women undergoing their first IVF cycles for endometriosis and tubal factor infertility were recruited in the study. The study included a total of 107 patients with 50 in the endometriosis group (Group1) and 57 in the tubal group (Group 2).

Participants/materials, setting, methods

Follicular fluid from women undergoing IVF in both the groups was collected and evaluated for Oxidative stress biomarkers including Reactive Oxygen species (ROS), Total Antioxidant Capacity (TAC), 8-Isoprostane (8-IP) levels. ROS levels were detected by chemiluminescence and TAC and 8-IP using enzyme immunoassays.

Main results and the role of chance

Levels of ROS {(39.6 cpm vs 54.8 cpm) (p = 0.2)}were comparable in both the groups. Levels of 8-IP were significantly higher in group 1 as compared to the group 2 {(85.2  pg/ul vs 39.2  pg/ul) (p = 0.01)}. TAC levels were higher in endometriosis group compared to the tubal group {(5.4 mM of Trolox vs 4.1 mM of Trolox) (p = 0.005)} which could explain comparable ongoing clinical pregnancy rate in both groups (24.0% vs 24.5%, p = 0.34). There was no correlation of OS biomarkers with ART outcomes in tubal factor. Follicular fluid in Group 1 revealed a negative correlation of ROS with cleavage rate (r = - 0.42, p = 0.002) and positive correlation of TAC with fertilization rate (r = 0.44, p = 0.001) and Good grade embryos (r = 0.4, p = 0.001).

Limitations, reasons for caution

The main limitation is the inability to assess the dietary intake and blood oxidative stress biomarkers in both the groups.

Wider implications of the findings

OS biomarkers especially 8-IP could be useful in prognosticating IVF outcomes in women with endometriosis with a potential role of addition of antioxidants in culture media during IVF in these women.

Trial registration number

Not Applicable

P-799 To evaluate the effect of Intra-ovarian platelet rich plasma instillation on the clinical outcome of women with diminished ovarian reserve: A prospective interventional study

Study question

Does intra-ovarian instillation of platelet rich plasma (PRP) improves the clinical outcome of IVF cycles in women with Diminished Ovarian reserve (DOR)?

Summary answer

PRP instillation leads to consistent improvement in Antral follicle count (AFC), thus achieving clinical pregnancy rate of 33.3% per cycle in women with DOR.

What is known already

There is rising incidence of females with diminished ovarian reserve (DOR) especially among Asian ethnicity. With the emergence of regenerative medicine, multiple studies have evaluated the role of intra-ovarian PRP, demonstrating a beneficial role in improving ovarian reserve parameters (serum Follicular stimulating hormone (FSH), serum anti-Mullerian hormone (AMH), AFC). Despite its’ favorable effects on biochemical markers and AFC, data regarding improvement in clinical outcome remains elusive and led to inception of this study.

Study design, size, duration

A prospective interventional study was conducted at Division of Reproductive Medicine of a tertiary care institute. 41 infertile females aged 20-39 years with DOR (AMH <1.2 ng /ml; AFC<5) were enrolled in the study during a 6-month period beginning from August 2021.

Participants/materials, setting, methods

After informed consent, patients received fresh autologous PRP, prepared from 30 ml venous blood. 1.5ml of PRP instilled in each ovarian stroma between day 7-10 of menstrual cycle under sedation. Patients were followed up for three-consecutive months to assess ovarian reserve parameters including serum FSH, AMH and AFC. Patients showing significant improvement in parameters were recruited for fresh IVF cycles using Antagonist protocol with 1% transdermal testosterone. Outcomes were analysed using linear mix effect model.

Main results and the role of chance

The average platelet concentration in PRP was ∼10,00,000 platelets/µL. The mean age of enrolled patients was 31.22±4.16 years. Linear improvement in AFC (3.63 vs 6.98 vs 7.97 vs 6.90, p<0.001) was observed from baseline to three consecutive follow-up months with maximal response witnessed in second month in 57.1% of those undergoing IVF cycle. However, there was no significant difference in Serum FSH (p=0.11) and AMH (p=0.16) from the baseline post intervention. Of the 41 patients, 35 (85.3%) responded to the treatment and underwent IVF antagonist cycle. 5 out of 35 IVF cycles were cancelled mid-cycle due to poor ovarian response. The mean dose of gonadotropin requirement was 2667.5±281.1 IU (Follicular stimulating hormone) and 1400±337.3 IU (Human menopausal gonadotropin). The average number of oocytes retrieved was 5.7±2.2 whereas mean number of MII oocytes was 4.63±1.85. The fertilization rate and the cleavage rate were 92.4% and 74.1% respectively. Of the thirty patients, eight patients underwent day 2 transfer due to poor grade of embryos. Mean number of grade 1- day 3 embryos was 1.25±0.55 with surplus embryos available for cryopreservation in 14 patients. The overall clinical pregnancy rate per transfer was 33.33%. No adverse events were reported.

Limitations, reasons for caution

This was a prospective single arm study. A randomized controlled trial comprising a “no-treatment” arm would establish a Level-I evidence. However, “no-treatment” arm in a developing country like ours, imposes financial burden on the couple with no guaranteed clinical success and thus raising ethical concern and need for ovarian rejuvenation.

Wider implications of the findings

With the impetus to provide a biological child to these DOR women, intra-ovarian PRP instillation as a method of ovarian rejuvenation holds promising results. Evidently, PRP is not only effective in improving ovarian reserve but this translates into an improved reproductive outcome in a population, previously limited to oocyte donation.

Trial registration number

REF/2022/01/051033

P-430 Sperm genomic integrity, telomere dynamics and gene expression in recurrent implantation failure

Study question

Does sperm affect the implantation and early embryogenesis?

Summary answer

Deranged sperm genomic integrity, limited repair mechanisms, aberrant gene expression have the potential to be transmitted to developing embryo and affect implantation and embryonic development.

What is known already

The terminally differentiated, transcriptionally quiscent sperm cells are vulnerable to a host of factors which might affect its function. The spermatozoa with truncated repair mechanisms have the potential to fertilize the oocyte, but eventually result in high rates of pre and post implantation losses. Oxidative stress, deranged genomic integrity, aberrant gene expression in the sperm cell has the potential to affect fertilisation potential, implantation and embryonic viability. This has been seen to be correlated with decreased fertilisation, clevage rates and blastocyst development and thus impaired implantation rates.

Study design, size, duration

A case control study of 75 men from infertile couples who had recurrent implantation failure (RIF) in IVF cycles and 75 fertile controls at AIIMS, New Delhi, India. Study duration was 2 years.

Participants/materials, setting, methods

Semen samples from men from couples who had RIF were analyzed as per WHO 2010. Sperm reactive oxygen species (ROS) and DNA fragmentation index (DFI) was assessed by chemiluminiscence and sperm chromatin structure assay (SCSA) respectively. Relative sperm telomere length was evaluated from sperm DNA by q-PCR analysis. The expression of genes pertinent for early embryonic development was done by qPCR. The relative quantification was done after normalizing with GAPDH and β-actin by 2-ΔΔCt method.

Main results and the role of chance

Seminal ROS levels (RLU/sec/million sperm) were seen to be significantly higher [57.75 (10.1-1186.9)] in cases with respect to controls [16.7(1.15-53.9)] (p < 0.001***). The mean DFI of men undergoing ART was significantly higher (37.7 ± 5.7) vs 23.2 ± 4.6%; p < 0.001***) in cases as compared to controls. ROS and DFI levels correlated negatively with sperm concentration and progressive motility (p < 0.001***). We analyzed the expression of FOXG1, SOX3, STAT4, RPS6, RBM9, RPL10A, RPS17, RPL29, WNT5A, HSP90, TOMM7, EIF5A genes. The expression of SOX3, RBM9, WNT5A, HSP90, TOMM7, and EIF5A showed a significant difference from control levels. The relative sperm telomere length was found to be significantly lower in RIF patients as compared to controls (p < 0.001***).

Limitations, reasons for caution

The current study was a case control study and lacked randomization and also is limited by low sample size. There is a lack of stratification in the enrollment of participants due to difference in specific risk of occurrence and varied clinical history.

Wider implications of the findings

The analysis of spermatozoal gene expression is important for understanding the sperm differentiation, fertilization and early embryonic events. Correlation with oxidative stress, genomic integrity and telomere length may help in regulationof gene expression. It may help in establishing sperm gene expression as a potential biomarker.

Trial registration number

Not applicable

O-008 Improving outcomes in women with Mullerian anomalies

Mullerian Anomalies are present in approximately 5% to 7% of the general population and the incidence is a little more in infertile and recurrent miscarriage women. Most of the recent studies have reported that the obstetric outcome is compromised in this group with greater risk of infertility, recurrent pregnancy loss, intrauterine growth retardation, preterm birth and many other obstetric complications, which may be individually related to the different types of Mullerian Anomalies. In this presentation, We are going to discuss on how the outcomes are different in the various Mullerian Anomalies depending upon the degree of the defects related to different complications with more profound defects. We will also discuss on how to optimize the pregnancy outcomes with various interventions and what the literature review supports.

Trial registration number

Study funding

Funding source

P–771 I hear, I forget. I see and I remember. I do and I understand. An Insight into the need for training for add on techniques

Study question

Do embryologists need additional training or certifications before using add on techniques in the lab ?

Summary answer

Out of 173 respondents majority feel add on techniques require training and/or certifications, the mode of training varies for different add ons.

What is known already

Cochrane reviews have suggested that minimal evidence exists for the use of add on treatments in ART, the data on the prevalence of add ons in IVF is unclear but the presence of technologies in ART laboratories world over suggests a increasing trend of adoption of unproven techniques. No data exists suggesting the role of embryologists in performing the Add on techniques and how their training or lack of, can impact patient safety. The most common method of training comes from the manufacturers and there is a lack of structured trainings for add on treatments worldover.

Study design, size, duration

An internet based survey was designed keeping in mind commonly available laboratory add ons. It comprised of 9 sections and a total of 18 multiple choice questions. Answer choices ranged from a simple yes or no to more complex choices suggesting the type of training and the potential benefits of training.

Participants/materials, setting, methods

The Survey includes results from 173 embryologists from india with varying degree of experience. Add ons included in the survey were Sperm DNA Fragmentation test, IMSI, PICSI, Microfluidics, MACS, Advanced culture media, Oocyte vitrification, Assisted hatching, Time Lapse imaging, spindle view and Electronic Witnessing. The most common practice suggestions were tabulated and identified.

Main results and the role of chance

The survey reports huge need for training for different add on treatments (SDF –91.4%, IMSI - 81.2%, PICSI- 66.5%, Microfluidics- 55.9%, MACS –55.3%, MicroTese- 86.9%, using advanced culture medias{Calcium ionophore- 73.4%, Hyaluronan rich media- 52.1%, growth cytokine rich media–48.5%, Theophylline for sperm motility–50.9%},oocyte Vitrification 85.5%, Assisted Hatching 75.4%, Time-lapse and Electronic witnessing 77.3%, Polarised microscopy for spindle assessment 73.5%). The Most preferred mode of training for more invasive procedures was Hands on training, followed by On the job training and validation followed by workshops(SDF- 62.6%, IMSI- 61%,PICSI–56.1%, MACS and Microfluidics 38.8%,microTese- 50.6%,Oocyte freezing 85.5%, assisted hatching 67.8%,Time-lapse and electronic witnessing 77.3%, Spindle view 73.5% ). The most preferred mode of training for non invasive procedures was Workshops and Observerships, followed by CME’s, followed by product Leaflets(44.4%,42.1%,13.5% respectively). The most common answer for the disadvantages of not being trained was unable to use the technology to its fullest potential(88.5%), whereas the most common answer for the benefit of being trained was better outcomes with said technologies(76.6%).

Limitations, reasons for caution

This study includes responses from embryologists who have varied levels of experience, while the need for training can be established based on these results, a junior level embryologist might answer the survey differently as compared to a senior or a lab director.

Wider implications of the findings: This is a first of its kind large survey, suggesting the need for training and validation from the perspective of the embryologist. This data can be used in formulating guidelines for future trainings and can help regulators in deciding on the most preferred mode of training.

Trial registration number

-

P6391Major acute cardiovascular events in patients with inflammatory bowel disease

Introduction

Traditional risk factors for coronary heart disease have been reported in around 85% patients who present with myocardial infarction. More recently, inflammation and immune mediated diseases have been associated with ischemic heart disease.

Inflammatory Bowel Disease (IBD) is an immune mediated disorder which comprises of ulcerative colitis and Crohn's disease. Estimated prevalence of IBD in the United States in 2004 was 1.4 million people. These patients have an overall increased risk of thrombotic complications with microvascular thrombosis hypothesized to contribute in disease pathogenesis.

Results from a recent meta-analysis were consistent with increased risk of ischemic heart disease among IBD patients, with risk greater in females and younger patients, although heterogeneity was considerable in overall data. Also, in a recent study, IBD was found to be associated with an increased risk of acute myocardial infarction and heart failure despite lower prevalence of coronary risk factors in IBD patients.

IBD pathogenesis involves sustained activation of immune responses with upregulation of cytokines including but not limited to IL-1 beta, IL-6 and TNF-alpha. Upregulation of these cytokines has also been reported in coronary atherosclerosis.

Based on above information, we explored incidence of MACE (Major Adverse Cardiac Event) in this patient population from our health system data-base.

Methods

Propensity scores were estimated for all 15,292 (0.4%) patients with inflammatory bowel disease from a total patient pool of 3,917,894 patients in our health system to assemble a 1:1 matched cohort balanced for age, gender, race and known cardiovascular risk factors including hypertension, hyperlipidemia, diabetes mellitus and smoking (current and former). ICD-9 and ICD-10 codes were used to identify cardiovascular risk factors and outcomes.

Results

Matched patients (n=30,584) had a mean age of 51 years, with 58% of all being women, and 63% Caucasian. During the median follow up of 4.4 years all-cause mortality was observed in 1.7% and 1.2% of patients from IBD and non-IBD groups respectively (hazard ratio {HR}, 1.31; 95% confidence interval {CI}, 1.08–1.58; p=0.005). Combined outcome for myocardial infarction or all-cause mortality was noted in 4.1% and 3.4% from IBD and non-IBD groups respectively (HR, 1.16; 95% CI, 1.03–1.30; p=0.014) while HRs for cardiovascular mortality, myocardial infarction and unstable angina independently were 1.04 (0.74–1.47; p=0.833), 1.05 (0.89–1.23; p=0.591) and 1.10 (0.83–1.46; p=0.524) respectively.

Conclusion

Inflammatory bowel disease did not show association with myocardial infarction, cardiovascular mortality or unstable angina when matched for known cardiovascular risk factors, but was associated with increased all-cause mortality and combined end-point of all-cause mortality or myocardial infarction.

ID: 22: DIFFERENTIAL ACTIONS OF ESTROGEN RECEPTOR α AND β VIA NON-GENOMIC SIGNALING IN HUMAN PROSTATE STEM-PROGENITOR CELLS

Genomic signaling via estrogen receptors (ER) has been widely studied and implicated as the main ER signaling pathway in prostate development and carcinogenesis. Non-genomic ER signaling has also been reported in prostate epithelium although down-stream cascades have not been clarified. Our lab has recently identified ERs in human prostate epithelial stem/progenitor cells and shown that that 17β-estradiol (E2) can stimulate stem cell symmetric self-renewal and progenitor cell proliferation. In this study we interrogate non-genomic membrane initiated ER signaling in this prostate stem/progenitor cell population. Human prostate stem-progenitor cells were enriched from primary prostate epithelial cell cultures (PrEC) of young, disease-free donors using a 3D prostasphere (PS) model as previously described. Cells were labeled using ERα or ERβ antibodies along with prostate stem cell markers CD49f and TROP2 followed by triple channel FACS to quantify ERα+/ERβ+ cell numbers. To explore ERα, the benign human prostate stem cell line WPE with extremely low levels of ERα and ERβ, was stably transfected with a lentiviral-ERα expression vector. The human prostate cancer stem-like cell line HuSLC (ERβ++, ERα−) was utilized to interrogate ERb actions. Cells were exposed to 10 nM estradiol (E2) over a 15 to 60 minute time course +/− ICI 182,870 (ICI), an ERα/β antagonist. FACS analysis of day 7 PS cells labeled for ERα or ERβ revealed 66% of day 7 PS cells as ERα+ and 40% as ERβ+. Among ERα or ERβ positive PS cells, 4% were Trop2+/CD49fhigh (stem-like cells) and 10–12% were Trop2+/CD49fmedium (early stage progenitor cells). PS exposed to 10 nM E2 showed sequential phosphorylation of Src, Erk1/2, p38, Akt and NFκB (p65) over 60 minutes. Phosphorylation of up-and downstream targets (EGFR, Jnk, GSK 3α/β, p70 S6 kinase, PRAS40, MSK1/2) was also seen using a phospho-kinase array. Furthermore, phosphorylation of ERα at S167 was noted over 60 min of E2 exposure enabling enhancement of genomic ERα transactivational activity in a feed-forward manner. ICI attenuated Akt and Erk1/2 phosphorylation, confirming membrane bound ERs are involved in downstream signaling. E2 treatment of HuSLCs showed phosphorylation of Erk1/2 but not Akt, indicating that ERβ signals exclusively through the MAPK pathway in these cells. Conversely, E2 treatment of WPE-stem cells overexpressing ERα resulted in robust phosphorylation of Akt but lower levels of Erk1/2 phosphorylation suggesting that Akt activation may be more reliant on ERα signaling. To identify pathway specific roles, specific inhibitors were added to PS cultures. PS treated with LY294002 (Akt inhibitor) for 7 days attenuated the E2-mediated increase in PS number and size. Inhibition of the NFκB downstream of the Akt pathway by IKK VII (IKK inhibitor) blocked p65 phosphorylation, abrogated the E2-induced increase in stem cell symmetric self-renewal and blunted E2 stimulation of progenitor cell proliferation. Analysis of PS cyclin mRNA levels revealed a G1 arrest of progenitor cells upon IKK inhibition suggesting an essential role of NFκB in progenitor cell amplification. MAPK pathway inhibition with U0126(Erk1/2 inhibitor) resulted in an attenuation of the E2-mediated increase in PS number and size and an increase stem cell symmetric self-renewal suggesting that MAPK pathway activation promotes commitment to stem and progenitor cell expansion. Taken together, the present findings reveal that human prostate stem-progenitor cells express both ERα and ERβ which differentially activate different signaling cascades originating at the membrane. These signaling events may lead to unique downstream actions that influence prostate stem-progenitor cell proliferation as well as lineage commitment decisions.

Isolated Bell's palsy - an unusual presentation of dengue infection

Dengue fever is a very common arthropod - borne infection in tropical countries. Neurological complications in dengue fever are relatively uncommon and among these, isolated cranial neuropathies have been reported only very rarely. We present an unusual neurological complication of Bell's palsy (lower motor neuron 7 th nerve palsy) associated with dengue infection. To the best of our knowledge, there have been very few documented cases of Flavivirus causing isolated Bell's palsy.

Practice-based, clinical trial of a silorane-based composite resin system in posterior teeth

INTRODUCTION

Newer monomer systems have been introduced in an attempt to improve the success rate of direct composite restorations by minimising shrinkage.

AIMS AND OBJECTIVES

To evaluate the in vivo performance of a silorane-based resin composite system (Filtek Silorane, also known as P90), used together with a two-step self-etch bonding system (P90 System Adhesive, Self-Etch Primer and Bond), for the restoration of Class I and Class II cavities in human permanent posterior teeth.

MATERIALS AND METHODS

A total of 53 restorations were completed and patients were recalled one year later. The restorations were assessed by two ndependent clinicians, using the Modified U.S. Public Health Service evaluation criteria for the following parameters: retention, colour match, marginal discolouration, secondary caries, anatomic form, marginal adaptation, surface texture, occlusal and interproximal contacts.

RESULTS

Of the 41 restorations assessed at the one year follow-up, 92.7% showed clinically acceptable scores for all the parameters evaluated. Cronbach's alpha values ranged from 0.72-1.00 showing a good inter-examiner agreement and reliability.

CONCLUSION

Silorane-based composite, Filtek Silorane, when used in conjunction with the recommended adhesive system showed a clinically acceptable performance in posterior teeth restorations over a one year clinical service.

Usefulness of multiplex PCR in the diagnosis of genital tuberculosis in females with infertility

The purpose of this investigation was to evaluate the usefulness of multiplex polymerase chain reaction (m-PCR) in detecting uterine tuberculosis in women with infertility. In a prospective study, endometrial curetting from 620 females with infertility were investigated using laparoscopy, hysteroscopy, histopathology, smear microscopy, mycobacterial culture in BACTEC MGIT™ 960, and in-house m-PCR. The mean age of the women was 29.75 ± 4.66 years. The majority (596) sought medical attention for infertility; of them, 455 (76.34 %) presented with primary and 141 (23.65 %) with secondary infertility. A total of 158 (25.48 %) women were diagnosed as having uterine tuberculosis by at least one of the diagnostic methods. Among them, laparoscopy was positive in 46 (29.11 %), hysteroscopy in 77 (48.73 %), histopathology in only 8 (5.06 %), smear for acid fast bacilli in 4 (2.53 %), and liquid culture in 24 (15.18 %) patients. The in-house m-PCR was positive in 135 (85.44 %) women. Of these, 129 (95.55 %) samples were positive for Mycobacterium tuberculosis, while 6 (4.44 %) were positive for non-tuberculous mycobacterial DNA. Of the 129 M. tuberculosis PCR-positive women, 112 received anti-tubercular treatment and 23 of these conceived and fell pregnant after the completion of treatment. For the diagnosis of uterine tuberculosis, m-PCR was found to be the most efficient diagnostic tool compared to the other methods.

Successful management of primary nontuberculous mycobacterial infection of hepatic allograft following orthotopic liver transplantation for hepatitis C

Nontuberculous mycobacteria are a rare cause of disease in solid organ and hematopoietic stem cell transplant recipients. The impact of mycobacterial infections in transplant recipients necessitates prompt diagnosis and early initiation of therapy. However, diagnosis remains difficult and there is a lack of specific recommendations for the choice of anti-mycobacterial drugs, duration of therapy, and monitoring of graft function as well as immunosuppression in these patients. Issues involved in the management are illustrated by an index case of hepatic allograft infection due to Mycobacterium avium complex.

Comet assay: a prognostic tool for DNA integrity assessment in infertile men opting for assisted reproduction

BACKGROUND & OBJECTIVES

The growing concern on transmission of genetic diseases in assisted reproduction technique (ART) and the lacunae in the conventional semen analysis to accurately predict the semen quality has led to the need for new techniques to identify the best quality sperm that can be used in assisted procreation techniques. This study analyzes the sperm parameters in the context of DNA damage in cytogenetically normal, AZF non deleted infertile men for DNA damage by comet assay.

METHODS

Seventy infertile men and 40 fertile controls were evaluated for the semen quality by conventional semen parameters and the sperms were also analyzed for DNA integrity by comet assay. The patients were classified into oligozoospermic (O), asthenozoospermic (A), teratozoospermic (T), oligoasthenoteratozoospermic (OAT) categories and infertile men with normal semen profile. The extent of DNA damage was assessed by visual scoring method of comets.

RESULTS

Idiopathic infertile men with normal semen profile (n=18) according to conventional method and patients with history of spontaneous abortions and normal semen profile (n=10) had high degree of DNA damage (29 and 47% respectively) as compared to fertile controls (7%). The O, A, T and OAT categories of patients had a variably higher DNA damage load as compared to fertile controls.

INTERPRETATION & CONCLUSION

The normal range and threshold for DNA damage as a predictor of male fertility potential and technique which could assess the sperm DNA damage are necessary to lower the trauma of couples experiencing recurrent spontaneous abortion or failure in ART.

Antioxidant levels in blood and seminal plasma and their impact on sperm parameters in infertile men

Excess reactive oxygen species (ROS) beyond the scavenging capacity of antioxidants leads to DNA damage and oxidation of lipoprotein components at the cellular and subcellular level. The oxidative stress (OS) adversely affects sperm function by altering membrane fluidity, permeability and impairs sperm functional competence. In the present study, the OS status in seminal plasma and blood serum in infertile men and its relationship with spermatozoa parameters have been investigated. Four groups of infertile men viz., oligozoospermic (n = 15), asthenozoospermic (n = 17), teratozoospermic (n = 19), and oligoasthenoteratozoospermic (n = 9), and healthy fertile controls (n = 40) have been analyzed for superoxide dismutase (SOD), catalase (CAT), glutathione (GSH) and malondialdehyde (MDA) in seminal plasma and blood serum. Significant correlation between blood serum SOD and sperm count has been observed in patients (p = 0.018) and controls (p = 0.021). Similarly, significant correlation between blood serum GSH and sperm progressive motility in patients (p = 0.036) and controls (p = 0.029) is observed. The low seminal MDA is associated with increase in sperm progressive motility in patients (p = 0.039) and controls (p = 0.028). Positive correlation is found between increased seminal MDA levels and abnormal sperm morphology in both patients and controls (r = 0.523, p = 0.029; r = 0.612, p = 0.034 respectively). Correlations between blood SOD and sperm count and between blood GSH levels and progressive motility suggest that these can be important biochemical markers in assaying the sperm count and motility. A negative correlation of motility with seminal MDA indicates that sperm membrane lipid peroxidation affects the fluidity and thus mobility of sperm axoneme. This affects functional competence of the sperm and acts like a biological safeguard. The results of the present study suggest the prospects of using the blood serum and seminal plasma antioxidants as a valuable tool to evaluate the sperm reproductive capacity and functional competence.

DNA integrity and semen quality in men with low seminal antioxidant levels

Accurate transmission of information coded in the sperm genome is vital to the pre- and post-natal development of the offspring. Recent advances in reproductive biology have proposed evaluation of sperm DNA integrity as an important assessment tool to infer the presence of DNA strand breaks, numerical abnormalities in sperm chromosome complement, and alterations in the epigenetic regulation of the paternal genome. Oxidative stress (OS), characterized by increased free radicals, may lead to the production of apurine sites, apyrimidine sites, oxidation of nucleotides of sperm genome. This study was performed to assess the impact of OS on DNA integrity in sperms. 52 infertile men [oligozoospermic-13, asthenozoospermic-15, teratozoospermic-19, oligoasthenoteratozoospermic-5] and 20 fertile controls were investigated for products of lipidperoxides as malondialdehyde; antioxidants such as superoxide dismutase, catalase and glutathione in seminal plasma by biochemical methods. DNA integrity of the sperms was analyzed by visual scoring method in which the comets were graded into 4 categories (A-D) on the basis of their tail length indicative of increasing levels of DNA damage. Significant increase in DNA damage (higher number of sperms in group D) in cases (oligozoospermic (O)-20%, asthenozoospermic (A)-24%, teratozoospermic (T)-28%, OAT-43%) as compared to controls (8%) was found. Increased malondialdehyde levels, abnormal sperm morphology and higher DNA damage were observed in the cases. The antioxidants superoxide dismutase, catalase and glutathione had a positive association with sperm count and motility while a negative association with the percentage of dead sperms and abnormal morphology was observed. This study highlights the influence of low antioxidants on sperm genome integrity and indicates sperm DNA integrity as a better and more reliable prognostic tool for infertility evaluation than simple quantitative and morphologic evaluation of spermatozoa.

Radial artery occlusion, a rare presentation of Behçet's disease

Behçet's disease (BD) is a multi-system inflammatory disorder which presents with recurrent orogenital ulceration, uveitis, and erythema nodosum. Medium vessel vasculitis of upper limb is extremely rare and it is only reported in patients with Behçet's disease on long follow up. Mean duration from diagnosis of disease to development of vasculitis is 5.8 years. We present a patient who presented with gangrene of fingers with absent radial pulse and during course of his illness he developed features of Behçet's disease. Diagnosis was established by clinical features and histopathology and patient was treated with steroids and colchicine.

Osteoporosis in Indians

Osteoporosis is characterized by low bone mass with micro architectural deterioration of bone tissue leading to enhance bone fragility, thus increasing the susceptibility to fracture. Although exact numbers are not available, based on available data and clinical experience, on estimated 25 million Indians may be affected. Osteoporotic fractures in India occur commonly in both sexes, and may occur at a younger age than in the West. Recently published data have clearly demonstrated widespread vitamin D deficiency across India, at all ages and in both sexes, particularly in the urban areas. Poor sunlight exposure, skin pigmentation and a vitamin D-deficient diet are some obvious causes for this finding. Indians have low BMD as compared to the western Caucasians. This could be attributed to differences in skeletal size; however, the high prevalence of vitamin D deficiency is a major factor in the low BMD and poor bone health of Indians. Healthy lifestyle (diet, exercise and sunlight exposure) can have a major positive impact on the bone metabolism and bone health of Indians. These public health measures are recommended for the population at large as they are efficacious, safe and cost-effective. The peak bone mass of the population can be increased significantly by appropriate and timely intervention in children. Pharmacological interventions are expensive and should therefore be targeted to only those at high risk of fractures.

The impact of private-sector provision on equitable utilisation of coronary revascularisation in London

OBJECTIVE

To investigate the impact of including private-sector data on assessments of equity of coronary revascularisation provision using NHS data only.

DESIGN

Analyses of hospital episodes statistics and private-sector data by age, sex and primary care trust (PCT) of residence. For each PCT, the share of London's total population and revascularisations (all admissions, NHS-funded, and privately-funded admissions) were calculated. Gini coefficients were derived to provide an index of inequality across subpopulations, with parametric bootstrapping to estimate confidence intervals.

SETTING

London.

PARTICIPANTS

London residents undergoing coronary revascularisation April 2001-December 2003.

INTERVENTION

Coronary artery bypass graft or angioplasty.

MAIN OUTCOME MEASURES

Directly standardised revascularisation rates, Gini coefficients.

RESULTS

NHS-funded age-standardised revascularisation rates varied from 95.2 to 193.9 per 100,000 and privately funded procedures from 7.6 to 57.6. Although the age distribution did not vary by funding, the proportion of revascularisations among women that were privately funded (11.0%) was lower than among men (17.0%). Privately funded rates were highest in PCTs with the lowest death rates (p = 0.053). NHS-funded admission rates were not related to deprivation nor age-standardised deaths rates from coronary heart disease. Privately funded admission rates were lower in more deprived PCTs. NHS provision was significantly more egalitarian (Gini coefficient 0.12) than the private sector (0.35). Including all procedures was significantly less equal (0.13) than NHS-funded care alone.

CONCLUSION

Private provision exacerbates geographical inequalities. Those responsible for commissioning care for defined populations must have access to consistent data on provision of treatment wherever it takes place.