Primary Infertility Research Articles

P-691 Effect of body mass index on early and late pregnancy loss in women with polycystic ovary syndrome undergoing in vitro fertilization and embryo transfer

Abstract Study question Are early and late pregnancy loss both affected by elevated body mass index (BMI) in women with polycystic ovary syndrome (PCOS) undergoing IVF-ET? Summary answer Late pregnancy loss but not early pregnancy loss was adversely affected by elevated BMI in women with PCOS undergoing IVF-ET. What is known already PCOS, the most common endocrine disorder in women of reproductive age, affects 5–18% of women. Obesity appears to be closely associated with PCOS. High BMI of the women with PCOS has been clearly associated with pregnancy loss. However, available data are limited for distinguishing between early and late pregnancy loss in PCOS women with different BMI and age. We performed a large cohort study of PCOS women conceived after IVF-ET to access the risk of early and late pregnancy loss. Study design, size, duration A retrospective cohort study of 3213 pregnancies after IVF-ET in women with PCOS from January 2015 to October 2022. Participants/materials, setting, methods The participants were the PCOS women with a positive human chorionic gonadotropin (hCG) after IVF-ET treatment in the reproductive centre of an university hospital. We studied early (≤12 weeks and biochemical pregnancy loss included) and late (>12 weeks) pregnancy loss in overweight group (BMI≥24 kg/m2) compared to normal group (BMI<24 kg/m2). Main results and the role of chance From 3213 PCOS women conceived after IVF-ET treatment, 1715 (53.4%) women were in overweight group and 1498 (46.6%) in normal group. Baseline characteristics age, primary infertility, pregnancy loss history, endometrial thickness, numbers and types of embryo transferred were not different between two groups. Overweight women had higher serum basal total testosterone and androstenedione levels. Early pregnancy loss (EPL) occurred in 24.2% (415) of overweight women with PCOS versus 21.6% (323) of those with normal weight (OR 1.16, 95% CI 0.98–1.37, P = 0.08). Rates of ELP were also comparable in both groups stratified by age. Overweight women had higher rates of late pregnancy loss (LPL) (6.6% in overweight group versus 3.3% in normal group, OR 2.11, 95% CI 1.50–3.00, P < 0.001). In subgroup analyses, young and advanced-age women with PCOS both had increased chances of LPL with elevated BMI. Logistic regression showed BMI was an independent risk factor of LPL considering age, androgen level, history of previous pregnancy loss, and infertility type. Limitations, reasons for caution Due to the retrospective study, records about gestation-related disease history and smoking were not complete and not shown. However, all patients with IVF-ET were asked to control gestation-related conditions suitable for pregnancy. Proportion of smoking was low and women who planned to conceive were advised to stop smoking before treatment. Wider implications of the findings This study enables physicians to counsel PCOS women undergoing IVF their risk of pregnancy loss more accurately based on personal characteristics. Trial registration number not applicable

P-093 The effect of antioxidant supplementation on sperm quality in infertile men: a randomized placebo-controlled clinical trial

Abstract Study question Is sperm quality improved in infertile men after administration for three months of a combination of antioxidants as compared to placebo? Summary answer Administration in infertile men for three months of a combination of antioxidants as compared to placebo does not improve sperm quality. What is known already In infertile men, limited evidence exists to support treatment with a combination of antioxidants for improving sperm quality. A recent Cochrane meta-analysis suggested that treatment of these patients with combinations of antioxidants as compared to placebo or no treatment results in an increase in sperm motility (MD + 12.71 95%CI +11.33 to + 14.08, 7 studies, 684 patients), while no beneficial effect was observed on DNA fragmentation index (DFI) and on the probability of live birth. Nevertheless, combinations of antioxidants are widely used in clinical practice at present. Study design, size, duration This randomized placebo-controlled trial evaluated the effect of a combination of antioxidants on sperm motility (primary outcome). Secondary outcomes were sperm concentration, morphology, DFI and levels of reactive oxygen species (ROS). For this purpose, 79 infertile men, were randomized, using a computer-generated randomization list, between 2019-2022, to receive either a combination of antioxidants (n = 40) or placebo (n = 39) for three months. This was a quadruple-blind trial (participants, clinicians, outcome assessors, data analyst). Participants/materials, setting, methods Sperm variables were evaluated according to WHO criteria, ROS levels by the detection of 8-hydroxy-2-deoxy-guanosine peroxidation product on sperm and DFI by flow cytometry. For all outcomes, the changes between treatment initiation and completion were assessed in both the antioxidant and the placebo groups and compared statistically. Values are expressed as mean (95%CI of the mean) and statistical significance was set at p = 0.05. Main results and the role of chance Nine patients dropped out from the study, since they did not perform the second sperm analysis for personal reasons and thus did not complete the study process. No differences were observed between the antioxidants and the placebo group regarding male age {mean difference (MD) -1.3 years, 95%CI -1.4 to + 4.1}, smoking (antioxidants: 41.6%, 95%CI 25.5 to 59.2 vs placebo: 43.5%, 95%CI 27.8 to 60.3), exercise (antioxidants: 45.4%, 95%CI 28.1 to 63.6 vs placebo: 16.1%, 95%CI 5.4 to 33.7) and primary infertility (antioxidants: 82.3%, 95%CI 65.4 to 93.2 vs placebo: 85.7%, 95%CI 69.7 to 95.1). No statistically significant differences were observed in infertile men who received a combination of antioxidants or placebo, between the changes of pre and post treatment values, regarding sperm motility (-3.5%, 95%CI: -13 to + 5.9, p = 0.742), concentration (-1.9%, 95%CI: -15.7 to + 11.8, p = 0.0.77), morphology (-0.10%, 95%CI: -0.8 to 0.6, p = 0.793), DFI (0.2%, 95%CI: -3.8 to + 4.4, p = 0.891) and levels of ROS (-1.2%, 95%CI: -3.2 to + 0.8, p = 0.231). No side effects were reported in antioxidants combination treated patients for the duration of follow-up. Limitations, reasons for caution The current RCT did not explicitly include men with abnormal DFI, limiting the extrapolation of the results obtained in this group of patients. Moreover, it was not designed to evaluate the probability of pregnancy either spontaneously or after Medically Assisted Reproduction (MAR). Wider implications of the findings The current study does not support the use of antioxidants for enhancing male infertility. Future relevant studies should focus on identifying the optimal population and duration of treatment. Trial registration number NCT04256278

P-737 Congenital tubal anomalies: exploring its relationship with tubal factor infertility: observational-descriptive study

Abstract Study question Is there any relation between congenital Fallopian tube anomalies and tubal factor infertility in subset of infertile women? Summary answer Nearly 15% of women who underwent diagnostic laparoscopy revealed congential tubal anomaly (15%), including total or partial agenesis of tubes. What is known already The fallopian tubes play a crucial role in the reproductive process. These structures are 10-12 cm in length, consists of four parts from proximal to distal side: intramural, isthmic, ampullary and fimbrial [1]. Any abnormalities in their development or structure can severely affect fertility. Fallopian tube agenesis, whether partial or complete, constitutes one such anomaly. While there have been numerous advances in the understanding and management of fallopian tube disorders, partial or complete fallopian tube agenesis remains an enigmatic entity with unknown prevalance in the general population. Study design, size, duration Observational study was conducted between 2020 and 2023. All couples with primary infertility were evaluated in an outpatient clinic using basic hormone analysis, semen analysis, sonography and hysterosalpingogram as a standard of care. All women with suspected tubal pathology were offered to have diagnostic laparoscopy (LS) in order to confirm the anomaly. When tubal and/or Mullerian anomalies were detected, urinary system was examined by intravenous pyelography. Other suspected pathologies were examined by abdominopelvic CT x-ray. Participants/materials, setting, methods All women with suspected tubal pathology were offered to have diagnostic laparoscopy in order to confirm the anomaly. Surgeries was performed by two experienced surgeons, after having informed consent. When tubal and/or Mullerian anomalies were detected, urinary system was examined by intravenous pyelography. Other suspected pathologies were examined by abdominopelvic CT x-ray imaging. All anomalies have been reported in an electronic database. Main results and the role of chance A total of 4230 infertile couples were admitted to clinics. Mean age of women in the study population is 30±2.3 years. Overall duration of infertility is 1.2±0.6 years. Among them, 895 women were diagnosed to have suspected tubal pathology after HSG examination (21%). Diagnostic LS was performed to 220 women. Flowchart of the patients is given in figure-1. Among them, 113 (51,3%) women revealed tubal pathologies/anomalies and 107 (49,7%) revealed normal findings. Total of 34 women revealed congenital proximal and/or distal tubal anomaly. Half of these cases (17/34) were complete agenesis and remaning were either with proximal or mid-distal portion agenesis. Majority of women 32/34 (94 %) with tubal pathology revealed at least 1 uterine anomaly as well. Among them, 19 (55.9 %) of these patients was confirmed to have unicornuate uterus, 6 (17.6 %) had uterus didelphys, 4 (11.8 %) had bicornuate uterus, and 3 (8.8%) had uterine septum. No uterine anomaly was observed in 2 (5.9 %) patients. Total of 16 women (14%) were diagnosed to have other system anomalies. Limitations, reasons for caution Lack of a control group in normal population in order to compare incidences. Secondly, our sample size is not enough to precisely conclude on exact prevalances. Third, we did not report fertility data following LS. Wider implications of the findings Tubal factor infertility is one of the major etiologic factor among primary infertility cases and congenital tubal anomalies were reported to be relatively higher (15%) in these younger women contrary to general expectations. Second important finding is high congenital uterine anomaly incidence in women with congenital tubal anomalies. Trial registration number not applicable

P-467 Fertility preparedness and influencing factors in women undergoing fertility treatment: Turkish sample

Abstract Study question What is the level of fertility preparedness among women undergoing fertility treatment and what factors influence this preparedness? Summary answer The readiness of the participants to undergo fertility treatment was found to be high. Factors that increase and decrease women’s prepareadiness were also identified. What is known already It is a common problem in practice to stop and not continue infertility treatment, which has a long physical, emotional and financial burden. Although there are many reasons for this, it has been found that couples move from one treatment process to another without feeling ready. In addition to the stress of infertility and treatment, couples drop out of treatment due to low readiness. Therefore, measuring the readiness of couples prior to fertility treatment and determining the factors that influence readiness may be effective in the continuation and success of treatment. Study design, size, duration It was a descriptive and cross-sectional study conducted on 375 Turkish-speaking women in a virtual environment using the Google survey technique. Infertile women who received treatment in fertility clinics of any hospital or private IVF centers worldwide and spoke Turkish constituted the population of the research. The data were collected between February 2021 and January 2022. Participants/materials, setting, methods A total of 375 women with primary infertility who agreed to be part of the study were included. Data were collected by ‘Descriptive Information Form’, ‘Fertility History Form’ and ‘Fertility Preparedness Scale for Women Receiving Fertility Support’ measurement tools. The cut-off value of the Fertility Preparedness Scale (FPS) is 56 points (min 23 - max 115) and a score of less than 56 points indicates that the participant was not sufficiently prepared for fertility treatment. Main results and the role of chance In the present study, the mean score was X¯ = 83.01 (min 39-max115). Most of the participants (94.67%) were above the cut-off value. This showed us that 94.67% of the women had a high level of prepareadiness. Factors such as advancing age, prolongation of infertility, increase in number of treatments, female factor of infertility were negative factors related to fertility preparedness. Besides increased education level, increased income, secondary infertility, feel less pressure from their families and being able to share with the social circle about the treatment were positive factors that increased the woman’s prepareadiness for treatment.According to the results fertility prepareadiness it has a very important place in starting and continuing fertility treatment. There are many factors that influence fertility prepareadiness. If a woman/couple starts well prepared in this expensive and stressful treatment process, financial loss can be prevented, treatment success can be improved and treatment discontinuation can be reduced. Limitations, reasons for caution The fact that the study was conducted online and the possibility of participation of people at different stages of treatment (beginning, while waiting for a pregnancy test, etc.) may have affected the fertility prepareadiness results. Wider implications of the findings There is a need for an experimental randomized controlled trial with objective assessment of fertility prepareadiness. It would also be useful for health professionals to measure the prepareadiness of women/couples through pre-treatment assessment in clinics. Assessment of prepareadiness and identification of influencing factors is important to provide appropriate support. Trial registration number non-clinical trials

P-571 Mutations in FOXO3 mutation cause human premature ovarian insufficiency

Abstract Study question Do variants in front fork transcription factor 3 (FOXO3) account for premature ovarian insufficiency (POI) in humans? Is there is a potential treatment for POI caused by FOXO3 mutations? Summary answer Heterozygous variants in FOXO3 cause human female infertility owing to POI by inducing oocyte apoptosis. What is known already Front fork transcription factor 3 (FOXO3) is a member of the forkhead box family of transcription factors. Previous study had reported that FOXO3 encodes an evolutionarily conserved primary regulator and an effective inhibitor of primordial follicle activation. The null mutants of Foxo3 or its ortholog in multiple organisms displayed POI owing to deficiencies in maintaining the ovarian reserve. However, whether FOXO3 variants can underline POI phenotype in humans were unclear, and the causal relationship has not yet been established with functional evidence. Study design, size, duration 107 primary infertility families with POI were recruited for pathogenic variants screening. The proband with and her parents were verified for FOXO3 variants. Participants/materials, setting, methods All the patients were diagnosed with POI were confirmed by clinical analyses. Exome sequencing and subsequent bioinformatic analyses were performed to screen for candidate pathogenic variants. The pathogenicity of identified variants was assessed and studied in vivo in mice carrying the equivalent mutations. Main results and the role of chance Novel heterozygous variant in FOXO3 was identified in the patient with POI. Mice modeling the Foxo3 variant identified in patients recapitulated the ovarian reserve defects of patients, confirming the pathogenicity of the identified variants. The mutation caused constitutive activation of FOXO3 lead to POI by inducing oocyte apoptosis, which will facilitate the genetic diagnosis of POI in patients and provide a potential therapeutic target for female fertility. Limitations, reasons for caution A limitation of the current study is the small sample size. More primary infertility patients with POI should be screened to enrich the pathogenetic mutations of FOXO3. Wider implications of the findings FOXO3 was detected as a novel gene underlie human POI, thus providing new targets for the molecular diagnosis and treatment. Trial registration number the National Natural Science Foundation of China (NSFC) (Grant number:82302083)

A family case of male infertility with total asthenozoospermia caused by structural abnormalities in the axoneme of the sperm flagellum

The article describes a family case of primary male infertility caused by primary ciliary dyskinesia (PCD). According to the data of electron microscopy of spermatozoa, two siblings with total asthenotheratozoospermia have a total absence of external and internal dynein axoneme handles in the flagella of spermatozoa, indicating the presence of PCD. Both patients had a history of repeated failures of IVF/ICSI programs. The patients did not have situs viscerum inversus and signs of damage to the respiratory system. The other two brothers were healthy and fertile, and both have two children. Non-severe asthenozoospermia was revealed in one of fertile brothers (who is in a consanguineous marriage), and situs viscerum inversus was mentioned in his son. Whole-exome sequencing revealed a pathogenic variant of the c.461A>C in exon 4 of the CCDC103 gene in a homo/hemizygous state in both siblings with PCD, in their fertile brother – in a heterozygous state. The use of transmission electron microscopy of spermatozoa with exome sequencing made it possible to identify the cause of total asthenotheratozoospermia and diagnose the genetic form of male infertility associated with an ultrastructure anomaly of the axoneme.

P-744 A new hysteroscopic-assisted mock embryo transfer (HAMET) to predict success in ART cycles

Abstract Study question Could HAMET increase pregnancy rates in predicted and unexpected difficult transfer patients? Summary answer Data of this study show a strong correlation between HAMET and pregnancy rates. What is known already Mock embryo transfer is regularly performed to adequately plan the correct strategy for positioning embryos inside the uterus of patients predicted to have difficult access to uterine cavity procedure. Study design, size, duration This is a single-center, observational, retrospective study conducted at S.I.S.Me.R. center in Bologna, Italy. 1184 consecutive diagnostic hysteroscopies were performed for patients suffering for primary or secondary infertility before ART. All patients from 18 to 49 years old underwent a mock embryo transfer performed with 10 to 15 μl of methylene blue dye. Diagnostic hysteroscopy was performed immediately after mock embryo transfer to assess if the dye has entered the uterine cavity. Participants/materials, setting, methods Out of the 1184 patients who underwent hysteroscopy, in 617 patients 1118 transfers were executed after IVF-ICSI cycles. Patients were subdivided in: group A where whole cavity including fundus was filled by blue; group B where cavity but not fundus was filled by methylene blue; group C patients with partial captation or with no captation at all of dye. The difficulty of mock embryo-transfer (scale 1 to 3) was also recorded by the physician. Main results and the role of chance the results of 1118 transfers are summarized in the table below. While patients with whole cavity plus fundal captation (group A) had the highest implantantion rate (IR) compared to group B and C, reflecting the same difference in the clinical pregnancy rate (CPR), the live birth rate (LBR) was statistically superior only for group A when compared to group B. Limitations, reasons for caution Main limitation of these findings is the absence of control group. Wider implications of the findings HAMET is able to predict which patients have the higher chances to achieve a pregnancy and, even more important, a term pregnancy. The use of HAMET it is also useful to assess the capability of physicians to enter the uterine cavity when the cervical canal route is not regular. Trial registration number not applicable

P-465 Rehabilitation services and the infertility journey: a study on women’s experiences in Ethiopia

Abstract Study question How does infertility affect women in Ethiopia, and can rehabilitation service providers mitigate its impact? Summary answer Introducing rehabilitation services for women with infertility in Ethiopia could mitigate the frequent adverse psychosocial consequences and maintain women’s integration into family and community structures. What is known already Infertility is a disease that generates a disability as an impairment of function. Globally, millions of people are affected, and women bear the brunt of its consequences. In Ethiopia, infertility can cause significant distress and burden for women who are unable to meet societal expectations of motherhood. Despite this impact, no previous research has been conducted in Ethiopia to explore the role of rehabilitation services in providing support for these women. Study design, size, duration We followed a sequential mixed methods design that consisted of three parts: The national prevalence of infertility in Ethiopia was first determined using data from the 2016 Ethiopian Demographic and Health Survey (DHS); using Interpretive Phenomenology, the lived experiences of Ethiopian women living with infertility was explored; and finally, an Interpretive Description approach was applied to evaluate the role of rehabilitation services in assisting women with infertility. Data were collected between 2022 and 2023. Participants/materials, setting, methods For the first part, we performed secondary data analysis from 15,683 women in Ethiopia through the 2016 Ethiopian DHS. The data were analyzed using two approaches to infertility – the demographic and current duration. In the second part, 13 women undergoing treatment at a fertility center were interviewed. In the third part, 14 rehabilitation, medical, and policy service providers were purposefully selected from diverse institutions across three different geographical locations in Ethiopia. Main results and the role of chance Using the demographic definition, the overall prevalence of infertility was 7.6% (95% CI 6.6-8.8), with a prevalence of primary and secondary infertility of 1.4% (95% CI 1.0-1.9) and 8.7% (95% CI 7.5-10.1), respectively. The current duration approach resulted in a prevalence of overall infertility of 24.1% (95% CI 18.8-34.0) at 12-months, 13.4% (95% CI 10.1-18.6) at 24-months, and 8.8% (95% CI 6.5- 12.3) at 36-months. Thus, the demographic definition resulted in a lower estimate compared to the current duration approach which could be more appropriate for the early detection and management of infertility in Ethiopia. According to participants, infertility had far-reaching consequences that substantially affected women’s psychological, socio-cultural, and spiritual lives. Despite this, women developed various coping mechanisms and resilience. Women had minimal access to psychosocial and financial support and no access to rehabilitation services. Finally, interviewees recognized the potential of rehabilitation services to maximize the day-to-day functioning and overall well-being of women with infertility. Limitations, reasons for caution Using demographic proxies to determine exposure to pregnancy can make estimation unreliable. The fertility center only treated married couples; hence, single, separated, or divorced women were not included. Results are context-specific and cannot be extrapolated to all infertility cases in Ethiopia or elsewhere. Wider implications of the findings This is the first study to explore infertility in Ethiopia from a rehabilitation perspective. Based on the prevalence and impact, infertility in Ethiopia represents a major public health issue. Strengthening policies, integrating rehabilitation services into fertility care, and recognizing infertility as a disabling condition are crucial steps toward addressing infertility. Trial registration number not applicable

P-598 Novel inactivating homozygous mutation of the luteinizing hormone/choriogonadotropin receptor (LHCGR) and first live birth after in vitro maturation (IVM): a breakthrough

Abstract Study question How can pregnancy and live birth be achieved in patients with inactivating homozygous luteinizing hormone/choriogonadotropin receptor (LHCGR) mutation? Summary answer We report the first live birth after IVM in a patient with a novel homozygous inactivating LHCGR mutation (exon 6,c.470A>G). What is known already LH plays a fundamental role in female reproductive physiology and is responsible for steroidogenesis, oocyte maturation, ovulation and subsequent progesterone production by the corpus luteum. LH binds to the LHCGR located on the membrane of theca cells and mature granulosa cells. Inactivating mutations of the LHCG receptor lead to the impossibility to obtain final oocyte maturation both during natural cycles and after ovarian stimulation for in vitro fertilization purpose. Until now, egg donation represented the only option to treat their infertility. Study design, size, duration A case report. Participants/materials, setting, methods A 35 year-old nulliparous patient was referred to our university hospital for primary infertility. Main results and the role of chance The 35-year-old nulliparous patient presented with primary spaniomenorrhea but timely and spontaneous onset of secondary sexual characteristics. Serum LH levels were high (ranging from 15 to 30 IU/L) and to a lesser extent so were FSH levels. The ovarian reserve was normal for age, as assessed by serum AMH levels and ultrasound. There was no argument for polycystic ovarian syndrome, 21-hydroxylase deficiency, Cushing’s syndrome or hyperprolactinemia. Two previous attempts of controlled ovarian stimulation with gonadotropins and ovulation trigger with hCG and GnRH-agonist trigger had failed, resulting in low estradiol levels despite correct follicular growth on ultrasound and absence of ovulation after trigger. We identified by genetic analysis a novel homozygous inactivating LHCGR mutation (exon 6, c.470A>G) that had never been described previously. IVM was performed. A total of 7 oocytes were obtained after IVM, resulting in 4 Day 3 embryos. All embryos were frozen. Subsequently, 2 Day 3 embryos were replaced after endometrial preparation by hormone replacement therapy. The patient became pregnant and gave birth to a healthy baby. Two Day 3 embryos remain. Limitations, reasons for caution By definition, a case-report requires further studies to confirm our findings. Wider implications of the findings We describe a novel inactivating LHCGR mutation with subsequent live birth after IVM. As a growing number of gonadotropin receptor mutations are identified, this live birth successfully obtained places IVM as the only reliable option for these patients to conceive with their own eggs. Trial registration number not applicable

P-039 Parthenogenetic chimeras may be the cause of the development of a case of 46, XX/46, XY chimeras complicated by severe oligozoospermia

Abstract Study question How did the 46,XX/46,XY chimeric case of severe oligozoospermia arise? Summary answer DNA analysis suggested the possibility of monogenetic chimerism as a mechanism for the development of this case. What is known already Sex-chromosome discordant chimerism in humans(XX/XY chimerism)is a rare chromosomal abnormality. Although the first case was described in 1962, its incidence is still unknown. The XX/XY chimera manifests variable genital phenotypes. The XX/XY chimera is classified into subtypes; tetragametic chimeras, parthenogenetic chimeras, androgenetic chimeras and sesquizygotic twinning chimeras. Genotyping of XX/XY chimeras is important no only to clarify its developmental mechanism but also for diagnosis and treatment. As a result, patients occasionally present with infertility. We present a case of a parthenogenetic chimera with a karyotype of XX/XY in relation to infertility. Study design, size, duration case research. We researched from July 2023 to December 2023. Participants/materials, setting, methods A 38-year-old man diagnosed with azoospermia by his previous physician presented to our clinic with primary infertility for 1 year and 6 months. At 28 years old, he presented with left testicular inflammation and subsequent atrophy. He has no sexual problems. He has an older sister and a younger sister, both married with children. Main results and the role of chance Physical findings: BH 163 cm, BW 53 kg, BMI 19.95, external genitalia: male. Semen analysis: severe oligozoospermia: mostly immobile sperm with some sperm moving slightly in situ. Morphology (Kurger strict criteria): no abnormal sperm morphology. Left testicular hypoplasia: USG: 12 ml right testis, 1 ml left, no other problems. Abdominal MRI: no abnormalities in the kidney to the bladder. No uterus or ovaries. Prostate and seminal vesicles normal; AMH 3.34ng/ml (0.77-14.5) Testosterone 6.55ng/ml (1.95-7.63), DHEA-S 199 μg/dl(106-464),LH 6.2, FSH 7.5, E2 32.5, PRL 12.43, blood type A, Rh+, RH-Hr:CcDee, HLA-A, B, C, DR: all undetermined, Y chromosome SRY (FISH): SRY signal numbers 0 and 1 were observed. Chromosome analysis (G band): 46, XX[22]/46, XY[8]. SNP microarray chromosome examination: presumptive parthenogenic chimerism Treatment: His wife underwent oocyte pick up and intracytoplasmic sperm injection(ICSI) was performed using his frozen sperm. One blastocyst was frozen, but one frozen-thawed blastocyst transfer during an HRT cycle failed to result in pregnancy. The use of assisted reproductive technology(ART) is currently ongoing. Limitations, reasons for caution DNA analysis of both parents was necessary to determine the cause of the problem, but the patient refused to have her parents tested. Wider implications of the findings By accumulating and studying a large number of cases like this one, it may be possible to correctly treat patients with 46, XX/46, XY chimeric infertility. Trial registration number not applicable

O-126 Blastocyst spent culture medium metabolite levels and reproductive outcomes

Abstract Study question Is there any relationship between blastocyst spent culture medium metabolite levels and reproductive outcomes? Summary answer Metabolomic analysis of 173 metabolites revealed differences in pregnancy, implantation, and live birth rates, highlighting specific metabolites' associations with reproductive outcomes. What is known already Identifying embryos with higher implantation potential poses a significant challenge in assisted reproductive technology (ART). Currently, morphological criteria are utilized for this selection; however, this method does not consistently offer precise predictions of successful implantation. In recent years, there are several hypothesis to employ metabolomic approaches to assess developing embryos and discriminate preferable profiles associated with embryo viability. Metabolomics involves the non-targeted identification and quantification of low molecular weight end-products of metabolism, referred to as metabolites. However, there is limited knowledge regarding the impact of metabolomic profile on implantation rates. Study design, size, duration This prospective case control study enrolled 70 patients who underwent intracytoplasmic sperm injection (ICSI) and single blastocyst transfer. Spent culture mediums (SCM) were collected in fifth day of each embryo. Metabolite levels of SCMs were measured by Liquid Chromatography-Mass Spectrometry. Metabolite levels were compared according to pregnancy, implantation and live birth rates. Participants/materials, setting, methods Normo-responder patients aged between 21 and 39, experiencing primary infertility, whose embryos progressed to the blastocyst stage and underwent single blastocyst transfer. Human Metabolome Database and Compound Discoverer 3.3 was used for the identification of the metabolites. Statistical Package for the Social Sciences (SPSS) software were used for statistical analysis. p<.05 was considered statistically significant. Main results and the role of chance The baseline parameters between groups were not significantly different between pregnant and non-pregnant patient groups. A total of 173 metabolites were analysed. When the metabolomics compared according to pregnancy results(68.5%), 1-(4-Methoxyphenyl)-3-pentanone, morpholine propane sulfanoic acid, naproxen were found higher in pregnant group while 4-indolecarbaldehyde, eicosapentaenoic acid, hepes were significantly higher in non-pregnant group (p<.05). According to the implantation (65.7%) rates, 1-(4-Methoxyphenyl)-3-pentanone was significantly higher in the implantation group. According to the live birth rates (54.2%), 1-(4-Methoxyphenyl)-3-pentanone, 15,16-Dihydroxyoctadecanoic acid, ALA-PRO, HEPES, Naproxen, pyroglutamylglycine, lactamide (p<.05) was higher in the live birth group. 1,2,3,4-Tetrahydro-β-carboline-3-carboxylic acid, diethyl ether and L-Glutamine was higher in non-livebirth group. Limitations, reasons for caution These results can not be generalized to the entire population due to small sample size of our study. More work is needed on the subject. Wider implications of the findings We detected significant differences in some of the metabolites in patients with different reproductive outcomes. The metabolomic analysis of blastocyst spent culture medium can be used as an adjunt method for improving non invasive embryo evaluation in clinical practice after evidence based results. Trial registration number none

P-193 Does the day of laser-assisted hatching affects the clinical outcomes of single vitrified blastocyst transfer cycles? A propensity score–matched study

Abstract Study question What is the impact of different days of laser-assisted hatching on the clinical outcomes of single vitrified blastocyst transfer cycles? Summary answer Clinical pregnancy of single vitrified blastocyst were similar, irrespective of day of laser-assisted hatching. What is known already Assisted hatching aims to create a weakness in the ZP to aid embryo hatching and implantation. Day 5 assisted hatching is typically performed shortly before the embryo transfer while day 3 assisted hatching is performed before blastocyst culture expansion and vitrification. Despite over 25 years of use, there is still no standardized protocol for AH, and published data on its efficacy are controversial and inconclusive. While efforts have been made to study the link between AH techniques and pregnancy outcomes, there is limited consensus for optimizing AH protocols like the day of performance. Study design, size, duration This was a retrospective study based on data collected between January 2022 and October 2023. Propensity score matching (PSM) was performed in a 1:1 matching ratio. 123 patients of day 3 laser assisted hatching group (D3 LAH group) were successfully matched to 123 cycles of day 5 laser assisted hatching group (D5 LAH group). The D5 LAH group was from March 2023 to October 2023, and the D3 LAH from January 2022 to February 2023. Participants/materials, setting, methods Single vitrified day 5 embryo transfer, embryos survived after warming, and patient agreed to receive LAH were include in this study. We excluded donation cycles, missing data, severe female factors. Primary outcome is clinical pregnancy. Comparisons between groups were performed with chi-square test, Fisher’s exact test, Mann–Whitney U test, and Student’s t-test where appropriate, with a P value <0.05 considered statistically significant. A multivariable analysis in the GEE model was adjusted for the confounding factors. Main results and the role of chance After propensity score matching, there was no significant difference in patient characteristics between the groups, creating similar cohorts. For example, the frequency of primary infertility was significantly different between groups initially (61% vs 46.7% in D5 LAH vs D3 LAH respectively, P = 0.004). Following propensity score matching the rate of primary infertility was similar in both groups (with SMD=0.08). Standardized mean difference (SMD) < 0.1 suggests adequate variable balance after propensity matching. Clinical pregnancy rate were similar between two groups: 66/123 (53.7%) D3 LAH cycles and 75/123 (61%) D5 LAH cycles. When generalized estimating equation were performed: only TE grade, but not the day of laser assisted hatching, was noted to be an independent predictor of clinical pregnancy (OR = 0.068; 95% CI: 0.005-0.977; p = 0.048). Poor TE grade had a weak negative relationship with clinical pregnancy of single blastocyst cycles. Limitations, reasons for caution The main limitation of the study is its retrospective design and small sample size. Wider implications of the findings Clinical outcomes are comparable between day 3 laser assisted hatching and day 5 laser assisted hatching, although clinical pregnancy can be slightly improved with higher TE grade. Trial registration number not applicable

Effect of Body Mass Index (BMI) on In Vitro Fertilization (IVF) Outcomes in Women with Polycystic Ovary Syndrome (PCOS)

Objective: Obesity is known to have negative impaction on reproductive health and ovarian functions. It may alter endocrine axis and quality of oocytes, and indirectly effect the success of in vitro fertilization (IVF). Methods: Medical records of patients with polycystic ovary syndrome (PCOS) who were applied for IVF between 2018 and 2024 were reviewed. Demographics, indications for reproductive treatment, IVF outcome parameters and the factors contributing to morbidity of treatment were recorded. Student’s test with one-way analysis of variance (ANOVA) and Kruskal-Wallis tests were used to compare the variables. P<0.05 was considered statistically significant. Results: 186 patients with PCOS were divided as lean (BMI<25 kg/m2, control), overweight (BMI 25-30 kg/m2) and obese (BMI>30 kg/m2). Mean ages and primary infertility rates were similar (both, p>0.05), but duration of infertility was longer in overweight and obese patients (p<0.05). Although patients with higher BMI required more induction dose for the cycle, number of retrieved oocytes did not change significantly, with achieved chemical and clinical pregnancy (each, p>0.05). Moreover, fertilization rates of transferred oocytes and rates of adverse outcomes during pregnancies were similar in the groups (each, p>0.05). Although overweight and obese patients with PCOS required more gonadotropin induction for IVF cycle (2311 vs 1920 vs 1752 IU, respectively, p<0.05), the numbers of metaphase II and fertilized oocytes were seen to be similar with increasing BMI (each, p>0.05). Conclusion: There is longer infertility duration and a higher requirement for gonadotropins in overweight and obese patients with no effect of BMI on most of IVF parameters such as retrieved oocyte, clinical pregnancy, obstetric complication and delivery rate.

Sperm extraction in nonmosaic Klinefelter syndrome patients: A case series and literature review of sperm extraction in Klinefelter syndrome patients.

Klinefelter syndrome (KF) is a group of chromosomal disorders with at least one extra X chromosome in male individuals that leads to infertility and diminished hair growth in affected males. In this study, we present a case series of 16 nonmosaic KF and an extensive literature review. This is a retrospective study including 16 nonmosaic Klinefelter Syndrome patients that underwent micro-testicular sperm extraction (m-TESE) at our center between January 2016 and December 2022. Frequencies and percentages were used to present categorical variables, whereas continuous variables were presented as the median and interquartile range (IQR). The sperm retrieval rate (SRR) was assessed using a one-sample proportions test with continuity correction. Fisher's exact test was to assess the differences between patients with negative and positive retrieval in terms of the categorical variables. A Wilcoxon rank-sum test was applied to explore the between-group differences in the numerical variables. A literature search was performed for additional publications of discussing m-TESE among KF patients. The median (IQR) age of patients was 40.0 years (34.5-47.0). All of the patients had nonobstructive azoospermia, and the majority of them (93.8%) had primary infertility. The most common histopathological findings were atrophic tubules (57.1%), followed by Sertoli cell-only (28.6%). Sperm retrieval was positive for two patients with a rate of 12.5% (95% confidence interval 2.2 to 39.6). Patients with positive sperm retrieval were significantly younger than their peers with negative retrieval (median = 28.0, IQR = 27.5 to 28.5 vs. median = 41.5, IQR = 35.8 to 47.0, P = 0.031). The successful conception rate was 100% (n = 2) using intracytoplasmic sperm injection with a birth rate of 100% (n = 2). Our observed SRR among nonmosaic KF patients was marginally lower than the reported literature. Younger-age patients were significantly more likely to benefit from the procedure.

Variations in Plasma Glucose, Testosterone, and Tumor Necrosis Factor-alpha in Relationship with Polycystic Ovary Syndrome and Viral Seromarkers in Infertile Women: A Case–Control Observational Study

Study Background: Polycystic ovary syndrome (PCOS) is a common cause of infertility in Nigeria which is associated with insulin resistance. Insulin resistance may be induced by elevated inflammatory cytokines, androgen excess (testosterone), and irregular menstruation or anovulation. Aim and Objective: This work was designed to determine possible variations in plasma glucose, testosterone, and tumor necrosis factor-alpha (TNFα) in relationship with PCOS and viral seromarkers in infertile women. Materials and Methods: Two hundred and fourteen (214) primary infertility women with PCOS aged 37 ± 4.93 years diagnosed through ultrasound were recruited as test subjects while one hundred (100) age-matched primary infertility women without PCOS were recruited as control. All subjects were negative to Giemsa thick blood film staining for the detection of Plasmodium and Ziehl–Neelsen staining for the detection of acid–fast bacilli. HIVp24 antigen and antibody, plasma testosterone, antibody to hepatitis C virus (anti-HCV), and envelope antigen to hepatitis B Virus (HBeAg) were determined in the subjects by enzyme-linked immunosorbent assay while blood glucose was measured spectrophotometrically. Results: The results obtained showed a higher frequency of 0.93% (2) HIVP24antigen-antibody, 6.5% (17) anti-HCV, 14.5% (31) HBeAg, and 0.5% (1) HIVP24 + HBeAg (except for HIVP24 antigen and antibody) in PCOS women than the frequency of viral seromarkers of 1% (1) HIVP24 antigen and antibody, 6% (6) anti-HCV, 8% (8) HBeAg, and 0% (0) HIVP24 + HBeAg in non-PCOS control women. There was a significant association between PCOS and expression of viral seromarkers; there was a significantly higher fasting plasma glucose and testosterone level in all PCOS women with or without viral seromarkers (P < 0.05). There was a significantly higher plasma TNFα in PCOS women that expressed viral seromarkers than in PCOS women who do not express any of the viral seromarkers (P < 0.05). There was a significantly higher plasma TNFα in PCOS and non-PCOS women although more in PCOS women that expressed viral seromarkers than in women without any viral seromarker (P < 0.05). Conclusion: PCOS may be characterized by elevated plasma fasting glucose, testosterone, and expression of viral seromarkers while viral infection could also trigger higher plasma TNFα in PCOS women than in non-PCOS women infected with viral agent.

A misleading case of Müllerian anomaly: fibroid degeneration and growth involving nonfunctional, noncommunicating rudimentary horn

ObjectiveTo report a rare, misleading fibroid degeneration involving a non-functional, non-communicating horn in a woman with a unicornuate uterus. While the presence of a functional rudimentary horn may lead to signs and symptoms that recommend its removal, non-functional cases are rarely reported, and due to their apparent functional inactivity, the need for their removal has never been reported. No previous report showed the possibility of a degenerative process in a non-functional rudimentary horn causing patient discomfort. DesignThis is a step-by-step narrated video showing a unique case of fibroid degeneration and growth of a non-functional, non-communicating rudimentary horn in a unicornuate uterus (ASRM classification 2021) and its surgical management. SettingUniversity Academic Hospital ‘‘A.O.U. delle Marche – Università Politecnica delle Marche” Ancona, Italy. SubjectA 48-year-old Caucasian nulliparous premenopausal woman was referred to our institution because of abdominal pain and an enlarging adnexal mass. Her personal history showed primary infertility with a previous diagnosis of unicornuate uterus. Given the possibility of ectopic ureters in these occurrences, a complete computed tomography scan was performed, and no genitourinary alterations were found. Pre-operative imaging (ultrasound evaluation, computed tomography, and magnetic resonance) provided a provisional diagnosis of a suspicious ovarian fibroma. InterventionsConsidering the patient’s age, lack of desire for pregnancy, and volumetric increase of the adnexal mass, a laparoscopic intervention to perform mass removal and prophylactic bilateral salpingectomy was planned. The patient was counseled about the low risk of an underlying malignant transformation. Therefore, the decision to remove the intact mass via a mini-laparotomy at the end of the surgery was shared.Once the abdominal cavity was entered, the right unicornuate uterus was found in anatomical continuity with the ipsilateral broad ligament, fallopian tube, and ovary. These structures were wholly attached to the right pelvic wall.On the other side, cranially compared to the right hemi-uterus, a roundish myoma-like mass was detected in direct connection with the left broad ligament, fallopian tube, and ovary.In light of a changed intraoperative finding, the amputation of the left rudimentary horn and prophylactic bilateral salpingectomy were performed. Main outcome measuresShowing the fibroid degeneration and growth of a non-functional, non-communicating rudimentary horn in a unicornuate uterus (ASRM classification 2021) treated laparoscopically. ResultsLaparoscopic removal of the uterine horn was successful, and no intra- and postoperative complications occurred. The patient was in good health at the six-month follow-up visit. The histopathological examination confirmed the fibroid degeneration and the absence of endometrium. ConclusionThe lack of symptomatic cases of rudimentary non-functional horns reported in the literature led gynecologists to consider them a silent Mullerian anomaly. This unique case demonstrates that even non-functional rudimentary horns can undergo symptomatic transformation processes requiring surgery. This information may be helpful for more comprehensive counseling of women and for considering the possibility of this occurrence in the diagnostic work-up of misleading Müllerian anomalies. With this in mind, surgical treatment can also be better planned as the technical aspects change compared to what is expected for an adnexal pathology.

Predictive Value of Teratospermia During Initial Sperm Analysis on the Success of Intrauterine Insemination Cycles

ObjectiveTo evaluate the predictive value of sperm morphology, specifically teratospermia, seen during initial semen analysis on the success of intrauterine insemination (IUI) cycles and pregnancy outcomes. MethodsA retrospective cohort analysis on patients undergoing IUI at a large US fertility network. Baseline demographic characteristics, primary infertility diagnoses, and pregnancy outcomes were recorded. A total of 27,925 IUI cycles in 16,169 unique patients were analyzed. IUI cycles were grouped by a sperm morphology of 1% (n=3,799), 2% (n=5,506), 3% (n=4,857), or 4% or greater (n=13,763). The outcome measures were pregnancy rate (positive pregnancy test), clinical pregnancy rate (ultrasound confirmation of a gestational sac with a yolk sac around 5-6 weeks), live birth rate, and miscarriage rate. ResultsSperm morphology is a significant predictor of pregnancy rate (p= <0.001), clinical pregnancy rate (p=0.011), and live birth rate (p=0.026) following IUI. In each of these outcome measures, patients with 1% normal forms had the lowest percentage of success, and patients with 4% or greater normal forms had the most success. Relative outcome percentages, however, were similar in each group. Live birth rates in the 1%, 2%, 3% and > 4% group were 12.3%, 13.1%, 12.7% and 13.9%, respectively. Sperm morphology is not a significant predictor of miscarriage rate per clinical pregnancy post IUI (p=0.054). ConclusionsSperm morphology was a statistically significant predictor of pregnancy, clinical pregnancy, and live birth but not miscarriage rate after an IUI cycle. Higher morphology percentages were associated with increasingly favorable outcomes. However, the small observed differences did not demonstrate clinical significance.

Factors Causing Primary Infertility In Couples Of Reproductive Age: Literature Review

Primary infertility, the inability of couples of reproduvtive age to conceive after 12 months of unprotected sexual intercourse, is a complex health problem with multiple causative factors. This literature review aims to identify and analyze factors associated with primary infertility in couples of reproductive age. The search method was conducted on electronic databases such as PubMed, ScienceDirect, and Google Scholar with the keywords “primary infertility”, “infertility factors”, “reproductive age couples”, and “literature review”. The results of the literature review found that primary infertility can be caused by various factors, both from the man (sperm quality disorders, sexual function, reproductive tract infections, chromosomal abnormalities, varicocele, lifestyle), woman (ovulation disorders, fallopian tubes, endometriosis, uterus, hormonal, lifestyle), and partner (age, lifestyle, environment, stress). These factors can be interrelated and result in primary infertility. It can be concluded that primary infertility is a complex and multifactorial health issue. Understanding these factors is important to help couples achieve pregnancy and improve their quality of life.

CHARACTERISTICS OF FOLLICULAR FLUID MORPHOLOGY AND LEVELS OF MATRIX METALLOPROTEINASE-1 AND ITS INHIBITOR-1 IN PATIENTS WITH POLYCYSTIC OVARIES IN ASSISTED REPRODUCTIVE TECHNOLOGY

Assisted reproductive technologies in patients with polycystic ovary syndrome (PCOS) is an effective way to realize reproductive function with a global pregnancy rate of 25–30 %. The purpose of the study is to establish the correlation between the levels of matrix metalloproteinase-1 (MMP-1) and its inhibitor-1 (TIMP-1) with follicular fluid morphology in PCOS patients undergoing assisted reproductive technology. Materials and Methods. The authors examined 26 PCOS patients aged 24–40. All patients were diagnosed with primary and secondary infertility lasting from 1 to 10 years. A comparative analysis of patients was carried out depending on the presence (n=12) or absence (n=14) of concomitant pathology, a history of endometrial hyperplasia. Clinical, anamnestic, instrumental and laboratory methods were used for analysis. Concentrations of MMP-1 and TIMP-1 in follicular fluid was determined by quantitative solid-phase ELISA. Follicular fluid morphology was studied according to wedge-shaped dehydration method. Statistica 10.0 wasnused for statistical data processing. Results. TIMP-1 level in PCOS patients was 2550±57.8 ng/ml, in PCOS patients with endometrial hyperplasia – 2694.4±87.8 ng/ml (p&lt;0.01). At the same time, the average MMP-1 level was low – 1.5±0.1 ng/ml. In PCOS patients, the 3rd (reactive) type of facies and markers indicating impaired blood supply were detected in the follicular fluid. In PCOS patients with endometrial hyperplasia, the 4th (chaotic) type of facies and markers indicating impaired elasticity, vascular sclerosis, and vasospasm was observed. It was found that the higher the TIMP-1 level, the more markers indicating destructive changes in the vessels of ovarian tissue (r=0.7) and the lower the chances of getting pregnant in assisted reproducrtive technology programs. Conclusions. In PCOS patients over 32 years of age, infertility duration of more than 4 years, having endometrial hyperplasia and surgical interventions in the past medical history (tubectomies for sactohydrosalpinx), TIMP-1 level significantly (p&lt;0.05) increases (≥2694 ng/ml) in the follicular fluid. Moreover, markers indicating destructive changes (vascular sclerosis, vasospasm and endothelial dysfunction) are identified. Thus, the chances of getting pregnant in assisted reproducrtive technology programs become lower.

A novel homozygous LRRC6 mutation causes male infertility with asthenozoospermia and primary ciliary dyskinesia in humans.

Dysfunction of motile cilia, including respiratory cilia and sperm flagella, typically leads to primary ciliary dyskinesia and male infertility or low fertility in humans. Genetic defects of LRRC6 have been associated with primary ciliary dyskinesia and asthenozoospermia due to abnormal ultrastructure of ciliated axonemes. To identify novel mutations of the LRRC6 gene related to multiple morphological abnormalities of the sperm flagella and male infertility and investigate the underlying molecular mechanisms involved. The LRRC6 mutations were identified by whole exome sequencing and confirmed with Sanger sequencing. Papanicolaou staining, scanning, and transmission electron microscopy were performed to investigate the morphological and ultrastructural characteristics of spermatozoa. Further tandem mass tagging proteomics analyses were performed to explore the effect of mutations and confirmed by immunostaining and western blotting. Intracytoplasmic sperm injection was applied for the assisted reproductive therapy of males harboring biallelic LRRC6 mutations. In this study, we identified a novel homozygous LRRC6 mutation in a consanguineous family, characterized by asthenozoospermia and primary ciliary dyskinesia. Further Semen parameter and morphology analysis demonstrate that the novel LRRC6 mutation leads to a significant reduction in sperm flagella length, a decrease in sperm progressive motility parameters, and abnormalities of sperm ultrastructure. Specifically, the absence of outer dynein arms and inner dynein arms, and incomplete mitochondrial sheath in the flagellar mid-piece were observed by transmission electron microscopy. In addition, tandem mass tagging proteomics analysis revealed that spermatozoa obtained from patients harboring the LRRC6 mutation exhibited a significant decrease in the expression levels of proteins related to the assembly and function of dynein axonemal arms. Functional analysis revealed that this novel LRRC6 mutation disrupted the function of the leucine-rich repeat containing 6 protein, which in turn affects the expression of the dynein arm proteins and leucine-rich repeat containing 6-interacting proteins CCDC40, SPAG1, and ZMYND10. Finally, we reported a successful pregnancy through assisted reproductive technology with intracytoplasmic sperm injection in the female partner of the proband. This study highlights the identification of a novel homozygous LRRC6 mutation in a consanguineous family and its impact on sperm progressive motility, morphology, and sperm kinetics parameters, which could facilitate the genetic diagnosis of asthenozoospermia and offer valuable perspectives for future genetic counseling endeavors.