Ashraf Moini

Background: Polycystic ovary syndrome (PCOS) is a prevalent endocrine disorder with variable clinical presentations, posing diagnostic challenges. Methods: This article presents a narrative review of the pertinent literature regarding the ultrasound parameters for the diagnosis and prediction of reproductive-metabolic dysfunctions in PCOS. A comprehensive search was conducted in PubMed and Embase databases for articles published in English from inception until 2025 using keywords and phrases including ‘polycystic ovary syndrome,’ ‘ultrasound,’ ‘ovarian volume,’ ‘antral follicle count,’ ‘follicle distribution pattern,’ ‘ovarian stroma,’ and ‘Doppler indices.’ Inclusion criteria comprised studies addressing diagnostic ultrasound markers for PCOS and their association with reproductive and metabolic outcomes. Results: A review of the existing studies in this area showed that follicle number per ovary (FNPO) remains a core diagnostic marker for PCOS. The Rotterdam criteria define PCOM as ≥ 12 antral follicles per ovary; however, updated guidelines recommend thresholds of ≥ 20–25 to accommodate higher-resolution imaging. FNPO correlates strongly with hyperandrogenism and metabolic disturbances but requires consideration of ultrasound technology and operator proficiency for interpretation. Ovarian volume (OV) > 10 mL has been classically used, though ethnicity- and age-specific cutoffs have been proposed. OV correlates variably with reproductive and metabolic features. Follicle Distribution Pattern (FDP): Two main patterns—peripheral cystic pattern (or “string of pearls”) and general cystic pattern —reflect differences in follicle arrangement that are linked to endocrine profiles. FDP is not yet formally included in diagnostic criteria due to heterogeneity in associations and classification. Ovarian stromal area/ovarian area (SAOA) ratio: a higher SAOA ratio (> 0.32) suggests increased stroma proportion seen in PCOS and is associated with androgen excess. Doppler Indices (RI and PI) reveal changes in vascular resistance and pulsatility in ovarian and uterine arteries in PCOS. Lower RI and PI values typically indicate increased stromal vascularization, aiding diagnosis, though not yet routine clinically. Conclusion: Future research should prioritize prospective, multiethnic studies to establish age- and race-specific diagnostic and predictive thresholds. It is suggested that in future studies, the power of various sonographic markers for detecting and predicting metabolic disorders associated with PCOS be evaluated using artificial intelligence-equipped devices.

Background Isthmocele is a defect at the site of the cesarean section scar and is increasingly being recognized as a common complication following cesarean delivery. It may cause abnormal uterine bleeding, pelvic pain, and fertility issues. This study aimed to identify risk factors associated with isthmocele formation after the first cesarean section. Methods This prospective cohort study included 262 women aged 14–50 years who underwent their primary cesarean section at Arash Women’s Hospital from 2021 to 2024. Previous cesarean deliveries, the history of myomectomy, repeated uterine curettage, and age outside the 14–50 years were exclusion criteria. Demographic, obstetric, surgical, and postoperative data were collected. A transvaginal ultrasound was used for the detection of an isthmocele. Univariate and multivariate logistic regression analyses were performed to identify associated factors with isthmocele formation. Results Isthmocele was detected in 19% (n = 50) of patients. Women with isthmocele had higher gestational age at delivery (39.2 ± 0.9 vs. 38.5 ± 1.7 weeks; p = 0.04), shorter delivery intervals (4.6 ± 1.3 vs. 5.2 ± 0.9 years; p = 0.01), more frequent retroverted uterus (28% vs. 11.3%; p = 0.003) and locking suture repair (20% vs. 7.1%; p = 0.005). In multivariable analysis, gestational age (OR = 1.71, 95% CI 1.19, 2.45) and retroverted uterus (OR = 2.82, 95% CI 1.25, 6.35) increased the odds of isthmocele, while longer inter-delivery intervals were protective (OR = 0.65, 95% CI 0.44, 0.97). Conclusions Isthmocele is a frequent complication after primary cesarean section. Modifiable factors, such as the timing of delivery, management of infection, inter-pregnancy interval, and surgical technique, should be considered in reducing the risk.

Background: An artificial ovary has emerged as a novel alternative approach to prevent the reintroduction of cancerous cells after ovarian tissue autotransplantation. This study evaluates the ability of decellularized Wharton’s jelly (dWJ) to facilitate human ovarian follicle growth in a xenotransplantation model. Materials and Methods: Two transplanted groups were established; one consisted of a decellularized Wharton’s jelly/alginate (dWJ/Alg) composite, and an alginate (Alg) group was used as the control group. Each artificial ovary received approximately 20 partially isolated viable human ovarian follicles, subsequently undergoing xenotransplantation into ovariectomized, non-immunodeficient NMRI mice. Grafts were extracted at 1, 2, 4, or 5 weeks for comprehensive histological and immunohistochemical evaluations. Additionally, mouse blood serum was collected for hormonal analysis. Results: H&E staining confirmed granulosa cell proliferation and follicle growth in dWJ/Alg after 1 week of grafting. While human ovarian-like structures and cell proliferation were visible in other grafts, follicles were not observed. Conversely, immunohistochemical staining for Vimentin, Ki67, and CD45 confirmed the presence of human cells, proliferative cells, and inflammatory cells, respectively. However, hormonal assays revealed no significant difference in estrogen or progesterone levels between the experimental groups. Conclusions: It seems that Wharton’s jelly/alginate hydrogel can be used as an artificial niche for simulating the ovarian environment, effectively supporting the growth of xenotransplants of isolated human follicles.

This study compared the effectiveness of cabergoline and hydroxychloroquine in preventing ovarian hyperstimulation syndrome (OHSS) in patients with polycystic ovary syndrome (PCOS) undergoing controlled ovarian stimulation. This double-blind, parallel, and randomized clinical trial was performed from April to June 2024. Forty-two patients with PCOS who were candidates for assisted reproductive techniques were randomized into two groups. The first group received 0.5 mg of cabergoline, and the second group received 400 mg of hydroxychloroquine for 8 days. Then, ultrasounds were conducted on days 3 and 5 after oocyte retrieval to assess for OHSS. Three and five days after oocyte retrieval, laboratory findings, and clinical outcomes were similar between the cabergoline and hydroxychloroquine groups. Key laboratory parameters, including hemoglobin, hematocrit, sodium, potassium, blood urea nitrogen, and creatinine, did not show significant differences between the groups. On day three, OHSS incidence didn’t have a significant difference between the hydroxychloroquine and cabergoline groups, both for the mild (31.58% vs. 42.86%) and moderate (15.79% vs. 9.52%) groups. Mild cases were observed in one of the patients in both groups 5 days after pickup (p = 0.942). No patients in the cabergoline group required hospitalization or treatment, compared to one in the hydroxychloroquine group (p = 0.127). The incidence of OHSS was similar between cabergoline and hydroxychloroquine, with no significant differences observed in laboratory parameters or clinical outcomes after oocyte retrieval. However, given the study’s sample size, further research is needed before these findings can be generalized to a larger population. http://www.irct.ir ; Registration number: IRCT20240305061171N1; Registration date: 2024 June 29.

Endometriosis is a common gynecological disease that occurs in between 6 and 10% of women who are at reproductive maturity. The presence of endometrial tissue outside the uterine cavity is the defining characteristic of this disease. Although the etiology of endometriosis remains controversial, there is a general consensus that multiple biological processes such as angiogenesis and vasculogenesis, oxidative stress, and inflammation contribute to its complex pathophysiology. Patients' expectations and priorities influence the treatment plan that is selected. For instance, therapy with hormone medications is inappropriate for endometriosis patients who wish to become pregnant since these medications interfere with ovulation. On the other hand, considering that the current endometriosis treatments are associated with recurrence of pain and disease despite the treatment of the disease and have many side effects, the design and application of non-hormonal drugs in this field is very necessary. Therefore, in this article, we tried to have an overview on non-hormonal treatments by considering angiogenesis, oxidative stress, and inflammation as important biological processes involved in endometriosis.

Objective: The purpose of this study was to evaluate the impact of preimplantation genetic testing for aneuploidy (PGT-A) on clinical outcomes among high-risk patients.Methods: This retrospective study involved 1,368 patients and the same number of cycles, including 520 cycles with PGT-A and 848 cycles without PGT-A. The study participants comprised women of advanced maternal age (AMA) and those affected by recurrent implantation failure (RIF), recurrent pregnancy loss (RPL), or severe male factor infertility (SMF).Results: PGT-A was associated with significant improvements in the implantation rate (IR) and the ongoing pregnancy rate/live birth rate (OPR/LBR) per embryo transfer cycle in the AMA (39.3% vs. 16.2% [p<0.001] and 42.0% vs. 21.8% [p<0.001], respectively), RIF (41.7% vs. 22.0% [p<0.001] and 47.0% vs. 28.6% [p<0.001], respectively), and RPL (45.6% vs. 19.5% [p<0.001] and 49.1% vs. 24.2% [p<0.001], respectively) groups, as well as the IR in the SMF group (43.3% vs. 26.5%, p=0.011). Additionally, PGT-A was associated with lower overall incidence rates of pregnancy loss in the AMA (16.7% vs. 34.3%, p=0.001) and RPL (16.7% vs. 50.0%, p<0.001) groups. However, the OPR/LBR per total cycle across all PGT-A groups did not significantly exceed that for the control groups.Conclusion: PGT-A demonstrated beneficial effects in high-risk patients. However, our findings indicate that these benefits are more pronounced in carefully selected candidates than in the entire high-risk patient population.

Objectives: The effect of cabergoline on reducing the incidence rate of ovarian hyperstimulation syndrome (OHSS) has been confirmed by several studies. Currently, what is discussed in this regard is when cabergoline should be started to be most effective in reducing the occurrence and developing rates of OHSS. Materials and Methods: A clinical trial conducted at Arash Women’s Hospital from March to November 2023 included 200 infertile women with polycystic ovary syndrome (PCOS) at risk of OHSS during in-vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment. Participants were divided into two groups: the experimental group received cabergoline from the start of GnRH antagonist administration for 15 days, and the control group received cabergoline for eight days after oocyte trigger. Measurements of hematocrit (Hct) percentage, serum creatinine (Cr), sodium (Na), and potassium (K) levels, and abdominal circumference were taken three days after ovum pick-up. The study monitored patients until menstruation and focused on the occurrence and severity of OHSS as primary outcomes. Results: The data analysis showed that the two groups were comparable regarding basic characteristics. In the following, the OHSS rate in the early administration group was significantly lower than the control group (14% vs. 47%, P<0.001). In the study group, the severity of all OHSS cases was mild, while the control group reported a moderate severity of OHSS (P<0.001). Conclusions: Earlier initiation of cabergoline from the time of administration of the GnRH antagonist compared to its initiation from the day of oocyte triggering has more effectively reduced the rate and severity of OHSS and improved patient satisfaction. Trial Registration: The study was registered in the Iranian Registry of Clinical Trials on 2023-05-30 (identifier: IRCT20090526001952N16, https://www.irct.ir) during the recruitment phase.

To compare the ovarian reserve and the results of infertility treatment, as well as to investigate the relapse rate in the first year after the assisted reproductive technology (ART) cycle in patients with multiple sclerosis (MS) referred to Royan Institute. This retrospective study was carried out to evaluate all women diagnosed with MS and referred to Royan Institute for assessment and treatment of possible infertility between 2011 and 2022. The control group consisted of randomly selected healthy women with tubal factor infertility who were referred for treatment during the same time period and matched in terms of age. A comparison was made between groups in terms of ovarian reserve and infertility treatment outcomes. Additionally, patients with MS who met the criteria were monitored via telephone to evaluate the symptoms, disability and relapse rate both pre- and post-ART. Over the course of a decade, the database documented a total of 60 cases diagnosed with MS. Upon examination of the records, it was found that in 27 patients only admission was done without any hormonal assessment or infertility treatment cycle and 5 patients proceeded with the intrauterine insemination cycle. Eventually, 28 women with MS underwent the ART cycle and all of them were treated with interferon beta, glatiramer acetate, or some oral disease modifying therapies. No statistically significant difference in terms of the basal levels of luteinizing hormone, follicle-stimulating hormone and anti-Müllerian hormone was found between the MS and control groups (P > 0.05). Two groups were comparable in terms of menstrual status. The study revealed that both groups exhibited similarities in terms of the controlled ovarian stimulation protocol and duration, the dosage of gonadotropin administered, as well as the ovarian response type, clinical pregnancy rate, and live birth rate (P > 0.05). After follow up, only 2 patients (9.5%) reported relapse of symptoms within one year after ART. The ovarian reserve and ovarian stimulation cycle and pregnancy outcomes following the ART cycle in MS patients were similar to the age-matched control group. The relapse rate of multiple sclerosis did not show a significant increase within a year following the ART cycle.

Background: Breast cancer (BC) treatment decreases fertility capacity, but unnecessary fertility preservation procedures in women who would not be infertile after treatment would be a waste of time and resources and could cause the unwarranted exposure of cancer cells to exogenous sex hormones. It has been largely shown that post-treatment ovarian reserve is directly associated with pre-treatment anti-mullerian hormone levels (AMH0). A threshold for AMH0, or a model including AMH0 and patient characteristics that could distinguish the patients who will be infertile after treatments, still needs to be defined. Accordingly, this study was performed to specifically target this high-priority concern. Methods: Women≤45 years old with newly diagnosed non-metastatic BC were entered in this multicenter prospective cohort study. AMH0 and two-year post-treatment AMH (AMH2) were measured, and hormonal patient features were recorded as well. Receiver operating characteristic (ROC) curve analysis, decision tree (DT), and random forest analyses were performed to find a cut-off point for AMH0 and define a model involving related features for the prediction of AMH2. Results: The data from 84 patients were analyzed. ROC curve analysis revealed that AMH0>3 ng/mL (Area under the curve=0.69, 95% CI: 0.54‒0.84) was the best indicator for predicting AMH2≥0.7 (sensitivity=79%, specificity=60%). The best model detected by DT and random forest for predicting an AMH2>0.7 with a probability of 93% consisted of a combination of AMH0>3.3, menarche age<14, and age<31. Conclusion: This combination model can be used to withhold fertility preservation procedures in BC patients. Performing larger studies is suggested to further test this model.

Background: The effect of laparoscopic ovarian drilling (LOD) before in vitro fertilization/ intracytoplasmic sperm injection (IVF/ICSI) cycles on pregnancy outcomes is an unclear and challenging subject. Objective: To evaluate the impact of LOD before IVF/ICSI cycles on controlled ovarian stimulation and pregnancy outcomes in polycystic ovary syndrome (PCOS) women with a history of more than 2 IVF failures. Materials and Methods: In this randomized clinical trial, women with PCOS diagnosis who referred to Arash Women’s hospital, Tehran, Iran for IVF/ICSI cycle from August 2015-January 2018 were evaluated. Eligible participants were allocated into 2 groups randomly (n = 17/each group). The participants in the LOD group (intervention) were treated with laparoscopic couture, and after one month, they underwent IVF/ICSI cycles using the gonadotropin-releasing hormone antagonist protocol. The control group had no intervention. The oocyte and embryo qualities, ovarian hyperstimulation syndrome rate, the rates of chemical and clinical pregnancy and early miscarriage, live birth, and pregnancy complications, were compared between groups. Results: Finally, 34 participants were evaluated. The controlled ovarian stimulation outcomes were similar between groups. The ovarian hyperstimulation syndrome rate in the LOD group was significantly lower than in the control group (p = 0.04). One case of spontaneous pregnancy was reported in the LOD group. No significant difference was observed between groups in clinical pregnancy, miscarriage, and live birth rates. The rates of pregnancy complications (gestational diabetes mellitus, preeclampsia, and preterm birth) were similar between groups. Conclusion: Performing LOD before IVF/ICSI cycles did not improve the pregnancy outcomes in PCOS women, a clinical trial with a larger sample size is needed to prove these results. Key words: Laparoscopy, General surgery, Polycystic ovary syndrome, Embryo implantation, Immunology, Pregnancy outcome.