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Prevention of moderate and severe ovarian hyperstimulation syndrome: a guideline. Fertil Steril 2024; 121:230-245. [PMID: 38099867 DOI: 10.1016/j.fertnstert.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 02/05/2024]
Abstract
Ovarian hyperstimulation syndrome is a serious complication associated with assisted reproductive technology. This systematic review aims to identify who is at high risk for developing ovarian hyperstimulation syndrome, along with evidence-based strategies to prevent it and replaces the document of the same name last published in 2016.
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2
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Singh R, Kaur S, Yadav S, Bhatia S. Gonadotropins as pharmacological agents in assisted reproductive technology and polycystic ovary syndrome. Trends Endocrinol Metab 2023; 34:194-215. [PMID: 36863888 DOI: 10.1016/j.tem.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/29/2023] [Accepted: 02/02/2023] [Indexed: 03/04/2023]
Abstract
Polycystic ovary syndrome (PCOS) is a complex endocrinopathy associated with subfertility/infertility and pregnancy complications. Most PCOS women opt for assisted reproductive technologies (ART) for successful conception; however, optimization of the relative doses of the gonadotropins [follicle-stimulating hormone (FSH), luteinizing hormone (LH)/human chorionic gonadotropin (hCG)] for appropriate steroidogenesis, without causing ovarian hyperstimulatory syndrome (OHSS), is challenging. Embryonic factors probably do not contribute to pregnancy loss in PCOS women, albeit hormonal imbalance impairs the metabolic microenvironment critical for oocyte maturation and endometrial receptivity. Certain clinical studies have confirmed the role of metabolic corrections in increasing the rate of pregnancy in PCOS women. This review focuses on the impact of untimely high LHCGR and/or LH levels on oocyte/embryo quality, pregnancy outcomes in ART, and exploring LHCGR as a potential drug target in PCOS women.
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Affiliation(s)
- Rita Singh
- Division of Molecular Endocrinology and Reproduction, Department of Zoology, University of Delhi, Delhi, India.
| | - Surleen Kaur
- Division of Molecular Endocrinology and Reproduction, Department of Zoology, University of Delhi, Delhi, India
| | - Suman Yadav
- Division of Molecular Endocrinology and Reproduction, Department of Zoology, University of Delhi, Delhi, India
| | - Smita Bhatia
- Department of Zoology, Ramjas College, University of Delhi, Delhi, India
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Fitz VW, Mahalingaiah S. Optimization of assisted reproductive technology outcomes in patients with polycystic ovarian syndrome: updates and unanswered questions. Curr Opin Endocrinol Diabetes Obes 2022; 29:547-553. [PMID: 36218224 DOI: 10.1097/med.0000000000000780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW Narrative review of recent literature on optimization of assisted reproduction technology outcomes in patients with polycystic ovarian syndrome (PCOS). RECENT FINDINGS The key areas of focus include pre cycle treatment with the goal of cohort synchronization, methods of ovulation suppression and trigger medication. There is no definitive evidence that precycle treatment with combined oral contraceptives (COCs) or progestins improve or negatively impact in vitro fertilization outcomes in patients with PCOS. The reviewed evidence supports consideration of progestins as suppression of premature ovulation in patients with PCOS as an alternative to gonadotropin releasing hormone (GnRH) antagonist if a freeze all protocol is planned. There is limited prospective evidence in PCOS populations regarding use of a dual trigger using GnRH agonist and human chorionic gonadotropin (hCG). SUMMARY This review has implications for clinical practice regarding ovarian stimulation protocols for patients with PCOS. We also identified areas of research need including the further exploration of the value of pre cycle COC or progestin use in a PCOS population, also the use of GnRH agonist in combination with hCG in a well defined PCOS population and using GnRH agonist trigger alone as a control.
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Affiliation(s)
- Victoria W Fitz
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Massachusetts General Hospital
| | - Shruthi Mahalingaiah
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Massachusetts General Hospital
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Ansaripour S, Tamizi N, Sadeghi MR, Mohammad-Akbari A. Comparison of Triggering Final Oocyte Maturation with Follicle Stimulating Hormone Plus Human Chorionic Gonadotropin, versus Human Chorionic Gonadotropin Alonein Normoresponder Women Undergoing Intracytoplasmic Sperm Injection: A Randomized Clinical Trial. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2022; 16:162-166. [PMID: 36029051 PMCID: PMC9396009 DOI: 10.22074/ijfs.2021.532311.1141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 11/22/2021] [Indexed: 06/15/2023]
Abstract
Few studies have so far been done about the role of follicle stimulating hormone (FSH) in final oocyte<br />maturation. However, none of these studies have been performed solely on normoresponder patients. This study aimed<br />to determine whether oocyte maturation, as well as fertilization and pregnancy rates, could be improved in normoresponder women with concomitant FSH and human chorionic gonadotropin (hCG) trigger compared to those with the hCG trigger alone.<br />Materials and Methods: In this prospective randomized clinical trial, 117 normoresponder women, aged 19-40 years<br />who were candidates for the gonadotropin-releasing hormone (GnRH) antagonist protocol at Avicenna Infertility<br />treatment Center, were enrolled and claasified in two groups. Final oocyte maturation was triggered using 10000 IU of<br />hCG plus 450 IU of FSH in the first group (59 subjects) and 10000 IU of hCG alone in the second group (58 subjects).<br />The primary outcome was clinical pregnancy rate.<br />Results: Mean age of the patients was 33.21 ± 4.41 years. There was no difference in clinical pregnancy among the<br />two groups (30.9% vs. 25.5%, P=0.525). There was no statistically significant difference in fertilization rate (80.0%<br />vs. 74.1%, P=0.106), implantation rates (18.9% vs. 16.7%, P=0.352), and chemical pregnancy rates (38.2% vs. 32.7%,<br />P=0.550). Oocyte maturation rate (84.2% vs. 73.6%, P<0.001), 2 pronuclei (2PNs) (6.53 ± 2.54 vs. 5.36 ± 2.85,<br />P=0.021) and total embryos (5.85 ± 2.43 vs. 4.91 ± 2.58, P=0.046) were significantly higher in the first group.<br />Conclusion: Adding FSH to hCG for oocyte triggering, significantly improved oocyte maturation rates and total embryos.<br />While there was no significant difference in the clinical and chemical pregnancy rates, between these two groups<br />(registration number: IRCT20190108042285N1).
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Affiliation(s)
- Soheila Ansaripour
- Nanobiotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Nayereh Tamizi
- Nanobiotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran. Email :
| | - Mohammad Reza Sadeghi
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Azam Mohammad-Akbari
- Nanobiotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran
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Anaya Y, Cakmak H, Mata DA, Letourneau J, Zhang L, Lenhart N, Juarez-Hernandez F, Jalalian L, Cedars MI, Rosen M. Triggering with 1,500 IU of human chorionic gonadotropin plus follicle-stimulating hormone compared to a standard human chorionic gonadotropin trigger dose for oocyte competence in in vitro fertilization cycles: a randomized, double-blinded, controlled noninferiority trial. Fertil Steril 2022; 118:266-278. [PMID: 35705380 DOI: 10.1016/j.fertnstert.2022.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 04/29/2022] [Accepted: 05/03/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess if triggering with 1,500 IU of human chorionic gonadotropin (hCG) with 450 IU of follicle-stimulating hormone (FSH) induces noninferior oocyte competence to a standard dose of hCG trigger used in in vitro fertilization (IVF). The alternative trigger will be considered noninferior if it is at least 80% effective in promoting oocyte competence. DESIGN Randomized, double-blinded, controlled noninferiority trial. SETTING Academic infertility practice. PATIENTS Women aged 18-41 undergoing IVF with antral follicle count ≥8, body mass index ≤30 kg/m2, and no history of ≥2 IVF cycles canceled for poor response were enrolled. Participants with a serum estradiol >5,000 pg/mL on the day of trigger were excluded because of high risk of ovarian hyperstimulation syndrome. INTERVENTIONS Participants were randomized to receive an alternative trigger of 1,500 IU of hCG plus 450 IU of FSH or a standard trigger dose of hCG (5,000 or 10,000 IU) for final oocyte maturation. MAIN OUTCOME MEASURES The primary outcome was total competent proportion, defined as the probability of 2 pronuclei from an oocyte retrieved. The alternative trigger will be considered noninferior to the standard trigger if a 1-sided 95% confidence interval (CI) of the relative risk (RR) is not <0.8. Secondary outcomes included oocyte recovery and maturity, intracytoplasmic sperm injection fertilization, embryo quality, pregnancy rates, as well as serum and follicular hormones. Secondary outcomes were compared using a 2-sided superiority test. Outcomes were analyzed by intention-to-treat and per-protocol. RESULTS A total of 105 women undergoing IVF were randomized from May 2015 to June 2018. The probability of the primary outcome was 0.59 with the alternative trigger and 0.65 with the standard trigger, with a RR of 0.91 and a 1-sided 95% CI of 0.83. Noninferiority of the alternative trigger was demonstrated. Live birthrate from all fresh transfers in the alternative trigger group vs. standard trigger was 46.9 vs. 46.4% (RR, 1.01; 95% CI, 0.62-1.62), respectively. Live birthrate per randomized participant was 48.1% in the alternative trigger group vs. 62.7% with the standard trigger (RR, 0.73; 95% CI, 0.48-1.11). No participants had a failed retrieval. CONCLUSION Triggering with 1,500 IU of hCG plus 450 IU of FSH promoted noninferior oocyte competence compared to a standard hCG trigger dose. TRIAL REGISTRATION NCT02310919.
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Affiliation(s)
- Yanett Anaya
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California.
| | - Hakan Cakmak
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
| | - Douglas A Mata
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joseph Letourneau
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California; Division of Reproductive Endocrinology and Infertility, Utah Center for Reproductive Medicine, University of Utah, Salt Lake City, Utah
| | - Li Zhang
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Nikolaus Lenhart
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
| | - Flor Juarez-Hernandez
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
| | - Liza Jalalian
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
| | - Marcelle I Cedars
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
| | - Mitchell Rosen
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
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Ansaripour S, Tamizi N, Sadeghi MR, Mohammad-Akbari A. Comparison of Triggering Final Oocyte Maturation with Follicle Stimulating Hormone Plus Human Chorionic Gonadotropin, versus Human Chorionic Gonadotropin Alonein Normoresponder Women Undergoing Intracytoplasmic Sperm Injection: A Randomized Clinical Trial. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2022. [PMID: 36029051 PMCID: PMC9396009 DOI: 10.22074/ijfs.2021.532258.1141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Few studies have so far been done about the role of follicle stimulating hormone (FSH) in final oocyte<br />maturation. However, none of these studies have been performed solely on normoresponder patients. This study aimed<br />to determine whether oocyte maturation, as well as fertilization and pregnancy rates, could be improved in normoresponder women with concomitant FSH and human chorionic gonadotropin (hCG) trigger compared to those with the hCG trigger alone.<br />Materials and Methods: In this prospective randomized clinical trial, 117 normoresponder women, aged 19-40 years<br />who were candidates for the gonadotropin-releasing hormone (GnRH) antagonist protocol at Avicenna Infertility<br />treatment Center, were enrolled and claasified in two groups. Final oocyte maturation was triggered using 10000 IU of<br />hCG plus 450 IU of FSH in the first group (59 subjects) and 10000 IU of hCG alone in the second group (58 subjects).<br />The primary outcome was clinical pregnancy rate.<br />Results: Mean age of the patients was 33.21 ± 4.41 years. There was no difference in clinical pregnancy among the<br />two groups (30.9% vs. 25.5%, P=0.525). There was no statistically significant difference in fertilization rate (80.0%<br />vs. 74.1%, P=0.106), implantation rates (18.9% vs. 16.7%, P=0.352), and chemical pregnancy rates (38.2% vs. 32.7%,<br />P=0.550). Oocyte maturation rate (84.2% vs. 73.6%, P<0.001), 2 pronuclei (2PNs) (6.53 ± 2.54 vs. 5.36 ± 2.85,<br />P=0.021) and total embryos (5.85 ± 2.43 vs. 4.91 ± 2.58, P=0.046) were significantly higher in the first group.<br />Conclusion: Adding FSH to hCG for oocyte triggering, significantly improved oocyte maturation rates and total embryos.<br />While there was no significant difference in the clinical and chemical pregnancy rates, between these two groups<br />(registration number: IRCT20190108042285N1).
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Affiliation(s)
- Soheila Ansaripour
- Nanobiotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Nayereh Tamizi
- Nanobiotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran,P.O.Box: 1983969412Nanobiotechnology Research CenterAvicenna Research InstituteACECRTehranIran
| | - Mohammad Reza Sadeghi
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Azam Mohammad-Akbari
- Nanobiotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran
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Vainer-Rotbart S, Sheiner E, Harlev A, Bar G, Levy A. The Association between Ovarian Hyperstimulation Syndrome and Pregnancy Complications following Fertility Treatments. Am J Perinatol 2021. [PMID: 34327685 DOI: 10.1055/s-0041-1732458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study was aimed to assess the association between ovarian hyperstimulation syndrome (OHSS) and pregnancy complications among women who conceived following fertility treatment. STUDY DESIGN A retrospective population-based cohort study, including all singleton deliveries of patients conceived following ovulation induction (OI) or in vitro fertilization (IVF) between 1988 and 2016, was conducted. All births occurred in a single tertiary medical center. A comparison was performed between deliveries of women who had experienced OHSS at early gestation and subsequently had a pregnancy and women without OHSS. Women lacking prenatal care, multiple gestations, and stillbirths were excluded from the analyses. A multivariable logistic regression model was used to control for confounders. RESULTS During the study period, 351,373 deliveries met the inclusion criteria, of which 6,748 were deliveries of infants who were conceived by either IVF or OI. Of this study population, 105 cases (1.6%) composed the exposed group, that is, women who had experienced OHSS with a subsequent live birth. In the multivariate analyses, after controlling for confounders, OHSS was not found as an independent risk factor for preeclampsia, gestational diabetes mellitus (GDM), intrauterine growth restriction (IUGR), preterm delivery (both <37 and <34 weeks), low birth weight (LBW), very LBW (VLBW), small for gestational age (SGA), and caesarean delivery. In a subanalysis conducted solely on the IVF population, similar results were found, aside from the association between OHSS and preterm delivery before 34 weeks of gestation which was statistically significant (adjusted odds ratio [AOR] = 2.3 95% confidence interval [CI]: 1.0-5.3, p = 0.049). CONCLUSION In our population, OHSS was not found as a risk factor for adverse pregnancy and perinatal outcome. In IVF patients, OHSS is a risk factor for preterm delivery before 34 weeks of gestation. KEY POINTS · OHSS is not a risk factor for pregnancy complications.. · Complications investigated were preeclampsia, GDM, prematurity, and others.. · In IVF patients, OHSS is a risk factor for preterm delivery..
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Affiliation(s)
- Shirah Vainer-Rotbart
- Department of Public Health, Faculty of Health Sciences Ben Gurion University of the Negev, Givatayim, Israel
| | - Eyal Sheiner
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Avi Harlev
- Fertility and IVF Unit, Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Guy Bar
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Amalia Levy
- Department of Public Health, Faculty of Health Sciences Ben Gurion University of the Negev, Givatayim, Israel
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Wald K, Letourneau J, Eshima-McKay R, Monks J, Mok-Lin E, Cedars M, Rosen M. Ovarian stimulation and egg retrieval in the acutely ill patient: special considerations. J Assist Reprod Genet 2019; 36:2087-2094. [PMID: 31396851 DOI: 10.1007/s10815-019-01556-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 08/02/2019] [Indexed: 01/28/2023] Open
Affiliation(s)
- Kaitlyn Wald
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, 499 Illinois Street, 6th Floor, San Francisco, CA, 94158, USA.
| | - Joseph Letourneau
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, 499 Illinois Street, 6th Floor, San Francisco, CA, 94158, USA.,University of Utah Center for Reproductive Medicine, Salt Lake City, UT, USA
| | - Rachel Eshima-McKay
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, USA
| | - John Monks
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, USA
| | - Evelyn Mok-Lin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, 499 Illinois Street, 6th Floor, San Francisco, CA, 94158, USA
| | - Marcelle Cedars
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, 499 Illinois Street, 6th Floor, San Francisco, CA, 94158, USA
| | - Mitchell Rosen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, 499 Illinois Street, 6th Floor, San Francisco, CA, 94158, USA
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Dashti S, Aflatoonian A, Tabibnejad N. Comparison of Oocyte Maturation Trigger Using Follicle Stimulating Hormone Plus Human Chorionic Gonadotropin versus hCG Alone in Assisted Reproduction Technology Cycles. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2019; 13:102-107. [PMID: 31037919 PMCID: PMC6500079 DOI: 10.22074/ijfs.2019.5701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 12/02/2018] [Indexed: 11/23/2022]
Abstract
Background The goal of this study was to investigate oocyte maturation, fertilization and pregnancy rates among
infertile women, by concomitant follicle stimulating hormone (FSH) administration at the time of human chorionic
gonadotropin (hCG) trigger, compared to hCG trigger alone. Materials and Methods In this prospective randomized controlled trial, 109 infertile women between the ages of
20 and 40 years, received gonadotropin-releasing hormone (GnRH) antagonist and fresh embryo transfer. Following
the procedure, the subjects were randomly divided into two groups on the oocyte-triggering day. In the experimental
group, final oocyte maturation was achieved by 5000 IU hCG plus 450 IU FSH. In the control group, however, oocyte
triggering was performed by 5000 IU hCG, only. The primary outcome was clinical pregnancy and the secondary out-
comes included oocyte recovery rate, oocyte maturity rate, fertilization proportion rate, fertilization rate, implantation
rate and chemical pregnancy rate. Results Fifty-four women were appointed to the group with the FSH bolus injection at the time of hCG trigger and
55 women were assigned to the hCG alone group. Women in the FSH group had a significantly higher metaphase II
(MII) oocyte (7.17 ± 3.50 vs. 5.87 ± 3.19), 2 pronuclear embryos (2PNs) (5.44 ± 3.20 vs. 3.74 ± 2.30) and total em-
bryos (4.57 ± 2.82 vs. 3.29 ± 2.13) compared to hCG alone group, respectively. Furthermore, fertilization rate (0.75
± 0.19 vs. 0.68 ± 0.25), implantation rate (14.2 vs. 8.5%) as well as clinical (27.9 vs. 15.9%) and chemical (32.6 vs.
20.5%) pregnancy rates were higher in the FSH group, but no statistically significant difference was found (P>0.05). Conclusion Combination of FSH and hCG for oocyte triggering improves oocyte maturity and fertilization propor-
tion rates without increasing the chance of implantation, chemical and clinical pregnancy rates (Registration number:
IRCT2017082724512N5).
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Affiliation(s)
- Saeedeh Dashti
- Research and Clinical Center for Infertility, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Abbas Aflatoonian
- Research and Clinical Center for Infertility, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran. Electronic Address:
| | - Nasim Tabibnejad
- Research and Clinical Center for Infertility, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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