Hyperthermia-induced infertility in women: an urgent narrative review of environmental and occupational risks: a literature review

Female infertility is a global health challenge with multifactorial causes, yet the role of exogenous hyperthermia as a significant and growing risk factor remains underappreciated in clinical practice. This narrative review synthesizes current evidence on how environmental and occupational heat exposure impairs female reproductive function, focusing on physiological mechanisms, epidemiological data, and preventive strategies. Hyperthermia exerts its detrimental effects through multiple pathways, including increased oxidative stress, disruption of the hypothalamic-pituitary-ovarian axis, and direct damage to oocyte quality and endometrial receptivity. Rising global temperatures and more frequent heatwaves, particularly in low-resource settings and among women in high-heat occupations such as agriculture, manufacturing, and food services, create a double burden of environmental and occupational heat stress with limited protective infrastructure. Current occupational safety guidelines are largely based on male physiology and fail to adequately safeguard female reproductive health. Recognizing hyperthermia as a tangible threat to fertility is critical, and there is an urgent need for female-specific research, revised occupational health standards, and clinical guidance for at-risk patients. Addressing this challenge requires coordinated efforts from gynecologists, occupational physicians, policymakers, and climate scientists to protect reproductive health in a warming world

Comparison of different treatment modalities in gestational diabetes mellitus and their maternal and fetal outcomes

Background: Gestational diabetes mellitus (GDM) is associated with significant maternal and fetal morbidity. Optimal management strategies after failure of lifestyle modification remain debated. Objectives were to compare maternal and fetal outcomes among women with GDM managed with medical nutrition therapy (MNT) alone, MNT with metformin, and MNT with metformin plus insulin. Methods: This prospective observational study was conducted in a tertiary care teaching hospital over 18 months. Ninety pregnant women diagnosed with GDM were enrolled and managed as per institutional protocol and endocrinology consultation. Participants were grouped based on treatment modality: diet alone (n=51), diet plus metformin (n=27), and diet plus metformin with insulin (n=12). Maternal outcomes (mode of delivery, pre-eclampsia, puerperal sepsis, shoulder dystocia) and fetal outcomes (birth weight, NICU admission, congenital malformations, perinatal mortality) were analysed. Appropriate statistical tests were applied with p≤0.05 considered significant. Results: Majority of women (56.7%) were managed with diet alone. Post prandial blood sugar differed significantly across treatment groups (p<0.001). Caesarean section rates increased with treatment intensity (27.5% in diet alone versus 83.3% in insulin group; p=0.004). NICU admissions were significantly higher in the insulin group (41.7%; p=0.027). No statistically significant differences were observed in pre-eclampsia, congenital malformations, or perinatal mortality among groups. Conclusions: Most women with GDM can be effectively managed with medical nutrition therapy alone. Requirement of pharmacotherapy reflects higher glycemic burden and is associated with increased operative deliveries and NICU admissions, without a significant increase in major adverse maternal or fetal outcomes

Rescue cerclage revisited: the role of adjunctive pessary in cervical incompetence

Background: Emergency cervical cerclage is an established intervention for women presenting with painless cervical dilatation; however, outcomes are strongly influenced by the degree of cervical compromise at presentation and multiple other factors. Cervical pessary is a non-invasive option for preventing preterm birth, but its role as an adjunct to emergency cerclage remains inadequately explored. Methods: This was a retrospective observational study in women with cervical insufficiency who underwent emergency cervical cerclage between January 2020 and December 2025 at a tertiary care centre in India. Pregnancy and neonatal outcomes were compared between women who underwent emergency cerclage with adjunctive pessary (Group A) and those who underwent cerclage alone (Group B). A predefined subgroup analysis was performed among women presenting with advanced cervical dilatation (≥2 cm). Results: Thirty women were included (Group A, n=7 and Group B, n=23). Women in group A presented with significantly greater cervical dilatation at admission (2.57 vs 1.44 cm; p=0.002). Overall pregnancy outcomes, including latency period, gestational age at delivery, and neonatal survival, were comparable between groups. In the subgroup with cervical dilatation ≥2 cm at the time of presentation (Subgroup A, n=6; Subgroup B, n=6), early pregnancy expulsion occurred more frequently in subgroup B (50%) than subgroup A (0%), showing a trend toward statistical significance (p=0.053). Subgroup A demonstrated a longer mean latency period (10.8 vs 6.8 weeks), though this difference was not statistically significant (p=0.37). Conclusions: In women undergoing emergency cervical cerclage, particularly those with advanced cervical dilatation, adjunctive pessary use may reduce pregnancy loss at earlier gestation and support pregnancy prolongation.

Beyond perceptions: evaluating South Asian background and its association with obstetric outcomes

Background: Perineal lacerations are common complications of vaginal delivery and can lead to pain, infection, incontinence, dyspareunia, and impaired pelvic floor function. These injuries occur more often after operative vaginal deliveries (OVDs). Clinicians at St. Joseph’s Medical Center (SJMC) raised concerns that severe third- and fourth-degree lacerations may be higher than expected and disproportionately affect South Asian women, a population that may be at increased risk of obstetric anal sphincter injuries (OASIs) due to shorter perineal body length and unique pelvic anatomy. Methods: A retrospective review of 937 randomly selected delivery records from 2018–2025 at SJMC in Stockton, California was conducted. Ethnicity was verified by chart review and patients were contacted when necessary, and data was stratified by ethnicity to evaluate associations with caesarean delivery, OVDs, and perineal lacerations. Results: South Asian women accounted for nearly 40% of all caesarean deliveries, over 40% of OVDs and perineal tears. Notably, of the Asian population group, South Asians experienced 100% of the severe 4th degree perineal tears reported. And, from the entire eligible study population, South Asians contributed to nearly 17% of severe perineal tears. Conclusions: Although provider bias persists in viewing South Asian women as higher risk, the data suggest SJMC obstetricians maintain low overall adverse outcomes while identifying a subgroup that may benefit from further study

Association of disorders of coagulation profile with feto-maternal outcome in abruptio placentae

Background: Placental abruption is a significant cause of maternal morbidity and perinatal mortality. There is a paucity of literature on evaluation of coagulation profile in patients with placental abruption and their feto-maternal outcome. Therefore, the present study was designed to evaluate disorders of coagulation system and feto-maternal outcome in patients with placental abruption. Methods: It was a prospective, observational study on 254 pregnant women diagnosed as abruption at >28 weeks gestation. Women were tested for prothrombin time, activated Partial Thromboplastin Time (aPTT), Internalised Normalised Ratio (INR), plasma fibrinogen, factor VIII, Von Willebrand Factor, factor IX, protein C, protein S and antiphospholipid antibodies. They were followed till discharge for feto-maternal outcome. Variables were compared using Unpaired t-test/Mann-Whitney Test/Chi-Square test/Fisher’s exact test. Results: Prolonged prothrombin time was found in 251/254 (98.82%) women, factor VIII and factor IX deficiency was found in 248/254 (97.64%) and 247/254 (97.24%) women respectively. Of 254 women, 143 (56.30%) had prolonged aPTT, 134 (52.76%) had raised INR decreased serum fibrinogen was found in 111/ 254 (43.70%) women. Cases of abruption with any one coagulation defect had adverse maternal and fetal outcome. It was interesting to find that a proportion of women who had no coagulation defect were not associated with hypertensive disorders of pregnancy, delivered vaginally, and had no NICU admission or neonatal death. Conclusions: Most of the abruption cases had factor VIII, factor IX deficiency and prolonged prothrombin time and had adverse feto-maternal outcome. However, women without any coagulation disorders had a favourable outcome

Association between trigger-intrauterine insemination interval, ovulation trigger agent, and clinical pregnancy in intrauterine insemination cycles: a 300-case analysis

Background: Intrauterine insemination (IUI) is a commonly employed first-line treatment for couples with unexplained infertility and mild male factor infertility due to its simplicity, low cost, and minimal invasiveness. Ovulation is typically induced using pharmacological triggers to allow accurate scheduling of IUI either with human chorionic gonadotropin (hCG) or gonadotropin-releasing hormone (GnRH) agonists. While insemination is commonly performed between 24 and 40 hours after the trigger, studies have reported variable pregnancy rates across different timing intervals, and no universal consensus has been established. Given these uncertainties, further evaluation of both the timing of insemination and the choice of ovulation trigger is warranted. Hence this study aims to assess how the interval between ovulation trigger and IUI influences clinical pregnancy outcomes, and to compare pregnancy rates between cycles using a GnRH agonist versus hCG as the trigger. Methods: A retrospective analysis was conducted on 300 IUI cycles performed at Janani Fertility Centre, Trichy, Tamil Nadu. Eligible cases included couples with unexplained infertility, male partners aged 23–40 years, and female partners aged 22–38 years with bilaterally patent fallopian tubes. Cycles with abnormal semen parameters, incomplete or frozen samples, double IUI, or donor sperm use were excluded. Patients were grouped according to the interval between trigger administration and IUI: <36 hours (group A, n=70), 36–38 hours (group B, n=140), and >38 hours (group C, n=90). Trigger type was hCG (n=187) or GnRH agonist (n=113). Categorical variables were analyzed using the Chi-square test. Results: Clinical pregnancy rates differed significantly across timing groups: group A: 8.6%, group B: 25.7%, and group C: 15.6%. The highest pregnancy rate occurred when IUI was performed 36–38 hours after the ovulation trigger. Trigger comparison showed higher pregnancy rates with hCG (25%; 47/187) than with GnRH agonist (8%; 9/113). Conclusions: IUI performed 36–38 hours after ovulation trigger is associated with the highest likelihood of clinical pregnancy, indicating optimal synchronization of ovulation and insemination at this interval. Additionally, hCG appears more effective than GnRH agonist as a trigger for improving pregnancy outcomes in IUI cycles

Efficacy of thymosin alpha-1 as an immunomodulatory adjuvant in patients with recurrent implantation failure: a real-world retrospective analysis

Background: Recurrent implantation failure (RIF) remains a major challenge in assisted reproductive technology (ART), affecting approximately 10–15% of couples undergoing treatment. Immune dysregulation is considered an important contributor to implantation failure. Thymosin Alpha-1, an immunomodulatory agent, has shown promising results in difficult-to-treat infertility cases. This study evaluated the real-world effectiveness of Thymosin Alpha-1 as an adjuvant therapy in patients with RIF in an Indian clinical setting. Methods: This retrospective, observational study was conducted at a private infertility center in India. Medical records of adult women aged over 30 years diagnosed with RIF over a one-year period were analyzed. All included patients received Thymosin alpha-1 (1.6 or 3.2 mg daily or on an alternate-day regimen) for a minimum of 118 days. Demographic characteristics, comorbidities, infertility-related conditions including polycystic ovary syndrome (PCOS), endometrial features, immunological parameters, treatment regimens and outcomes were evaluated. Results: Most patients were aged 31–35 years (41.1%), followed by 36–40 years (25.6%). Thyroid disorders (5.6%) and diabetes (2.2%) were uncommon, while 82.2% had no comorbidities; latent tuberculosis was present in 13.3%. Anovulatory cycles were observed in 17.8% of patients and 71.1% had a thin endometrium. Immunological parameters showed marked variability, including mean CD16+56 natural killer cell counts of 175±103 cells/µl and mean TNF-α levels of 18.4±41.2 pg/ml. PCOS was identified in a subset of patients. All patients with RIF (n=90) who received thymosin alpha-1 therapy for at least 118 days demonstrated positive reproductive outcomes, regardless of dosing regimen. Conclusions: Thymosin alpha-1 therapy was associated with encouraging outcomes in patients with RIF, supporting its role as an effective immunomodulatory adjuvant

Impact of advanced maternal age on obstetric and neonatal outcomes: an Indian cohort analysis

Background: To describe clinical profile, labour characteristics, maternal and neonatal outcomes of advanced maternal age pregnancies. Methods: This retrospective observational study evaluated maternal, labour, and neonatal outcomes among women of advanced maternal age (AMA), with comparisons across normal maternal age, very advanced maternal age (VAMA), and extremely advanced maternal age (EAMA) groups. Demographic characteristics, mode of conception, comorbidities, labour profile, and neonatal outcomes were analysed. Results: A total of 99,467 mothers delivered during the study period (January 2013 and December 2023), with majority belonging to normal age group (91.40%). AMA accounted for 6.77%, VAMA was 0.73%, EAMA was 0.07% and teenage pregnancy accounted for 1.03%. Proportion of AMA increased significantly over time, rising from 5.79% in 2013 to 14.83% in 2023. Most AMA pregnancies were singleton (94.45%), with a mean BMI of 28.05 ± 4.99 kg/m²; 1.23% were morbidly obese. Although spontaneous conception predominated (83.15%), assisted reproduction especially IVF (12.07%) was significantly more frequent. AMA mothers had a higher comorbidity burden, with multi-system disease in 39.33%. Caesarean delivery was common with 68.03%, with higher preterm birth rates (21.13%). Neonates showed more growth abnormalities (SGA 16.28%, LGA 12.55%) and higher NICU admissions (17.43%), live birth rates remained high (98.30%). Risk severity increased progressively in VAMA and EAMA groups. Conclusions: AMA is associated with increased maternal comorbidity, caesarean delivery, preterm birth, and neonatal morbidity. These risks escalate further with increasing maternal age, underscoring the need for targeted antenatal surveillance, individualized risk stratification, multidisciplinary care, specialized intrapartum and neonatal care pathways

Placental stiffness assessment using shear wave elastography in normal and preeclamptic pregnancies: a cross-sectional analytical study

Background: Preeclampsia is a multisystem hypertensive disorder associated with abnormal placentation and increased placental stiffness. Shear wave elastography (SWE) is a non-invasive imaging modality that quantitatively evaluates tissue elasticity. This study aimed to compare placental stiffness in normal and preeclamptic pregnancies and determine an optimal diagnostic cut-off value. Methods: This hospital-based cross-sectional analytical study was conducted in the Department of Radiodiagnosis at Dr. S.N. Medical College, Jodhpur between January 2025 and December 2025. A total of 120 pregnant women between 27-40 weeks of gestation were enrolled: 60 normotensive controls and 60 preeclamptic patients. Placental SWE measurements were obtained using a Philips Affiniti 70 ultrasound system. Nine readings were taken from fetal, central, and maternal placental regions. Receiver operating characteristic (ROC) curve analysis was performed to determine diagnostic performance. Results: Mean SWE was significantly higher in preeclamptic women compared to controls (4.59±0.41 m/s vs 2.51±0.10 m/s; p=0.068). Median SWE values yielded an AUC of 0.968. A cut-off value of 4.32 kPa demonstrated sensitivity of 86.7% and specificity of 96.7%. Central placental regions showed significantly higher stiffness in preeclamptic pregnancies. Conclusions: Placental stiffness measured by SWE is significantly increased in preeclampsia. SWE may serve as a reliable, safe, and non-invasive adjunct tool for evaluating placental pathology and identifying pregnancies at risk

Efficacy and safety of mifepristone as a sole induction agent in intrauterine fetal demise in scarred and unscarred uterus

Background: Termination of pregnancy in the second and third trimester due to intrauterine fetal demise (IUFD) or lethal fetal anomalies requires safe and effective methods of induction of labour. Mifepristone, an antiprogestin, has been used for cervical ripening and labour induction. This study aimed to evaluate the efficacy and safety of mifepristone as a sole agent for induction of labour in pregnancies beyond 20 weeks of gestation in women with both scarred and unscarred uterus. Methods: This prospective clinical study was conducted in the Department of Obstetrics and Gynaecology at Shaheed Hasan Khan Mewati Government Medical College, Nalhar, Haryana over a period of one year after approval from the institutional ethics committee. A total of 54 antenatal women with gestational age >20 weeks requiring termination due to intrauterine fetal demise, lethal fetal malformation or PPROM were included. Tablet mifepristone 200 mg was administered orally at 12-hour intervals for a maximum of three doses. Patients were monitored for onset of labour and delivery. Primary outcome measured was successful vaginal delivery following induction with mifepristone alone. Secondary outcomes included induction-delivery interval, requirement of additional uterotonics and maternal complications. Results: Most patients belonged to the age group of 18–24 years (48.14%), and the majority were multiparous. Scarred uterus was present in 24.07% of cases while 75.93% had unscarred uterus. A total of 87.04% of women delivered within 72 hours of the first dose of mifepristone without the need for additional uterotonics. Additional induction methods such as misoprostol or intracervical Foley’s catheter were required in 12.96% of cases. The majority of patients (59.25%) delivered between 24–72 hours following the first dose of mifepristone. No cases of uterine rupture, scar dehiscence, retained products of conception, or requirement of caesarean section or hysterotomy were observed. Conclusions: Mifepristone is an effective and safe agent for induction of labour in pregnancies beyond 20 weeks with intrauterine fetal demise or lethal fetal anomalies in both scarred and unscarred uterus. Its use is associated with a high rate of successful vaginal delivery with minimal maternal complications