{"paper_id":"2119f2d2-e015-4a56-b6f3-1a97975771ba","body_text":"Infertility is the failure to achieve pregnancy after 1 year of regular unprotected sexual intercourse. Factors related to the environment and lifestyle, such as smoking and obesity, can have a negative impact on fertility. Around 15% of infertile couples have unexplained infertility, while the remaining 85% of infertile couples have an identifiable cause. Male factor infertility, tubal disease, and ovulatory dysfunction are the most common causes of infertility. Ovulatory disorder contributes to around 25% of infertility cases, and around 75% of affected women diagnosed with polycystic ovary syndrome (PCOS).[ 1 ] Obesity negatively affects fertility; it can cause problems like irregular periods, chronic oligo-anovulation, and trouble getting pregnant. Obesity makes it more challenging to have a successful pregnancy and increases the chances of miscarriage.[ 2 ]\nEndometriosis is a condition where tissue similar to the lining of the uterus grows outside of it. It causes chronic pain in many women, and it is a common condition associated with infertility.[ 3 ] Endometriosis poses a very big challenge to women’s reproductive health. The typical site where the endometriosis growth appears includes the ovaries and the lining of the pelvis. Additionally, endometriosis lesions may develop in other areas such as the vagina, abdominal wall, bladder, fallopian tubes, intestine, and cervix.[ 4 ] In 19–28% of cases of endometriosis, both ovaries are affected, while around 15–44% of females with endometriosis are unaware of its presence.[ 5 ] In women with endometriosis undergoing  in vitro  fertilization/intracytoplasmic sperm injection (IVF/ICSI), especially those with endometriosis larger than 3 cm, there is an increased number of immature oocytes. Also, endometriosis negatively impacts ovarian reserve.[ 6 ]\nFurthermore, endometriosis may negatively impact oocyte quality, affecting maturation, morphological characteristics, and fertilization rates.[ 7 ] Endometriosis leads to various clinical issues such as inflammation, metabolic dysfunction, mood disorder, and increased cancer risk; it also causes pelvic pain, decreased work efficiency, and reduced quality of life. Oxidative stress, auto-immunity, and immune system dysregulation are the factors correlated with endometriosis. Melatonin, a natural molecule with anti-inflammatory and antioxidant properties, shows promise in managing endometriosis by inhibiting the modulating estrogen, proliferation, inflammation, and improving sleep quality.[ 8 ] Melatonin enhances the outcome of IVF embryo transfer (IVF-ET) by delaying ovarian ageing. Additionally, when added to  in vitro  culture, melatonin promotes oocyte maturation. Furthermore, it provides protection against mitochondrial injury in cases of PCOS.[ 9 ] This case presents the application of melatonin-assisted frozen embryo transfer (FET) for individuals with poor-quality oocytes and endometriosis.\n\nA couple, facing challenges with conceiving naturally for over 4 years, sought help from an assisted reproductive technology (ART) clinic situated in the rural area of Wardha. The wife was 34 years old, while her husband was 37.\nThe couple had no prior medical or surgical history. However, the female partner used to consume combined birth control pills and work the night shift. Additionally, she was diagnosed with endometriosis. The female and male both had healthy body mass index (BMI) values, with the female at 22 kg/m 2  and the male at 26 kg/m 2 .\nFollicle-stimulating hormone (FSH), anti-Mullerian hormone (AMH), luteinizing hormone (LH), progesterone, estrogen, and thyroid-stimulating hormone (TSH) tests were conducted to assess the hormonal levels. Estrogen was observed in the high range, while the progesterone level was found to be in the low range as displayed in  Table 1 . Additionally, structural abnormalities were assessed through ultrasound sonography, revealing no abnormalities. She had undergone two failed IVF cycles at another clinic.\nHormonal profile of female\nLegend: ng/ml (nanograms per milliliter), mIU/L (milli-international units per liter), IU/L (international units per liter), pg/mL (picograms per milliliter)\nHormonal tests, including LH and FSH, were conducted to examine the hormonal levels. Semen analysis was also performed to check sperm motility, morphology, count, and other semen parameters, as presented in  Table 2 . All the hormonal levels and semen parameters were found to be within the normal range representing good reproductive health.\nSemen parameters of male\nLegend: ml (milliliter), mil/ml (million per milliliter), pH (potential of hydrogen)\nA couple experiencing difficulty conceiving for the first time is a case of primary infertility. All factors of the male, including hormonal levels and semen parameters, were found to be within the normal range. However, the female was diagnosed with endometriosis, and her progesterone level was determined to be low.\nThe couple had a history of two failed IVF cycles due to poor-quality oocytes. The causative factors of this might be endometriosis and altered levels of estrogen and progesterone, indicating difficulty in conceiving through regular conventional methods. To address these challenges, it was decided to perform ovum pickup (OPU), followed by ICSI, to treat embryos with melatonin, and then FET. To increase the chances of successful pregnancy, it was decided to freeze blastocysts for FET. FET was chosen over fresh embryo transfer due to its benefits, which include better coordination with the women’s natural menstrual cycle and more effective preparation of the uterine line to enhance the chances of implantation and successful pregnancy.\nLater, the OPU was scheduled accordingly; the female partner underwent progesterone stimulation before the procedure. As planned, the OPU was performed, retrieving four oocytes of poor quality as presented in  Figure 1 . To address this problem, it was decided to proceed with ICSI and treat embryos with melatonin before conducting the FET. Melatonin, an antioxidant, reverses oxidative damage to oocytes and improves the embryo quality, the number of good-quality embryos, and fertilization rates.\nPoor-quality oocytes retrieved in OPU (ovum-pickup)\nAs planned, ICSI was performed, and the oocytes were injected with sperm. Subsequently, the embryos were cultured in culture media supplemented with 10–7 M melatonin for 72 hours. After this period, the embryos were taken out from the melatonin solution and transferred to conventional media for further growth over 48 hours. Exposure to melatonin is intended to enhance embryo development and increase the chances of producing good-quality blastocyst. After 120 hours (72 hours in melatonin and 48 hours in conventional culture media) or 5 days, the embryos developed into the two 3BB quality blastocysts; a grading system was used to assess the quality of embryos based on their developmental stage and morphology.\nThese embryos were then cryopreserved on two separate cryoprotecting straws (two on each straw). After 2 months, the female partner was prepared for embryo transfer. As per the plan, FET was performed, resulting in the transfer of two embryos. After transfer, the female partner was given rest for a few hours and then she was allowed to go home.\nThe female partner was advised to avoid heavy weight lifting and strenuous work. The female partner was advised to check her β-hCG level 14 days after embryo transfer, which revealed a positive indication of pregnancy with a level of 233 mIU/ml. She was prescribed some medicines and given instructions to follow. During her pregnancy, she was closely monitored to ensure compliance with the prescribed medications and instructions. Additionally, she was supervised for the rest of her pregnancy to ensure that she was following the medicines and instructions given to her.\n\nThe case presents a challenging scenario for the conception due to multiple factors including poor oocyte quality and endometriosis. The decision to proceed with OPU, ICSI, and FET seems appropriate given these challenges. The use of melatonin to improve embryo quality and the decision for FET over fresh embryo transfer were well founded. The successful formation of 3BB quality blastocyst after the melatonin treatment is promising as shown in  Figure 2 . In spite of this, careful monitoring and support are crucial throughout the process, considering the previous failure. The transfer of single embryos during FET reflects a wise approach to increase the chances of success while considering the potential risks and ethical considerations.\nDay 5 blastocyst (3BB quality) formed after melatonin treatment of Oocyte\nIn a study conducted by Fan  et al. ,[ 10 ] it was revealed that endometriosis adversely impacts oocyte quality through many factors, such as apoptosis, inflammation, oxidative stress, and steroidogenesis disorder in granulosa cells. Similarly, in a study conducted by Saito  et al. ,[ 11 ] it was revealed that endometriosis patients exhibit a higher incidence of apoptosis, increased oxidative stress, and alteration in the cell cycle compared to patients with other causes of infertility. Similarly, in our case, the quality of oocytes was reduced because of the endometriosis, causing the challenge in the treatment. In a study conducted by Lin  et al. ,[ 12 ] it was demonstrated that adding melatonin during prolonged  in vitro  maturation (IVM) improves oocyte quality and reduces reactive oxygen species (ROS) production and apoptosis. Furthermore, combining melatonin with both IVM and  in vitro  culture further enhances embryonic development and quality.\nIn a study conducted by Bao  et al. ,[ 13 ] it was demonstrated that supplementing the culture medium with melatonin increases the rate of good-quality embryos on day 3 for the patient with frequent poor-quality embryos. Moreover, it enhanced the blastocyst rate in vitrified warmed cleavage stage embryos. Similarly, in our case, when the embryos were treated with melatonin, a significant improvement in embryo quality was observed, ultimately resulting in a positive outcome.\n\nIn conclusion, in response to challenges involving poor oocyte quality and endometriosis, the couple opted for OPU, followed by ICSI and FET. Despite retrieving seven poor-quality oocytes during OPU, the embryos treated with melatonin developed into four 3BB-quality blastocysts, which were subsequently frozen. Following FET, the female partner obtained a positive pregnancy test result. This case highlights the efficacy of melatonin treatment in improving embryo quality and enhancing pregnancy rates in patients with endometriosis and poor-quality oocytes, thereby offering a promising approach in ART and reproductive medicine.\nThe authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.\nNil.\nThere are no conflicts of interest.","source_license":"CC0","license_restricted":false}