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Embryo transfer is just one of a range of assisted reproductive technologies - often the last one in a sequence of others - that has revolutionised the cattle breeding industry. The number of in vitro-produced embryos transferred annually now surpasses the number derived by traditional superovulation by a factor of four. Although issues with cryotolerance of IVP embryos, embryo loss, and, in some cases, calf birth weight remain to be fully resolved, IVP embryos are likely here to stay as a tool for genetic improvement in dairy herds, offering increased flexibility in sire usage allowing multiple pregnancies from elite dam-bull combinations to be generated and the ability to produce more embryos per unit time than traditional superovulation. What follows is a short personal look back at the last 30 years; if you are looking for deep insights into the underlying biology regulating embryo development, this is not the place to look! Please refer to some of the excellent recent reviews and research papers cited herein.

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One of the main factors that influences the fertility of cattle in grazing systems in hot tropical climates is heat stress. The objective of this study was to evaluate the effect of season, breed, hormonal and physiological condition on the quantity and quality of cumulus-oocyte complexes (COCs) and embryos produced in vitro, from Romosinuano (RM) and Tropical Milking (TM) donors. Three ovum pick-up and in vitro fertilization (OPU-IVF) were performed, one per season: hot dry (HD; 10, 10), hot humid (HH; 9, 9) and fresh dry (FD; 7, 10) in RM and LT donors. Serum levels of cortisol, insulin and glucose were measured, in addition to heart rate (HR), respiratory rate (RR) and rectal temperature (RT). Effect of season x genotype interaction (p ≤ 0.05) was observed in all COC variables and only in cleavage embryos (CLI) (p ≤ 0.05). Body weight (BW) affected all COC variables (p ≤ 0.01), except unviable (UNV) although affected degenerated embryos (DEG) (p ≤ 0.01) and total blastocysts (BLAST) (p ≤ 0.01). Cow age only affected viable COCs (VIAB) (p ≤ 0.05), code one blastocysts (BC1) and BLAST (p ≤ 0.01). Cortisol affected total COCs (COCsT), VIAB and total matured in vitro (TMIV) (p ≤ 0.01), as well as CLI, BC1 (p ≤ 0.01) and BLAST (p ≤ 0.05). Insulin affected COCsT (p ≤ 0.01), UNV (p ≤ 0.05), denuded oocytes (DE) (p ≤ 0.01), BC1 and code two blastocysts (BC2) (p ≤ 0.01). Glucose affected all COC variables (p ≤ 0.01), except UNV and all embryo variables except BC2. HR affected COCsT, DE, TMIV (p ≤ 0.01), CLI, BLAST and DEG (p ≤ 0.05). RR affected COCsT, UNV, VIAB, CLI (p ≤ 0.05), BC1, BLAST and DEG (p ≤ 0.01). RT only affected DE, VIAB (p ≤ 0.01) and BLAST (p ≤ 0.05). The seasonal climatic year variation of Veracruz and changes in physiological and hormonal variables have diverse effects on the cumulus-oocyte complexes and embryos produced by RM and TM donors.

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The efficiency of bovine in vitro embryo production can be significantly improved by splitting embryos at different stages. However, the blastocyst quality of in vitro-produced demi-embryos remains unexplored. The objective of this research was to compare embryo developmental rates and quality of bovine demi-embryos produced by two different strategies: (a) embryo bisection (BSEC) and (b) 2-cell blastomere separation (BSEP). To determine demi-embryos quality, we evaluated total blastocyst cell number and proportion of SOX2+ cells. Additionally, the expression of SOX2, NANOG, OCT4, CDX2, IFNT, BAX and BCL genes and let-7a and miRNA-30c Micro RNAs was analysed. BSEP resulted in improved blastocyst development, higher ICM cells and a significantly higher expression of IFNΤ than demi-embryos produced by BSEC. Let-7a, which is associated with low pregnancy establishment was detected in BSEC, while miRNA-30c expression was observed in all treatments. In conclusion, BSEP of 2-cell embryos is more efficient to improve in vitro bovine embryo development and to produce good quality demi-embryos based on ICM cell number and the expression pattern of the genes explored compared to BSEC.

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OBJECTIVE: To evaluate if it possible to improve ovarian reserve parameters and oocyte retrieval in poor responders who undergo intraovarian injection of platelet-rich plasma (PRP). METHODS: Prospective cohort study. We included 148 poor responders who underwent PRP injection between October 2021 and December 2022 in our institution, comparing pre and post PRP ovarian function. In addition, the IVF outcomes of a subgroup of patients was studied after the intervention in contrast with the previous treatment. RESULTS: An improvement in ovarian reserve was observed in relation to previous values: FSH (13.57 vs. 11.32, p=0.11), AMH (0.39 vs. 0.48, p=0.06), antral follicle count (3.98 vs. 5.75, p<0.001); as well as a higher number of oocytes retrieved (2.63 vs. 3.65, p=0.01) and produced embryos (1.64 vs. 2.22, p=0.03); without a great impact on pregnancy rates. CONCLUSIONS: Although experimental, intraovarian PRP could restore ovarian function and be postulated as an alternative to oocyte donation in patients with low ovarian reserve who do not accept this treatment. There is a lack of randomized controlled trials to support these findings.

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Intracytoplasmic sperm injection (ICSI) in horses is currently employed for clinical and commercial uses, but the protocol could be optimized to improve its efficiency. We have hypothesized that destabilization of plasma and acrosomal membranes prior to injection would positively impact the developmental potential of equine zygotes generated by ICSI. This study evaluated effects of the sperm treatment with lysolecithin on plasma and acrosomal membranes and on oocyte activation ability, initially following heterologous ICSI on bovine oocytes and subsequently employing equine oocytes. The effects of the lysolecithin -treatment on the efficiency of conventional and piezo-assisted equine ICSI were evaluated. To do this, the equine sperm were treated with different concentrations of lysolecithin and the sperm plasma membrane, acrosome and DNA integrity were evaluated by flow cytometry. The results showed that a lysolecithin concentration of 0.08 % destabilized the membranes of all sperm and affected DNA integrity within the range described for the species (8-30 %). In addition, the heterologous ICSI assay showed that lysolecithin treatment was detrimental to the sperm's ability to activate the oocyte, therefore, chemical oocyte activation was used after equine ICSI after injection with lysolecithin -treated sperm. This group showed similar developmental rate to the control group with and without exogenous activation. In conclusion, lysolecithin pre-treatment is not necessary when using ICSI to produce equine embryos in vitro. The results from the current study provide additional insight regarding the factors impacting ICSI in horses.

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OBJECTIVE: Adenomyosis associated with subfertility is a situation of a dilemma for the treating clinician as the treatment is highly controversial and there remains an overall lack of consensus regarding the value of conservative surgery with or without medical management to improve reproductive out-comes. Hence we proposed this classification based on mapping of the size of adenomyoma, its location, distance from the endometrial cavity, and any associated endometriosis by studying 100 women with adenomyosis undergoing IVF. METHODS: We did a prospective study over 2 years in 100 women with adenomyosis who underwent IVF. They were classified into 4 categories based on our management-based proposed classification and the pregnancy outcomes were studied in each group. RESULTS: According to our classification, 56% of women belonged to grade 1, 24% to grade 2, 8% to grade 3, and 12% to Grade 4 Adenomyosis. The Pregnancy rates were 71% in Grade 1, 66% with Medical management, and 33% with surgical management in Grade 2, Grade 3 were offered surrogacy, and 66% in Grade 4 Adenomyosis. CONCLUSIONS: Our classification is simple and allows cost-effective management based on the location and ex-tent of the disease with the help of ultrasonography.

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OBJECTIVE: Previous studies have shown that the meiotic spindle is not always aligned with the first polar body (PB) in metaphase II human oocytes. Polarized Light Microscopy (PLM) has been used to observe and locate the meiotic spindle to avoid disrupting it while injecting oocytes. The aim of this study is to evaluate the relationship between meiotic spindle view and IVF-ICSI outcomes in poor responder women. METHODS: This study was a retrospective analytical study, carried out from January to November 2019; involving 115 poor responder women who underwent IVF-ICSI cycles at the Halim Fertility Center, Indonesia. The patients were divided into two groups: group I without meiotic spindle viewing (non-MSV) as control group, and group II with meiotic spindle viewing (MSV) as the case group. The meiotic spindles were imaged before ICSI with Oosight microscopy. Baseline characteristics and IVF-ICSI outcomes of both groups were compared. RESULTS: Our study included 115 poor responder women with non-MSV group (71 women), and an MSV group (44 women). The results showed that there was no significant difference in the fertilization rate between the two groups (p>0.05), but the embryo cleavage rate was higher in the MSV group when compared to the non-MSV group; and there was a significant difference between the two groups (p<0.05). The fertilization rate was higher in aligned than misaligned spindle and there was a significant difference between the two groups (p<0.05). Good quality embryo was higher in MSV group than non-MSV group (59.05% vs. 63.95%). CONCLUSIONS: Meiotic spindle view might improve the outcome of IVF in poor responder women.

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OBJECTIVE: To analyze if partial premature ovulation (PPO) detection during oocyte pick-up (OPU) impairs the quality of the retrieved oocyte cohort. METHODS: The PPO concept refers to the situation when premature ovulation happens only in some of the follicles and it is detected during OPU. This study constitutes a retrospective analysis performed in an infertility clinic (Spain) during 2016-2021 with patients undergoing OPU after controlled ovarian hyperstimulation for an in vitro fertilization (IVF) treatment. Study code: 2110-VLC-091- VG, registered on December 9 2021. Data from women with PPO (n=111) were compared to a matched control sample of cycles without PPO (n=333) at a proportion of 1:3. RESULTS: Cycles were matched for age, body mass index (BMI), treatment year, embryo genetic analysis and stimulation protocol type. The mean numbers of oocytes (6.1 vs. 11.2), mature oocytes (4.7 vs. 8.8), correctly fertilized oocytes (3.6 vs. 6.6) and top-quality blastocysts (0.9 vs. 1.8) were significantly lower in the PPO group than the nonPPO group (p<0.05). However, maturation, fertilization, top-quality blastocyst and pregnancy rates were statistically comparable among groups (p>0.05). CONCLUSIONS: Cycles with PPO have fewer available oocytes and, thus, fewer available embryos for transfer, al though their quality is intact, and still offer chances of pregnancy in these cases. Hence cycle cancellation may not be worth associated money, time and morale losses once PPO is detected.

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In mouse embryos, inside cells are allocated in 16-cell embryos through a well-orchestrated sequence of events involving compaction and polarization. The emergence of inside cells is of great importance as itl later gives rise to the inner cell mass and epiblast. In this study, we report the sequence of critical events in embryology (compaction, inside cells allocation and fragmentation) in bovine 72 h.p.i. 9-16 cell embryos, while also investigating the effects of X-sorted semen on these events. We found a wide distribution of total cell numbers among embryos, attributed to an asynchronous cleavage pattern and blastomere death. Additionally, 13% of embryos displayed irregular shapes. The establishment of the inside cell compartment increased (p < 0.01) in embryos with more cells. However, only 53.8% of 16-cell embryos presented inside cells. Compaction was present in 32.4% embryos and was positively correlated (p = 0.03, OR 3.02) with the establishment of inside cells, occurring independently of cell number. Fragmentation was present in 36% embryos, being more frequent (p = 0.01) in embryos with lower cell numbers. A possible association between irregular shape and fragmentation was considered (p = 0.06). The use of X-sorted semen had no effect on most evaluated parameters. However, it did have a marked effect on cleavage rate (p < 0.01) and the arrest of 2- and 4- cell embryos. In conclusion, bovine embryos exhibit an asynchronous cleavage pattern, high levels of fragmentation, and demonstrate compaction and inside cell allocation later in development compared to mouse embryos. Semen X-sorting has major effects on cleavage and embryo arrest. Further studies are needed to elucidate the association between irregularly shaped embryos and fragmentation, as well as the effects of sex on inside cell allocation.

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Our main objective was to identify the male and female parameters associated with total fertilization failure (TFF) in IVF with nonmasculine indications. The present work, IRB equivalent INS 63209, is a case-control study that evaluated all cases with TFF after conventional IVF at the Center for Human Reproduction from January 2010 to December 2019 (n = 154). As a control group, we analyzed all patients who did not experience fertilization failure after conventional IVF in the same period (n = 475). We evaluated various parameters, both male and female, assessed during infertility treatment, and only cases without masculine etiology (normal seminal parameters) were included. Ages (female and male) were not different between the groups. Moreover, AMH (anti-Müllerian hormone), semen volume, preprocessing concentration and preprocessing motility were not significantly different (P > 0.05). However, the number of collected oocytes (study versus control groups, median [25-75 interquartile]: 2 [1-5] and 5 [3-8]); MII (2 [1-4] and 5 [2-7]); and postprocessing motility (85 [70-90] and 90 [80-95]) were significantly different between both groups (P < 0.05). Furthermore, a logistic regression analysis including all significant data demonstrated that the number of collected oocytes was significantly related to IVF failure. Patients with fewer than 5 oocytes had an OR of - 1.37 (- 0.938 to - 1.827) for TFF after conventional IVF. Our results showed that a lower follicular response to controlled ovarian stimulation, evidenced by a decreased number of collected oocytes, was the most important parameter associated with IVF failure in nonmasculine infertility.

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Components of the plasminogen/plasmin system, known to be present in the oocyte, play a key role in maturation and fertilization. The objective of this study was to examine the effect of plasminogen activation and plasmin inhibition by exogenous supplementation of the IVF medium with streptokinase (SK) or ɛ-aminocaproic acid (ε-ACA), respectively, on fertilization parameters and preimplantation embryo development. After in vitro maturation, bovine cumulus-oocyte complexes (COCs) were inseminated in the presence of SK or ε-ACA. The addition of SK to the IVF medium facilitated the adhesion of the spermatozoa to the zona pellucida without affecting the percentages of monospermy. Cleavage rates and blastocyst yield were similar between the SK and Control groups while they were lower with the ε-ACA treatment. Additionally, we found that the expression levels of embryo quality-related genes (SDHA and DNMT3A) could be modified in blastocysts by the addition of SK or ε-ACA during IVF. The results obtained indicate that supplementation of the IVF medium with SK did not greatly alter the embryonic developmental parameters related to embryo quality in blastocysts. Moreover, we noticed that ε-ACA treatment compromises the success of in vitro embryo development, thus highlighting the importance of the plasminogen/plasmin activity during the early stages of embryogenesis in bovine.

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The aim of this study was to investigate the effects of 10 mg/kg/week of nandrolone decanoate (DECA - Deca Durabolin®) on body composition, hormonal levels, spermatic parameters, redox status, and morphometric parameters of testicle and epididymis; furthermore, the fertility capacity of Wistar rats was measured thought in vitro fertilization (IVF). The animals (n = 16) were divided into two groups: control group (CTRL, n = 8), which received only vehicle composed by peanut oil and 10% of the benzoic alcohol and nandrolone decanoate group (DECA, n = 8), which received intramuscular injections of DECA for 8 weeks, both groups were treated for 8 weeks. The results demonstrate significative decrease in visceral fat, testosterone levels, and thiol content on epididymis, reduction on normal sperm parameters, and deleterious effect on testicles and epididymis tissue morphology showing reduction of germ height and luminal diameter on the DECA group. Thus, it can be concluded that high doses of nandrolone decanoate impairs male reproductive parameters.

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Traditionally, in vitro oocyte and embryo culture progresses through a series of varying culture medium. To investigate simplifying the in vitro production of bovine cumulus-oocyte complexes (COCs), this study used synthetic oviductal fluid (SOF) supplemented with conjugated linoleic acid (CLA). Special interest was placed on gene expression linked to lipid metabolism and oocyte maturation. COCs were matured in different media: Medium 199 (M199 group), M199 with 100 µM CLA (M199 + CLA group), SOF (SOF group), and SOF with 100 µM CLA (SOF + CLA group). COCs matured with SOF showed a higher relative abundance of mRNA of quality indicators gremlin 1 (GREM1) and prostaglandin-endoperoxide synthase 2 (PTGS2) in oocytes, and GREM1 in cumulus cells compared with in the M199 group. SOF medium COCs had a higher relative abundance of fatty acid desaturase 2 (FADS2) compared with the M199 group, which is essential for lipid metabolism in oocytes. Furthermore, the abundance of stearoyl-coenzyme A desaturase 1 (SCD1) in oocytes matured with SOF was not influenced by the addition of CLA, whereas the relative abundance of SCD1 was reduced in M199 medium with CLA. We concluded that maturation in SOF medium results in a greater abundance of genes linked to quality and lipidic metabolism in oocytes, regardless of the addition of CLA.

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A 29-year-old female who received assisted reproductive therapy (IVF) in our infertility clinic, at gestational age of 7w + 2d following embryo transfer, presented with a favorable rise of ß-hCG level with no detectable gestational sac in the uterine cavity in the vaginal ultrasonogram. First dose of MTX (78) with simultaneous ß-hCG titration of 110,000 pg/mL was administered. The patient underwent a second TVS in which a mass in favor of molar ectopic pregnancy was reported. With the suspicion of a molar EP the patient underwent explorative laparotomy. A 3x4 cm mass which was found adjacent to the right ovary was resected. Final pathology report was compatible with partial molar pregnancy. In the follow up period after surgical resection the patient recovered completely without any recurrence.

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OBJECTIVE: Lesbian couples must resort to adoption or donated semen to achieve parenthood, the latter usually involving assisted reproductive technology. The aim of this study is to assess homosexual women's knowledge about assisted reproductive techniques, the importance of perceived genetic and gestational relationships for their future mother-child bond, as well as their reproductive plans. METHODS: This is an observational study based on an anonymous survey disseminated online in several countries on different continents, addressed to homosexual women. RESULTS: From the 549 participants, most reported being well informed about reproductive options including assisted reproductive technology. The majority want to be a mother as part of a couple, mainly through assisted reproduction or step adoption of their partner's child. The importance of a genetic or gestational relationships with their future child varies greatly between women. Among the sampled women, pregnancy was believed to have a slightly greater impact on the future mother-child connection compared to genetics. CONCLUSIONS: Homosexual women are well informed about the assisted reproductive technology treatments. The majority considers it important to become a mother as a couple, mainly through assisted reproduction or step adoption of their partner's child. The importance given to gestation or genetic mother-child relationships varies greatly between women, and it seems they believe pregnancy may have a slightly greater impact on the future mother-child connection compared to genetics.

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In the present study, the cryoprotective effects of Lolium perenne antifreeze protein (LpAFP) on the vitrification of bovine embryos were evaluated. In vitro-produced blastocysts were divided into two groups: the control group (CG) without the addition of LpAFP and the treatment group (TG) with the addition of 500 ng/ml of LpAFP in the equilibrium and vitrification solution. Vitrification was carried out by transferring the blastocysts to the equilibrium solution [7.5% ethylene glycol (EG) and 7.5% dimethyl sulfoxide (DMSO)] for 2 min and then to the vitrification solution (15% EG, 15% DMSO and 0.5M sucrose). The blastocysts were deposited on a cryotop device and submerged in liquid nitrogen. Warming was carried out in three steps in solutions with different sucrose concentrations (1.0, 0.5, and 0.0 M, respectively). Embryos were evaluated for re-expansion/hatching, the total cell count, and ultrastructural analysis. There was no significant difference in the re-expansion rate 24 h after warming; however, there was variation (P < 0.05) in the hatching rate in the TG and the total number of cells 24 h after warming was higher in the TG (114.87 ± 7.24) when compared with the CG (91.81 ± 4.94). The ultrastructural analysis showed changes in organelles related to the vitrification process but, in the TG, there was less damage to mitochondria and rough endoplasmic reticulum compared with the CG. In conclusion, the addition of 500 ng/ml of LpAFP during the vitrification of in vitro-produced bovine embryos improved the hatching rate and total cell number of blastocysts after warming and mitigated intracellular damage.

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OBJECTIVE: To evaluate clinical and laboratory outcomes of oocyte donation cycles and compare the results from donors and recipients. METHODS: A retrospective cohort study was conducted at a reproductive medicine center. A 586 first fresh oocyte donation cycles, performed from 01/2002 to 12/2017 were included. The outcomes of 290 cycles from donors and 296 from recipients, resulting in 473 fresh embryo transfers, were analyzed. The oocyte division was equally made, whereas, at an odd amount, the donor always had a preference. The data were collected from an electronic database, and analyzed using Chi-square test, Fisher's exact test, Mann-Whitney U-test or Student t-test depending on the data distribution, and multivariate logistic regression, considering p<0.05. RESULTS: The main results comparing donor and recipient, were, respectively: fertilization rate (72.0±21.4 vs. 74.6±24.2, p<0.001), implantation rate (46.2% vs. 48.5%, p=0.67); clinical pregnancy rate (41.9% vs. 37.7%, p=0.39), live birth rates by transfer (33.3 vs. 37.7, p=0.54). CONCLUSIONS: Oocyte donation is often the way donors can access in vitro fertilization, and for recipients seems to be a good option for pregnancy. Demographic and clinical characteristics have a secondary role in oocyte donors under 35 years and patient without comorbidities under 50 years and were not associated with pregnancy outcomes, emphasizing the power of oocyte quality on the success of intracytoplasmic sperm injection treatment. An oocyte-sharing program that offers good and comparable results is fair and worth being encouraged.

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OBJECTIVE: Several strategies have been proposed for ovarian stimulation in older women, such as using an increased daily dose of gonadotropins (300-450 IU per day) with GnRH agonist (long or micro dose flare protocols), or using GnRH antagonist protocols. The objective of this study is to compare the efficacy of flexible GnRH antagonist protocol and GnRH agonist flare - pituitary block protocols for ovarian stimulation in women above 40 years old undergoing IVF. METHODS: This study was performed between January 2016 and February 2019. One hundred and fourteen women aged between 40 and 42 years who underwent IVF were divided into two groups; group I were treated by Flexible GnRH antagonist protocol (Antagonist group, n=68); and group II were treated by Flare GnRH agonist protocol (Flare group, n=46). RESULTS: Patients treated with the antagonist protocol had a significantly lower cancellation rate when compared with patients treated with flare agonist protocol (10.3% vs. 21.7%, p value 0.049). The other parameters evaluated did not show statistically significant differences. CONCLUSIONS: Our finding showed that both Flexible antagonist and Flare agonist protocols had comparable outcomes, with lower cycle cancellation rates for older patients treated with the antagonist protocol.

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OBJECTIVE: Acetamiprid (ACP) causes infertility and its effect appears to occur via oxidative stress. Melatonin has antioxidative properties. Thus, in this experimental study, we examined the protective effect of melatonin against toxic pathologic changes from ACP on reproductive system parameters of female mice. METHODS: The study included 30 female mice divided into 5 groups (6 mice in each group), as follows: Saline (control group); ACP (10, 20 mg/kg); ACP (10mg/kg) + melatonin (10mg/kg); and ACP (20mg/kg) + melatonin (10mg/kg). All mice were given intraperitoneal injections daily for one month. The groups were evaluated for ovarian histopathological changes and oocyte quality based on in vitro fertilization (IVF) parameters. RESULTS: ACP induced histological damages in the ovaries of mice and caused increases in the number of atretic follicles and decreases in the quality of oocytes based on IVF parameters. These alterations were significantly reduced by melatonin. CONCLUSIONS: Melatonin can decrease the toxic effects of ACP in the female reproductive system of mice. Further studies are needed.

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OBJECTIVES: Assisted Reproductive Technology (ART) has made great strides in the past forty-years, but no medical treatment comes without side effects. Despite several studies reporting high incidences of perinatal complications, the association is inconclusive. Also, the effect of racially and ethnically distinguished Asian population undergoing ART on perinatal outcomes is not well studied. Therefore, this study attempts to compare various perinatal outcome parameters in ART, and spontaneously conceived singleton pregnancies from a single high-volume tertiary care center. METHODS: This is a retrospective cohort study from a single tertiary infertility center, carried out from January 2011 to September 2020. The study included 1,125 IVF conceived babies (AB group) and 7,193 spontaneous conceived babies (SB group). The groups were compared using the Pearson Chi-square test and adjusted odds ratio, calculated using the multivariate analysis. RESULTS: Most of the perinatal complications, such as preterm birth (PTB), early preterm birth, low birth weight (LBW), extremely low birth weight, small for gestational age, large for gestational age babies, neonatal intensive care unit (NICU) admission, need for surfactant, meconium aspiration syndrome, neonatal seizures, intraventricular hemorrhage, hypoxic-ischemic encephalopathy, and patent ductus arteriosus was significantly increased in the AB group when compared to the SB group (p<0.05). In-vitro fertilization (IVF) independently increases the risk of LBW (aOR 2.530; 95% CI 2.194-2.917), PTB (aOR 4.004; 95% CI 3.496-4.587), NICU admission (aOR 2.003; 95% CI 1.610-2.492) and neonatal seizures (aOR 9.805; 95% CI 5.755-16.706).Conclusions: All ART-conceived pregnant patients should receive antenatal counselling regarding perinatal complications and should deliver at a tertiary care center with appropriate NICU support.

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