Skip to main content Accessibility help
×
Hostname: page-component-78c5997874-8bhkd Total loading time: 0 Render date: 2024-11-02T20:22:49.466Z Has data issue: false hasContentIssue false

34 - Reproductive Surgery for Endometriosis-Associated Infertility

from PART II - INFERTILITY EVALUATION AND TREATMENT

Published online by Cambridge University Press:  04 August 2010

Botros R. M. B. Rizk
Affiliation:
University of South Alabama
Juan A. Garcia-Velasco
Affiliation:
Rey Juan Carlos University School of Medicine,
Hassan N. Sallam
Affiliation:
University of Alexandria School of Medicine
Antonis Makrigiannakis
Affiliation:
University of Crete
Get access

Summary

In the reproductive-age female, estimates of the general prevalence of endometriosis range from 6 to 11 percent (1–4). Among infertile women, the prevalence of endometriosis has been estimated to be about 20 percent (5). This is in contrast to asymptomatic women undergoing tubal ligation who have a prevalence of 4 percent. Although endometriosis may not be the primary cause of infertility in many of these patients, evidence from several studies support that fecundity is reduced, even in patients with minimal to mild endometriosis (6–8). Having to sort through the diverse therapeutic approaches to endometriosis-associated infertility, to come to a decision regarding the treatment plan often can be a challenging process for even an experienced clinician.

The diversity of choices from expectant management to combined medical/surgical treatment reflects, to some extent, the complex nature of this disease and the explanations for the mechanisms of morbidity. Management decisions are further complicated by coexisting fertility factors, variability of endometriosis presentation, surgical outcome, and, until recently, relatively few good studies to guide us to the best treatment course. Endometriosis may interfere with reproductive outcome by disrupting the hormonal, anatomical, and immunologic milieu of the pelvis. Generally, as the severity of disease increases, alterations within the pelvis become more pronounced, making the timely diagnosis and treatment important to minimize the clinical sequelae.

In patients whose reproductive goals are to maintain or restore fertility, the treatment objectives involve removing or destroying endometrial implants, restoring normal anatomy, and preventing or delaying disease recurrence.

Type
Chapter
Information
Publisher: Cambridge University Press
Print publication year: 2008

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Boling, RO, Abbasi, R, Ackerman, G, et al. Disability from endometriosis in the United States Army. J Reprod Med 1988;33: 49–52.Google ScholarPubMed
Wheeler, JM. Epidemiology of endometriosis-associated infertility. J Reprod Med 1989;34:41–46.Google ScholarPubMed
Velebil, P, Wingo, PH, Xia, Z, et al. Rate of hospitalization for gynecologic disorders among reproductive-age women in the United States. Obstet Gynecol 1995;86:764–769.CrossRefGoogle ScholarPubMed
Houston, , Noller, KL, Melton, LJ, et al. Incidence of pelvic endometriosis in Rochester, Minnesota, 1970-1979. Am J Epidemiol 1987;125:959–969.CrossRefGoogle Scholar
Eskenazi, B, Warner, ML. Epidemiology of endometriosis. Obstet Gynecol Clin North Am 1997;24:235–258.CrossRefGoogle ScholarPubMed
Hammond, MG, Jordan, S, Sloan, CS. Factors affecting pregnancy rates in a donor insemination program using frozen semen. Am J Obstet Gynecol 1986;155:480–485.CrossRefGoogle Scholar
Marcoux, S, Maheux, R, Berube, S. Laparoscopic surgery in infertile women with minimal or mild endometriosis: Canadian Collaborative Group in Endometriosis. N Engl J Med 1997;337: 217–222.CrossRefGoogle ScholarPubMed
Toma, SK, Stovall, DW, Hammond, MG. The effect of laparoscopic ablation or danocrine on pregnancy rate in patients with stage I or II endometriosis undergoing donor insemination. Obstet Gynecol 1992;80:253–256.Google ScholarPubMed
Harada, T, Iwabe, T, Terakawa, N. Role of cytokines in endometriosis. Fertil Steril 2001;76:1–10.CrossRefGoogle ScholarPubMed
Arici, A, Seli, E, Zeyneloglu, HB, et al. Interleukin-8 induces proliferation of endometrial stromal cells: a potential autocrine growth factor. J Clin Endocrinol Metab 1998;83:1201–1205.Google ScholarPubMed
Iwabe, T, Harada, T, Tsudo, T, et al. Pathogenetic significance of increased levels of interleukin-8 in peritoneal fluid of patients with endometriosis. Fertil Steril 1998;69:924–930.CrossRefGoogle ScholarPubMed
Dunselman, G, Hendrix, M, Bouckaert, P, Evers, J. Functional aspects of peritoneal macrophages in endometriosis of women. J Reprod Fertil 1988;82:707–710.CrossRefGoogle Scholar
Haney, A, Muscato, J, Weinberg, J. Peritoneal fluid cell populations in infertility patients. Fertil Steril 1981;35:696–698.CrossRefGoogle ScholarPubMed
Olive, DL, Weinberg, JB, Haney, AF. Peritoneal macrophages and infertility: the association between cell number and pelvic pathology. Fertil Steril 1985;44:772–777.CrossRefGoogle ScholarPubMed
Halme, J, Becker, S, Hammond, MG, et al. Increased activation of pelvic macrophages in infertile women with mild endometriosis. Am J Obstet Gynecol 1983;145:333–337.CrossRefGoogle ScholarPubMed
Muscato, JJ, Haney, AF, Weinberg, JB. Sperm phagocytosis by human peritoneal macrophages: a possible cause of infertility in endometriosis. Am J Obstet Gynecol 1982;144:503–510.CrossRefGoogle ScholarPubMed
Harlow, CR, Cahill, DJ, Maile, , et al. Reduced preovulatory granulosa cell steroidogenesis in women with endometriosis. J Clin Endocrinol Metab 1996;81:426–429.Google ScholarPubMed
Tummon, IS, Maclin, VM, Radwanska, E, et al. Occult ovulatory dysfunction in women with minimal endometriosis or unexplained infertility. Fertil Steril 1988;50:716–720.CrossRefGoogle ScholarPubMed
Curtis, P, Lindsay, P, Jackson, AE, Shaw, RW. Adverse effects on sperm movement characteristics in women with minimal and mild endometriosis. Br J Obstet Gynecol 1993;100:165–169.CrossRefGoogle ScholarPubMed
Oral, E, Arici, A, Olive, DL, Huszar, G. Peritoneal fluid from women with moderate or severe endometriosis inhibits sperm motility: the role of seminal fluid components. Fertil Steril 1996;66:787–792.CrossRefGoogle ScholarPubMed
Arumugam, K. Endometriosis and infertility: raised iron concentration in the peritoneal fluid and its effect on the acrosome reaction. Hum Reprod 1994;9:1153–1157.CrossRefGoogle ScholarPubMed
Reeve, L, Lashen, H, Pacey, AA. Endometriosis affects sperm-endosalpingeal interactions. Hum Reprod 2005;20:448–451.CrossRefGoogle ScholarPubMed
Suginami, H, Yano, K. An ovum capture inhibitor (OCI) in endometriosis peritoneal flUID:an OCI-related membrane responsible for fimbrial failure of ovum capture. Fertil Steril 1988;50:648–653.CrossRefGoogle ScholarPubMed
Coddington, CC, Oehninger, S, Cunningham, DS, et al. Peritoneal fluid from patients with endometriosis decreases sperm binding to the zona pellucida in the hemizona assay: a preliminary report. Fertil Steril 1992;57:783–786.CrossRefGoogle ScholarPubMed
Morcos, RN, Gibbons, WE, Findley, WE. Effect of peritoneal fluid on in vitro cleavage of 2-cell mouse embryos: possible role in infertility associated with endometriosis. Fertil Steril 1985;44: 678–683.CrossRefGoogle ScholarPubMed
Arici, A, Oral, E, Bukulmez, O, et al. The effect of endometriosis on implantation: results from the Yale University in vitro fertilization and embryo transfer program. Fertil Steril 1996;65:603–607.CrossRefGoogle Scholar
Pittaway, , Maxson, W, Daniell, J, et al. Luteal phase defects in infertility patients with endometriosis. Fertil Steril 1983;39: 712–713.CrossRefGoogle ScholarPubMed
Schenken, RS, Asch, RH, Williams, RF, Hodgen, GD. Etiology of infertility in monkeys with endometriosis: luteinized unruptured follicles, luteal phase defects, pelvic adhesions, and spontaneous abortions. Fertil Steril 1984;41:122–130.CrossRefGoogle ScholarPubMed
Schenken, RS, Asch, RH. Surgical induction of endometriosis in the rabbit: effects on fertility and concentrations of peritoneal fluid prostaglandins. Fertil Steril 1980;34:581–587.CrossRefGoogle ScholarPubMed
Kaplan, CR, Eddy, CA, Olive, DL, Schenken, RS. Effects of ovarian endometriosis on ovulation in rabbits. Am J Obstet Gynecol 1989;160:40–44.CrossRefGoogle Scholar
Dunselman, GA, Dumoulin, JC, Land, JA, Evers, JL. Lack of effect of peritoneal endometriosis on fertility in the rabbit model. Fertil Steril 1991;56:340–342.CrossRefGoogle ScholarPubMed
Chauhan, M, Barratt, CL, Cooke, SM, Cooke, ID. Differences in the fertility of donor insemination recipients – a study to provide prognostic guidelines as to its success and outcome. Fertil Steril 1989;51:815–819.CrossRefGoogle ScholarPubMed
Dunphy, BC, Kay, R, Barratt, CL, Cooke, ID. Female age, the length of involuntary infertility prior to investigation and fertility outcome. Hum Reprod 1989;4:527–530.CrossRefGoogle ScholarPubMed
Símon, C, Gutiérrez, A, Vidal, A, et al. Outcome of patients with endometriosis in assisted reproduction: results from in-vitro fertilization and oocyte donation. Hum Reprod 1994;9:725–729.CrossRefGoogle ScholarPubMed
Pellicer, A, Oliveira, N, Ruiz, A, et al. Exploring the mechanism(s) of endometriosis-related infertility: an analysis of embryo development and implantation in assisted reproduction. Hum Reprod 1995;10(Suppl. 2):91–97.CrossRefGoogle ScholarPubMed
Brizek, CL, Schlaff, S, Pellegrini, VA, et al. Increased incidence of aberrant morphological phenotypes in human embryogenesis – an association with endometriosis. J Assist Reprod Genet 1995;12: 106–112.CrossRefGoogle ScholarPubMed
Hughes, EG, Fedorkow, DM, Collins, JA. A quantitative overview of controlled trials in endometriosis-associated infertility. Fertil Steril 1993;59:963–970.CrossRefGoogle ScholarPubMed
Adamson, GD, Hurd, SJ, Pasta, DJ, Rodriguez, BD. Laparoscopic endometriosis treatment: is it better?Fertil Steril 1993;59: 35–44.CrossRefGoogle ScholarPubMed
Gruppo Italiano per lo Studio dell' Endometriosi. Ablation of lesions or no treatment in minimal-mild endometriosis in infertile womena randomized trial. Hum Reprod 1999;14:1332–1334.
Bruhat, MA, Mage, C, Chapron, C, et al. Present-day endoscopic surgery in gynecology. Eur J Obstet Gynecol Reprod Biol 1991;41: 4–13.CrossRefGoogle ScholarPubMed
Operative Laparoscopy Study Group, . Postoperative adhesion development following operative laparoscopy: evaluation at early second-look procedures. Fertil Steril 1991;55:700–704.Google Scholar
Carbon Dioxide Laser Laparoscopy Study Group. Initial report of the carbon dioxide laser laparoscopy study group: complications. J Gynecol surg 1989;5:269–272.
Azziz, R, Steinkampf, MP, Murphy, A. Post-operative recuperation: relation to the extent of endoscopic surgery. Fertil Steril 1989;51:1061–1064.CrossRefGoogle ScholarPubMed
Peterson, HB, Hulka, JF, Phillips, JM. American Association of Gynecologic Laparoscopists 1988 membership survey on operative laparoscopy. J Reprod Med 1990;35:587–589.Google Scholar
Luciano, AA, Manzi, D. Treatment options for endometriosis: surgical therapies. Infertil Reprod Med Clin N Am 1992;3:657–682.Google Scholar
Redwine, DB. Treatment of endometriosis-associated pain. Infertil Reprod Med Clin N Am 1992;3:683–695.Google Scholar
Adamson, GD. Laparoscopic treatment of endometriosis. In: Adamson, GD, Martin, DC, eds. Endoscopic Management of Gynecologic Disease. Philadelphia: Lippincott-Raven;1996: 147–187.Google Scholar
American Society for Reproductive Medicine. Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril 1997;67:817–821.CrossRef
Adamson, GD, Frison, L, Lamb, EJ. Endometriosis: studies of a method for design of a surgical staging system. Fertil Steril 1982;38:659–666.CrossRefGoogle ScholarPubMed
Fedele, L, Parozzini, F, Bianchi, S, et al. Stage and localization of pelvic endometriosis and pain. Fertil Steril 1990;53:155–158.CrossRefGoogle ScholarPubMed
Hoeger, KM, Guzick, DS. Classification of endometriosis. Obstet Gynecol Clin North Am 1997;24:347–359.CrossRefGoogle ScholarPubMed
Guzick, DS, Silliman, NP, Adamson, GD, et al. Prediction of pregnancy in infertile women based on the American Society for Reproductive Medicine's revised classification of endometriosis. Fertil Steril 1997;67:822–829.CrossRefGoogle ScholarPubMed
Adamson, GD, Pasta, DJ. Pregnancy rates can be predicted by validated endometriosis fertility index (EFI). Fertil Steril 2002;77(Suppl. 1):S48.CrossRefGoogle Scholar
Epstein, RM, Alper, BS, Quill, TE. Communicating evidence for participatory decision making. JAMA 2004;291(19):2359–2366.CrossRefGoogle ScholarPubMed
Adamson, GD, Pasta, DJ. Surgical treatment of endometriosis-associated infertility: meta-analysis compared with survival analysis. Am J Obstet Gynecol 1994;171:1488–1505.CrossRefGoogle ScholarPubMed
The Practice Committee of the American Society for Reproductive Medicine. Endometriosis and infertility. Fertil Steril 2004; 81:1441–1446.
Akande, VA, Hunt, LP, Cahill, DJ, Jenkins, JM. Differences in time to natural conception between women with unexplained infertility and infertile women with minor endometriosis. Hum Reprod 2004;19:96–103.CrossRefGoogle ScholarPubMed
D'Hooghe, TM, Debrock, S, Hill, JA, Meuleman, C. Endometriosis and subfertility: is the relationship resolved?Semin Reprod Med 2003; 21(2):243–254.Google ScholarPubMed
Garcia, CD, David, SS. Pelvic endometriosis: infertility and pelvic pain. Am J Obstet Gynecol 1977;129:740–747.CrossRefGoogle ScholarPubMed
Schenken, RS, Malinak, LR. Conservative surgery versus expectant management for the infertile patient with mild endometriosis. Fertil Steril 1982;37:183–186.CrossRefGoogle ScholarPubMed
Seibel, MM, Berger, MJ, Weinstein, FG, Taymor, ML. The effectiveness of danazol on subsequent fertility in minimal endometriosis. Fertil Steril 1982;38:534–537.CrossRefGoogle Scholar
Portuondo, JA, Echanojauregui, AD, Herran, C, Alijarte, I. Early conception in patients with untreated mild endometriosis. Fertil Steril 1983;39:22–25.CrossRefGoogle ScholarPubMed
Olive, DL, Stohs, GF, Metzger, DA, Franklin, RR. Expectant management and hydrotubations in the treatment of endometriosis-associated infertility. Fertil Steril 1985;44:351–352.CrossRefGoogle ScholarPubMed
Hull, ME, Moghissi, KS, Magyar, DM, Hayes, MF. Comparison of different modalities of endometriosis in infertile women. Fertil Steril 1987;47:40–44.CrossRefGoogle ScholarPubMed
Thomas, EJ, Cooke, ID. Successful treatment of asymptomatic endometriosis: does it benefit infertile women?Br Med J 1987;294:1117–1119.CrossRefGoogle ScholarPubMed
Bayer, SR, Seibel, MM, Saffan, DS, et al. Efficacy of danazol treatment for minimal endometriosis in infertile women. A prospective randomized study. J Reprod Med 1988;33:179–183.Google ScholarPubMed
Rodriguez-Escudero, FJ, Neyro, JL, Corcostegui, B, Benito, JA. Does minimal endometriosis reduce fecundity?Fertil Steril 1988; 50:522–524.CrossRefGoogle ScholarPubMed
Badawy, SZA, El Bakry, MM, Samuel, F, Dizer, M. Cumulative pregnancy rates in infertile women with endometriosis. J Reprod Med 1988;33:757–760.Google ScholarPubMed
Paulson, JD, Asmar, P, Saffan, DS. Mild and moderate endometriosis: comparison of treatment modalities for infertile couples. J Reprod Med 1991;36:151–155.Google ScholarPubMed
Inoue, M, Kobayashi, Y, Honda, I, et al. The impact of endometriosis on the reproductive outcome of infertile patients. Am J Obstet Gynecol 1992;167:278–282.CrossRefGoogle ScholarPubMed
Schenken, RS, Malinak, LR. Reoperation after initial treatment of endometriosis with conservative surgery. Am J Obstet Gynecol 1978;131:416–424.CrossRefGoogle ScholarPubMed
Buttram, VC. Conservative surgery for endometriosis in the infertile female: a study of 206 patients with implications for both medical and surgical therapy. Fertil Steril 1979;31:117–123.CrossRefGoogle ScholarPubMed
Rantala, ML, Kahanpaa, KV, Koskimies, AI, Widholm, O. Fertility prognosis after surgical treatment of pelvic endometriosis. Acta Obstet Gynaecol Scand 1983;62:11–14.CrossRefGoogle ScholarPubMed
Gordts, S, Boeckx, W, Brosens, IA. Microsurgery of endometriosis in infertile patients. Fertil Steril 1984;42:520–525.CrossRefGoogle ScholarPubMed
Rock, JA, Guzick, DS, Sengol, C, et al. The conservative surgical treatment of endometriosis: evaluation of pregnancy success with respect to the extent of disease as categorized using contemporary classification system. Fertil Steril 1981;35:131–137.CrossRefGoogle Scholar
Olive, DL, Martin, DC. Treatment of endometriosis-associated infertility with CO2 laser laparoscopy: the use of one- and two-parameter exponential models. Fertil Steril 1987;48:18–23.CrossRefGoogle ScholarPubMed
Nezhat, C, Crowgey, R, Nezhat, F. Videolaseroscopy for the treatment of endometriosis associated with infertility. Fertil Steril 1989;51:237–240.CrossRefGoogle ScholarPubMed
Gruppo Italiano per lo Studio dell'Endometriosi. Ablation of lesions or no treatment in minimal-mild endometriosis in infertile womena randomized trial. Hum Reprod 1999;14: 1332–1334.
Olive, DL. Endometriosis: does surgery make a difference?OBG Management 2002;Jul:56–70.Google Scholar
Diamond, MP, Daniell, JF, Feste, J, et al. Adhesion reformation and de novo adhesion formation following reproductive pelvic surgery. Fertil Steril 1987;47:864–866.CrossRefGoogle Scholar
Adamson, GD, Subak, LL, Pasta, DJ, et al. Comparison of CO2 laser laparoscopy with laparotomy for treatment of endometriomata. Fertil Steril 1992;57:965–973.Google ScholarPubMed
Canis, M, Mage, G, Wattiez, A, et al. Second-look laparoscopy after laparoscopic cystectomy of large ovarian endometriomas. Fertil Steril 1992;58:617–619.CrossRefGoogle ScholarPubMed
Alborzi, S, Momtahan, M, Parsanezhad, ME, et al. A prospective, randomized study comparing laparoscopic ovarian cystectomy versus fenestration and coagulation in patients with endometriomas. Fertil Steril 2004;82:1633–1637.CrossRefGoogle ScholarPubMed
Sayegh, R, Garcia, CR. Ovarian function after conservational ovarian surgery: a long-term follow-up study. Int J Gynaecol Obstet 1992;39:303–309.CrossRefGoogle ScholarPubMed
Marconi, G, Vilela, M, Quintana, R, Sueldo, C. Laparoscopic ovarian cystectomy of endometriomas does not affect the ovarian response to gonadotropin stimulation. Fertil Steril 2002;78: 876–878.CrossRefGoogle Scholar
Hemmings, R, Bissonnette, F, Bouzayen, R. Results of laparoscopic treatments of ovarian endometriomas: laparoscopic ovarian fenestration and coagulation. Fertil Steril 1998;70:527–529.CrossRefGoogle Scholar
Loh, F-H, Tan, AT, Kumar, J, Ng, S-C. Ovarian response after laparoscopic ovarian cystectomy for endometriotic cysts in 132 monitored cycles. Fertil Steril 1999;72:316–321.CrossRefGoogle ScholarPubMed
Donnez, J, Wyns, C, Nisolle, M. Does ovarian surgery for endometriomas impair the ovarian response to gonadotropin?Fertil Steril 2001;76:662–665.CrossRefGoogle ScholarPubMed
Canis, M, Pouly, JL, Tamburro, S, et al. Ovarian response during IVF-embryo transfer cycles after laparoscopic ovarian cystectomy for endometriotic cysts of >3 cm in diameter. Hum Reprod 2001;16:2583–2586.CrossRefGoogle ScholarPubMed
Muzii, L, Bianchi, A, Croce, C, et al. Laparoscopic excision of ovarian cysts: is the stripping technique a tissue-sparing procedure?Fertil Steril 2002;77:609–614.CrossRefGoogle ScholarPubMed
Jones, KD, Sutton, CJG. Pregnancy rates following ablative laparoscopic surgery for endometriomas. Hum Reprod 2002;17:782–785.CrossRefGoogle ScholarPubMed
Garry, R. The effectiveness of laparoscopic excision of endometriosis. Curr Opin Obstet Gynecol 2004;16:299–303.CrossRefGoogle ScholarPubMed
Gupta, S, Agarwal, A, Agarwal, R, Loret de Mola, JR. Impact of ovarian endometriomas on assisted reproduction outcomes. Reprod Biomed Online 2006;13:349–360.CrossRefGoogle ScholarPubMed
Demirol, A, Guven, S, Baykal, C, Gurgan, T. Effect of endometriomas cystectomy on IVF outcome: a prospective randomized study. Reprod Biomed Online 2006;12:639–643.CrossRefGoogle ScholarPubMed
Canis, M, Pouly, JL, Tamburro, S, Mage, G, Wattiez, A, Bruhat, MA. Ovarian response during IVF–embryo transfer cycles after laparoscopic ovarian cystectomy for endometriotic cysts of >3 cm in diameter. Hum Reprod 2001;16:2583–2586.CrossRefGoogle ScholarPubMed
Kennedy, S, Bergqvist, A, Chapron, C, D'Hooghe, T, Dunselman, G, Greb, R, Hummelshoj, L, Prentice, A, Saridogan E on behalf of the ESHRE Special Interest Group for Endometriosis and Endometrium Guideline Development Group. Hum Reprod 2005;10:2698–2704.CrossRefGoogle Scholar
Rizk, B. Treatment of Infertility associated with endometriosis. In: Rizk, B, and Abdalla, H, eds. Endometriosis. Oxford: UK, Health Press, 2003: chapter 6; 85–86.Google Scholar
Reich, H, McGlynn, F, Salvat, J. Laparoscopic treatment of cul-de-sac obliteration secondary to retrocervical deep fibrotic endometriosis. J Reprod Med 1991;36:516–522.Google ScholarPubMed
Adamson, GD, Hurd, SJ, Rodriguez, BD.Laparoscopy versus laparotomy for treatment of posterior cul-de-sac obliteration. Presented at the American Association of Gynecologic Laparoscopists; September 24–27, 1992; Chicago. Abstract.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×