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  1. Home
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  3. Management of Infertility for the MRCOG and Beyond
  • Cited by 1
Publisher:
Cambridge University Press
Online publication date:
June 2014
Print publication year:
2014
Online ISBN:
9781107445178
DOI:
https://doi.org/10.1017/CBO9781107445178
Subjects:
Obstetrics and Gynecology, Reproductive Medicine, Medicine
Information

Book description

Demands on the gynaecologist from patients seeking help with suboptimal fertility continue to grow, and fertility-related issues are often in the gaze of the media. Obstetricians and gynaecologists need to ensure that they are up to date, informed and knowledgeable to successfully engage with their patients. Written by nationally recognised leaders in the field, this volume concisely reviews contemporary clinical practice. Using an aetiology-based approach, the evidence underpinning the management of ovulatory dysfunction, male infertility, endometriosis, tubal, uterine factor, and unexplained infertility is critically reviewed. The role of assisted reproduction treatment is elaborated and a new chapter describes the clinical and laboratory techniques involved. The book provides a comprehensive summary for candidates preparing for the Part 2 MRCOG examination, covering the RCOG curriculum for infertility management. It will be enormously helpful to health professionals working in fertility clinics and an essential aide-memoire to those undertaking special interest training in infertility.

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Contents

Contents
  • 1 - Epidemiology and initial assessment
    pp 1-12
  • View abstract

    Summary

    This chapter discusses the prevalence of infertility and the importance of the initial assessment of the infertile couple. Education of the public about the known decline in fertility that occurs with age, particularly in women older than 35 years, is important. The preliminary investigation centres on the need to demonstrate that the woman is ovulating. Semen analysis remains the most important means of assessment for male. In the fertility clinic setting, a pelvic ultrasound examination may be useful. Diagnostic categories in most studies include male factors, disorders of ovulation, tubal factors, endometriosis and uterine factors related to infertility, and unexplained infertility. Ovulatory disorders, often associated with irregular menstruation, are associated with reduced chances of natural conception. Ovulation induction provides good chances of success if there are no other complicating factors such as tubal compromise or severe impairment in sperm quality.
  • 2 - Male factor infertility
    pp 13-30
  • View abstract

    Summary

    Male factors are implicated in as many as 25% of couples with infertility. Assisted reproductive technology (ART) techniques such as intracytoplasmic sperm injection (ICSI) have revolutionised the treatment of infertility and allowed men with severe oligozoospermia, and many with azoospermia, to father their own children. The aetiology of male factor infertility is broadly divided into genetic and acquired causes. Varicoceles are possibly associated with impaired testicular function and infertility. Treatment with certain drugs or exposure to radiation or chemicals can affect actively dividing germ cells causing defective spermatogenesis, and this may be temporary or permanent. Both partners must always be involved in the investigation and management of infertility. Semen analysis is one of the fundamental investigations of the infertile couple irrespective of whether the man has previously fathered children or not. ICSI has become the gold standard treatment for male factor infertility.
  • 3 - Ovulatory disorders
    pp 31-44
  • View abstract

    Summary

    Ovulatory disorders can arise from any level of the hypothalamic-pituitary-ovarian axis. Ovulatory dysfunction may result from a lack of available oocytes or of follicles. Pelvic imaging, which is often undertaken at the time of examination by transvaginal ultrasound scan, can confirm normal pelvic organs and also provide an assessment of ovarian morphology, in particular polycystic appearance. Semen analysis for the male partner must be considered an absolute minimum. It is important to consider tubal patency if ovulation induction is planned and, in women with risk factors for tubal disease, prior assessment should be considered mandatory either by laparoscopy or contrast imaging. Liaison with endocrine colleagues is recommended when more complex endocrine disorders are involved. General fertility advice is important, including advice (for both partners) on weight management, smoking, alcohol and drugs, as is confirming an up-to-date smear result and female folic acid supplementation.
  • 4 - Tubal infertility
    pp 45-56
  • View abstract

    Summary

    The management of tubal disease depends on the initial pathological process and the severity of damage. In vitro fertilisation (IVF) remains the main treatment strategy for women with severely damaged fallopian tubes. The main causes of tubal factor infertility include previous tubal infection, previous surgery, endometriosis and congenital abnormalities. Infection, endometriosis and surgery affect tubal function via different mechanisms but all lead to inflammation. Classification of tubal disease is essential for use in clinical trials but also as a potential prognostic indicator to assist patients and clinicians in decisions regarding further management. The tubal disease is classified into grade I - minor, grade II - intermediate or moderate and grade III - severe. Once tubal disease has been identified, management options include expectant management, tubal cannulation, surgery and IVF. Several prognostic factors need to be considered when counselling women regarding their individual further management options.
  • 5 - Endometriosis-related infertility
    pp 57-66
  • View abstract

    Summary

    Endometriosis causes pain and infertility for millions of women worldwide. The prevalence of endometriosis is 6-10% in women of reproductive age, and 30-50% of women with pelvic pain and/or infertility. For definitive diagnosis and staging of endometriosis, a surgical procedure, generally a laparoscopy, is necessary to visualise disease implants. More recently, magnetic resonance imaging (MRI) has been used as a non-invasive tool in the diagnosis of deep endometriosis. The aim of treatment of endometriosis is to remove or reduce disease deposits. This may be attempted through medical or surgical means. Although assisted conception treatments such as ovulation induction with intrauterine insemination (IUI), or in vitro fertilisation (IVF), do not treat endometriosis per se, they can successfully treat the associated infertility. All couples presenting with failure to conceive should undergo a full evidence based fertility work-up. This includes a semen analysis, confirmation of ovulation and tubal patency testing.
  • 6 - Uterine factors in infertility
    pp 67-76
  • View abstract

    Summary

    Septate uteri are the most prevalent congenital uterine anomaly in infertile women. Women with septate uteri have reduced conception rates and increased risks of first-trimester miscarriage, preterm birth and malpresentation at delivery. The prevalence of arcuate uteri in infertile women is almost identical to that of the general/fertile population. Acquired uterine abnormalities described in the chapter include endometrial polyps, intrauterine adhesions, and uterine fibroids. Hysteroscopic myomectomy is now considered the gold standard treatment for submucosal fibroids. Abdominal myomectomy remains the routine approach for most surgeons faced with multiple or large intramural fibroids. For appropriately trained surgeons, a laparoscopic approach may be adopted. Hysteroscopic resection of submucosal fibroids before IVF treatment is recommended. Although subfertile women who have otherwise asymptomatic fibroids may benefit from a myomectomy procedure, this approach should be individualised given the absence of any good randomised controlled trials (RCT) in this area.
  • 7 - Unexplained infertility
    pp 77-84
  • View abstract

    Summary

    Expectant management has a key role in the management of unexplained infertility. The decision to treat couples with unexplained infertility should take into account their chances of spontaneous conception, which is affected by female age, duration of infertility and occurrence of a previous pregnancy. The rationale for the use of oral clomifene citrate in unexplained infertility is the belief that it corrects subtle ovulatory dysfunction and encourages the release of more than one oocyte. Clomifene is inexpensive, non-invasive and requires little clinical monitoring, but it can cause multiple pregnancies, including high-order multiples. Intrauterine insemination (IUI) has been used widely for the treatment of unexplained infertility. It is thought to enhance the chance of pregnancy by increasing the number of motile spermatozoa within the uterus, bringing them in close proximity to the oocyte. Although more effective than IUI, superovulation (SO) along with IUI is associated with high rates of multiple births.
  • 8 - Assisted reproduction – preparation and work-up of couples
    pp 85-96
  • View abstract

    Summary

    This chapter addresses issues related to patient selection and preparation prior to undergoing assisted reproductive technology (ART) techniques, and the role of regulatory control in ART and welfare of the child assessment. It discusses the special aspects of ART including gamete and embryo donation, pre-implantation genetic screening (PGS) and diagnosis (PGD) and fertility preservation. Before the processing of patient gametes or embryos, the couple should be screened for hepatitis B, hepatitis C and HIV to assess their risk of cross-contamination. In the UK, the regulatory control of ART lies with the Human Fertilisation and Embryology Authority (HFEA). The risk of implantation failure and pregnancy loss secondary to aneuploidy increases with advanced maternal age, particularly after the age of 35 years. Fertility preservation described in the chapter includes sperm cryopreservation, oocyte cryopreservation, and ovarian tissue cryopreservation.
  • 9 - Assisted reproduction – clinical and laboratory procedures
    pp 97-112
  • View abstract

    Summary

    This chapter focuses on in vitro fertilisation (IVF), the most common assisted reproductive technology (ART) procedure. The use of IVF has radically transformed the way in which we approach the management of infertility, irrespective of the diagnosis, and it is integral to the infrastructure of a modern fertility service. Monitoring of treatment includes follicle tracking with ultrasound and ovarian steroid measurement. In the early days of IVF, oocyte collection procedures were done under laparoscopic guidance. After oocyte retrieval, freshly ejaculated seminal fluid is prepared to concentrate motile spermatozoa in a fraction that is free of seminal plasma and debris. Embryologists then have to decide whether they are going to perform conventional IVF or need to inject sperm directly into the oocyte (intracytoplasmic sperm injection (ICSI)). Two major complications of ART to consider are multiple pregnancy and ovarian hyperstimulation syndrome (OHSS).

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