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Robotic surgery is emerging as a viable option for gynecological surgeons in general gynecology, urogynecology, oncology, and reproductive surgery. The ZEUS was the first robotic system utilized in gynecological surgery. It is replaced by the robotic system used currently in gynecological surgery: the da Vinci immersive telerobotic system. The da Vinci surgical system consists of three components: a surgeon's console, a patient-side cart with four interactive arms, and a vision cart. The surgeon experiences several benefits while utilizing the da Vinci surgical system. Urogynecologists have started to adopt the new robotic technology. Three studies have examined short-term outcomes, long-term outcomes, and feasibility of robotic-assisted sacrocolpopexy. There are potential uses of robotic-assisted laparoscopic surgery in the field of reproductive medicine. The ability to perform surgery from a remote location can have a significant impact on patient care and access to care, and should be incorporated into future robotic models.
During the preclinical development of in-vitro fertilization (IVF) in the human, oocytes were frequently obtained at laparotomies for various indications and the time for the operative procedure was generally not scheduled close to ovulation. The ovaries could now easily be scanned without using the full-bladder technique, and transvaginal ultrasound-guided oocyte retrieval (TVOR) could generally be performed with only use of some sedative in combination with local anesthesia. In order to increase the oocyte recovery rate it was found that Teflon tubing between needle and sampling tube was optimal. Today there are various sampling sets commercially available, including needle, tubing, and sampling tubes. The different complications of TVOR are bleeding and infection. In conclusion, available data regarding possible adverse effects of ultrasonography on oocytes have been interpreted to indicate that the technique, in this respect, is as safe as laparoscopy.
This chapter discusses the outcome of in vitro fertilization (IVF) in medically complicated patients. A confounding factor for IVF pregnancies is the increased number of multiple pregnancies and the relatively increased number of high-risk pregnancies among women with chronic medical problems. Cancer patients present particular challenges to the IVF unit. Standard IVF protocols are used for controlled ovarian hyperstimulation in human immunodeficiency virus (HIV) discordant couples. The main concerns about IVF and malignant disease relate to the issue of the potential delay in the starting of the patient's chemotherapy or of any possible effect of hormonal changes on the cancer. Obesity might affect the outcome of IVF and pregnancy, but with careful management, a good outcome can be achieved. It has been suggested that systemic lupus erythematosus (SLE) may reduce the success of IVF-ET. The presence of antinuclear antibodies may reduce the implantation rate in IVF patients.
Intrauterine insemination (IUI) is one of the most commonly performed treatments for infertile or hypofertile couples. General indications for IUI include cervical factor infertility, male infertility, minimal to mild endometriosis, and unexplained infertility. Age of the female, duration of infertility, follicular count, presence of trilaminar endometrium, sperm count and morphology are the various parameters which determines the outcome of IUI. The choice of IUI versus other forms of artificial insemination, the use of natural cycles versus controlled ovarian hyperstimulation (COH), timing of insemination, the number of IUI cycles to be carried, whether the couple will need single or double insemination, the type of catheter, and the choice of sperm preparation technique are the various options available to the couples. Contamination with viruses has also occurred during use of reproductive technologies. However, there is evidence that use of IUI with washed sperm may decrease the risk of contamination.
Hyperprolactinemia has a detrimental effect on fertility both in women and men, leading to galactorrhea anovulation, amenorrhea, oligomenorrhea, impotence, gynecomastia, and low semen profile. Men with hyperprolactinemia not only show abnormal semen analysis but also abnormal histological structure of the testicles with distorted seminiferous tubules and abnormal sertoli cells. Many physiological and or pathological changes involving lactotroph cells can result in hyperprolactinemia. The majority of prolactinomas contains only lactotroph cells and produce prolactin in excess. Antihypertensive drugs like methyldopa and reserpine increases prolactin secretion. A dopamine agonist drug should usually be the first line of treatment for patients with hyperprolactinemia of any cause including lactotroph adenomas of all sizes. Bromocriptine, cabergoline, pergolide are the available dopamine agonists to treat hyperprolactinemia. Dopamine agonists decrease prolactin secretion and reduce the size of the lactotroph adenoma in more than 90 percent of patients. Surgical and radiation treatment are also useful.
This chapter focuses on the association between acquired and inherited thrombophilia and implantation failure (IF). The pathogenesis of recurrent IF in patients with thrombophilic gene mutation may involve the effect of hypofibrinolysis on trophoblast migration. Trophoblastic migration and invasion during implantation involve extracellular matrix degradation, which is facilitated by matrix metalloproteinases (MMP). Recently, a variety of pathogenetic mechanisms have been suggested to explain the prothrombotic effect of antiphospholipid antibody (APA), the main cause of acquired thrombophilia. Recently, it has been suggested that APA may negatively impact the transformation of the endometrium into decidua, creating a hostile environment for blastocyst implantation. The chapter investigates the main therapeutic modalities such as heparin, aspirin (ASA), corticosteroids, and intravenous immunoglobulin alone or in combinations for treatment of IF. It is premature to recommend anticoagulation for patients with thrombophilia and IF.
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