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This chapter addresses the controversies surrounding the impact and surgical management of hydrosalpinges and uterine leiomyoma on in vitro fertilization (IVF) cycle outcome. Evidence accumulated over the last 15 years suggests that either unilateral or bilateral hydrosalpinges may exert deleterious effects on IVF cycle outcome. Hydrosalpinx fluid may have a direct embryotoxic effect and may also inhibit fertilization. This deleterious effect may be mediated by the presence of inflammatory cytokines present within hydrosalpinx fluid. Several groups have reported that only large hydrosalpinges, visible on ultrasound, resulted in reduced implantation and pregnancy rates. The impact of uterine leiomyomata specifically on the outcome of assisted reproductive technologies has been evaluated with conflicting results. Evaluation of the uterine cavity by hysteroscopy or sonohysterography should be a routine part of the pre-cycle evaluation. The accuracy of routine ultrasound evaluation and hysterosalpingography is more limited.
Clinical manifestation of anovulation is oligomenorrhea or amenorrhea. Patients with hyperandrogenemia and polycystic ovaries (without ovulation disorders) and patients with polycystic ovaries and ovulation disorders (without hyperandrogenism) may now be included in polycystic ovary syndrome (PCOS) diagnosis. The majority of anovulatory patients (about 80%) will have normal serum concentrations of estradiol (E2) and follicle-stimulating hormone (FSH) and a small proportion (approximately 10%) decreased concentrations of both hormones. Traditionally, ovulation induction treatment in normogonadotropic anovulation is started with an antiestrogen (CC) and, in case of treatment failure or absence of conception, this is followed by exogenous FSH. The most serious complications resulting from ovulation induction are caused by the limited control of follicular development. Increased availability of genetic profiles will be helpful to accomplish a more patient-tailored approach by identification of beneficial subgroups for certain interventions.
This chapter reviews the evidence surrounding the effect of reproductive surgery for tubal abnormalities, endometriosis, and uterine fibroids on in vitro fertilization (IVF) cycle outcome. Salpingectomy and proximal tubal occlusion are two surgical options in the treatment of distal tubal disease. Proximal tubal occlusion represents a significantly less invasive approach, which requires less surgical dissection and operating time while still eliminating retrograde flow of hydrosalpingeal fluid into the endometrial cavity. Consideration should be given to resection of submucosal fibroids and intramural lesions that distort directly impinge upon the endometrial cavity prior to IVF. Pregnancy rates achieved with assisted reproductive technology (ART) have increased progressively in recent years, and in endometriosis, patients achieve levels of success that are significantly higher than those obtained with alternative therapies. The prolonged use of a GnRH agonist, in at least a subset of endometriosis patients, appears to improve IVF cycle outcome.
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