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Increased understanding of the intricacies of the follicular development and selection processes has been critical to the development of many of the new developments in ovarian stimulation in clinical practice. This chapter reviews these clinically related physiological aspects of ovarian stimulation, and discusses the resulting new concepts of ovarian stimulation. Recent studies have indicated that anti-Mullerian hormone (AMH) may be a more reliable and robust predictor of ovarian response during ovarian stimulation. The long ovarian stimulation protocol combining GnRH agonist with exogenous gonadotropin administration has been the most popular treatment regime for the past 20 years. The objectives of ovarian stimulation in assisted reproductive technology (ART) are evolving. A further development which promises to further reduce the burden of ovarian stimulation is the introduction of a long-acting follicle stimulating hormone (FSH) preparation which greatly reduces the number of injections required during an in vitro fertilization (IVF) treatment cycle.
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.
Assisted reproductive technology (ART) is available to two-thirds of the world's population, and world-class experts, representing research from 18 different countries, have contributed to this groundbreaking textbook, detailing the techniques and philosophies behind medical procedures of infertility and assisted reproduction. This is one of the most rapidly changing and hotly debated fields in medicine. Different countries have different restrictions on the research techniques that can be applied to this field, and, therefore, experts from around the world bring varied and unique authorities to different subjects in reproductive technology. Encompassing the latest research into the physiology of reproduction, infertility evaluation and treatment, and assisted reproduction, it concludes with perspectives on the ethical dilemmas faced by clinicians and professionals. This book will be the definitive resource for those working in the areas of reproductive medicine world wide.
This chapter describes the technique of embryo transfer (ET) to evaluate the various modifications proposed in order to maximize the chances of pregnancy, and discusses the different approaches available for managing difficult ETs. Before embarking on an ET, the following factors should be considered: embryo selection, choice of the catheter, performing a trial (mock or dummy) ET, ET medium, ultrasound, flushing the cervical mucus before performing ET. Randomized trials have shown that ultrasound guidance and the use of soft catheters as opposed to firm catheters are associated with higher pregnancy rates. They have also shown that the presence of air in the catheter, its immediate removal, bed rest after ET, sexual intercourse, and the administration of aspirin after ET do not affect the results. Routine use of antibiotics, uterine relaxants, and medication to increase uterine blood flow await further evaluation.
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.
The past three decades have witnessed a transformation in reproductive medicine from science fiction to one of the most advanced medical disciplines. Our textbook is a confirmation of the tremendous achievements in scientific research that changed the course of our clinical practice. Thirty years of in vitro fertilization (IVF) was celebrated this year in Alexandria, honoring Robert Edwards specifically. More than four million IVF babies have been born worldwide. The doors that were opened by Robert Edwards and Patrick Steptoe lead to many miracles. Intracytoplasmic sperm injection, in vitro maturation, oocyte vitrification, pre-implantation genetic diagnosis, and ovarian transplantation are dreams that were fulfilled. Many couples still have no hope of having their own families and demand us to keep moving forward.
The authors of the chapters of this book have lead the world for the three decades. They contributed their finest and most advanced research. We find in every one of them a sincere desire to uphold the ethics and the respect in our society. The friendship and cordiality between them has been amazing. They represented the six continents truly, and many of them have worked in more than one continent. It is not surprising that they worked together in such an elegant and a unique way. The different chapters are individualized in style, but the spirit of the book has united them. From reproductive physiology to surgery and assisted reproduction, the authors move with great elegance. The ethical and moral issues have been thoughtfully considered.
The evaluation and treatment of low responders in assisted reproductive technology (ART) remains a challenge. Poor responders have a higher incidence of cycle cancellation, lower fertilization, and lower pregnancy and implantation rates. Static tests for the prediction of poor responders include day 3 measurement of the concentration of serum follicle- stimulating hormone (FSH), serum inhibin B, serum estradiol (E2), and serum anti-Mullerian hormone (AMH) as well as the determination of the antral follicle count (AFC), the ovarian volume (OVVOL), and the ovarian blood flow. Dynamic tests assess the response of the ovary to a defined dose of an ovarian stimulation agent. They include the clomiphene citrate (CC) challenge test, the FSH stimulation test, as well as the gonadotrophin agonist stimulation test. Various adjuvant therapies have been suggested for improving the results of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) in poor responders.
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