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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.
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 successful treatment of endometriosis-associated symptoms typically requires surgical as well as medical intervention. Progestogens are efficacious and inexpensive treatment of pelvic endometriosis. A variety of medications have been used as add-back therapy in addition to gonadotrophin-releasing hormone (GnRH) agonist for treatment of endometriosis which includes progestogen alone, progestogen and estrogen combination, or progestogen and bisphosphonates. GnRH antagonists have been used for the treatment of pelvic endometriosis; however, they have not been as widely accepted as GnRH agonists. Selective progesterone receptor modulators introduce a new dimension in the medical treatment of endometriosis. Aromatase inhibitors which inhibit estrogen production in endometriotic implants are an attractive option for the management of endometriosis. Antiangiogenesis therapy has been investigated in rodents, demonstrated that angiostatic agents prevent the development of endometriosis-like lesions in the chicken chorioallantoic membrane. Nonsteroidal inflammatory drugs are very helpful in pelvic pain and dysmenorrhea associated with endometriosis.
Microlaparoscopy offers the advantage of carrying out many diagnostic and operative gynecologic procedures in a rapid, minimally invasive approach. Proper patient selection is very important for the success of the procedure. Microlaparoscopy could be performed either with general anesthesia or with local anesthesia under conscious sedation, which is a state of depressed consciousness allowing communication with the patient during the procedure. An umbilical incision is made (a local anesthetic block is done first in a case of conscious sedation) through which the interlocking trocar with the Verres needle is introduced to the abdomen. Most of the patients can leave the office within one hour of the procedure. Microlaparoscopy is currently used for infertility assessment, surgical management of endometriosis, lysis of pelvic adhesions, ovarian drilling, gamete intrafallopian transfer, tubal embryo transfer, hydrosalpinx removal before in vitro fertilization (IVF), and management of ectopic and heterotopic pregnancy.
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.
Ovarian hyperstimulation syndrome (OHSS) is characterized by ovarian enlargement and a shift of fluid from the intravascular to the extravascular space. OHSS is classified into mild OHSS, moderate OHSS, and severe OHSS. Vascular endothelial growth factor is a powerful mediator of vessel permeability. Angiogenin may play a role in neovascularization leading to the development of OHSS. The different complications of OHSS are vascular complications, liver dysfunction, renal complications, respiratory complications, and gastrointestinal complications. Current management of OHSS relies on the prediction and active prevention. Any patient undergoing ovarian stimulation is at risk of OHSS but it appears to be more frequent in younger women (aged less than 35 years) and women with polycystic ovarian syndrome (PCOS). This chapter discusses oestradiol monitoring of ovulation, ultrasonographic monitoring of OHSS, and prevention and treatment of OHS that includes basic treatment and surgical treatment.
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