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The endometrial scratch has become a popular intervention in IVF, particularly in the management of patients presenting with recurrent implantation failure. However, randomised controlled trials that fail to show any benefit on clinical outcomes have recently been published. Given the invasive nature and uncertain putative mechanism of action, there is now a narrative that it should no longer be part of the therapeutic repertoire. In this article, the debate is not about whether the scratch should be used in routine clinical practice: there is enough convincing evidence to indicate it should not. What is challenged is the notion that the studies thus far performed allow the conclusion to be drawn that it will not be of value to any patient and has therefore ‘had its day’. A case is made for a different approach to assessing the efficacy of interventions in the management of recurrent implantation failure.
Clinical case studies have long been recognized as a useful adjunct to problem-based learning and continuing professional development. They emphasize the need for clinical reasoning, integrative thinking, problem-solving, communication, teamwork and self-directed learning - all desirable generic skills for health care professionals. This volume contains a selection of cases on assisted reproduction that will inform and challenge reproductive medicine practitioners at all stages in their careers. Both common and uncommon cases are included. The aim is to reinforce diagnostic skill through careful analysis of individual presenting patterns, and to guide treatment decisions. Each case consists of a clinical history, examination findings and special investigations, before a diagnosis is made. Clinical issues raised by each case are discussed and major teaching points emphasized. Selective references are provided. The book provides a useful complementary adjunct to existing textbooks of reproductive medicine, and an excellent resource for teaching and continuing professional development.
In vitro fertilization (IVF) treatment itself has been shown to evoke psychological symptoms in women. The relation between distress and IVF success rates seems more complex than commonly believed. Psychological problems are considered to be an effect of infertility rather than a cause. Since the psychological consequences model of infertility became popular in the 1980s, professionals in the infertility field have recommended the provision of psychosocial counseling to couples with fertility problems. Counseling might be more beneficial for couples who already experience high levels of distress at the start of their first IVF cycle. Future research should therefore be aimed at identifying couples that are particularly vulnerable to distress during treatment. Educational interventions which focus on information provision and skills training lead to more positive changes in people with fertility problems than counseling interventions, which focus on emotional expression and support.
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.
This chapter focuses on the primary antiphospholipid syndrome, that is, in the absence of systemic lupus erythematodes. Women with thrombophilia have an increased baseline risk of venous thromboembolism. In antiphospholipid syndrome, lupus anticoagulant is more strongly related to venous thrombosis and pregnancy complications than antibodies against phospholipids. The chapter reviews the evidence regarding potential clinical implications of acquired and inherited thrombophilia for both venous thromboembolism and for pregnancy failure. Treatment guidelines vary with regard to the administration of heparin for antiphospholipid syndrome and recurrent miscarriage. For women with antiphospholipid syndrome, the evidence regarding the efficacy of aspirin with or without the addition of low-molecular-weight heparin is not solid, whereas two small trials have shown a clear benefit of unfractionated heparin. For women with inherited thrombophilia, low-molecular-weight heparin to prevent pregnancy loss is definitely experimental as solid evidence is not yet available.