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Expectant management has a key role in the management of unexplained infertility. The decision to treat couples with unexplained infertility should take into account their chances of spontaneous conception, which is affected by female age, duration of infertility and occurrence of a previous pregnancy. The rationale for the use of oral clomifene citrate in unexplained infertility is the belief that it corrects subtle ovulatory dysfunction and encourages the release of more than one oocyte. Clomifene is inexpensive, non-invasive and requires little clinical monitoring, but it can cause multiple pregnancies, including high-order multiples. Intrauterine insemination (IUI) has been used widely for the treatment of unexplained infertility. It is thought to enhance the chance of pregnancy by increasing the number of motile spermatozoa within the uterus, bringing them in close proximity to the oocyte. Although more effective than IUI, superovulation (SO) along with IUI is associated with high rates of multiple births.
Demands on the gynaecologist from patients seeking help with suboptimal fertility continue to grow, and fertility-related issues are often in the gaze of the media. Obstetricians and gynaecologists need to ensure that they are up to date, informed and knowledgeable to successfully engage with their patients. Written by nationally recognised leaders in the field, this volume concisely reviews contemporary clinical practice. Using an aetiology-based approach, the evidence underpinning the management of ovulatory dysfunction, male infertility, endometriosis, tubal, uterine factor, and unexplained infertility is critically reviewed. The role of assisted reproduction treatment is elaborated and a new chapter describes the clinical and laboratory techniques involved. The book provides a comprehensive summary for candidates preparing for the Part 2 MRCOG examination, covering the RCOG curriculum for infertility management. It will be enormously helpful to health professionals working in fertility clinics and an essential aide-memoire to those undertaking special interest training in infertility.
Infertility affects up to one in six couples and remains a major cause of distress in both men and women. Concerns about fertility continue to grow across the world along with economic and social pressures causing women to delay childbirth, and the impact of lifestyle factors such as obesity, smoking and alcohol intake.
The last two decades have witnessed a shift towards evidence-based fertility treatment and greater awareness of the need to ensure the highest standards of safety. Management of infertility has moved away from an aetiological pathway where physicians identify and then treat an underlying pathology, to a prognostic approach where the decision to initiate treatment is driven by awareness of a couple's chances of spontaneous conception and what can be achieved with intervention.
To address the changes in the way fertility problems are now diagnosed, investigated and managed, we have substantially redesigned the third edition of this book, enlisting a new cast of authors and expanding the scope of the text. While the evidence base underpinning the choice of tests and treatments is sometimes far from secure, clinical decisions should be made jointly with patients and should maximise health gains while minimising costs and risks.
Infertility remains an integral part of core training for those taking the MRCOG examination. We hope that this book will provide a concise guide to fertility practice for trainees as well as for specialists.
A number of tests have been used to predict ovarian ageing/poor ovarian reserve. Despite the large number of tests in current use, an ideal test has yet to be developed. The most comprehensive systematic review for tests of ovarian reserve concluded that an in vitro fertilisation (IVF) cycle itself may be a more reliable predictor of ovarian response to stimulation than any of the existing tests. The predictive value of four of the most commonly used tests are: basal serum follicle-stimulating hormone, antral follicle count (AFC), serum inhibin B and serum antimillerian hormone (AMH). Internationally, a number of fertility prediction tests have been marketed, and the tests have been mainly developed within an IVF setting, using data on outcomes of ovarian stimulation. Serum AMH concentration and AFC tests can predict oocyte yield but not oocyte quality or pregnancy.
This chapter presents suggested options for the elimination of multiple pregnancies including selective fetal reduction, single blastocyst transfer and elective single-embryo transfer (eSET). Selective fetal reduction carries a risk of miscarriage and poses serious ethical and legal questions. Three trials comparing eSET with elective double embryo transfer (DET) were identified. All involved women who had undergone embryo transfer in a fresh in vitro fertilisation (IVF)/intracytoplasmic sperm injection (ICSI) cycle. It is clear that in a selected population the cumulative outcome of eSET is comparable with that of DET while virtually eliminating multiple pregnancies. The outcome of an eSET policy can be substantially enhanced in conjunction with an efficient and reliable embryo cryopreservation programme. Twin pregnancies resulting from IVF treatment are associated with higher maternal and perinatal morbidity. More data from pragmatic trials are to demonstrate whether a policy of eSET is effective, acceptable and financially viable in other clinical settings.
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