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Endometriosis causes pain and infertility for millions of women worldwide. The prevalence of endometriosis is 6-10% in women of reproductive age, and 30-50% of women with pelvic pain and/or infertility. For definitive diagnosis and staging of endometriosis, a surgical procedure, generally a laparoscopy, is necessary to visualise disease implants. More recently, magnetic resonance imaging (MRI) has been used as a non-invasive tool in the diagnosis of deep endometriosis. The aim of treatment of endometriosis is to remove or reduce disease deposits. This may be attempted through medical or surgical means. Although assisted conception treatments such as ovulation induction with intrauterine insemination (IUI), or in vitro fertilisation (IVF), do not treat endometriosis per se, they can successfully treat the associated infertility. All couples presenting with failure to conceive should undergo a full evidence based fertility work-up. This includes a semen analysis, confirmation of ovulation and tubal patency testing.
A number of studies have shown that the presence of ovaries of polycystic morphology, regardless of whether there are additional features of the full polycystic ovary syndrome (PCOS), significantly increase the risk of developing moderate to severe ovarian hyperstimulation syndrome (OHSS). in vitro maturation (IVM) is an approach with the potential to increase both the simplicity and safety of assisted reproductive technology (ART) treatment through the absence of the need for ovarian stimulation. IVM is a promising technique for women with anovulatory PCOS. The success rates are currently lower than those achieved with in vitro fertilisation (IVF) but IVM is safer and easier to undertake for the woman and it avoids gonadotrophin stimulation and the attendant risk of OHSS. While IVM is apparently safer for the woman, long-term paediatric studies are required before IVM can be fully assessed, which is also the case for other ART treatments.
Tim J. Child, Women's Centre, John Radcliffe Hospital, Oxford, UK,
Imran R. Pirwany, McGill Reproductive Centre, Royal Victoria Hospital, Montreal, Quebec, Canada,
Seang Lin Tan, McGill Reproductive Centre, Royal Victoria Hospital, Montreal, Quebec, Canada
When an appropriate follicular response to gonadotrophin stimulation has been achieved, the patient receives a subcutaneous injection of 5000 or 10000 iu of human chorionic gonadotrophin (HCG) to commence the final stage of oocyte maturation. Many women require more than one in vitro fertilisation (IVF) cycle and oocyte retrieval can be a painful procedure. Therefore, adequate sedation and analgesia is important for oocyte retrieval. The vacuum pressure for follicular aspiration should be less than 150 mmHg, since at pressures above this the rate of oocyte injury increases. Randomized controlled trials demonstrate that follicular flushing after aspiration does not significantly increase the number of oocytes retrieved or the pregnancy rate. During oocyte retrieval the aspiration needle should avoid endometriomas. This chapter discusses risks of oocyte retrieval, immature oocyte recovery and embryo transfer with embryo transfer procedures applicable in special circumstances.
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