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Human Assisted Reproductive Technology: Future Trends in Laboratory and Clinical Practice offers a collection of concise, practical review articles on cutting-edge topics within reproductive medicine. Each article presents a balanced view of clinically relevant information and looks ahead to how practice will change over the next five years. The clinical section discusses advances in reproductive surgery and current use of robotic surgery for tubal reversal and removal of fibroids. It looks into the refinement of surgical procedures for fertility preservation purposes. Chapters also discuss non-invasive diagnosis of endometriosis with proteomics technology, new concepts in ovarian stimulation and in the management of polycystic ovary syndrome, and evidence-based ART. The embryology section discusses issues ranging from three-dimensional in-vitro ovarian follicle culture, and morphometric and proteomics analysis of embryos, to oocyte and embryo cyropreservation. This forward-looking volume of review articles is key reading for reproductive medicine physicians, gynecologists, reproductive endocrinologists, urologists and andrologists.
The relocation of ovaries for their protection in women diagnosed with cancer in the pelvis was mentioned as early as 1958 by McCall et al. At that time, the procedure was termed oophoropexy and considered to be revolutionary, controversial and "cutting edge" fertility preservation. Ovarian function is compromised when damaged during surgery, exposed to radiation, and/or chemotherapy. Chemotherapy has been found to have a highly variable chance of acute ovarian failure. In general, for gynecological malignancies, cervical and uterine cancers are the most likely indications for adjuvant or definitive radiation treatment to the pelvis, but pelvic radiation is also done for Hodgkin's lymphoma, pediatric sarcomas and rectal cancer. Ovarian function is almost guaranteed to be entirely lost without some intervention before pelvic radiation therapy. Ovarian transposition is a relatively simple option that should be considered with all patients at risk for ovarian failure due to radiation.
This chapter discusses fertility preservation and reviews the recent evidence on the pathophysiology of chemotherapy/radiotherapy-induced gonadal toxicity and the recent data on the indications and the outcomes of techniques used for fertility preservation in female cancer patients. The exact incidence of premature ovarian failure (POF) following chemotherapy is difficult to establish since many factors contribute to ovarian failure. Several reproductive-age malignancies afflicting pelvic organs can be cured with radiotherapy. These include cervical, vaginal, and anorectal carcinomas, some germ cell tumors, Hodgkin's disease, and central nervous system tumors. A wide variety of strategies have been assessed for fertility preservation in females which includes chemoprotection, ovariopexy, and assisted reproductive technologies. Keeping the testicles outside the field of radiation or being shielded has been shown to be an effective strategy to prevent radiation-induced testicular damage. Semen cryopreservation and testicular tissue cryopreservation are fertility preservation measures in male using assisted reproductive technologies.
Uterine anomalies are a relatively common congenital abnormality, with uterine septum being the most common (Table 8.1.1). This is even truer in patients with recurrent pregnancy loss, in whom rates of uterine abnormalities may approach 15% to 27%. Historically, the uterine septum has been approached via laparotomy through either a Tompkins or Jones procedure. These successful but highly morbid procedures required laparotomy, significant hospital stays, and subsequent cesarean delivery and had a high risk of adhesion formation. More recently, this surgery has been supplanted by hysteroscopic or other minimally invasive methodologies for treatment. This section focuses on the embryologic development of the genital tract that may lead to mullerian abnormalities, discusses the work-up of patients before treatment, evaluates the appropriate candidates for surgical procedures, and discusses the technical aspects of the procedure itself, postoperative recommendations, and results of various modalities of treatment. In addition, complications specific to these procedures are reviewed.
It is unclear what the exact rate of mullerian abnormalities is in the general population as there have been no good cross-sectional studies of normal patients. It is believed that the incidence is in the range of 1% to 6%, and there are numerous variations. The American Fertility Society (now the American Society for Reproductive Medicine) has published a classification system to standardize the nomenclature among surgeons (Tables 8.1.1, 8.1.2).
The development of surgical robotics is a dynamic process, a constant interplay between clinical need and technologic capability. As both of these factors are constantly changing, it is unlikely that the form the surgical robot takes today will be the form it takes in 20 years. In many aspects, the technology has progressed beyond perceived clinical need. This has created a novel challenge for the surgeon — to determine whether a technologic innovation with apparent benefit has meaningful clinical application. This process has defined the in corporation of robotic technologies into many surgical disciplines, including gynecologic, cardiothoracic, urologic, abdominal, and pediatric surgeries. In whatever way this interplay of technology and clinical need progresses, surgeons are left with the task of guiding its impact on patient care.
The term robot is a misnomer when describing this surgical device. Derived from the Czech robota meaning “drudgery,” this term implies autonomous function, which most surgical robots do not have. Instead, they are better described as computerassisted telemanipulators, implying that they are subject to human control. The complexity of surgical procedures does not currently allow for devices that work entirely autonomously. Nevertheless, the term robot has added a flare of futurism to the endeavor and has been the one most commonly used in the literature.
Uterine leiomyomas are monoclonal smooth muscle tumors. Early research on isoform analysis of glucose-6-phosphate dehydrogenase in the smooth muscle cells of uterine leiomyomas pointed to the monoclonal nature of this tumor. Each leiomyoma lesion in the uterus may have a distinct isoform and are presumed to arise independently. Cytogenetic abnormalities of several chromosomes have been identified within these smooth muscle tumors with normal karyotype in the adjacent non-tumorous regions. These cytogenetic mutations have been identified in about 40% of uterine leiomyomas. Some of the mutations involve genes involved in cellular growth regulation. Correlation between the genotype of the leiomyomas and the phenotype has not led to conclusive observations.
Uterine leiomyomas are usually well-circumscribed tumors. They can occur in any part of the uterus, including the cervix. They may also occur in the round ligaments. Generally they are divided into subserosal, intramural, and submucosal. The subserosal and submucosal uterine leiomyomas can become pedunculated. The submucosal uterine leiomyomas can protrude into the uterine cavity or become pedunculated, and protrude through the cervix. Uterine leiomyomas can become separated from the uterus, and can be found in different areas such as the retroperitoneal space between the leaves of the broad ligament of the uterus.
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