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The cervix is the cylindrical portion of the uterus which enters the vagina and lies at right angles to it. It is well documented in the literature that pregnancy following assisted reproductive technologies (ART) has a higher risk of adverse outcomes. A meta-analysis comparing in-vitro fertilization (IVF) with spontaneous conceptions showed that IVF singleton pregnancies had significantly higher odds of perinatal mortality. Cervical funneling is described as dilatation of the internal os so that the cervical canal changes in shape, with bulging of the bag of membranes through the dilated cervix into the cervical canal. Vasa previa is diagnosed by transvaginal or transabdominal ultrasound, and with Doppler flow studies. Cervical pregnancy is a rare ectopic pregnancy defined as implantation of the gestational sac in the endocervix. Due to its difficult diagnosis, cervical pregnancy should be differentiated from the cervical stage of spontaneous abortion, nabothian cyst, and cervical choriocarcinoma.
The male is solely responsible for the failure to conceive in about 20% of infertile couples, and contributory in another 30–40%. Reduced male fertility can derive from congenital or acquired urogenital abnormalities, infection of male accessory glands, increased scrotal temperature, endocrine disturbances, genetic abnormalities or immunological factors. However, no demonstrable etiology can be diagnosed in 48.5% of cases of male infertility. An abnormal semen analysis (SA) suggests the presence of a male factor; however, a normal SA does not preclude a male factor being present.
The goals of the evaluation of the infertile male are to identify:
potentially correctable conditions
irreversible conditions amenable to assisted reproductive technologies (ART) using male gametes or donor insemination if the male partner's sperm is not procurable
life- or health-threatening conditions that may underlie infertility and require medical attention
genetic abnormalities that may affect the health of off spring if passed on via advanced reproductive techniques.
Traditionally, evaluation of infertility is postponed until one year of unprotected intercourse. However, it is justified to initiate an evaluation earlier if one of the following conditions is present:
defined male infertility risk factors
female infertility risk factors, including advanced age (> 35 years)
the male or female partner requests an earlier evaluation.
Initial evaluation of the male usually consists of two semen analyses separated by at least a month, a medical and reproductive history, and a focused physical examination by a urologist/andrologist.
Many couples whose infertility treatment requires in-vitro fertilization (IVF) also need intracytoplasmic sperm injection (ICSI) as a part of the procedure. In many respects ICSI has revolutionized infertility treatment as a whole. Both research data and clinical experience have shown that providing a sperm sample during this crucial stage of IVF/ICSI treatment could increase performance anxiety for both fertile and infertile men. The successful use of assisted reproductive technologies over the past 25 years or more has brought with it procedures that allow couples who cannot conceive using their own gametes the alternative of achieving pregnancy through the use of donated oocytes, donated sperm, and even donated embryos. The psychological evaluation is also intended to rule out gross psychopathology and depression, potential substance abuse, as well as a history of current or past family violence or abuse. Marital stability is also assessed within the context of the consultation.
Transrectal ultrasound (TRUS) evaluates the distal components of the ejaculatory duct system including the ampullae of the vas deferens, the seminal vesicles, ejaculatory ducts, and the prostate. Patients with complete distal ejaculatory obstruction and partial distal obstruction are ideal candidates for TRUS evaluation. The examination can be performed with the patient in the lithotomy, knee-chest, or lateral decubitus position. Lateral decubitus position is the preferred position as this provides easy access for the operator and less discomfort for the patient. On TRUS examination, the seminal vesicles appear as hypoechoic areas with fine septations. Anteroposterior diameter up to 15 mm is considered normal. Importantly, TRUS can reveal the anatomical relationship between ejaculatory channels and calcifications. It can also detect proximal dilatation of the ejaculatory tract, which indirectly implies the presence of a distal obstruction. TRUS can also be used for therapeutic aspiration and reduction in the size of obstructive cysts.
Encompassing a broad spectrum of conditions, ejaculatory dysfunction (EjD) includes premature ejaculation (PE), anejaculation(AE), and retrograde ejaculation (RE). This chapter discusses the incidence rate, diagnosis methods and treatment options available for treating EjD. Behavioral/psychological treatments, topical anesthetic agents, serotonin reuptake inhibitors (SSRIS) and phosphodiesterase (PDE)-5 inhibitors are the treatment options available for PE. Penile vibratory stimulation, electroejaculation, and surgical sperm extraction from the epididymis or testes are all successful methods for obtaining sperm for later use with ART in AE where the success rates of other methods are low. Common causes of RE can be categorized as anatomic, neurogenic, pharmacological, or idiopathic in origin. Anticholinergics, alpha-adrenergic agonists, or similar combinations may be used to modulate bladder neck activity but are not as effective as imipramine, which should be considered the first-line therapeutic agent for RE.
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