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  • Cited by 2
  • 2nd edition
  • Edited by Gab Kovacs, Monash IVF, Melbourne, Australia
Cambridge University Press
Online publication date:
December 2010
Print publication year:
Online ISBN:

Book description

The fully revised and updated second edition of this practical handbook provides comprehensive coverage of all aspects of subfertility, including treatment and diagnosis. Each chapter is written by a recognized world expert in the field and, together, they aim to provide state of the art answers to all the problems of subfertility in a single volume. The introductory chapter provides a flow-chart approach to systematic diagnosis and treatment. Clearly written and easy to read, the subsequent chapters describe what questions to ask, how to investigate, and what each treatment requires. With an expanded international team of authors, this new edition also offers new chapters devoted to third party reproduction and in vitro maturation of oocytes. From medical students studying for examinations to consultant physicians, this volume is a 'must-have' reference for anyone dealing with couples who have fertility problems.


‘The authors offer clear guidance and plans for those starting in the field, who need a template if they are to acquire good habits of clinical practice and data gathering ... the book can be highly recommended to newcomers as a clear guide to practice and knowledge.'

Francoise Shenfield Source: Journal of the Royal Society of Medicine

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  • Chapter 6 - Ultrasound in the investigation of the subfertile female
    pp 60-75
  • View abstract


    This introduction presents an overview of the concepts discussed in this book. This book provides a comprehensive approach to each of the possible factors that act as a barrier to conception. The probability of conception depends on the success rate of the particular treatment, and the number of cycles of treatment that a couple undertake. This has been applied to the lifetable analysis of repeated treatment cycles by donor insemination, ovulation induction, and in vitro fertilization (IVF). There are the three main fertility parameters (eggs, sperm, and tubes), and if these are found to be relatively normal and the couple still does not conceive, then it is termed as unexplained or idiopathic subfertility. The most effective option to proceed to next if unexplained subfertility is diagnosed is IVF. The chapter presents an overview of how other chapters of the book are organised.
  • Chapter 7 - Treatment options for male infertility
    pp 76-87
  • View abstract


    Preconception counseling is far beyond providing information about pregnancy to women prior to conception. It is an ultimate period for risk assessment, health promotion and medical/psychosocial interventions. Low pre-pregnancy weight increases risks for preterm birth and low birth weight both associated with significant neonatal morbidity. The assessment of the woman's vaccination history is strongly recommended before beginning the treatment of infertility. Identified risk factors that require referral to genetic counseling include developmental delay, congenital anomalies or any genetic family disorders, chromosomal anomalies or known genetic conditions in at least one member of a couple. For the majority of chronic diseases, optimal control prior to conception is associated with favorable maternal and neonatal outcomes. Men should be targeted because their lifestyle and general health affect semen quality and the health of their offspring, and influence women's compliance with recommendations.
  • Chapter 8 - The management of anovulation (including PCOS)
    pp 88-99
  • View abstract


    The first interview with a specialist for any patient is important as it allows a bond of trust to be established and the patient to gain confidence in the advice and strategies that the specialist recommends. This bond is more important with infertility patients. A good starting point in history-taking is to enquire about the couple's occupations. Religious, ethnic or cultural background may determine the way they are evaluated and could exclude certain treatment options. After completing the history-taking one should proceed with a physical examination. For the female, a general examination should include vital signs, assessment of the development of secondary sexual characteristics and any sign of endocrine disorders. Physical examination of the male should begin with assessing the secondary sexual characteristics, including body habitus, hair distribution and breast development. By the end of the physical examination, a provisional plan of the investigations and treatment options should be discussed.
  • Chapter 9 - The role of artificial insemination with partner semen in an ART program
    pp 100-111
  • View abstract


    Usually investigation for infertility is carried out by gynecologists, because if a couple failed to conceive it has been traditionally expected that the woman has a problem and should visit a doctor. The general examination starts when the patient comes into the consulting room from observations of body habitus, skin, hair excess, gait and posture. Ultrasonography is a more accurate method compared with bimanual examination so more precise data about ovaries and uterus may be obtained with a transvaginal ultrasound probe than with palpation. The assessment of ovulation involves history, examination and investigation. At hysterosalpingography (HSG) radio-opaque dye is injected through the small canula via the cervix into the uterine cavity under X-ray screening. In patients with infertility, diagnostic hysteroscopy is usually combined with laparoscopy. X-chromosome abnormalities may affect fertility in women with Turner syndrome, especially in mosaic form.
  • Chapter 10 - Early pregnancy loss
    pp 112-122
  • View abstract


    A complete history and physical exam is the cornerstone of the evaluation of the infertile male. The semen analysis is critical in the initial evaluation of the infertile man and to a large extent guides further work-up. Karyotype analysis and microdeletion analysis of the Y chromosome are indicated for men with severe oligospermia or azoospermia because of the common detection of genetic anomalies in men with low sperm production. Computer-assisted semen analysis (CASA) has been developed to overcome the highly subjective nature of conventional analysis of sperm morphology and quality. The post-coital test evaluates the interaction between sperm and the cervical mucus environment in the woman. In light of an abnormal post-coital test or in cases of idiopathic infertility, antisperm antibody testing may be obtained. With a thorough understanding of the proper work-up algorithm, there is less unnecessary testing, which will benefit patients both financially and emotionally.
  • Chapter 11 - In vitro fertilization:
    pp 123-134
  • indications, stimulation and clinical techniques
  • View abstract


    The use of pelvic ultrasound to investigate the subfertile female needs a close collaboration between the gynecologist and the radiologist. Ultrasonography is now a must in the investigation of ovulation disorders, along with clinical findings and hormonal assays. It allows estimation of the ovarian function, mainly estrogen secretion, through measurement of the endometrial thickness: endometrial atrophy or severe hypotrophy (thickness more than 5 mm) indicates hypoestrogenism. It also contributes greatly to the diagnosis of ovulation disorders, in particular polycystic ovary syndrome (PCOS) and primary ovarian failure (POF), along with the clinical/biological data. The ultrasound is sensitive in detecting those lesions that are responsible for infertility through interference with egg migration and implantation and/or with sperm progression, such as fibroids, polyps, synechiae, or malformations. The 3D ultrasound can help in the diagnosis of uterine malformations. The majority of tubal obstructions are secondary to sexually transmitted infections, particularly gonorrhea and chlamydia.
  • Chapter 12 - In vitro maturation
    pp 135-147
  • View abstract


    Male reproductive dysfunction is the sole or contributory cause in half of infertile couples. Some health issues are more prevalent in infertile men and must be sought and the opportunity taken to assess and improve general and sexual health. Spontaneous conception may occur in many couples with male factor subfertility. In counseling patients, the severity of the male's reproductive problem, the duration of unprotected intercourse, and its frequency and timing, and the female partner's age and reproductive status are all important variables. There is a substantial background rate of spontaneous conception in subfertile men such that about 30% of couples with sperm densities of 1-5 million/ml as the only apparent fertility issue, achieved pregnancy over a two- to three-year period. Depending on the couple's age and reproductive history, some couples are happy to delay treatment in the hope that they will conceive while others express a wish for immediate intervention.
  • Chapter 13 - The use of donor insemination
    pp 148-157
  • View abstract


    Chronic anovulation is an important cause of infertility, accounting for approximately 20% of all causes. Men should have had a semen analysis and women should have had the basic infertility work-up including an assessment of tubal patency. In 1973 the World Health Organization published a simple classification of anovulation, namely, WHO I, II and III. WHO I patients are characterized by a history of amenorrhea. WHO II is characterized by a history of oligomenorrhea, although there may be some with amenorrhea. Central obesity is a cardinal feature of women with polycystic ovary syndrome (PCOS) with an increased waist-hip ratio. WHO III is characterized by oligoamenorrhea, and may present with menopausal symptoms, such as hot flushes, night sweats, and vaginal dryness. This chapter presents the treatment for WHO I, II, and III patients. The treatment involves lifestyle modification, aromatase inhibitors, insulin-sensitizing drugs, and hyperprolactinemia.
  • Chapter 14 - Using donor oocytes
    pp 158-165
  • View abstract


    The rationale behind intrauterine insemination (IUI) with partner sperm is bypassing the cervical-mucus barrier and increasing the number of motile spermatozoa with a high proportion of normal forms at the site of fertilization. This chapter examines the value and position of homologous intrauterine insemination in an assisted reproductive technology (ART) program. Some of the factors influencing IUI success include site of insemination, number of inseminations, exact timing of IUI, sperm preparation methods and fallopian tube sperm perfusion. Artificial inseminations can be done intravaginally, intracervically (ICI), pericervically using a cap, intrauterine (IUI), transcervical intrafallopian (IFI) or directly intraperitoneal (IPI). Most studies refer to IUI, which seems to be an easy and better way of treatment. IUI should be promoted as the best first-line treatment in most cases of subfertility provided at least one tube is patent and an IMC after sperm preparation of more than 1 million can be obtained.
  • Chapter 15 - Embryo donation:
    pp 166-175
  • practice and ethical dilemmas
  • View abstract


    Among married women in the USA, 4% have experienced two clinical pregnancy losses and 3% three. The frequency of losses in human preimplantation embryos is very high. Of morphologically normal embryos, approximately 25-50% show chromosomal abnormalities, depending on maternal age. Luteal phase deficiency (LPD) has long been hypothesized, specifically due to inadequate progesterone secreted by the corpus luteum. Decreased conception rates and increased fetal losses are logically associated with overt hypothyroidism or hyperthyroidism. Only women with poorly controlled diabetes mellitus have increased risk for fetal loss. Leiomyomas plausibly could cause early pregnancy loss, but analogous to Müllerian fusion anomalies the coexistence of uterine leiomyomas and reproductive losses need not necessarily imply a causal relationship. An association between second- and third-trimester pregnancy loss and acquired thrombophilias is accepted, but the role thrombophilias play in first-trimester losses is less certain.
  • Chapter 16 - Endometriosis and its treatment
    pp 176-184
  • View abstract


    In vitro fertilization (IVF) and other assisted reproductive techniques are now fully accepted modalities of treatment for subfertility in our modern world. The indications for IVF have increased with the development of newer techniques such as ICSI, surgical sperm retrieval, embryo biopsy, and cryopreservation techniques, and IVF has become the cumulative step for the diagnosis and treatment for unexplained infertility. Certain indications for subfertility discussed in this chapter include tubal infertility, endometriosis, ovarian dysfunction, surrogacy, and male factor. The typical IVF cycle involves the following stages: stimulation for multiple follicular development, monitoring follicular growth and development, trigger of follicular maturation, oocyte recovery and identification, insemination/ICSI, embryo culture, embryo replacement, luteal phase support and confirmation of pregnancy. Traditionally, pregnancy rate per cycle has been used to compare results but gradually cumulative pregnancy outcome over the course of treatment may become more pertinent to the couple.
  • Chapter 17 - The role of surgery in female subfertility
    pp 185-192
  • View abstract


    In vitro fertilization (IVF) has completely changed the field of reproductive medicine. More than 80% of oocytes were reported to resume meiosis independent of the menstrual cycle day and gonadotropin support in in vitro maturation (IVM) medium. Collection and IVM of these already existing immature oocytes provides multiple metaphase II (MII) oocytes that can be fertilized in vitro. Young women with high antral-follicle counts achieve the highest pregnancy rates with IVM. Therefore, IVM is considered an established treatment option for women with polycystic ovaries (PCO) or polycystic ovarian syndrome (PCOS) who need treatment with assisted reproductive technologies (ART). Age of the woman and the number of oocytes collected are the two most important determinants of pregnancy following an IVM cycle. Young women with PCO are the best candidates for IVM treatment. IVM is a relatively new technology and clinical experience with this technique is limited compared to conventional IVF.
  • Chapter 18 - Laboratory techniques in IVF
    pp 193-210
  • View abstract


    Donor insemination (DI) remains a very important treatment option with acceptable pregnancy rates. In order to optimize pregnancy rates with DI, careful consideration should be given to various aspects of this service, including the recruitment and screening of sperm donors, cryopreservation of semen, and the screening and management of recipients. This chapter examines these important aspects of treatment to consider how to optimize DI services in the future. Treatment using DI was initially designed to treat male factor infertility. However, DI remains a therapeutic option for male factor infertility when either too few or no sperm are obtained at surgical sperm aspiration. With the advent of intracytoplasmic sperm injection (ICSI) many assumed that DI would become a very limited treatment. Although the numbers of cycles have reduced considerably there has been an increasing trend for DI to be used for other groups of patients such as single women and lesbians.
  • Chapter 19 - Infertility counseling
    pp 211-224
  • View abstract


    Women are delaying childbirth and trying to conceive when they are over 35 years old and at this age their chances of achieving a pregnancy with their own oocytes suffer a progressive and dramatic drop. The main indications for which a woman undergoes oocyte donation are usually occult ovarian failure, advanced age and repeated failure of in vitro fertilization (IVF). The women who donate oocytes are young, with no previous pathology and with a high reproductive potential. This explains the high clinical pregnancy rates that are usually achieved with this treatment. Patients with ovarian failure due to Turner syndrome attend hospitals asking to be included in the oocyte-donation programs. It is very important to remember that in women with Turner syndrome, the risk of aortic dissection or rupture during pregnancy may be 2% and the risk of death during pregnancy is increased as much as 100-fold.


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