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Uterine and tubal abnormalities alone or in combination with other factors are present in 17%–25% of all couples who seek care for infertility treatment. The prevalence is higher in older women and in those with secondary infertility. Although suspected at the history, it is usually confirmed by ultrasound/ laparoscopy and/or MRI depending on the cause. Multiple pathologies are identified under the umbrella of tubal and uterine factors, some are associated with infertility but very few are proven to be the only cause of infertility. Treatment depends on the condition. It ranges from no intervention to surgery to in vitro fertilisation (IVF). With advances in the technology of IVF, surgery is becoming a lost art, especially for tubal factors. Various surgical techniques have been suggested for uterine factors. Given most tubal and uterine factors have association rather than causation for infertility, the effect of surgery on improving fertility is debatable. We will discuss the causes of uterine and tubal factors, their implications on fertility, diagnostic modalities and treatment options with limitations of the available evidence. A good history and a high index of suspicion along with primary and secondary prevention of tubal and uterine factor infertility are important to prevent long-term implications.
This chapter focuses on in vitro fertilisation (IVF), the most common assisted reproductive technology (ART) procedure. The use of IVF has radically transformed the way in which we approach the management of infertility, irrespective of the diagnosis, and it is integral to the infrastructure of a modern fertility service. Monitoring of treatment includes follicle tracking with ultrasound and ovarian steroid measurement. In the early days of IVF, oocyte collection procedures were done under laparoscopic guidance. After oocyte retrieval, freshly ejaculated seminal fluid is prepared to concentrate motile spermatozoa in a fraction that is free of seminal plasma and debris. Embryologists then have to decide whether they are going to perform conventional IVF or need to inject sperm directly into the oocyte (intracytoplasmic sperm injection (ICSI)). Two major complications of ART to consider are multiple pregnancy and ovarian hyperstimulation syndrome (OHSS).
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.
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