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Prolactin exerts many physiologic functions, perhaps the most prominent of which is inducing lobuloalveolar growth of the mammary gland, along with stimulation of lactogenesis or milk production after giving birth. The majority of prolactinomas contains only lactotroph cells and produce prolactin in excess. The major mechanism is a threefold increase in prolactin secretion, and a one-third decrease in metabolic clearance rate. Oligomenorrhea, amenorrhea, galactorrhea, infertility, hot flashes, vaginal dryness, headaches, and visual changes are clinical manifestations of hyperprolactinemia in premenopausal women. Women who have lactotroph microadenoma causing hyperprolactinemia and hypogonadism and cannot tolerate or do not respond to dopamine agonists and do not want to become pregnant can be treated with estrogen and progestin. Cabergoline is the most effective of the dopamine agonists but is the most expensive. Intravaginal administration of dopamine agonists reduces their side effects.
The use of transvaginal ultrasound has not only revolutionized the diagnosis of cervical pregnancy (CP) but also dramatically improved patient survival and allowed physicians to consider other fertility sparing treatment options. Management of CP depends on a number of factors. These include the gestational age, patient stability, the desire to maintain future fertility, and the available resources and expertise where the patient is managed. Generally, if the gestational age is less than 9 weeks without fetal cardiac activity, systemic chemotherapy in the form of methotrexate alone is the first line of treatment. If there is fetal heart activity and the gestational age is less than 12 weeks, intra-amniotic potassium chloride injection (3-5ml of 2 mEq/ml) should be done first, followed by systemic methotrexate. Uterine artery embolization (UAE) has been used for many years in the treatment of symptomatic uterine fibroids and in acute obstetric hemorrhage.
This chapter discusses the outcome of in vitro fertilization (IVF) in medically complicated patients. A confounding factor for IVF pregnancies is the increased number of multiple pregnancies and the relatively increased number of high-risk pregnancies among women with chronic medical problems. Cancer patients present particular challenges to the IVF unit. Standard IVF protocols are used for controlled ovarian hyperstimulation in human immunodeficiency virus (HIV) discordant couples. The main concerns about IVF and malignant disease relate to the issue of the potential delay in the starting of the patient's chemotherapy or of any possible effect of hormonal changes on the cancer. Obesity might affect the outcome of IVF and pregnancy, but with careful management, a good outcome can be achieved. It has been suggested that systemic lupus erythematosus (SLE) may reduce the success of IVF-ET. The presence of antinuclear antibodies may reduce the implantation rate in IVF patients.
Female fertility begins to decline many years before menopause, despite continued regular ovulatory cycles. Decreased fecundity with increasing female age has long been recognized in demographic and epidemiological studies. Traditionally, the evaluation of the infertile female consists of: (i) ovulation assessment (ovulatory factors), (ii) evaluation of the uterine morphology (ovulation assessment) and tubal patency (tubal factors), (iii) assessment of the presence of pelvic pathology (by laparoscopy) (peritoneal factors), and (iv) postcoital test (cervical factors). Hysterosalpingography (HSG), laparoscopy are widely used in assessing infertility. Chlamydia antibody testing is a screening method for assessing tubal infertility. HSG, sonohysterography, hystero-salpingo contrast sonography (HyCoSy), magnetic resonance imaging (MRI) and hysteroscopy are used in assessment of uterine factors related to infertility. Currently, the best method to monitor ovulation is transvaginal ultrasound, which can be used to demonstrate the growth of a dominant follicle and provide presumptive evidence of ovulation and leutinization.
Intrauterine insemination (IUI) is one of the most commonly performed treatments for infertile or hypofertile couples. General indications for IUI include cervical factor infertility, male infertility, minimal to mild endometriosis, and unexplained infertility. Age of the female, duration of infertility, follicular count, presence of trilaminar endometrium, sperm count and morphology are the various parameters which determines the outcome of IUI. The choice of IUI versus other forms of artificial insemination, the use of natural cycles versus controlled ovarian hyperstimulation (COH), timing of insemination, the number of IUI cycles to be carried, whether the couple will need single or double insemination, the type of catheter, and the choice of sperm preparation technique are the various options available to the couples. Contamination with viruses has also occurred during use of reproductive technologies. However, there is evidence that use of IUI with washed sperm may decrease the risk of contamination.
There is a wide range of single-gene disorders that could be screened for using preimplantation genetic diagnosis (PGD). These mostly include Mendelian disorders like autosomal or X-linked disorders, whether recessive or dominant. The most common autosomal dominant diseases include myotonic dystrophy, Huntington disease, neurofibromatosis, and adenomatous polyposis coli. The aim of genetic counseling is to enable couples and families with genetic disadvantages to live and reproduce as normally as possible. Couples undergoing PGD should be advised to have protected intercourse or to abstain from sex to avoid the risk of spontaneous pregnancy during that cycle. Polar body biopsy is also known as preconception or pre-fertilization biopsy, and in some countries, it is the only form of PGD that is legally approved. Fluorescent in situ hybridization (FISH) is particularly useful when examining interphase nuclei, as with blastomeres.
Hyperprolactinemia has a detrimental effect on fertility both in women and men, leading to galactorrhea anovulation, amenorrhea, oligomenorrhea, impotence, gynecomastia, and low semen profile. Men with hyperprolactinemia not only show abnormal semen analysis but also abnormal histological structure of the testicles with distorted seminiferous tubules and abnormal sertoli cells. Many physiological and or pathological changes involving lactotroph cells can result in hyperprolactinemia. The majority of prolactinomas contains only lactotroph cells and produce prolactin in excess. Antihypertensive drugs like methyldopa and reserpine increases prolactin secretion. A dopamine agonist drug should usually be the first line of treatment for patients with hyperprolactinemia of any cause including lactotroph adenomas of all sizes. Bromocriptine, cabergoline, pergolide are the available dopamine agonists to treat hyperprolactinemia. Dopamine agonists decrease prolactin secretion and reduce the size of the lactotroph adenoma in more than 90 percent of patients. Surgical and radiation treatment are also useful.
Microlaparoscopy offers the advantage of carrying out many diagnostic and operative gynecologic procedures in a rapid, minimally invasive approach. Proper patient selection is very important for the success of the procedure. Microlaparoscopy could be performed either with general anesthesia or with local anesthesia under conscious sedation, which is a state of depressed consciousness allowing communication with the patient during the procedure. An umbilical incision is made (a local anesthetic block is done first in a case of conscious sedation) through which the interlocking trocar with the Verres needle is introduced to the abdomen. Most of the patients can leave the office within one hour of the procedure. Microlaparoscopy is currently used for infertility assessment, surgical management of endometriosis, lysis of pelvic adhesions, ovarian drilling, gamete intrafallopian transfer, tubal embryo transfer, hydrosalpinx removal before in vitro fertilization (IVF), and management of ectopic and heterotopic pregnancy.
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