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Treatment with progesterone has been found to improve pregnancy rates in menstruating women with luteal phase defect. Vaginal route of progesterone supplementation has gained wide application mainly due to patient comfort and effectiveness. The use of human chorionic gonadotropin (hCG) may rescue the function of the failing corpus luteum in in vitro fertilization (IVF) cycles. In a prospective randomized study that compared the efficacy of luteal phase support (LPS) using either hCG, hCG in combination with daily vaginal progesterone or vaginal progesterone only, there were no statistically significant differences in the clinical ongoing pregnancy rate between the three groups. A recent trial evaluating the addition of oestrogen (E2) to vaginal progesterone in gonadotropin releasing hormone (GnRH) antagonist cycles showed that the endocrine profile was similar in the group that received progesterone and E2 or progesterone alone.
This chapter discusses the methods currently used for the assessment of ovarian reserve and the prediction of ovarian response to stimulation. It highlights that even when using very low follicle stimulating hormone (FSH) levels the accuracy in the prediction of ovarian reserve is only modest, making it inferior to other markers currently used. Antral follicle count (AFC) was found to correlate with, but was superior to, biochemical markers such as basal estradiol (E2), inhibin B, and FSH in predicting ovarian responsiveness. The combination of markers has been proposed for a better estimate of functional gonadal capacity. Ovarian reserve tests have only modest predictive value, especially in the prediction of occurrence of pregnancy and live birth. More studies are needed to evaluate the use of anti-Mullerian hormone (AMH) in conjunction with AFC in the prediction of ovarian reserve and ovarian response.
Clinically, adenomyosis is usually seen in women in their thirties but has been seen from the early twenties into the postmenopausal period. Pathologically, adenomyosis is confirmed if there are ectopic endometrial glands and stroma in the myometrium. This induces hyperplasia and hypertrophy of the adjacent smooth muscle, causing uterine enlargement. The sonographic diagnosis of fibroids has long been confused with that of adenomyosis. Leiomyomata or fibroids are common in women, with an increased incidence of 7 times in blacks and nulliparous women. In adenomyosis, the myometrium has areas of increased echogenicity that may be subtle and best appreciated with higher-resolution ultrasound scanners. The diagnosis of adenomyosis should not depend only on the sonographic appearance but must rather consider the whole picture or triad of history, sonographic features, and signs of tenderness. Adenomyosis has been suspected as cause of infertility. The treatment of adenomyosis is mainly symptomatic.
A transvaginal scan (TVS) is performed with an empty bladder using a curvilinear, multifrequency, endocavity transducer with a typical central frequency of 6.5MHz. A fibroid outline is usually well visualized by TVS, even in the very small lesion, because of the pseudocapsule. The mixed tissue make-up of the fibroid produces a heterogeneous echo pattern on an ultrasound scan and can be highly attenuating of the ultrasound beam in some lesions. The most common gynecological symptoms of fibroids are menorrhagia and dysmenorrhea and, when significantly enlarged, they can also cause compression of adjacent pelvic structures. Most studies that have examined the relationship between fibroids and miscarriage rates have looked predominantly at intramural fibroids, with few data available on impact of submucosal fibroids. Myolysis is ablation of a fibroid mass by use of radiofrequency (RF) electricity, cryoprobes or focused ultrasound.
This chapter discusses the physiology of the luteal phase both in natural and stimulated cycles, with emphasis on the current evidence-based approaches for luteal phase support in assisted reproduction. Progesterone (P) and estrogen (E) are required to prepare the uterus for embryo implantation and to modulate the endometrium during the early stages of pregnancy. A meta-analysis of all available quasi randomized trials showed that the use of gonadotropin-releasing hormone (GnRH) agonists increased in vitro fertilization (IVF) pregnancy rates by 80-127 percent in women who responded normally to exogenous gonadotrophins. It was shown that the addition of a high dose of E2 to daily P supplementation significantly improved the probability of pregnancy in women treated with a long GnRH agonist protocol for controlled ovarian stimulation. Vaginal P supplementation before embryo transfer may be useful in quieting uterine contractions and thereby reducing embryo displacement.
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