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Acute gynaecological emergencies are conditions of the female reproductive system that threaten the woman’s life, her sexual function or her fertility. Common gynaecological emergencies present as acute abdomen, abnormal vaginal bleeding, or a combination of both.
The main gynaecological emergencies could be divided into early pregnancy problems, gynaecologic causes of severe pelvic pain (acute pelvic inflammatory disease, pelvic endometriosis, torsion and rupture of an ovarian neoplasm, torsion or degeneration of a uterine leiomyoma, ovarian hyperstimulation syndrome), severe vaginal bleeding, vulvar abscesses, toxic shock syndrome and sexual violence.
This chapter reviews the role of gonadotropin-releasing hormone (GnRH) antagonists in ovulation induction for in vitro fertilization (IVF). Although the purpose of the development of GnRH antagonists was originally a non-steroid contraceptive drug, it was found that GnRH antagonists have potential benefit in assisted reproduction. GnRH antagonists act by immediate suppression of pituitary gonadotropin release and rapid recovery of normal secretion of endogenous luteinizing hormone (LH) and follicle stimulating hormone (FSH). The inhibition of LH secretion is more pronounced than that of FSH, this being most likely due to the different forms of gonadotropin regulation and the prolonged FSH half-life, or the immunoactive and bioactive forms of FSH. The effect of oral contraceptive pills (OCP) for cycle scheduling prior to GnRH antagonist protocol on IVF cycle parameters and pregnancy outcome was studied. All OCP-pretreated cycles required significantly longer stimulation than non-pretreated cycles and higher total dosage of FSH.
The aim of treatment with a gonadotropin-releasing hormone (GnRH) agonist is elimination of the luteinizing hormone (LH) surge and fluctuating LH concentrations, which compromise outcome in cycles of ovarian stimulation for in-vitro fertilization (IVF). This chapter addresses the characteristics of the standard long-course protocol. It is most common to initiate treatment in the luteal phase to minimize the consequences of the flare effect seen in the first few days of treatment with a GnRH agonist. The down-regulation effect of agonists can be established and maintained by multiple applications of nasal spray, single daily injection, or depo formulations lasting variable lengths of time. When the patient is down-regulated at the start of follicle stimulating hormone (FSH) treatment, subsequent follicular growth and recruitment is dictated by two elements: the ovarian reserve, which dictates the number of follicles available for recruitment, and the profile of circulating FSH concentrations.
This chapter reviews the regimens used in controlled ovarian hyperstimulation for in vitro fertilization (IVF) in the following categories: normal, poor, and high responders. Luteal suppression with gonadotropin releasing hormone (GnRH) agonists is usually associated with higher cancellation rates, increased dosages of gonadotropins, and prolonged days of stimulation in low responders. Several studies have compared the use of GnRH antagonist with the long GnRH agonist protocols in low responders. There are two different methods of ovulatory triggers for oocyte maturation: exogenous human chorionic gonadotrpin (hCG) and GnRH agonist in antagonist cycles. Minimal stimulation protocols are being used more commonly in IVF. The use of such stimulation protocols can be applied in cases of both poor and high responders. When in vitro maturation (IVM) is performed, fertilization is usually performed with intracytoplasmic sperm injection (ICSI), and endometrial preparation with estrogen and progesterone is necessary.
This chapter describes the principal putative causes of implantation failure and reviews therapeutic strategies. Recurrent implantation failure is a significant and distressing clinical problem. Adjuvant medical therapies to those required for ovarian hyperstimulation are frequently applied for improving embryo implantation and particularly when the clinician is faced with recurrent implantation failure. The appropriate management of the medically complicated patient presenting for in-vitro fertilization (IVF) can be complex and often requires an interdisciplinary approach. Standard ovarian hyperstimulation and the resultant supraphysiological estradiol levels have been shown to impact negatively on endometrial receptivity and embryo quality. Studies of mild ovarian stimulation regimens have shown encouraging results. Although fewer embryos are obtained, an increased percentage of euploid embryos per number of oocytes retrieved have been reported. Significant improvements in clinical pregnancy rates can be achieved by giving due attention to embryo transfer technique.
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