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  1. Home
  2. Books
  3. Infertility and Assisted Reproduction
  • Cited by 8
Publisher:
Cambridge University Press
Online publication date:
August 2010
Print publication year:
2008
Online ISBN:
9780511547287
DOI:
https://doi.org/10.1017/CBO9780511547287
Subjects:
Obstetrics and Gynecology, Reproductive Medicine, Medicine
Information

Book description

Assisted reproductive technology (ART) is available to two-thirds of the world's population, and world-class experts, representing research from 18 different countries, have contributed to this groundbreaking textbook, detailing the techniques and philosophies behind medical procedures of infertility and assisted reproduction. This is one of the most rapidly changing and hotly debated fields in medicine. Different countries have different restrictions on the research techniques that can be applied to this field, and, therefore, experts from around the world bring varied and unique authorities to different subjects in reproductive technology. Encompassing the latest research into the physiology of reproduction, infertility evaluation and treatment, and assisted reproduction, it concludes with perspectives on the ethical dilemmas faced by clinicians and professionals. This book will be the definitive resource for those working in the areas of reproductive medicine world wide.

Reviews

'The future [of medicine] is always difficult, but the authors have made a nice summary of the latest trends and certainly good suggestions to where we are presently moving toward.'

Source: Acta Obstetricia et Gynecologica Scandinavica

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Contents

Page 2 of 3

Contents
  • 23 - Clomiphene Citrate for Ovulation Induction
    pp 202-219
  • View abstract

    Summary

    Clomiphene revolutionized the management of infertility in 1967 when it was approved for treatment of anovulation due to polycystic ovaries (PCO). The pharmacokinetics and pharmacodynamics of clomiphene explain its characteristic actions. After ovulation induction with clomiphene, serum progesterone and estradiol serum levels are increased during the luteal phase of the cycle in a direct dose-response relationship. Ultrasound of the ovaries should always be performed before initiating clomiphene treatment for the first time to rule out preexisting ovarian neoplasm, endometriomas, and persistent corpus luteum cysts to evaluate the number and size of antral follicles. Progesterone is used to confirm ovulation to determine if the dose of clomiphene is sufficient. Pregnancy rates may be increased in clomiphene cycles by increasing the number of follicles that develop, by improving endometrial conditions and cervical mucus, and by intrauterine insemination (IUI) when numbers of sperm on a postcoital test are low or absent.
  • 24 - Aromatase Inhibitors for Assisted Reproduction
    pp 220-227
  • View abstract

    Summary

    This chapter discusses the potential role of the new group of medications called aromatase inhibitors in assisted reproduction. When an aromatase inhibitor is applied during controlled ovarian hyperstimulation (COO), estrogen production per growing ovarian follicle has been found to be significantly lower than when aromatase inhibitors are not used. The use of aromatase inhibitors for in vitro maturation is an exciting application that can involve a brief aromatase inhibitor-induced rise in endogenous gonadotropin secretion leading to multiple ovarian follicles, followed by retrieval of immature oocytes. Both lowering supraphysiological levels of estrogen during COH and improving response to COH by enhancing endogenous gonadotropin production and increasing the ovarian follicular sensitivity to gonadotropin stimulation could be of benefit in particular groups of patients, for example, poor responders, endometriosis-associated infertility, polycystic ovarian syndrome (PCOS), and survivors of estrogen-dependant malignancies, for example, breast cancer.
  • 25 - Pharmacodynamics and Pharmacokinetics of Gonadotrophins
    pp 228-234
  • View abstract

    Summary

    This chapter highlights the pharmacokinetics and pharmacodynamics of several recombinant products available for use in controlled ovarian stimulation protocol. It summarizes current research regarding follicle-stimulating hormone (FSH), luteinizing hormone (LH), and chorionic gonadotropin (CG) in animal models as these models have important implications in the study and treatment of human infertility. FSH has its action through binding to the FSH receptor (FSHR), a G-protein-coupled receptor. Recombinant human FSH (rhFSH) has been shown to be effective in follicular recruitment in humans and various species of non-human primates including macaques. LH and CG bind with high affinity to the LH receptor (LHR), a glycoprotein G-protein-coupled receptor with seven transmembrane domains. Animal models have been invaluable for the understanding of the activities/actions of LH, FSH, LHR, and FSHR. Recombinant products are effective in follicular recruitment and oocyte maturation and can simulate an endogenous LH surge to induce ovulation.
  • 26 - The Future of Gonadotrophins: Is There Room for Improvement?
    pp 235-242
  • View abstract

    Summary

    This chapter focuses on the potential future developments in the field of gonadotrophins, and describes where the pharmaceutical companies are focusing their efforts to provide better, cheaper, and safer molecules. Follicle-stimulating hormone (FSH) purified from urine or prepared through recombinant technology is central to current therapy for infertile couples, and different companies are developing new formulations and new devices to inject the different products. An alternative approach to solve the pharmacological issue about recombinant and urinary products is the route of small molecule or hormone mimetic. Over the past few years, various companies have filed different patent applications claiming a variety of small-molecule leutenizing hormone receptor (LHR) and FSH receptor (FSHR) agonists and antagonists. Two new long-acting gonadotrophins developed by fusing the carboxyterminal peptides (CTP) of human chorionic gonadotropin (hCG) to native recombinant human FSH (hFSH) have been reported. Small-molecule gonadotrophin mimetics are currently reported to be in development.
  • 27 - Ovarian Hyperstimulation Syndrome
    pp 243-257
  • View abstract

    Summary

    Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication of ovulation induction, which may cause serious impact on the patient's health, with 0.1-2 percent of the patients developing severe forms of the syndrome. Many substances involved in the regulation of vascular permeability (VP) have been implicated in causing OHSS. The use of low doses of dopamine may be useful in severe OHSS patients. The OHSS primary prevention is to reduce its incidence, being the most important step to identify patients at risk that will undergo in-vitro fertilization (IVF) treatment, using a softer stimulation protocol and giving these patients special attention and close monitoring than usual with frequent ultrasound and serum estradiol levels. Until recently, OHSS treatment was reduced to the management of its complications. New data as the vascular endothelial growth factor (VEGF) system studies are providing new insights for prevention and treatment of OHSS.
  • 28 - Reducing the Risk of High-Order Multiple Pregnancy Due to Ovulation Induction
    pp 258-269
  • View abstract

    Summary

    Ovulation induction (OI) that is not part of an in vitro fertilization (IVF) cycle is the cause of 40-70 percent of high-order multiple pregnancies (HOMP), pregnancies with three or more conceptus, and 11-21 percent of twins, in countries where modern infertility treatment is practiced. Clomiphene Citrate (CC) increases follicular stimulation hormone (FSH) secretion from the pituitary by temporarily blocking the negative feedback of estrogen that is necessary to regulate production and secretion of FSH. Pulsatile gonadotropin-releasing hormone (GnRH) administered subcutaneously or intravenously results in pregnancy and multiple pregnancies similar to low-dose gonadotropins. A widely used technique for reducing HOMP during controlled ovarian hyperstimulation-intauterine insemination (COH-IUI) treatment is to withhold human chorionic gonadotropin (hCG) administration when excessive numbers of follicles or estradiol (E) concentrations are present. OI should not be attempted, and IVF should be used instead for women who cannot safely carry a twin pregnancy.
  • 29 - Hyperprolactinemia
    pp 270-285
  • View abstract

    Summary

    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.
  • 30 - Medical Management of Polycystic Ovary Syndrome
    pp 286-293
  • View abstract

    Summary

    This chapter discusses polycystic ovary syndrome (PCOS) and its clinical manifestations. It also explores the incidence of insulin resistance in PCOS. Insulin resistance can be encountered in women with PCOS. Diagnosis and treatment are also independent on insulin resistance. Management of women with PCOS depends on the symptoms. These could be ovulatory dysfunction-related infertility, menstrual disorders, or hirsutism. Treatment of hirsutism involves administration of oral contraceptive pills and antiandrogens. Clomiphene citrate, dexamethazone, gonadotropin and aromatase inhibitors are used in the treatment of ovulatory disorders. Gonadotropin-releasing hormone agonist plays a major role in IVF treatment as well as in superovulation. There are several insulin-sensitizing agents available to reduce insulin levels, and the most commonly used for women with PCOS is metformin. Metformin has replaced the surgical treatment of PCOS with ovarian drilling. Metformin improves insulin resistance and hyperandrogenism, decreases serum lipids, and improves glucose homeostasis.
  • 31 - Surgical Management of Polycystic Ovary Syndrome
    pp 294-301
  • View abstract

    Summary

    This chapter focuses on the surgical management of polycystic ovary syndrome (PCOS). The mechanism of action of laparoscopic ovarian drilling (LOD) is unclear. Its beneficial effect is apparently due to destruction of the androgen-producing stroma. Patients who were resistant to clomiphene citrate (CC) may respond to this medication after the procedure. Sensitivity to exogenous gonadotrophin treatment is increased. Gonadotrophin treatment following LOD is associated with a lower duration of stimulation, lower total dose of gonadotrophins, and higher pregnancy rates. LOD and metformin therapy improve menstrual disturbances and ovulatory dysfunction to a similar extent. The pregnancy rates after both treatments are also similar, but the safety of metformin in pregnancy is unproven. The improvement in hyperandrogenism is thought to be secondary to the reduction in LH concentrations and the decreased androgen production by the ovarian stroma.
  • 32 - Endometriosis-Associated Infertility
    pp 302-308
  • View abstract

    Summary

    This chapter illustrates the different opinions regarding the pathophysiology and management of endometriosis-associated infertility. Pelvic inflammation due to endometriosis may cause adhesion formation and scarring, which leads to a disruption and decrease in fertility. Medical treatment using GnRH agonists can only be used prior to in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). When moderate or severe endometriosis causes anatomic distortion of the pelvis in women who wish to maintain or restore fertility, surgery may be the treatment of choice. Clomiphene citrate and intrauterine insemination (IUI) treatment triple the monthly fecundity rate from 3.3 to 9.5 percent, as compared with nontreatment cycles, in patients with surgically corrected endometriosis. If laparoscopic surgery will be performed before IVF-ICSI cycles, a less invasive and conservative technique should be used during the operation such as cyst aspiration or fenestration.
  • 33 - Medical Management of Endometriosis
    pp 309-317
  • View abstract

    Summary

    The successful treatment of endometriosis-associated symptoms typically requires surgical as well as medical intervention. Progestogens are efficacious and inexpensive treatment of pelvic endometriosis. A variety of medications have been used as add-back therapy in addition to gonadotrophin-releasing hormone (GnRH) agonist for treatment of endometriosis which includes progestogen alone, progestogen and estrogen combination, or progestogen and bisphosphonates. GnRH antagonists have been used for the treatment of pelvic endometriosis; however, they have not been as widely accepted as GnRH agonists. Selective progesterone receptor modulators introduce a new dimension in the medical treatment of endometriosis. Aromatase inhibitors which inhibit estrogen production in endometriotic implants are an attractive option for the management of endometriosis. Antiangiogenesis therapy has been investigated in rodents, demonstrated that angiostatic agents prevent the development of endometriosis-like lesions in the chicken chorioallantoic membrane. Nonsteroidal inflammatory drugs are very helpful in pelvic pain and dysmenorrhea associated with endometriosis.
  • 34 - Reproductive Surgery for Endometriosis-Associated Infertility
    pp 318-326
  • View abstract

    Summary

    The optimal management approach to the infertile patient with endometriosis requires an evaluation of the extent of disease and the reproductive goals of the patient. The surgical approaches to endometriosis treatment are accomplished by laparotomy or laparoscopy. Surgical treatment for endometriosis-associated infertility employs techniques that are designed to minimize trauma, maintain hemostasis, and reduce operating time while facilitating the removal of all disease. The probability of conception may potentially be affected by other factors in addition to the outcome of surgery. In these patients, further assistance with ovulation induction or assisted reproductive technologies (ART) after surgery may be beneficial. Ovarian endometriomas are typically treated utilizing various techniques such as cyst stripping or ablation, drainage, and wide excision. The development of an endometriosis scoring system that has good correlation with the severity of reproductive impairment would contribute significantly to future studies.
  • 35 - Congenital Uterine Malformations and Reproduction
    pp 327-331
  • View abstract

    Summary

    This chapter discusses the congenital uterine malformations and their reproductive implications. Patients with congenital absence of the vagina usually lack the uterus as well. Imperforate hymen and transverse vaginal septum are vertical fusion anomalies. Double uterus, septate uterus and unicornuate uterus are obstructive lateral fusion anomalies. In strassman procedure a transverse fundal incision is made in case of a bicornuate uterus and the two uterine cavities are unified. In Tompkins procedure for septate uteri a median bivalve is made and no tissue is excised. The two cavities are opened and unified. In Jones procedure which is usually reserved for the wide septum, a wedge resection of the septum is done and the uterine cavities are unified. In uterus didelphys, there is duplication of the uterus, cervix, and vagina. Fertility of women with didelphic uterus was comparatively good. Patients with congenital uterine malformations undergoing IVF have a good pregnancy rate.
  • 36 - Unexplained Infertility
    pp 332-338
  • View abstract

    Summary

    Unexplained infertility is a diagnosis made by exclusion after a complete infertility evaluation. Standard testing for infertility should include semen analysis (evaluated according to the WHO criteria), assessment of ovulation (serum progesterone determination in the midluteal phase), and an evaluation of tubal patency. At present, other additional investigations contribute relatively little to effective diagnosis of unexplained infertility. Laparoscopy is required to make a diagnosis of endometriosis or adnexal adhesions, but in the presence of tubal patency, these lesions seem to be of lesser significance. The use of intrauterine insemination (IUI) together with ovulation induction in normally ovulating women carries a risk of ovarian hyperstimulation syndrome and multiple pregnancy. Based on the available information, it is reasonable to recommend an escalating course of gonadotropin ovarian stimulation with IUI and then in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI).
  • 37 - “Premature Ovarian Failure”: Characteristics, Diagnosis, and Management
    pp 339-346
  • View abstract

    Summary

    Premature ovarian failure (POF), sometimes termed premature menopause, is an enigmatic disorder. Among the various causes of POF that now have been identified, it is clear that some are present only in those who have no oocytes remaining, whereas others may be associated with remaining follicles and offer the potential for ovulation and spontaneous pregnancy. The causes of POF include cytogenetic abnormalities of the X chromosome, enzymatic defects, defective gonadotropin secretion or action, environmental insults, and autoimmune disorders. The objectives of the evaluation of young women with hypergonadotropic amenorrhea are to identify any treatable causes and any potentially dangerous associated disorders. It is important to make the diagnosis in a timely fashion. In vitro fertilization with donor oocytes is the most effective way of providing a pregnancy for any affected woman, but should be used with caution in women with Turner syndrome and the fragile X premutation.
  • 38 - Medical Strategies to Improve ART Outcome: Current Evidence
    pp 349-360
  • View abstract

    Summary

    This chapter describes five sequential medical steps to successful implantation and reviews the evidence supporting their efficacy and safety. The steps are: selection and preparation of the patient, optimizing the ovarian stimulation protocol, analysing the need of adjuvant medical therapies, embryo transfer and management of the luteal phase. Aspirin, nitric oxide donors, aromatase inhibitors, ascorbic acid, glucocorticoids and insulin-sensitizing drugs are the commonly used adjuvant drugs. Luteal phase length can be restored by stimulating the corpora lutea with human chorionic gonadotropin (hCG) (luteal phase support) or supplementation with progesterone. Improving embryo implantation continues to pose a major challenge to clinicians. While much progress has been made in technical aspects of in vitro fertilization (IVF) treatment to optimize embryo quality and stimulation regimens, it is becoming increasingly clear that patient-related factors may be just as important or more important in determining the chance of success of treatment.
  • 39 - Surgical Preparation of the Patient for In Vitro Fertilization
    pp 361-370
  • View abstract

    Summary

    This chapter reviews the evidence surrounding the effect of reproductive surgery for tubal abnormalities, endometriosis, and uterine fibroids on in vitro fertilization (IVF) cycle outcome. Salpingectomy and proximal tubal occlusion are two surgical options in the treatment of distal tubal disease. Proximal tubal occlusion represents a significantly less invasive approach, which requires less surgical dissection and operating time while still eliminating retrograde flow of hydrosalpingeal fluid into the endometrial cavity. Consideration should be given to resection of submucosal fibroids and intramural lesions that distort directly impinge upon the endometrial cavity prior to IVF. Pregnancy rates achieved with assisted reproductive technology (ART) have increased progressively in recent years, and in endometriosis, patients achieve levels of success that are significantly higher than those obtained with alternative therapies. The prolonged use of a GnRH agonist, in at least a subset of endometriosis patients, appears to improve IVF cycle outcome.
  • 40 - IVF in the Medically Complicated Patient
    pp 371-374
  • View abstract

    Summary

    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.
  • 41 - Polycystic Ovary Syndrome and IVF
    pp 375-380
  • View abstract

    Summary

    Polycystic ovary syndrome (PCOS), characterized by ovulatory dysfunction and hyperandrogenism, is the most common cause of infertility in women. Ovarian function in infertile women with PCOS is characterized by disordered folliculogenesis and abnormal steroidogenesis. Clomiphene citrate is then the first-line active medical treatment. There has been a long-standing debate regarding the gonadotrophin of choice for ovarian stimulation in women with PCOS. Recent meta-analysis assessing the effect of (gonadotropin-releasing hormone) GnRH antagonists in assisted reproduction technologies (ART) concluded that GnRH antagonist protocol is a short and simple protocol with good clinical outcome. Metformin appears to improve reproductive function in some women with PCOS. More research is necessary to define the optimal place of IVF, the best ovulation induction protocol, the choice of gonadotropin, the use of GnRH analog, antagonist, and the impact of coadministration of metformin for anovulatory infertile PCOS patients subjected to IVF.
  • 42 - Endometriosis and Assisted Reproductive Technology
    pp 381-385
  • View abstract

    Summary

    Most of the available evidence supports the hypothesis that endometriosis compromises fertility. According to ESHRE 2005 guidelines for the diagnosis and treatment of endometriosis, treatment with intrauterine insemination (IUI) improves fertility in minimal-mild endometriosis: IUI with ovarian stimulation is effective but the role of unstimulated IUI is uncertain. Lower pregnancy and implantation rates have been documented in women with severe (stage III or IV) endometriosis when compared to mild (stage I or II) endometriosis. Assisted Reproductive Technology (ART) may bypass some of the mechanisms of endometriosis-associated infertility, but the disease may have an impact on cycle outcome. Oocyte donation appears as an alternative in patients with endometriosis with low response, poor embryo quality, or repeated ART failures. Surgery for endometriomas in women undergoing ART is indicated in symptomatic women; otherwise, it does not add any benefit to cycle outcome. However, careful surgery does not compromise ovarian reserve.
  • 43 - Evidence-Based Medicine Comparing hMG/FSH and Agonist/Antagonist and rec/Urinary hCG/LH/GnRH to Trigger Ovulation
    pp 386-394
  • View abstract

    Summary

    This chapter compares the role of human menopausal gonadotrophin (hMG), follicle-stimulating harmone (FSH) agonist/antagonist and recombinant/urinary human chorionic gonadotrophin (hCG)/luteinizing hormone (LH)/gonadotrophin-releasing hormone agonist (GnRHa) in triggering ovulation. With the use of GnRHa, hCG was necessary to induce final follicular maturation and triggering of ovulation. Accordingly, in the 1980s, the use of gonadotrophins, GnRHa, and hCG became a standard successful protocol for ovulation induction in assisted conception cycles. The GnRH antagonists emerged as an alternative to GnRHa in preventing premature LH surges. Recombinant FSH (recombinant-human FSH), which is free of LH activity, is used in many cases of controlled ovarian hyperstimulation (COH) after downregulation with long protocol. The conclusions of the meta-analyses are that there is no advantage for either recombinant FSH or urinary FSH concerning the clinical pregnancy rate, miscarriage rate, or ovarian hyperstimulation syndrome (OHSS) rate.
  • 44 - Luteal Phase Support in Assisted Reproduction
    pp 395-406
  • View abstract

    Summary

    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.
  • 45 - Thrombophilia and Implanation Failure
    pp 407-415
  • View abstract

    Summary

    This chapter focuses on the association between acquired and inherited thrombophilia and implantation failure (IF). The pathogenesis of recurrent IF in patients with thrombophilic gene mutation may involve the effect of hypofibrinolysis on trophoblast migration. Trophoblastic migration and invasion during implantation involve extracellular matrix degradation, which is facilitated by matrix metalloproteinases (MMP). Recently, a variety of pathogenetic mechanisms have been suggested to explain the prothrombotic effect of antiphospholipid antibody (APA), the main cause of acquired thrombophilia. Recently, it has been suggested that APA may negatively impact the transformation of the endometrium into decidua, creating a hostile environment for blastocyst implantation. The chapter investigates the main therapeutic modalities such as heparin, aspirin (ASA), corticosteroids, and intravenous immunoglobulin alone or in combinations for treatment of IF. It is premature to recommend anticoagulation for patients with thrombophilia and IF.
  • 47 - The Prediction and Management of Poor Responders in ART
    pp 428-442
  • View abstract

    Summary

    The evaluation and treatment of low responders in assisted reproductive technology (ART) remains a challenge. Poor responders have a higher incidence of cycle cancellation, lower fertilization, and lower pregnancy and implantation rates. Static tests for the prediction of poor responders include day 3 measurement of the concentration of serum follicle- stimulating hormone (FSH), serum inhibin B, serum estradiol (E2), and serum anti-Mullerian hormone (AMH) as well as the determination of the antral follicle count (AFC), the ovarian volume (OVVOL), and the ovarian blood flow. Dynamic tests assess the response of the ovary to a defined dose of an ovarian stimulation agent. They include the clomiphene citrate (CC) challenge test, the FSH stimulation test, as well as the gonadotrophin agonist stimulation test. Various adjuvant therapies have been suggested for improving the results of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) in poor responders.
  • 48 - Oocyte Donation
    pp 443-447
  • View abstract

    Summary

    Pregnancy rates obtained with oocyte donation (OD) are the highest when compared to any other assisted reproduction technique (ART). OD is not only the solution for many infertile couples but also a reference model for obtaining useful knowledge of the physiology of reproduction and consequently to be applied in other ART. One of the controversies regarding ovarian stimulation for in vitro fertilization (IVF) regards the impact that successive cycles could have on oocyte recovery in terms of quality and quantity of the obtained oocytes. Age of the recipient, smoking, body mass index (BMI), and endometriosis are the various factors influencing embryo implantation. Endometriosis could affect uterine receptivity through alteration of the local environment by means of endocrine and paracrine mechanisms or due to changes in immune response. Gonadotropin-releasing hormone (GnRH) analogs could have a positive effect on the physiology of endometrial cells of patients with endometriosis.
  • 49 - In Vitro Maturation of Human Oocytes
    pp 448-455
  • View abstract

    Summary

    This chapter discusses the process of in vitro maturation (IVM) of human oocytes. Oocyte maturation in vitro is profoundly affected by culture conditions. Different media have been used for in vitro oocyte maturation. The presence of estradiol in the culture medium of immature oocytes has no effect on the progression of meiosis, but improves fertilization and cleavage rates. Oocyte retrieval in IVM cycles is also largely performed in the follicular phase in routine practice. Immature human oocytes can be recovered from the ovaries during both the follicular and luteal phase. Polycystic ovary syndrome (PCOS) patients having the highest risk of ovarian hyperstimulation syndrome (OHSS), and the best chance for pregnancy due to a higher antral follicle count (AFC) have been the most appropriate candidates for routine IVM treatment. Luteal support is started on the day that maturation is achieved and intracytoplasmic sperm injection (ICSI) is performed.
  • 50 - Oocyte and Embryo Freezing
    pp 456-465
  • View abstract

    Summary

    Embryo cryopreservation is crucial for both the efficiency and the safety of assisted reproduction treatments. The potential risks of damage for cryopreserved-thawed embryos include exposure to medium biochemical contaminants, ice crystal formation within the embryo, toxic effect of cryoprotectants, damage during thawing process, physical damage during embryo manipulation, and DNA damage during embryo storage; but freezing itself cannot be considered a mutagenic procedure. Conventional embryo freezing concerns multicell embryos. Cryopreservation of early-stage embryos can be considered a valid alternative to conventional embryo cryopreservation. Cryopreservation of unfertilized oocytes presents more technical problems than early-stage embryo cryopreservation. The most alarming risk related with oocyte cryopreservation is aneuploidy in embryos conceived with this method. Children born from cryopreserved oocytes should be accurately monitored to ascertain the correct growth and development and to exclude possible genetic anomalies and malformations.
  • 51 - Cryopreservation of Male Gametes
    pp 466-477
  • View abstract

    Summary

    This chapter discusses the techniques, methodology, and procedures that are highly relevant to the current practice of assisted human reproduction and sperm banking. Cryopreservation of sperm cut down the necessity of obtaining fresh sperm for subsequent assisted reproductive technology (ART) cycles. Abundant evidence exists in literature indicating that frozen sperm are as good as fresh sperm in fertilizing oocytes and subsequent developments. The success of cryopreservation is affected by many factors including membrane permeability, amount of intracellular water, type of cryoprotectant, and the method of freezing and thawing. Four cryoprotectants that are most often used for cryopreservation of human spermatozoa are: glycerol, dimethylsulfoxide (DMSO), ethylene glycol, propanediol, egg yolk and buffering agents. The American Society for Reproductive Medicine (ASRM) practice committee recommends evaluations of potential sperm donors incorporating recent information about optimal screening and testing for sexually transmitted infections, genetic diseases, and psychological assessments.

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