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Reproductive Medicine: Challenges, Solutions and Breakthroughs
Gautam N Allahbadia, Rubina Merchant, Sulbha Arora
SECTION 1: GYNECOLOGICAL ENDOSCOPY
CHAPTER 1:
Philosophy of Endoscopy in Infertility
OVERVIEW
INTRODUCTION
Ancient Indian Perspective
History of Endoscopy in Infertility
Endometriosis
CLINICAL DISCUSSION
Endoscopy in Infertility
Endoscopic Tubal Surgery
Laparoscopic Myomectomy
Endoscopy in Endometriosis
CONCLUSION
CHAPTER 2:
Hysteroscopic Markers of Genital Tuberculosis
OVERVIEW
INTRODUCTION
The Problem of Tuberculosis
Genital Tuberculosis
CLINICAL DISCUSSION
Pathogenesis
Causative Organism
Mode of Spread
Sites of Genital Tuberculosis
Endometrial Tuberculosis
Macroscopically
Microscopically
CASE STUDIES
Clinical Presentation
Diagnosis
Hysterosalpingography
Role of Hysteroscopy
Findings (Figs 2.1 to 2.8)
TB-PCR-DNA
RNA Detection by Transcription-mediated Amplification-improved PCR
Recent Advances
CONCLUSION
CHAPTER 3:
Hysteroscopic Intratubal Sterilization
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Instrumentation and Technique
Premedication
Problem Solving and Troubleshooting
Spasm of the Tube
Abnormal Position of the Tube
Retraction after Release of the Device
Shallow Insertion Depth
Excessive Insertion Depth
Bleeding after the Procedure
Postoperative Complaints
Total or Partial Perforation
Regret after the Sterilization
Efficacy of Sterilization
X-ray Abdomen
Hysterosalpingography
Transvaginal Ultrasound
Combined Hysteroscopic Sterilization and Operative Hysteroscopy
Overview of Technologies and Technical Characteristics
Results
Effectiveness of Micro-inserts Placement
About Menorrhagia
CONCLUSION
ACKNOWLEDGMENT
CHAPTER 4:
Ovarian Drilling by Transvaginal Fertiloscopy for the Treatment of Polycystic Ovary Syndrome
OVERVIEW
INTRODUCTION
MATERIALS AND METHODS
Patients
The Procedure
The Balloon Introducer (Figs 4.2 and 4.3)
The Bipolar Electrode
Surgical Procedure (Figs 4.4A and B)
RESULTS
CLINICAL DISCUSSION
CONCLUSION
CHAPTER 5:
Laparoscopic Ovarian Cauterization: How Many Punctures are Optimal?
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Endocrine Changes following LEOS
Ovarian Stromal Blood Flow Changes after LEOS in Women with PCOS
Laparoscopic Ovarian Drilling
How Many Punctures to be Made?
Complications of LEOS
Results after Surgery
LEOS versus Gonadotropins
Cost of LEOS versus Gonadotropins
Recent Advances
LASER versus Ovarian Surgery
CONCLUSION
Key Points for Clinical Practice
CHAPTER 6:
Laparoscopic Recanalization after Tubal Sterilization
OVERVIEW
INTRODUCTION
PREREQUISITES
Reasons for Reversal Demand
Prevention
Psychological Background
CLINICAL DISCUSSION
Method of Tubal Sterilization
Presurgical Infertility Investigations
Other Occasional Investigations
Classical Therapeutic Tools
Tubal Microsurgery
In Vitro Fertilization
Laparoscopic Tubal Recanalization
Technical Aspects
Results
Practical Management
CONCLUSION
CHAPTER 7:
Does Surgery for Endometriosis Improve the ART Outcomes?
INTRODUCTION
How Much do We Know About Endometriosis?
CLINICAL DISCUSSION
Is the IVF Outcome Affected in Endometriosis?
How does Endometriosis Affect the Outcome of IVF?
Management Options in Endometriosis-related Infertility
Case 1
Case 2
Does Endometrioma Affect IVF?
Endometrioma: Excision or Ablation
Prolonged GnRH Agonist Therapy Prior to an IVF Cycle in Endometriosis Patients
Fertility Outcome after Surgery for Grade III / IV Endometriosis in our Practice
Additional Procedures Required and Complications
Keys to a Successful Endometriosis Unit
CONCLUSION
CHAPTER 8:
Radical Excision of Endometriosis Improves the Fertility Outcome
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Radical Excision of Grade I Endometriosis
Deep Rectovaginal Endometriosis
Treatment Options
Medical Management
Surgical Management
Adenomyomectomy
Results
CONCLUSION
CHAPTER 9:
Laparoscopic Myomectomy: Is it Worth it?
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
CASE STUDIES
CONCLUSION
CHAPTER 10:
Laparoscopic Hysterectomy in the Frozen Pelvis
OVERVIEW
INTRODUCTION
Causes for Frozen Pelvis
Patient Evaluation
CLINICAL DISCUSSION
Preparation for Surgery
Surgical Technique
Abdominal Entry
Omental and Bowel Adhesiolysis
Identify Landmarks
Entry into the Retroperitoneum
Adnexal Mobilization and Division of Infundibulopelvic Ligament
Ureter Identification
Bladder Separation
Coagulation and Division of Uterine Vessels
Cul-de-sac Obliteration
Vaginal Closure and Hemostasis
Identifying Bowel Injury
Cystoscopy
Results
CONCLUSION
CHAPTER 11:
Complications of Laparoscopic Hysterectomy
OVERVIEW
INTRODUCTION
Options of Laparoscopic Hysterectomy
Potential Advantages and Disadvantages of Laparoscopic Hysterectomy
Indications for Laparoscopic Hysterectomy
CLINICAL DISCUSSION
Complications of Laparoscopic Hysterectomy
Intraoperative Complications
Postoperative Complications
The Evolution of Laparoscopic Hysterectomy at Kaplan Medical Center
RECENT ADVANCES
Robot-assisted Laparoscopic Hysterectomy
CONCLUSION
CHAPTER 12:
Making Hysteroscopic Surgery Safer
OVERVIEW
INTRODUCTION
History
Hysteroscopic Technique
Distention Media
Fluid Management Systems
CLINICAL DISCUSSION
Clinical Use and Recent Advances
Intrauterine Adhesions
Treatment of IUA
Endometrial Polyps
Uterine Leiomyomas
Uterine Septum
Endometrial Ablation for Abnormal Uterine Bleeding
Retained Products of Conception (RPOC)
Sterilization
Complications of Hysteroscopy
CONCLUSION
CHAPTER 13:
Resection of the Uterine Septum or In Vitro Fertilization: What Comes First?
OVERVIEW
RATIONALE
INTRODUCTION
clinical Discussion
Diagnosis
Adverse Reproductive Outcome
Treatment
Indications
CONCLUSION
SECTION 2: OVARIAN STIMULATION PROTOCOLS
CHAPTER 14:
Gonadotropin Preparations in Infertility Treatment
OVERVIEW
INTRODUCTION
HISTORICAL OVERVIEW
History of drug development and technology for infertility treatment:
CLINICAL DISCUSSION
Pituitary Gonadotropins
Follicle Stimulating Hormone
Luteinizing Hormone (LH)
Midcycle LH Surge
The Need for a Surrogate LH Surge
The Natural LH Surge
Pituitary LH
Human Menopausal Gonadotropin (hMG)
Purified Urinary FSH
Highly Purified Urinary FSH
Recombinant Human FSH (rhFSH) Preparation
Is There a Difference in Safety?
Is There a Difference in Outcome?
Ovarian induction without IVF
Ovarian Stimulation for IVF
Corifollitropin-alfa
Efficacy
Recombinant Human LH (rhLH)
Human Chorionic Gonadotropin (hCG)
Recombinant hCG
Future Directions
CONCLUSION
CHAPTER 15:
The Choice of Starting Dose in In Vitro Fertilization
OVERVIEW
RATIONALE
INTRODUCTION
Follicle stimulating Hormone and Folliculogenesis
CLINICAL DISCUSSION
Choice of Gonadotropins for Superovulation
Starting Dose of FSH for COH
FSH Dosage for the ‘Standard Patient’
FSH Dosage for ‘Poor Responders’
Individualizing the FSH Dose for Assisted Reproduction: rFSH Normogram
Individualizing the FSH Dose for Assisted Reproduction: A Novel Algorithm
Practical Approach for FSH Starting Dosage
CONCLUSION
CHAPTER 16:
Evaluation and Treatment of the Female Partner before ART
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Evaluation of the Female Partner
History and Physical Examination
Diagnostic Evaluation
Tests for Ovulation
Tests for Ovarian Reserve
Other Hormonal Tests
Tests for Tubal Patency
Cervical Factors
Peritoneal Factors
TREATMENT
CONCLUSION
CHAPTER 17:
Aromatase Inhibitors for Ovulation Induction
INTRODUCTION
CLINICAL DISCUSSION
Rationale for the Use of Aromatase Inhibitors in Anovulatory Women
Mechanism of Action of Letrozole
Comparison of the Success Rates of Letrozole and Clomiphene Citrate
Combining Gonadotropins and Aromatase Inhibitors
Outcome of Pregnancies Achieved with Aromatase Inhibitors
CONCLUSION
CHAPTER 18:
Intrafollicular Consequences of the Use of Aromatase Inhibitors in ART
OVERVIEW
INTRODUCTION
Human Aromatase Activity
CLINICAL DISCUSSION
Aromatase Activity in the Ovaries
Modulators of Ovarian Aromatase Activity
Polycystic Ovary Syndrome (PCOS) and Aromatase Inhibitors
Clinical Applications of Aromatase Inhibitors
Ovulation Induction
Aromatase Inhibitors in Ovulatory Infertility/Superovulation
Intrauterine Insemination (IUI)
In vitro Fertilization (IVF)
Do Aromatase Inhibitors Improve Implantation?
Safety of Aromatase Inhibitors
CONCLUSION
CHAPTER 19:
Addition of Luteinizing Hormone in Controlled Ovarian Stimulation Protocols using Recombinant FSH
OVERVIEW
INTRODUCTION
Physiological Role of LH in Folliculogenesis
Gonadotropin Preparations
Use of Gonadotropins in Ovarian Stimulation
CLINICAL DISCUSSION
LH Threshold and Ceiling Activity
Controlled Ovarian Stimulation Protocols
Addition of LH to rFSH
COH in Polycystic Ovary Syndrome
CONCLUSION
CHAPTER 20:
Gonadotropin-releasing Hormone Antagonists: An Unfulfilled Expectation?
OVERVIEW
INTRODUCTION
Mode of Action
CLINICAL DISCUSSION
GnRH Antagonists for In Vitro Fertilization
Cetrorelix
Ganirelix
GnRH Antagonists and Pregnancy Outcomes
Need for LH Supplementation
GnRH Antagonists in Poor Responders
Benefits of the Use of GnRH Antagonists for IVF
GnRH agonist for triggering final oocyte maturation in the GnRH antagonist protocol
CONCLUSION
CHAPTER 21:
Rationale for the Use of Insulin Sensitizing Drugs in Polycystic Ovary Syndrome
INTRODUCTION
CLINICAL DISCUSSION
Insulin Sensitizers
Metformin
Side Effects of Metformin
Thiazolidinediones
Side Effects of Thiazolidinediones
α-Glucosidase Inhibitors (Acarbose)
Side Effects of Acarbose
D-Chiro Inositol (DCI)
Herbal Medicine (Hyponidd) Containing Acarbose and DCI
Acarbose
DCI
Side Effects
CONCLUSION
CHAPTER 22:
Does Natural Cycle IVF or Minimal Stimulation have a Role in Clinical Practice Today?
OVERVIEW
INTRODUCTION
DEFINITION
CLINICAL DISCUSSION
Proposed Approaches
Natural Cycle IVF with Controlled LH Surge Ovulation
CONCLUSION
CHAPTER 23:
Minimal Monitoring of Ovarian Stimulation: Is it Safe?
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Aims of Monitoring
Monofollicular Ovulation
Ovarian Stimulation for Intrauterine Insemination
Controlled Ovarian Hyperstimulation for IVF/ICSI
Proposed Monitoring of Ovarian Stimulation
CONCLUSION
SECTION 3: CONTEMPORARY CLINICAL MANAGEMENT
CHAPTER 24:
Do We Need HSG in the Era of 3D/4D Ultrasonography?
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Hysterosalpingography (HSG)
Procedure
Three-dimensional Ultrasonography (3D USG)
Hysterosalpingo-contrast-sonography (HyCoSy)
Procedure
Different dyes used for HyCoSy
Three-dimensional Coded Contrast Imaging (3D Cci) During HyCoSy
Procedure
Laparoscopy
Fertiloscopy
CONCLUSION
CHAPTER 25:
How to Approach Submucous Myomas in Infertile Women?
OVERVIEW
INTRODUCTION
CLASSIFICATION OF SUBMUCOSAL FIBROIDS (Table 25.1)
CLINICAL DISCUSSION
Impact of Fibroids on Assisted Conception (Table 25.2)
Preoperative Diagnostic Assessment
Role of Preoperative GnRH Agonist
Preparation of the patient
Anesthesia
Surgical Technique
Basic
Main Techniques of Resection
Postoperative Care and Follow-up
Gynecare Versapoint
Mechanism of Versapoint (Fig. 25.6)
Limitatons with Versapoint
Complications with Versapoint
CONCLUSION
CHAPTER 26:
Alternatives to Myomectomy
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Medical Therapy
Oral Contraceptives
Progestin Therapy
Progestin-containing Intrauterine Contraceptive Devices
Androgen Therapy
Steroid Synthesis Inhibitors
GnRH antagonists
Future Directions for Treatment
Aromatase inhibitors
Steroid antagonists
Selective estrogen receptor modulators (SERMs)
Selective progesterone receptor modulators
Regulation of growth factor pathways
Gene therapy
Myolysis
Uterine Artery Embolization (UAE)
Technical aspects
Clinical outcome
Risks and complications
Postembolization syndrome
Pregnancy outcome after UAE
Randomized trial of embolization versus surgical treatment for fibroids (REST)
MRI-guided Focused Ultrasound (MRgFUS)
Technical aspects
Clinical outcome
Results from other studies
Risks and Complications
Pregnancy after MRgFUS
CONCLUSION
CHAPTER 27:
Diagnosis of Genital Tuberculosis: Newer Techniques for an Old Disease
OVERVIEW
INTRODUCTION
Endometrial Biopsy
Laboratory Evaluation
CLINICAL DISCUSSION
Direct Approach
Microscopy
Culture
Microcolony Detection on Solid Media
Septi-chek AFB Method
Radiometric BACTEC 460 TB Method
Mycobacteria Growth Indicator Tube
MB/Bac T
ESP Culture System II
Rapid Identification of Mycobacterial Isolates
PCR Method
Xpert MTB/RIF Test
Histopathology
Serological Diagnosis of Tuberculosis
Antigen Detection in Body Fluids
Antigen 5 (38 kDa Antigen)
A-60 Antigen
30 kDa Antigen
Tuberculosis Skin Testing (TST)
Previous Vaccination with BCG
MPB 64 Patch Test
Interferon Gamma Release Assay
QuantiFERON-TB Gold
QuantiFERON-TB Gold In-tube
T-Spot IGRA Test
Indirect Approach
Detection of Antibodies for Diagnosis of TB
CONCLUSION
CHAPTER 28:
Management of Polycystic Ovary Syndrome
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Menstrual Disturbances/Disorders
Polycystic Ovary Syndrome in Adolescents
Obesity2
Hirsutism
Infertility
The Impact of PCOS on ART
Surgical Management
New Trends in PCOS: In vitro Maturation
CONCLUSION
CHAPTER 29:
Recurrent Endometriosis: Physiopathology, Epidemiology, Prevention and Treatment
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Physiopathology of Recurrent Endometriosis
Recurrent Endometriosis due to the Development of New Lesions
Recurrent Endometriosis due to the Reactivation of Existing Lesions
Epidemiology of Recurrent Endometriosis
Frequency of Recurrent Post-therapeutic Endometriosis
Risk Factors Associated with Recurrent Endometriosis (Table 29.6)
Prevention of Recurrent Endometriosis
Prevention of Recurrence by Conservative Surgical Management
Prevention of Endometriosis by Medical Management
Treatment of Recurrent Endometriosis
Iterative Conservative Surgery
Medical Treatment of Recurrent Endometriosis
Radical Surgery in Recurrent Endometriosis
CONCLUSION
CHAPTER 30:
Treatment of Deep Rectovaginal Endometriosis
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Definition and Topography of Rectovaginal Endometriosis
Rectovaginal and Rectal Endometriosis
Endometriosis of the Sigmoid
Preoperative Evaluation
Digital Examination
Colonoscopy
Vaginal and Rectal Ultrasound
Magnetic Resonance Imaging
Clinical Management
Expectant Management
Medical Management
Surgical Management
Endometriosis of the Rectovaginal Septum and Rectum
Sigmoid Endometriosis
Results and Follow-up
Rectosigmoid Endometriosis and Fertility
RECENT ADVANCES
CONCLUSION
CHAPTER 31:
Management Practices for Endometriotic Cysts Associated with Infertility
OVERVIEW
INTRODUCTION
Epidemiology of Ovarian Endometriomas
Ovarian Endometriomas and Infertility
CLINICAL DISCUSSION
Therapeutic Tools
Abstention
Hormonal Suppression
Ultrasound-guided Cyst Aspiration
Surgical Treatment
In Vitro Fertilization
Impact of Ovarian Endometriomas on IVF Results
Impact of Previous Surgical Treatment of Ovarian Endometrioma on IVF Results
CONCLUSION
Role of Surgery, IVF and Ultrasound-guided Aspiration
Role of Abstention
CHAPTER 32:
Management of Mild to Moderate Endometriosis in the Infertile Patient
OVERVIEW
INTRODUCTION
Assessment of the Disease
Prognostic Factors
CLINICAL DISCUSSION
Expectant Management
Surgical Treatment of Early Stage Endometriosis
Surgical Approach—Laparoscopy vs Laparotomy
Conservative Surgery
Peritoneal implants
Outcome
Ovarian Suppression
Management of Endometriotic Cysts Associated with Infertility
Treatment
Expectant
Hormonal Suppression
Ultrasound-guided Cyst Aspiration
Surgical Treatment
Cystectomy vs Ablation
In Vitro Fertilization (IVF)
Rectovaginal Endometriosis in an Infertile Patient
Frozen Pelvis with Extensive Endometriosis
Recurrence—Repeat Surgery vs IVF
ART in Endometriosis
Controlled Ovarian Stimulation
Impact of Endometriosis on IVF
Precautions During IVF in Patients of Endometriosis
Ovarian Stimulation and IUI vs IVF
Ovarian Suppression Prior to IVF
Surgical Treatment Prior to IVF
Impact of ART on Endometriosis
CONCLUSION
CHAPTER 33:
Hydrosalpinx and ART: Options and Rationale for Treatment
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Non-surgical Evaluation of the Fallopian Tubes
Hysterosalpingography (HSG)
Selective Salpingography
Hystero-contrast-sonography (HyCoSy)
Transvaginal Ultrasound
CLINICAL DISCUSSION
Hydrosalpinx and Fertility
Surgical Management of Hydrosalpinges
Alternative Management of Hydrosalpinges
Laparoscopic Management of Tubal Pathology
Distal Tubal Disease
Surgical Repair of Distal Tubal Disease
CONCLUSION
CHAPTER 34:
In Women with Unexplained Infertility, should IVF be the First or Last Treatment Option?
OVERVIEW
INTRODUCTION
Diagnosis
Controversies in Diagnosis
Evaluation of Fertilizing Capacity of Sperm
Tests for Ovarian Reserve
Uterine Receptivity
CLINICAL DISCUSSION
Management
Counseling
COH and IUI versus IVF
Should IVF be Recommended as the First-line of Treatment?
Age
Cost
Risk
Counseling and Choice of the Couple
Efficacy of Treatments
IVF versus ICSI
Repeated IVF Failure in Unexplained Infertility
CONCLUSION
CHAPTER 35:
Management of the Obese Infertile Patient
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Mechanisms by which Obesity may Affect Fertility in Women
Obesity as a Condition of Sex Hormone Imbalance in Women
The Obesity-PCOS Link: Pathophysiological Aspects
Management
Treatment
Case Report
RECENT ADVANCES
Potential Role of Endocannabinoid System
Role of Other Adipokines
Role of Topiramate
CONCLUSION
ACKNOWLEDGMENT
SECTION 4: THE ENDOMETRIUM
CHAPTER 36:
What can Clinicians do to Improve Implantation?
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Preconceptual Care
Adjuvant Pharmaceutical Therapies
Aspirin
Nitric Oxide Donors
Aromatase Inhibitors
Ascorbic Acid
Glucocorticoids
Progesterone
Insulin Sensitizing Drugs
GnRH Agonist
Ovarian Stimulation Regimen
Embryo Transfer Technique
Selecting the Optimal Embryo and Endometrium
CONCLUSION
CHAPTER 37:
Endometrial Receptivity in Infertility
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
The Implantation Window
The Receptive Endometrium
RECENT ADVANCES
Markers of Endometrial Receptivity
Morphological Markers
Biochemical Markers (Table 37.1)
Growth Factors
Genetic Regulation of Endometrial Receptivity
Clinical Applications
Clinical Strategies to Assess Endometrial Receptivity
Endometrial Biopsy for Histology
Ultrasound and Doppler
Endometrial Thickness and Morphology
Endometrial Volume using 2D or 3D Scan
Uterine and Ovarian Doppler
Endometrial and Sub-endometrial Blood Flow Assessment using 2D/3D Power Doppler
Endometrial Contractions
Evaluation of Biochemical Markers
β-3 Integrins
Cyclin E and P27
CONCLUSION
The Future
CHAPTER 38:
Management of a Persistently Thin Endometrium
OVERVIEW
RATIONALE
INTRODUCTION
CLINICAL DISCUSSION
Diagnosis
RECENT ADVANCES
Treatment
CONCLUSION
SECTION 5: ASSISTED REPRODUCTIVE TECHNIQUES
CHAPTER 39:
Luteal Phase Support in Ovarian Stimulation Cycles
OVERVIEW
INTRODUCTION
Definition
CLINICAL DISCUSSION
Physiology
Luteal Support Regimens
Progesterone
Human Chorionic Gonadotropin
Estrogen
GnRH Agonist (GnRH-a)
GnRH Antagonist Stimulated Cycles and the Luteal Phase
Duration of Luteal Phase Support
CONCLUSION
CHAPTER 40:
Should We Encourage Patients to Try Complementary Therapies as a Means of Improving Well-being and Fertility Success?
INTRODUCTION
The Stress of Infertility: Lack of Control
Addressing Stress and Infertility
Accompanying Program
Week 1: Informative
Week 2: Psychological Support
Weeks 3 and 4: Assertiveness Program and Meditation Techniques
Week 5: Reflexology
Week 6: The Waiting Period
CONCLUSION
CHAPTER 41:
Age and ART Success: Where do We Draw the Line?
OVERVIEW
INTRODUCTION
ART Success in Patients Aged 40 and Older
Predictive Factors for ART Success in AMA Patients
Infertility Diagnosis
Obstetric History
Number of Embryos
Basal FSH
How Many Cycles?
When is there no Chance at All?
CONCLUSION
Where do we Draw the Line?
CHAPTER 42:
Is There an Ideal Luteal Phase Support Protocol in ART?
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Methods of Luteal Phase Support
hCG Supplementation
Progesterone Supplementation
Mid-luteal Addition of Estradiol
Mid-luteal Addition of hCG in Cycles with Progesterone Supplementation
GnRH Agonist as Luteal Phase Support
RECENT ADVANCES
CONCLUSION
CHAPTER 43:
Intracytoplasmic Sperm Injection for All?
OVERVIEW
RATIONALE
INTRODUCTION
ICSI versus IVF for Unexplained Total Fertilization Failure after Conventional IVF
ICSI versus IVF for Unexplained Infertility after Failed Insemination
ICSI versus IVF for Male Factor Infertility
ICSI versus IVF for Tubal Factor Infertility
ICSI versus IVF for Poor Responders
ICSI versus IVF in Patients with PCOS
ICSI versus IVF for Patients with Increased Oocyte Immaturity
ICSI for Other Indications
The Effect ICSI versus IVF on Embryo Quality
The Effect ICSI versus IVF on the Obstetric Outcome
CONCLUSION
CHAPTER 44:
Selection Criteria for Oocyte and Sperm Donors in IVF Programs
INTRODUCTION
Oocyte Donation
CLINICAL DISCUSSION
Sourcing Oocyte Donors
Psychological Screening
Counseling
Ideal Oocyte Donors
Screening of Donors
Consent
Compensation to Donors
Donor Anonymity
Selection Criteria for Donor Sperms
CONCLUSION
CHAPTER 45:
Did We Really Stop Performing Tubal Procedures?
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Tubal Procedure
Gamete Intrafallopian Transfer1–3
Embryo Transfer
In Vitro Fertilization-Embryo Transfer5
Contrast between Tubal (GIFT) and ET(IVF-ET) Procedures
Dual Procedure (Applying Tubal and ET Procedures in Combination)
Results of a Retrospective Study
CONCLUSION
CHAPTER 46:
Procreation Options in Human Immunodeficiency Virus-infected Patients
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
CONCLUSION
CHAPTER 47:
Management of Poor Ovarian Response in ART: Myths and Facts
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
CONCLUSION
CHAPTER 48:
Nuances of Ultrasound-guided Embryo Transfers
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Factors Influencing Embryo Transfer Outcome
Different Modes of Embryo Transfer
Clinical Touch Method
Ultrasound-guided ET
Advantages of ultrasound-guided ET
Disadvantages of ultrasound-guided ET
Evidence Regarding UGET
Role of Mock (Trial) Embryo Transfer
Procedure of Ultrasound-guided ET
Vaginal Ultrasound and ET
Three-dimensional Ultrasound and ET
CONCLUSION
CHAPTER 49:
Follicular Fluid Environment and ART Outcome
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Synthesis of Follicular Fluid
Composition of Follicular Fluid
Non-hormonal Components
Hormonal Components
Paracrine Factors
Follicular Fluid in the Natural Cycle
Follicular Fluid in Ovarian Stimulation Cycles
GnRH Agonists vs No GnRH Agonists
GnRH Agonist Long vs Short Protocol
GnRH Agonists vs GnRH Antagonists
Recombinant FSH vs hp-hMG in GnRH Long Protocol Cycles
Follicular Fluid Hormonal Variations: Impact on Oocyte Quality
Impact of LH Administration
Markers of Oocyte Developmental Potential
Impact of Letrozole Administration
Intrafollicular Paracrine Factors
CONCLUSION
SECTION 6: THE ART LABORATORY
CHAPTER 50:
Improving Implantation: Choosing the Right Embryo
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Assessment of Embryo Quality: Non-invasive Methods
Morphology
Zygote Scoring
Omics
Time-lapse Imaging of Embryos (EmbryoScope)
Doppler Studies
Invasive Methods
Predicting the Embryo Quality
CONCLUSION
CHAPTER 51:
Oocyte Cryopreservation
OVERVIEW
RATIONALE
INTRODUCTION
CLINICAL DISCUSSION
Freezing Procedures
Slow Cooling
Rapid Thawing
Vitrification
Possible Damage to the Oocyte due to Cryopreservation
Influence of Cryoprotectants on Oocyte Function
Cytoskeletal Damage after Cryopreservation
Solution Effect during Slow Cooling
Results with Slow Cooling
Results with Vitrification
RECENT ADVANCES
CONCLUSION
CHAPTER 52:
Comparison of Two Freezing Techniques for Human Embryos: Slow Freezing and Vitrification
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Materials and Methods
Patients and IVF
Blastocyst Grading
Transfer of Blastocysts and Assessment of Pregnancy
Vitrification of Blastocysts
Blastocyst Warming and Assessment of Survival
Results
Study I
Study II
CONCLUSION
CHAPTER 53:
The Role of Co-culture in Implantation
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Types of Co-culture
Endometrial Co-culture
Blastocyst Culture after Intracytoplasmic Sperm Injection
Cumulus Co-culture
Experience at Our Center
Patient Selection
Ovarian Stimulation Protocol
Establishment of Co-culture System
In Vitro Culture
Results
CONCLUSION
CHAPTER 54:
Oocyte and Embryo Wastage in ART: It is in the Seed, not the Soil
OVERVIEW
INTRODUCTION
Natural Human Reproduction
Present Success of ART
Enormous Biological Loss: Both in Nature and Assisted Reproduction
CLINICAL DISCUSSION
Embryo and Oocyte Wastage
Chromosomal Abnormalities in Preimplantation Embryos
Analysis of Cleavage Stage Embryos
Programmed Cell Death and Embryo Wastage
Programmed Cell Death and Massive Oocyte Loss in the Human Ovarian Germ Cell Line
Implications for ART
What is a Good Embryo (The Seed)?
Role of Preimplantation Genetic Screening in Embryo Selection
Role of Metabolic Profiling of the Embryo
CONCLUSION
SECTION 7: PREIMPLANTATION GENETIC DIAGNOSIS
CHAPTER 55:
Preimplantation Genetic Diagnosis: Expansion of Indications and Technical Advances
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Indications and Conditions for PGD
Couples are at Risk of Transmitting a known Genetic Abnormality to their Children
Preimplantation Genetic Screening
Advanced Maternal Age
Recurrent Pregnancy Loss
Unsuccessful IVF Cycles and Unexplained Infertility
Male Factor Infertility
Mitochondrial Disorders
PGD for Neurogenic Ataxia Retinitis Pigmentosa
Human Leukocyte Antigen Matching
RECENT ADVANCES IN PGD
Late Onset Diseases
PGD for Alzheimer's Disease
Cancer Predisposition Syndromes
PGD for Sex Selection
Sex Selection
PGD for Non-medical Traits
Inherited Deafness
Technical Aspects of PGD
Intracytoplasmic Sperm Injection
Evaluation of Embryos
Biopsy Procedures
Polar Body Biopsy
Cleavage-stage Biopsy (Blastomere Biopsy)
Blastocyst Biopsy
Genetic Analysis Testing
Fluorescent in situ Hybridization
Polymerase Chain Reaction
Diagnosis and Misdiagnosis of PGD Applications Categorized by FISH and PCR
Preimplantation Genetic Haplotyping
PGH versus Previous PGD Techniques
Embryo Transfer and Cryopreservation of Surplus Embryos
Ethical Issues
Regulatory Authority
World Scenario
CONCLUSION
CHAPTER 56:
Preimplantation Genetic Diagnosis for Single Gene Disorders
INTRODUCTION
CLINICAL DISCUSSION
Genetic Counseling
Treatment-Related Counseling
Patient Selection
Intracytoplasmic Sperm Injection
Embryo Biopsy
First and Second Polar Body Biopsy
Cleavage Stage Biopsy
Blastocyst Biopsy
Diagnostic Methods
Gender Determination and Diagnosis of Chromosome Aneuploidies
Fluorescence in situ Hybridization
PCR-based Diagnosis
Nested PCR
Fluorescent PCR
Multiplex PCR
Allele Specific Drop-out: A Problem
Primed in situ Labeling
Whole Genome Amplification (WGA)
Embryo Transfer
CONCLUSION
CHAPTER 57:
Preimplantation Genetic Diagnosis for Selecting HLA Compatible Embryos
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Patients and Methods
Preclinical Work-up
PGD Study
IVF and Embryo Biopsy Procedure
Results
CONCLUSION
CHAPTER 58:
Preimplantation Genetic Diagnosis: Clinical Applications
OVERVIEW
INTRODUCTION
Preimplantation Studies: The Techniques
Obtaining Nuclear Material
Analyzing Methodologies
Polymerase Chain Reaction (PCR)
Whole Genome Amplification
Fluorescent in situ Hybridization (FISH)
Comparative Genomic Hybridization
CLINICAL DISCUSSION
Preimplantation Genetic Diagnosis (PGD)
Main Indications for PGD
Monogenic Disorders
Chromosomal Rearrangements
Late Onset Disorders
Mitochondrial Disorders
Preimplantation Genetic Screening (PGS)
Indications for PGS
Technical Problems and Limitations
CONCLUSION
CHAPTER 59:
Preimplantation Genetic Diagnosis: The Current State of the Art
INTRODUCTION
CLINICAL DISCUSSION
Preimplantation Genetic Diagnosis (PGD)
Blastomere Biopsy
Blastocyst Biopsy
Polar Body Biopsy (Oocyte Biopsy)
PGD for Group 1 Diseases (Aneuploidy)
Use of PGD in IVF Treatment
PGD for Group 2 Diseases
The Technique of PCR in PGD
Amplification Failure
Allele Drop-out
Contamination
Common Diseases Referred for PCR (Group 2)
Autosomal Recessive Disorders (PCR)
Autosomal Dominant Disorders (PCR)
X-linked Disorders (FISH)
Results of PGD Conducted by ESHRE Consortium Steering Committee12
Group I (Aneuploidy for FISH Technique)
Group II (Inherited Monogenic Recessive and Dominant Disorders) (ESHRE PGD 2000)
FURTHER ADVANCES IN PGD
Multiplex PCR
Fluorescent PCR
PCR for Embryo Selection in IVF
CONCLUSION
SECTION 8: ART OUTCOME AND BEYOND
CHAPTER 60:
Can We Improve the IVF Outcome?
INTRODUCTION
CLINICAL DISCUSSION
Factors Responsible for Success
Improving Embryo Quality
Assisted Hatching
The Role of the Endometrium
CONCLUSION
CHAPTER 61:
Does Seasonal Variability Affect ART Outcome?
OVERVIEW
INTRODUCTION
Seasonality in Human Reproduction
Mediators of the Seasonal Effect on Reproduction
Melatonin
Soltriol (Vitamin D3)
Seasonality in Assisted Reproduction
CONCLUSION
CHAPTER 62:
Natural Killer Cells as Predictors of Successful Implantation
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Peri-implantation Events and Placentation
Immune Cells of Decidua
Natural Killer Cells
NK Cell Localization and Trafficking
Fate of dNK Cells
dNK Cells Control Trophoblast Invasion and Vascular Remodeling in the Decidua
NK cells — Killers or Builders, or Both
NK Cells and IVF Success
CONCLUSION
ACKNOWLEDGMENT
CHAPTER 63:
Medical Treatment with Misoprostol for Early Failure of Pregnancies Conceived Following ART
OVERVIEW
INTRODUCTION
CHANGING TRENDS
CLINICAL DISCUSSION
Medical Treatment
Mifepristone Pretreatment
Medical Treatment in Infertility Patients
CONCLUSION
CHAPTER 64:
Management of Recurrent Miscarriages
OVERVIEW
INTRODUCTION
Etiology
Genetic Causes
Endocrine Causes
Mechanism by which insulin resistance causes miscarriages
Obesity
Anatomical Causes
Infections
Immunological Factors
Thrombophilia
Aging Gametes
Endothelial Dysfunction
Environmental Factors
Recurrent Miscarriages and Infertility
Investigations
Immunological Abnormalities
Thromboelastography
Natural Killer Cells and Cytokines
Karyotype
Thrombophilia
Special Investigations for Assisted Reproductive Techniques (ART)
Preimplantation Genetic Diagnosis (PGD)
CLINICAL DISCUSSION
Management
Tender Loving Care
Management of Specific Disorders
Genetic Disorders
Anatomic Defects
Infections
Endocrine Disorders
Luteal Phase Defect (LPD) and the Role of Progesterone
Polycystic Ovary Syndrome (PCOS) and Metformin Use during Pregnancy
Thrombophilia
Immunological Factors
CONCLUSION
ART as a Treatment for Recurrent Miscarriages
CHAPTER 65:
Current Concepts in Multifetal Pregnancy Reduction and Selective Termination
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Technique
Timing
Results
Special Cases
Selective Termination
Selective Termination in Dichorionic Diamniotic Twins
RECENT ADVANCES
Selective Termination in Monochorionic Diamniotic Twins
Timing
Results
CONCLUSION
CHAPTER 66:
The Association Between Congenital Malformations and Infertility, Infertility Treatment and ART
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
The Association Between Congenital Malformations and IVF Treatment
The Association Between Various Elements of IVF Treatment and the Risk of Congenital Malformations
Intracytoplasmic Sperm Injection (ICSI) and Congenital Malformations
Imprinting Disorders and IVF
The Association Between Diagnosis of Infertility and the Risk of Congenital Malformations in Non-IVF Conceptions
Spontaneous Conceptions
Ovulation Induction and the Risk of Congenital Malformations
CONCLUSION
CHAPTER 67:
Preservation of Ovarian Tissue: Pioneers Close to a New Border?
OVERVIEW
INTRODUCTION
Iatrogenic Female Infertility and the Failure of Conventional Treatments
Young women and Anticancer Treatment: Surviving but Sterile
Other Situations and their Fertility Risk
Conventional Solutions for Safeguarding Female Fertility
Newer Methods
CLINICAL DISCUSSION
Cryopreservation of Ovarian Tissues
The Autograft of Ovarian Strips
Autograft of Whole Ovary
The Cryopreservation of Primordial Follicles
Control of the Metastasis Risk
FUTURE PROSPECTS
CONCLUSION
CHAPTER 68:
Is Aspirin Useful in ART Protocols?
INTRODUCTION
Antithrombotic Effect
CLINICAL DISCUSSION
Aspirin and IVF
Meta-analysis of the Role of Aspirin in Patients Undergoing IVF-ICSI17
CONCLUSION
CHAPTER 69:
Cytokines and Embryo Implantation
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Implantation Steps
Embryo Signals
Inflammation and Implantation
The Th1/Th2 Cytokine Balance
A Cardinal Role for Uterine Natural Killer (NK) Cells
Angiogenic Cytokines
Other Regulations of Importance
Complement
Microarrays
CONCLUSION
CHAPTER 70:
Endometrial Cancer and Wish of Pregnancy: Is Conservative Treatment Possible?
OVERVIEW
INTRODUCTION
Risk Factors
Other Risk Factors
Symptomatology
Nutrition and Cancer Risk
Screening Procedures
Endometrial Biopsy
Pap Smear
Hysteroscopy
Dilatation and Curettage/Fractional
Transvaginal ultrasound (TVUS)
Magnetic Resonance Imaging
Staging
Prognostic Factors
CLINICAL DISCUSSION
Fertility Options
Conservative Management
Selection Criteria
Progestins
GnRH Agonists
Progesterone Containing Intrauterine Device
Unresolved Issues
Recent Research
CONCLUSION
SECTION 9: CURRENT CONCEPTS IN THE TREATMENT OF MALE INFERTILITY
CHAPTER 71:
Managing Azoospermia
OVERVIEW
INTRODUCTION
Etiologic Causes
Non-obstructive Azoospermia
Delivery Abnormalities
Obstructive Azoospermia
Ejaculatory Dysfunction
Evaluation
Step 1: Obstructive versus Non-obstructive Azoospermia
Secondary Evaluation
Step 2 : Etiology of Azoospermia
Obstructive Azoospermia
Non-obstructive Azoospermia
Therapy
Obstructive Azoospermia
Non-obstructive Azoospermia
Assisted Reproduction
CONCLUSION
CHAPTER 72:
The Effect of Smoking on Semen Quality in Infertile Men
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Case Studies
RECENT ADVANCES AND CONCLUSION
CHAPTER 73:
Is there an Ideal Sperm Retrieval Technique?
OVERVIEW
INTRODUCTION
Indications for Sperm Retrieval
CLINICAL DISCUSSION
Requirements of an Ideal Technique
Sperm Retrieval Techniques
Epididymal Sperm Retrieval—Open Methods
Epididymal Sperm Retrieval—Percutaneous Methods
Percutaneous epididymal sperm aspiration (PESA)
Testicular Sperm Retrieval—Open Methods
Testicular Sperm Retrieval—Percutaneous Methods
Ideal Technique
CONCLUSION
CHAPTER 74:
Why are We Still Ligating Varicoceles?
INTRODUCTION
History
Pathophysiology
Diagnosis
CLINICAL DISCUSSION
Why do We Need to Ligate a Varicocele in the Era of Assisted Reproduction?
Indications for Surgical Treatment of Varicocele
Surgical Procedures
Surgical Ligation (Figs 74.4A and B)
Advantages:
Disadvantage:
Laparoscopic Ligation
Subinguinal Microsurgical Ligation
Technique of Microsurgical Varicocelectomy
Percutaneous Approach
Complications of Varicocele Surgery
Results and Cost-effectiveness
Controversial and Debatable Areas
CONCLUSION
CHAPTER 75:
Is Cryopreserved Retrieved Sperm the Gold Standard for ART?
OVERVIEW
RATIONALE
INTRODUCTION
CLINICAL DISCUSSION
Case Studies
Donor Sperm Insemination
Freezing before Cancer Therapy to Maintain Reproductive Capacity
Patient's Convenience
Safe Sperm in Patients with Different Degrees of Oligoasthenoteratozoospermia (OAT)
Methodology of Sperm Cryopreservation
Method 1: Programmed Freezing Method
Method 2: Manual Freezing Method
Method 3: Vitrification
RECENT ADVANCES
Cryodamage
CONCLUSION
SECTION 10: ULTRASONOGRAPHY IN INFERTILITY
CHAPTER 76:
3D Ultrasound and Infertility: Evaluating the Uterus of the Infertile Patient
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Ultrasound Acquisition of Data
3DUS in Gynecologic Pelvic Examination
The Uterus
Uterine pathology
Congenital Müllerian malformations
Endometrial filling defects
Intrauterine Device
Endometrial Receptivity
Adenomyosis
Intrauterine Adhesions
CONCLUSION
CHAPTER 77:
Color Doppler and Prediction of Success in ART
OVERVIEW
INTRODUCTION
What is Color Doppler Ultrasound?
Ovarian Follicular Dynamics: From Basic Science to Clinical Practice
CLINICAL DISCUSSION
Relationship Between Uterine Blood Flow and Endometrial and Subendometrial Blood Flows During Stimulated and Natural Cycles
Endometrial and Subendometrial Perfusion are Impaired in Women with Unexplained Subfertility
The Role of Endometrial and Subendometrial Blood Flows, Measured by Three-Dimensional Power Doppler Ultrasound, in the Prediction of Pregnancy during IVF Treatment
The Role of Ultrasonography in the Evaluation of Endometrial Receptivity Following Assisted Reproductive Treatments: A Critical Review
Endometrial Evaluation in Superovulation Programs: Relationship with Successful Outcome
Doppler Evaluation of the Uterine and Spiral Arteries from Different Sampling Sites and Phases of the Menstrual Cycle during Controlled Ovarian Hyperstimulation
Transvaginal Color Flow Doppler in the Assessment of Ovarian and Uterine Blood Flow in Infertile Women
Endometrial Receptivity in the Light of Modern Assisted Reproductive Techniques
CHAPTER 78:
Uterine Contractility and Ultrasound
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Physiology of Uterine Contractions in the Non-pregnant uterus
Follicular Phase
Mid-luteal Phase
End Luteal Phase–early Follicular Phase
Uterine Contractility and Conception
Uterine Contractions and Sperm Transport
Uterine Contractility on the Day of Blastocyst Transfer
Role of Hormones in Uterine Contractility
Effect of Estrogen
Effect of Vaginal Progesterone
Assessment of Uterine Contractility
Intrauterine Pressure
Electromyography
High-resolution Transvaginal Ultrasound
RESEARCH PROSPECTS
CONCLUSION
SECTION 11: BATCH IVF
CHAPTER 79:
Does Batch IVF Compromise the IVF Laboratory?
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Infection Control and Protective Measures
Consumables
Records and Protocols
Maintenance Calibration and Equipments Monitoring
Staffing Requirements
Air Conditioning System
CONCLUSION
SECTION 12: MARKETING AND ADVERTISING IN IVF
CHAPTER 80:
Web Marketing for IVF Clinics
OVERVIEW
Why You Need a Website?
How Your Website Helps You?
Promoting Your website—An Ongoing Effort
CONCLUSION
CHAPTER 81:
Role of Mass Media in Marketing Your IVF Center
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Types and Functions of Mass Media
Types of Media that can be Employed in Marketing your IVF Clinic
Television
Radio
Internet
Newspapers
Magazines
Other Print Media
Outdoor Media
Composing Effective Messages for Specific Channels
Understanding How to Interact with Media
Media Effects
The Knowledge Gap
Agenda Setting
Cultivation of Perceptions
The Relationship of Mass Media to Other Forms of Communication
CONCLUSION
CHAPTER 82:
Cross-border Reproductive Care: A Worldwide Phenomenon
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
The Increase in Reproductive Tourism
Reasons for International Travel for IVF Treatment
Quality of Care
Local Availability
Law and Regulations
Cost
Social
Ethnic Needs
Is IVF Tourism a Good or a Bad Phenomenon?
CONCLUSION
SECTION 13: ART REGULATION
CHAPTER 83:
Is there a Worldwide Need for ART Regulatory Guidelines?
INFERTILITY AND HEALTH CARE SYSTEMS
Ethical Issues
Legal Status of Embryo
Presence of National Guidelines
Absence of Guidelines
CONCLUSION
CHAPTER 84:
Ethical Issues in Gamete Donation and Surrogacy
INTRODUCTION
CLINICAL DISCUSSION
Gametes donations
Artificial Insemination with Donor Semen
Common indications
Requirements for a sperm donor
Oocyte Donation or Embryo Donation
Other Issues in Gamete Donation
Surrogacy
General Considerations in Surrogacy
Possible Misuse of ART—Sale of Embryos and Stem Cells
Rights of a Child Born Through Various ART Techniques
FUTURE CHALLENGES
CHAPTER 85:
Accreditation and Supervision of ART Clinics: Worldwide Trends
OVERVIEW
INTRODUCTION
Initial History of IVF
CLINICAL DISCUSSION
Accreditation
Accreditation in India and the Subcontinent
In USA
Professional Accomplishments that have Enhanced Oversight of ART
Professional Society Guidelines and Practice
Professional Society Ethical Guidelines
In Canada
Monitoring Reproductive Health in Europe
Role of ESHRE
In UK
In Sweden
Systems for Quality Control (QC)
In Australia
Egg Sharing (Pros and Cons)
CONCLUSION
CHAPTER 86:
The Uterus in Third Party Reproduction: Medicolegal Status and Ethical Concerns
INTRODUCTION
CLINICAL DISCUSSION
What is Surrogacy?
Is Surrogacy Recognized in India?
Is Commercial Surrogacy Unethical?
Does the Surrogacy Contract Infringe upon the Right to Life and Liberty?
Right to Abort
Does the Child have the Right to Find his/her Genetic Parents?
Custody of the Child
Unresolved Issues
Complicating Issues Further
CONCLUSION
SECTION 14: THE FUTURE OF ART
CHAPTER 87:
Anti-Müllerian Hormone: Insights into a Novel Biomarker of the Ovarian Follicular Status
OVERVIEW
INTRODUCTION
CLINICAL DISCUSSION
Serum AMH Concentration is a Marker of the Ovarian Follicular Status
Serum AMH: A Reproductive Intercycle Measurement
Dynamics of Serum AMH Concentrations During the Menstrual Cycle and the Final Follicle Maturation and Luteinization
Dynamics of Serum AMH Levels during the Menstrual Cycle
Consequences of Final Follicle Maturation on Serum AMH Concentrations
Consequences of Follicle Luteinization and Corpus Luteum Formation on Serum AMH Concentrations
Serum AMH: A Qualitative Marker of the Ovarian Follicular Status
CONCLUSION
CHAPTER 88:
In Vitro Maturation of Oocyte: Will it Ever Replace the Traditional IVF Program?
INTRODUCTION
What are the Strategies Available to Prevent OHSS Today?
CONCLUSION
CHAPTER 89:
Stem Cell Therapeutic Potential: Miles to go Before We Sleep
OVERVIEW
INTRODUCTION
Cell Therapy and Regenerative Medicine
CLINICAL DISCUSSION
Screening of Donor Sources
Setting Standards for Cultured Human Stem Cell Lines
Culturing without a Feeder Layer of Animal Cells Improve Safety
Importance of Detailed Characterization of Human Stem Cell Populations
Assessment of Human Stem Cell Safety in Animal Models of Human Diseases
CONCLUSION
INDEX
TOC
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