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Case History

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Image not available. A couple attend the fertility clinic. The female partner is 38 years old and has a regular 30-day cycle. Her luteal phase progesterone is suggestive of ovulation. Her partner has had a normal semen analysis. They have been trying to conceive for two years.

What methods of assisted conception are available?

Which surgical procedures might improve the chances of conception?

What irreversible factors would affect the outcome of assisted reproduction treatments?

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Background

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What methods of assisted conception are available?

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Ovulation induction
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Image not available. Clomifene is an anti-oestrogen and is used to induce ovulation. It is associated with increased pregnancy rates per treatment cycle in patients with amenorrhoea and oligomenorrhoea.1 It has also been shown to increase clinical pregnancy rates slightly in women with unexplained infertility.2 The use of clomifene has about a 10% risk of multiple pregnancy; therefore ultrasound monitoring of the number of developing follicles must be offered, at least in the first cycle of treatment, to prevent the conception of high-order multiples. Gonadotrophins may also be used in clomifene-resistant women.

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Intrauterine insemination (IUI)
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Intrauterine insemination (Table 19.1) involves introducing prepared semen into the uterus. This can be done during the woman's own natural cycle, or as part of a stimulated cycle using clomifene or gonadotrophins. IUI has been shown to increase pregnancy rates in mild male factor infertility, unexplained subfertilty and subfertility related to minimal or mild endometriosis. Assuming that there are no complicating factors, such as a raised follicle-stimulating hormone (FSH), cumulative pregnancy rates may be as high as 35% after four cycles, particularly in male factor infertility.

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Table Graphic Jump Location
Table 19.1Currently used techniques for assisted reproduction
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Stimulated IUI carries with it a significant risk of multiple pregnancy and therefore unstimulated IUI is recommended.3 Up to six cycles of IUI may be of benefit. However some patients, especially those who are older at initial presentation, will choose not to have IUI and to embark upon in vitro fertilization (IVF) instead, because of higher success rates per cycle.

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Donor insemination
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Donor insemination is a valuable method of assisted conception in cases of obstructive and non-obstructive azoospermia or very poor semen quality, where the couple do not wish to undergo IVF with intracytoplasmic sperm injection (ICSI). It can also be used to avoid transmission of inheritable diseases. Couples may choose to use donor insemination if attempts at ICSI have failed. Frozen semen which has been quarantined for six months is used rather than fresh semen to avoid transmission of diseases such as human immunodeficiency virus. Donors ...

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