Infertility in Practice, Fourth Edition PDF

RepRoductive Medicine & Assisted
RM&ART
RepRoductive techniques seRies
Infertility
in Practice
Fourth Edition
A d A m H. B A l e n
Infertility
in Practice
REPRODUCTIVE MEDICINE AND ASSISTED REPRODUCTIVE
TECHNIQUES SERIES
David Gardner
University of Melbourne, Australia
Zeev Shoham
Kaplan Hospital, Rehovot, Israel
Kay Elder, Jacques Cohen

Human Preimplantation Embryo Selection, ISBN: 9780415399739
Michael Tucker, Juergen Liebermann
Vitrification in Assisted Reproduction, ISBN: 9780415408820
John D Aplin, Asgerally T Fazleabas, Stanley R Glasser, Linda C Giudice
The Endometrium, Second Edition, ISBN: 9780415385831
Nick Macklon, Ian Greer, Eric Steegers
Textbook of Periconceptional Medicine, ISBN: 9780415458924
Andrea Borini, Giovanni Coticchio
Preservation of Human Oocytes, ISBN: 9780415476799
Steven R Bayer, Michael M Alper, Alan S Penzias
The Boston IVF Handbook of Infertility, Third Edition, ISBN: 9781841848105
Ben Cohlen, Willem Ombelet
Intra-Uterine Insemination: Evidence-Based Guidelines for Daily Practice,
ISBN: 9781841849881
Adam H. Balen
Infertility in Practice, Fourth Edition, ISBN: 9781841848495
Infertility
in Practice
Fourth Edition
AdAm H. BAlen MB BS, MD, DS c , FRCOG

Professor of Reproductive Medicine and Surgery, Leeds Teaching Hospitals, UK
Boca Raton London New York
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Contents
Foreword......................................................................................................................ix
Preface.........................................................................................................................xi
Section I Infertility – Background, Diagnosis and

Counselling
1. Infertility – Epidemiology, Diagnosis and Counselling................................... 1
2. Prevention of Infertility.................................................................................... 13
3. Planning a Pregnancy....................................................................................... 27
4. Obesity and Reproduction................................................................................ 49
5. Investigating Infertility..................................................................................... 63
6. Counselling...................................................................................................... 135
Section II Management – Diagnosis and Treatment

7. Anovulatory Infertility and Ovulation Induction........................................ 145
8. Polycystic Ovary Syndrome........................................................................... 201
9. Premature Ovarian Insufficiency (Failure) and Oocyte Donation............ 239
10. Endometriosis.................................................................................................. 251
11. Tubal Infertility and Fibroids........................................................................ 269
12. Male Factor Infertility.................................................................................... 291
13. Unexplained Infertility................................................................................... 315
© 2011 Taylor & Francis Group, LLC vii

viii Contents
Section III Assisted Conception, Ethical Issues and

Regulation
14. Assisted Conception........................................................................................ 323
15. The Human Fertilisation and Embryology Authority and Regulation...... 365
16. Ethical Issues................................................................................................... 375
17. Follow-Up of Children Born from Assisted Reproduction Techniques..... 387
Section IV Complications of Treatment and

New Technologies
18. Complications of Ovarian Stimulation......................................................... 395
19. Emerging Technologies................................................................................... 417
Section V Pregnancy
20. Miscarriage after Fertility Treatment.......................................................... 427
21. Recurrent Miscarriage................................................................................... 441
22. Ectopic Pregnancy.......................................................................................... 451
Section VI Treatment Failure

23. When to Stop Treatment and Other Options............................................... 459
Useful Addresses..................................................................................................... 465

Books for Further Reading.................................................................................... 467
Appendix.................................................................................................................. 469

Foreword
It gives me great pleasure to write the foreword for the Fourth Edition of Infertility
in Practice, written by Professor Adam Balen. With the current emphasis on sophis-
ticated assisted reproductive techniques (ARTs), the critical contribution of clinical
experience and expertise and common practical sense to diagnosis and clinical deci-
sion making is often overlooked. This book presents a practical perspective and gives
the clinician a clear picture of the aetiology of infertility. The most common causes of
infertility, such as polycystic ovary syndrome (PCOS), endometriosis, tubal damage,
male factor and unexplained aetiology, have been described in detail, avoiding specu-
lations that are not based on scientific knowledge. Infertility treatment options are
described in detail, and the book gives the reader a clear understanding of the current
treatment practices.
I especially liked Chapter 14, Assisted Conception, which describes the present
view on treating patients in some special situations. For example, the indication
of hydrosalpinges in ultrasound is a clear sign for their removal as the procedure
improves implantation and pregnancy rates. Furthermore, in moderate-to-severe
endometriosis, in vitro fertilisation (IVF) is recommended if pregnancy is not
anticipated within 12 months after surgery. Similarly, in severe sperm dysfunction
or after unsuccessful cycles of superovulation combined with intrauterine insemina-
tion (IUI), IVF should be offered, and in men with azoospermia it is reasonable to
attempt 12 cycles of donor insemination in women younger than 35 years of age.
An interesting option is to test fertilisation after one IVF treatment before superovu-
lation and IUI.
Some of the less commonly used – and also these days, obsolete – ART treatments
are described briefly, but, understandably, the most frequently used procedures of
IVF have received most space and different stimulation options have been described
in detail. Also, special situations, such as ovarian cysts, PCOS and patients with
decreased ovarian reserve, have been clarified in separate chapters. The results of
different treatment options, and the impact of the number of attempts on pregnancy
outcome, have been described. Ethical issues are a very essential part of ART treat-
ments, and questions such as experiments on human pre-embryos, cloning, stem cell
research, fetal sex selection and reduction have been considered in many respects.
The book identifies potential ART-treatment-related complications and pregnancy
problems, and it summarises the present data on the possible health consequences of
the children born from ART treatments.
This fourth edition echoes the format of previous editions, but many of the tables
and images have been updated. All in all, the book gives an excellent insight into the
leading causes of infertility, infertility treatments, pregnancy and health of the child.
I believe that the readers can easily obtain a comprehensive understanding of the
recent developments in this particular field, and I am sure they would enjoy reading
© 2011 Taylor & Francis Group, LLC ix

x Foreword
this book. I would like to congratulate Adam Balen for the excellent work, and I wish
every s uccess to this new edition of Infertility in Practice.
Juha Tapanainen
Professor of Obstetrics and Gynaecology
University of Helsinki and Helsinki University Hospital
Helsinki, Finland

Preface
We are pleased to present the Fourth Edition of Infertility in Practice, which has
been updated every 5 years since being first published in 1997. Throughout this time,
our understanding of infertility and its management have continued to expand most
rapidly.
A great deal of public attention has been focused on the high-tech advances in
assisted conception therapies. In vitro fertilisation (IVF) has been available for the
past 35 years, and in many European countries, 2%–5% of babies are the result of IVF
therapy. Innovations, such as micromanipulation of gametes for therapy (e.g. intra-
cytoplasmic sperm injection or ICSI) and biopsy of embryos for pre-implantation
genetic diagnosis (PGD), broadened the applications for IVF technology and are now
firmly established techniques. Some recent advances, for example, cryopreservation
of ovarian tissue and oocytes, have generated great excitement because of the pros-
pect of preserving fertility before sterilising therapy for cancer. More controversial is
the potential to freeze oocytes as an insurance policy for young women who wish to
delay childbearing for social reasons. Other developments, such as cloning and stem
cell research, have created concerns about the potential abuse of such technology.
Although scientists have been busy improving the prospects for women with ovarian
failure and for men with very low sperm counts, the clinical approach to investigation
and therapy also has made great strides to minimise the time taken to reach diagnosis
and direct a couple to appropriate treatment.
Infertility in Practice has been written as a practical guide and is based on the
author’s experience of daily clinical practice. The aim of the book is to place the
modern approach to the management of infertility in the context of sound theory and
evidence-based therapy. We have striven to provide the reader with a comprehensive
classification of the causes of infertility, their investigation and management. In this
edition, we have revised the whole text, in particular the chapters on ovulation induc-
tion for anovulatory infertility and assisted conception, polycystic ovary syndrome and
obesity and reproduction – subjects in which we have developed particular interest.
We present new data on ovarian reserve testing, the effects of fibroids on reproduction
and many other areas of daily interest. We also have addressed the important issues of
counselling, ethics and the regulation of fertility therapies. A glimpse into the future
is provided in a chapter on emerging technologies, some of which are already being
incorporated into daily practice.
The treatments for most causes of infertility provide very satisfactory cumulative
chances of conception and of birth of a healthy child. However, the side effects
must be borne in mind, whether it is the immediate risk of ovarian hyperstimulation
syndrome and multiple pregnancy or the long-term possibility of ovarian cancer. In
this edition, we also discuss the outcome for the children born as a result of assisted
reproduction technology. The cost of treatment also must be considered.
© 2011 Taylor & Francis Group, LLC xi

xii Preface
When determining appropriate treatment for the management of infertility, there

may be one clear treatment or several potential options. Furthermore, there are often
a v ariety of drugs to choose between and several potential treatment protocols. It
is important to consider not only efficacy of treatment but also cost-effectiveness
based on a combination of scientific evidence and health economics. There has
been a trend for cost-effectiveness analyses to be sponsored by the pharmaceutical
industry. Although much research could not take place without industry support, it
is important to be cautious when interpreting such data [1]. Reproductive medicine
is evolving continually and often rapidly; therefore, guidelines for management and
its funding require regular revision. Statements on cost-effectiveness often make
reference to eligibility criteria without providing a balanced view on fairness. For
example, a woman aged 28 years with two children and tubal infertility will have
a much better chance of conceiving with in vitro fertilisation (IVF) than a woman
of 35 with no children and tubal infertility; yet, who deserves the treatment more?
In the United Kingdom, the National Institute for Health and Clinical Excellence
(NICE) produced guidelines in 2004 for the investigation and management of
infertility that were intended also to dictate National Health Service funding criteria
for fertility treatment [2]. Unfortunately, this attempt has not been translated into
any i mprovement in s upport for services for infertile couples. At the time of writing,
the draft of updated guidance from NICE is under consultation, with both a revision
of some of the clinical evidence and also suggested changes in eligibility criteria.
Unfortunately, the waters get m uddied between good medical practice and political
expediency, which to my mind is a serious flaw in the process. I have tried to provide
an up-to-date, practical guide to the management of infertility and have made refer-
ence to issues of c ost-effectiveness where appropriate.
References for further reading are provided throughout the book. However, the
list is not exhaustive as the book is written as a practical guide rather than a highly
academic work of reference. Many of the references are of contemporary reviews
which will enable the interested reader to explore the literature further.
I acknowledge the tremendous contribution of Howard Jacobs, my mentor and great
friend and the co-author of the first two editions, to our field over the years.
We hope that, whatever your expertise, Infertility in Practice will help in the
management of couples attending your clinic.
Adam H. Balen
Leeds, 2013
REFERENCES
1. Barlow D. Cost effectiveness modelling. Hum Reprod 2001; 16: 2479–80.
2. NICE. Fertility: assessment and treatment for people with fertility problems. London:
DoH & RCOG, 2004 (revised draft for consultation 2012).

1
Infertility – Epidemiology,
Diagnosis and Counselling
Introduction
Infertility is common. It has been suggested that approximately 9% of couples
are involuntarily childless, although the exact number inevitably depends on how
the complaint is defined [1]. Medical definitions of infertility tend to emphasise
the immediate problem brought to the consultation, reflecting the typically short-
term interaction of many doctors, particularly specialists, with their patients. Most
accepted definitions therefore involve the number of months before the consultation
during which the couple has been exposed to the chance of a pregnancy. When the
lifetime experience of a couple’s attempt to raise a family is considered, a quite dif-
ferent picture emerges. Studies from Oxford and Copenhagen revealed that at least
one-quarter of all couples experience unexpected delays in achieving their desired
family size [2,3] although only one half of these may seek treatment [3].
In recent years, there has been an increase in publicity about infertility and
reproductive medicine technologies that has helped in reducing both the stigma of
infertility and the reluctance of couples to seek advice. Indeed, we find that the taboo of
infertility in many respects has been replaced by discussion of obesity – which, paren-
thetically is more of a health concern and we find a more sensitive topic for discussion.
Herein, definitions of infertility that are measured in terms of the duration of
exposure to the chance of conceiving are discussed. It is important at the outset to
acknowledge that the single most important determinant of a couple’s fertility is the
age of the female partner. Green and Vessey [2] showed that for women up to and
including 25 years of age, the cumulative conception rate (CCR) (vide infra) is 60%
at 6 months and 85% at 1 year; that is, of 100 couples trying to conceive, 40 couples
will not be pregnant after 6 months and 15 couples will still not have conceived after
1 year of trying. For couples where the female partner is aged 35 years or older,
the conception rate is 60% at 1 year and 85% at 2 years; that is, fertility has halved
because of age alone.
The data in Figure 1.1 were taken from a study of the French national experience of
donor insemination [4]. This study was published several years ago and provides an
advantage not available to us today, namely that it was undertaken before the acquired
immunodeficiency syndrome (AIDS) epidemic prevented the use of fresh samples
for insemination. Furthermore, the age of the donors is more or less fixed; therefore,
the age-related variation is essentially attributable to women. It is worth reflecting on
© 2011 Taylor & Francis Group, LLC 1

2 Infertility in Practice
80
70
60
50
Percent
40
30 <25 years
26–30
20 31–35
>35
10
0
1 2 3 4 5 6 7 8 9 10 11 12
Cycles
FIGURE 1.1 Female fecundity as a function of age. Results of donor insemination in 2193 nul-
liparous women with azoospermic husbands. (From Schwartz D, Mayaux MJ, N Engl J Med 306,
404–6, 1982. With permission.)
the reason for the strikingly different effects the passage of years has on the fertility
of the two sexes. In men, the supply of sperm is continuous, with the germ cells of the
testis dividing all the time so that the average age of sperm in an ejaculate is measured
in months. However, women are born with a finite complement of eggs that do not
undergo further cell division until just after fertilisation.
Thus, an oocyte ovulated today is pretty well the same age as the woman from
whose ovary it came. Even deoxyribonucleic acid (DNA), the most stable molecule
in biology, is not completely invulnerable to the passage of years; this impact of age
on oocytes is consistent with its effect on the risk of congenital abnormalities, well
known in many cases to increase with maternal age.
Measuring Infertility and Response to Treatment

To decide whether a couple should be investigated and indeed to formulate a prognosis
for the success of treatment, the clinician needs a definition of normal fertility that
is sensitive to the fact that, in nature, the highest rates of fertility do not exceed 30%
conception per cycle. Using that figure, if 100 couples discontinue contraception, at the
end of 1 month 30 women can expect to be pregnant and 70 couples will need to try
again next month. At the end of the second month, 70 ÷ 3 = ~23 more women will have
conceived, giving a CCR of 30% + 23% = 53% at 2 months.

Infertility – Epidemiology, Diagnosis and Counselling 3
If we assume that the monthly rate of conception remains constant, it is easy to

see how theoretical CCRs can be calculated for any infertility diagnosis and for any
duration of treatment. In practice, monthly rates of conception do not remain constant
because the more fertile couples conceive in the earlier months, and when we turn
from theoretical examples to real clinical situations, follow-up is usually incomplete.
The question then arises as to how to deal with the results of couples who leave a
study before they have conceived or before their programme of treatment has been
completed. Moreover, couples leave treatment after different periods of time accord-
ing to their own needs and circumstances, for example, because of emotional stress,
financial constraints or the advice given to them by their specialists.
By convention, in the calculation of CCR, the outcome for those leaving a pro-
gramme for reasons other than pregnancy is assumed to be the same as for those who
remain in treatment. This assumption is the basis for the construction of CCR based
on life-table analysis, a method that was originally devised to describe survival from
malignant disease, but in the case of fertility is inverted to show increasing concep-
tion rather than declining survival. Figure 1.2 shows an example of a life-table analy-
sis of the fertility of a group of women treated by ovarian diathermy [5]. This method
of analysis can be easily adapted for use in a computer spreadsheet.
CCRs calculated from life tables have been used extensively to express fertility rates
in relation to age and disease and to compare the results of treatment in different centres.
An important extension of the CCR is the cumulative live birth rate (CLBR). Because
the rates of miscarriage and several obstetric complications are closely influenced by
maternal age and indeed other maternal factors that influence reproductive potential, the
fall-off with age of the CLBR is even more severe than that of the CCR. However, it is the
CLBR that patients want to know in response to the question, ‘What are our chances?’
Thus, it behoves us to acknowledge certain limitations in its interpretation. The
first limitation is that it has been shown that as the number of drop outs increases, the
calculated conception or birth rate increases. This finding means that the more care-
less clinics are in obtaining follow-up information, the more this method of describ-
ing results exaggerates their success. The second important point to note is that drop
outs from treatment are not random; people leave a programme largely because of
their experience with it. One may safely assume that the outcome of the whole group
would have been worse if those who had dropped out because of their, or the staff’s,
lack of confidence had stayed in, and their results would have contributed directly to
the determination of the group’s response to treatment. Because of the free-market
approach to infertility treatment, patients may enter a given clinic’s statistical record
after already having had treatment elsewhere. Thus, what may be recorded as a first
cycle may actually only be the first in that clinic for the couple concerned. This situ-
ation is the case particularly in countries, such as England, where the majority of
patients have been forced to fund their own treatment and many travel between clinics.
Definition of Infertility
The live birth rate (or the take-home baby rate) clearly depends both on the rate
of conception and the survival of the pregnancy, and in infertility practice this
rate is largely determined by the miscarriage rate. By convention, when a patient

80
60
Pregnancy (%)
40
20
1 2 3 4 5 6
Months after operation
All cases (50) Normal pelvis (22)
FIGURE 1.2 Cumulative conception rate – laparoscopic ovarian diathermy. The black bars refer
to all cases treated by ovarian diathermy, and the grey bars refer to those who had a normal pelvis at
laparoscopy. (From Armar NA and Lachelin GCL, BJOG 100, 161, 1993.)
is referred to as being infertile, it means a slow rate of conception – infertility

is rarely absolute. Indeed, some prefer the expression subfertility, although I shy
away from such semantics. As already mentioned, in most people, age is the most
important determinant of the conception rate. All other things being equal, a
couple in which the female partner is 25 years old or younger stands a 5 out of
6 chance of conceiving in the year after discontinuing contraception. If, despite
a regular menstrual cycle and a normal sex life, pregnancy has not occurred by
then, most authorities would accept that a couple has a fertility problem and would
offer investigation and treatment. If there is a history of menstrual disturbance,
assessment of the patient’s fertility should take into account how long it will take
her to accumulate the 12 or 13 ovulations that the woman with a normal cycle
has in 1 year. Clearly, if a woman ovulates only four times a year, it will take her
three times as long as a woman with a regular cycle to have the same chance of

getting pregnant. In that situation, it makes no sense to defer investigation for a

year. Similarly, if there is a history of pelvic inflammatory disease or a severe
attack of appendicitis (particularly if there has been peritonitis), or in the male
partner an attack of orchitis or a history of cryptorchidism, investigation should
begin sooner rather than later.
A more difficult problem is defining infertility in the couple with an older female
partner. In one way, one might consider delaying investigation because it takes longer
for a woman of 35 years and older to achieve a particular conception rate. Conversely,
the slope of the line relating the risk of childlessness to age gets much steeper as a
woman approaches 40 years of age. Furthermore, the prospects of achieving a preg-
nancy with treatment are parallel to this curve. There is therefore little time to lose
for such couples, and in our practice, we are more active in advising investigation and
treatment as the female partner passes her 35th birthday. There seems little point in
waiting beyond 1 year, and in many women, particularly those with some diagnostic
clue in their history, we recommend initiating investigation after 6 months of unpro-
tected intercourse.
Need and Demand for Infertility Treatment

A review published in 2007 examined the collective prevalence of infertility from
25 population surveys (of 172,413 women) worldwide [1]. There was a wide range of
infertility rates, ranging from 3.5% to 16.7% in developed countries and from 6.9%
to 9.3% in less developed countries, with a median overall prevalence of 9%, equat-
ing to more than 70 million women worldwide. Detailed analysis suggests that rates
of infertility do not differ significantly between countries, irrespective of whether
they are developed [1]. Overall, approximately 56% (range 27%–76%), that is, 40
million couples, seek medical care, although only an estimated 22% receive care [1].
It is not possible to extrapolate from these data whether the true rate of infertility is
rising, although possible reasons for a potential increase in infertility are discussed
below.
There have been three studies in the United Kingdom over the past 25 years. In
1988, Templeton et al. [6] surveyed 766 women aged 46–50 years in Scotland and
reported a lifetime rate of 14.1% with infertility of whom 70% sought medical care.
In 1993 and 1995, two surveys in England of 2377 and 728 women reported preva-
lence rates of 26.4% and 17.3%, respectively, of whom 50%–61% sought assistance
[7,8]. A key discussion relates to how infertility is defined within the population being
described and has to take into consideration not only duration but also age to provide
a sensible approach to commencing therapy when the predicted natural chance of
conception is low [9].
Is Infertility Becoming More Common?

According to the U.K. Government Statistical Services, there is a steadily rising pro-
portion of women in the United Kingdom who have never had a child. The mean
age of mothers at childbirth fell from 28.7 years for women born in 1920 to a low of

30
Completed childbearing Partly to completely based on fertility
projections
29
28
Years of age
27
26
25
0
1920 1930 1940 1950 1960 1970 1980 1990
Year of birth of women
FIGURE 1.3 Mean age at childbearing for women born from 1920 to 1990, United Kingdom.
(From Birth registrations England, Wales, Scotland and Northern Ireland 1935 to 2002: Office for
National Statistics, General Register Office for Scotland, Northern Ireland Statistics and Research
Agency. Birth order, England & Wales: Office for National Statistics, UK 2002-based national
population projections, 2003 to 2035: Government Actuary’s Department Completed family size.
2007. Available from: http//www.statistics.gov.uk.)
26.0 years for women born in the mid-1940s (Figure 1.3) [10]. Women born in the
1940s had the lowest average age at childbirth, contributing to the 1960s baby boom,
when family size was also larger. Since then, the average age at childbirth has risen
and is still projected to increase to more than 29 years for women born in the late
1970s onwards; in addition, women are having fewer children [10].
Amongst women who were born in 1948, 13% were childless at the age of 35; this
proportion had almost doubled for women born 10 years later. At the end of their
childbearing years, 21% of women born in 1920 were childless. This value fell to
13% of those born in 1949 and since then has steadily increased to just under 20%
for women who are soon to complete their reproductive years [10]. Forty percent of
women born in 1949 were still childless at age 25; this percentage increased to 69%
for women aged 25 who were born in 1979 [11,12]. There also has been a rise in
childlessness at age 35 from 15% of those born in 1949 to 27% of those born in 1969
(Table 1.1 and Figures 1.4 and 1.5) [12,13].
The proportions of women reaching the end of the childbearing years (age 45) who
remained childless rose from 9% to 18% of those born in 1959, the most recent cohort
of women to have reached the end of their childbearing years [12]. The average age of
married women giving birth for the first time has increased by 6 years since 1971 to
30 in 2003 [12] and has now dropped a little to 28 in 2009 [13].

TABLE 1.1
Percentage of Women Childless in England and Wales
Related to Year of Birth (see Figure 1.4)
Year of Birth Age 25 (%) Age 35 (%) Age 45 (%)
1925 46 19 17
1935 39 13 12
1945 34 11 9
1955 48 19 15
1965 60 25 –
1975 65 – –
Source: OPCS, Percentage of Women Childless at Age 25, 35
and 45: By Year of Birth, Social Trends 33, 2003.
Available from: http//www.statistics.gov.uk.
100
80
Percentage of women childless
Women’s year of birth
60 1968
40
1963
1958
20
1953
1948
0
15 20 25 30 35 40 45
Age of women
FIGURE 1.4 Percentage of women childless at successive ages in England and Wales.
During the 1960s, women were having more children and earlier in life, thereby
pushing the total fertility rate (TFR) upwards to just below three children per woman. In
England and Wales, women born in 1940 (who were in their twenties during the 1960s)
had, on average, 1.89 children by their 30th birthday, whereas this number had nearly
halved to 0.99 children by age 30 among women born in 1975. Women of childbearing

180
160
140
120 25–29
women in age group
Live births per 1000
30–34
100
80
20–24
60
35–39
40
<20
20
40+
0
1970 1975 1980 1985 1990 1995 2000 2005 2010
FIGURE 1.5 (See colour insert.) Age-specific fertility rates in the United Kingdom, 1970–2010.
(Reproduced with permission from Office of National Statistics, Frequently Asked Questions: Births
& Fertility, Office of National Statistics, London, 2011.)
age during the 1960s were generally having larger families than those of childbearing
age 20 years later. For example, women born in 1940 had on average 2.36 children dur-
ing their lifetime, whereas those born in 1960 had only 1.98 children and those born in
1975 are projected to have only 1.87 children on average. This decrease is partly due
to a rise in the proportion of women remaining childless; only 11% of women born in
1940 had no children compared with 19% of women born in 1960. For women born in
1965, the proportion projected to remain childless is 20%; for those born in 1970, the
projected proportion is 18%, and for those born in 1975 it is 19% [13].
The most recent statistics indicate that the U.K. TFR increased from a low point
of 1.63 in 2001 to 1.98 in 2010 [13]. Changes in the TFR can result from changes
in the timing of childbearing in women’s lives as well as any changes in completed
family size. There is no single explanation underlying the recent increases in fertil-
ity; these increases are likely to have resulted from a combination of the following
factors:
• Women born in the 1960s and 1970s who delayed their childbearing to older
ages are now catching up in terms of completed family size.
• More older women may be conceiving with the assistance of fertility therapy.
• Changes in support for families (e.g. maternity and paternity leave and tax
credits).
• Increases in the numbers of foreign-born women with above-average
fertility.
In addition, the age structure of the female population has an impact on the number
of births. For example, the number of women in their twenties is relatively high

c ompared with a few years ago, and this age structure is having an upwards impact
on births and will continue to do so in the next few years as these women move into
the peak childbearing ages.
Infertility as a complaint brought to medical attention is also on the increase. There
are several reasons for this increase. The first reason is a secular change in family
planning such that the mean age of mothers at first birth in Western countries is now
approximately 29.5 years, as opposed to 25 years two decades ago [14]. Furthermore,
the risks of pregnancy complications rise significantly with increasing maternal age
[15]. As mentioned, age is so crucial a determinant of fertility that the increasing age
at which many women now choose to start their family means that fertility problems
feature more in their lives than ever before. In the United States, women over the age
of 35 now account for more than 50% of all presentations for infertility. It is naturally
particularly galling for a woman to have conscientiously pursued safe contraception
for many years only to find that when she does plan to start a family, fertility eludes
her. There really needs to be a societal and political will to provide support for young
mothers who wish to pursue their careers and care for their children [16,17].
Another important change that seems to be occurring in several European countries
and in the United States is a decline in male fertility. Several studies have described
a fall in the average sperm density of both patients and donors in donor insemina-
tion programmes (see Chapter 2). Environmental pollution arising from oestrogenic
industrial waste is thought to be the most likely cause. The decline in sperm density
seems to be occurring at a time when there is an increase in the incidence of testicular
cancer and the frequency of hypospadias and cryptorchidism. Clinically, the changes
are very noticeable. Now, almost 40% of the couples we treat need assistance on the
male side, even if the main problem is anovulatory infertility, whereas a few years
ago many clinics provided ovulation induction without seeing the need to perform a
semen analysis at the outset (something that would be u nthinkable now).
Finally, people’s expectations of fertility treatment are steadily rising, fed no doubt
by charismatic doctors, exciting technology and a culture in which everyone is clear
about rights, even if a little vague about responsibilities and obligations. Moreover, peo-
ple from all walks of life now bring their infertility problems to medical clinics; for
example, lesbian couples, hitherto regarded as having chosen an inevitably c hildless
partnership, frequently now seek treatment for infertility. Quite apart from any value
judgements one might make, such requests illustrate the grey zone between the use of
biological technology for medical and social reasons. But, whatever one’s attitude (see
Chapter 16), the high expectations most people now have mean that facing the possibil-
ity of not succeeding, of not having children, for some couples is close to impossible. In
these cost-containing days of efficiency-based medicine, it is important to remember
that for many people experience is the only tutor they believe in. In the management of
infertility, some treatment for the couple with a dismal prognosis may not be out of place.
Principles of Infertility Treatment

In an ideal world, the objective of treatment would be the reversal of the specific pathol-
ogy causing childlessness, thereby permitting the couple to achieve the family size they
would have chosen had they not suffered from infertility. The reality is that a single

reversible cause is not all that common and there are biological, social and financial
constraints to be considered. One can nonetheless formulate certain principles. The
first, and probably the one principle that commands the widest agreement, is that the
interests of the unborn child must be foremost. Accepting this means that at the infertil-
ity consultation, one also will need to consider preparation for pregnancy, both physical
(e.g. diet, smoking) (see Chapter 3) and mental (need for counselling) (see Chapter 6).
Because multiple pregnancy can have such devastating effects, both in terms of
the obstetric outcome and on the life of the family, as much effort should be invested
in the safety of treatment as in its efficacy (see Chapter 18). For the correction of
anovulatory infertility, a single dominant follicle producing a single fetus and a sin-
gleton full-term normal delivery must be the target for which to aim. Ovulation induc-
tion, therefore, should not be undertaken in units where the ultrasound facilities are
inadequate to diagnose polycystic ovaries or to track follicle and endometrial growth
accurately. Despite the disappointment of having to discontinue treatment when the
ovaries overrespond (see Chapter 7), one should never be tempted to administer the
human chorionic gonadotropin (hCG) to trigger ovulation because of pressure from
the patient. It is to everyone’s advantage to have the criteria for administering hCG
clearly understood when treatment is first discussed, so if treatment does have to be
discontinued, disappointment is not compounded by misunderstanding.
In couples for whom assisted fertility therapy is required, the financial implications
need to be clearly stated at the outset, the cost and availability of drugs need to be
explored and the stressful nature of the procedure should be openly acknowledged.
The impact of age and the duration of infertility must be explained fully. The role
of counsellors and the availability of quick and efficient communication are very
important.
Finally, some thoughts about the safety of infertility treatment. The risks of
treatment can be thought of as immediate, such as technical problems as a conse-
quence of procedures (e.g. trauma and penetration of pelvic structures, anaesthetic
hazards), ovarian hyperstimulation (see Chapter 18) and multiple pregnancy (see
Chapter 18). Concern also has been expressed over long-term hazards, such as the
development of ovarian cancer in relation to infertility treatment (see Chapter 18).
We cannot know at present how real these risks will prove to be, but it behoves us
to inform our patients about them and not to allow treatment with such apparently
innocuous drugs as clomifene to go unsupervised month after month.
Since the third edition of Infertility in Practice was published 5 years ago, there
have been many advances in the understanding and management of infertility and
other updates to practice that are discussed in this new edition, for example, a greater
understanding of the pathophysiology of the polycystic ovary syndrome and relation
with insulin resistance; further refinement of regimens for superovulation, including
the use of gonadotropin-releasing hormone antagonists; and pre-implantation genetic
diagnosis (PGD) as a therapeutic tool opening up the possibility for aneuploidy
screening. We also have seen the publication of evidence-based guidelines for inves-
tigation and management, published variously by the Royal College of Obstetricians
and Gynaecologists, National Institute for Health and Clinical Excellence, European
Society for Human Reproduction and Embryology and the American Society for
Reproductive Medicine. It is reassuring to see a consolidation of knowledge in an
attempt to ensure evidence-based practice that, in the United Kingdom, has been used

to state the case for adequate funding of fertility care, although sadly with little effect
on the decision makers in government.
REFERENCES
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prevalence and treatment seeking: potential need and demand for infertility medical
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and a report of two new studies. Fertil Steril 1990; 54: 978–83.
3. Schmidt L, Munster K, Helm P. Infertility and the seeking of infertility treatment in
a representative population. Br J Obstet Gynaecol 1995; 102: 978–84.
4. Schwartz D, Mayaux MJ. Female fecundity as a function of age: results of artificial
insemination in 2193 nulliparous women with azoospermic husbands. Fédération
CECOS. N Engl J Med 1982; 306: 404–6.
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6. Templeton A, Fraser C, Thompson B. The epidemiology of infertility in Aberdeen.
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Obstet Gynecol Scand 1997; 76: 233–7.
9. Gurunath S, Pandian Z, Anderson RA, Bhattacharya S. Defining infertility –
a systematic review of prevalence studies. Hum Reprod Update 2011; 17: 575–88.
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Office of National Statistics, 2011.
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outcomes with increasing maternal age. Hum Reprod 2007; 22: 1264–72.
16. Balen AH, Rutherford AJ. Modern approaches to the management of infertility. Part
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17. Bewley S, Davies M, Braude P. Which career first? The most secure age for
childbearing remains 20–35. BMJ 2005; 331: 588–9.

2
Prevention of Infertility
Introduction
If the number of couples seeking investigation and treatment of subfertility is on the
increase, is fertility declining? If so, is this decline a global problem or unique to devel-
oping countries – and then, is it secondary to the older age at which women, in particu-
lar, are choosing to start a family or is it caused by environmental problems? Globally,
there is undoubtedly a problem with overpopulation, and there are those who raise over-
population as an issue when considering funding infertility therapy. However, in global
terms, the number of children conceived as a result of infertility therapy is tiny as is
the final family size of couples who undergo treatment. This chapter deals not with the
broader ethical debate, instead it outlines some of the preventable causes of infertility.
Male Infertility
Falling Sperm Counts
There has been a significant literature in recent years concerning the possible effects of
environmental pollutants (possibly oestrogens) on the increasing rates of cryptorchidism
and germ cell tumours and the decline in sperm concentrations over the past 20–50
years. Few of the studies were performed prospectively, and most observed either sperm
donors or men undergoing vasectomy. In many of the studies, important factors such as
age, ejaculatory frequency and periods of abstinence were not controlled. Single samples
from men also are misleading as there can be huge fluctuations in the same individual.
The scene was set by a study by Carlsen et al. [1] that reviewed 61 papers from 1938
to 1990, with semen analyses of nearly 1500 men. They concluded that there was a
40% decline in sperm concentration over the period studied, from 113 × 106/mL to 66 ×
106/mL (Figure 2.1) [1]. Yet, when Brake and Krause [2] reanalysed the data from 48
of the papers that covered the past 20 years, there was a significant increase in sperm
concentration. Furthermore, it has been suggested that the statistical analysis should
take into consideration the fact that the distribution of sperm concentrations is heavily
skewed towards lower values and that nearly all of the observed decline in mean sperm
count might actually be a consequence of the reduction in the lower reference range of
normal from 60 × 106/mL in the 1940s to the revised values of first 20 × 106/mL [3] and
now 15 × 106/mL [4]. Despite criticisms of meta-analyses, there is a body of evidence
that points to a real decline not only in sperm concentration but also in quality [5–8].

150
100
Sperm count (×106/mL)
50
1940 1950 1960 1970 1980 1990
Year
FIGURE 2.1 Linear regression of mean sperm density reported in 61 publications from 1938 to
1990 (represented by circles whose area is proportional to the number of subjects in study), each
weighted according to the number of subjects. (From Carlsen E et al., BMJ 305, 609–13, 1992.
With permission.)
There is also the possibility of increasing rates of infection being involved [9]. It has
even been suggested that the recent decline in teenage pregnancy rates in Denmark
may be the result of poor semen quality rather than safer contraceptive practice [10].
A study by Irvine et al. [11] has provided stronger evidence of a decline in semen
quality by examining the samples of 577 volunteer semen donors who donated
samples for research to a single laboratory over an 11-year period. The donors were
divided into four birth cohorts (born before 1959, 1960–1964, 1965–1969 and 1970–
1974), and it was found that the median sperm concentration fell from 98 × 106/mL in
those born before 1959 to 78 × 106/mL in those born after 1970 (p = .002). The total
number of sperm and motile sperm fell significantly by 29% and 24%, respectively.
In contrast to these seemingly convincing data are those that have been published
separately by Fisch [12,13] and Paulsen [14], neither of whom were able to demonstrate
a decline in sperm counts in North American populations. These conflicting data
have led to the suggestion that there are significant geographical variations in sperm
quality. The finding of higher sperm concentrations in North America (in particu-
lar New York) not only is difficult to explain but also affects the linear regression
analyses that have been performed to describe temporal changes of semen quality, as
the majority of the studies in the early part of the period studied were from New York,
whereas the later data were from Europe and developing countries.
A paper by Bahadur et al. [15] reanalysed the data published in the report by
Carlsen et al. [1] and included three additional European reports. Two models were

Prevention of Infertility 15
used to calculate the trend in sperm counts: a linear regression and a q uadratic
model analysis. The quadratic model actually suggested an upwards rise in
sperm count since 1975. This paper suggests that the change in sperm counts
in the United States over time is greater than in European, Asian, African and
South American communities and that it is demography again that accounts for
the fluctuations in values with time. Additional data have indicated significant
regional differences between European cities and also seasonal variations with
higher counts in winter [16]. Overall, there remains controversy [17], and clearly
longitudinal studies are required, particularly in those countries where concerns
have been expressed.
Hypospadias, Cryptorchidism and Testicular Cancer

In addition to the concerns about deteriorating semen quality, incidences of
hypospadias, cryptorchidism and testicular cancer are on the rise [18]. It has
been suggested that environmental oestrogenic pollutants may be to blame. There
are many oestrogenic chemicals that might accumulate in our ecosystem (e.g.
organochlorine pesticides (including dichlorodiphenyltrichloroethane or DDT),
polychlorinated biphenyls (PCBs), surfactants and products of combustion). The
Western diet is high in animal fats, proteins and refined carbohydrates and leads
to an increase in endogenous oestrogen concentrations, which might affect the
developing male fetus [19]. Cow’s milk contains substantial amounts of o estrogens;
indeed more than one-half of British cows that are farmed for their milk are
pregnant. In addition, many plant foods (e.g. soya) contain weak oestrogens

called phytoestrogens. Synthetic oestrogens such as diethylstilbestrol and ethinyl
estradiol not only have been ingested by mothers but also may find their way into
drinking water. Oestrogens in river water have been detected by the large increases
in the yolk protein vitellogen whose secretion is normally induced only by oestro-
gen. The finding of hermaphroditic fish in British rivers has been used to monitor
oestrogenic pollution.
An increasing quantity of maternal beef consumption during pregnancy has been
shown to correlate inversely with sperm concentration in adult sons; these sons
also have a significantly greater risk of infertility [20]. This finding suggests that
xenobiotics in beef may alter testicular development in utero and have a long-term
adverse effect on fertility. Furthermore, organic farmers who were asked to provide
semen samples when attending a conference were found to have significantly higher
sperm concentrations than printers, electricians or metal workers [21], lending further
credence to the possible effects of environmental toxins on spermatogenesis. It is
difficult to disentangle confounding factors that may influence occupational exposure
to chemicals that may affect fertility and, of course, additional factors influencing the
female partner. Overall, it appears that exposure to pesticides and heavy metals, such
as lead, has a detrimental effect, but it is hard to find correlations with other occupa-
tional hazards [22].
Hypospadias is a common congenital anomaly, with a prevalence of 0.04%–0.4%,
and it results when the urethra opens into the ventral aspect of the penis at any point
from the glans, down the shaft or even perineum [23]. Hypospadias may be associated
with cryptorchidism, and although exogenous endocrine-disrupting chemicals have

the potential to induce hypospadias, it is unclear whether human exposure is high

enough to exert this effect and several gene defects and other factors such as placental
insufficiency have been implicated [23].
Undescended Testes (Cryptorchidism)

The gonad differentiates into the testis during week 8 of intrauterine life, at which time
the gubernaculum has developed through a gap into the anterior abdominal wall to the
genital swellings (the future scrotum). Between weeks 8 and 12, the cremasteric muscle
develops, and the processus vaginalis herniates from the peritoneum ventral to the
gubernaculum. The testes continue to develop, and at 28 weeks, the processus vaginalis
extends to the scrotum, the gubernaculum swells and the epididymis and testes descend
rapidly, with the epididymis descending first (for normal anatomy, see Figure 5.42a
and b). The gubernaculum atrophies, and the upper part of the processus vaginalis should
close, but if it does not, a hernia or hydrocele may result. Testicular descent is dependent
on testosterone and its active metabolite dihydrotestosterone. Anti-Müllerian hormone
(AMH), formerly known as Müllerian inhibitory factor (MIF), may also play a role.
Boys with undescended testes have a 40% rate of epididymal and vasal abnormali-
ties, compared with 0.5%–1% in the normal population. These abnormalities may
have resulted from the failure of testicular descent, ductal immaturity or an abnormal
hormonal environment. Ipsilateral testicular testosterone is necessary for normal duc-
tal development. By the age of 6 months, the gonadocytes have usually developed into
adult spermatogonia, which in turn start to mature into primary spermatocytes by the
age of 3 years. This process is delayed and arrested in boys with testes that remain
undescended after the age of 1 year.
Retractile testes occur four times as often as undescended testes and do not require
surgery. The testis can be milked into the scrotum, where it remains for a few sec-
onds, whereas if the cryptorchid testis can be brought down it quickly springs back.
Intramuscular injections of human chorionic gonadotropin (hCG) invariably cause
retractile testes to descend but not the cryptorchid testis.
Most men with unilateral undescended testes are fertile but with a reduced sperm
count. The undescended testis produces few, if any, sperm after orchidopexy as the
shrunken testis is largely fibrotic. Bilateral undescended testes in adulthood carry
a very poor prognosis for fertility. Although it is thought that orchidopexy should
be performed at a young age, there is actually no difference in subsequent fertility
whether the procedure is performed early or late in the age range of 4–14 years.
Hormonal therapy, instituted at any age, does not appear to help.
Carcinoma in situ has been found in cryptorchid testes that have not been brought
down before the age of 10 years, and if left untreated, this condition is likely to develop
into testicular cancer. Men with undescended testes have a relative risk of develop-
ing a testicular germ cell cancer of 5.9 compared with controls; the relative risk on
the ipsilateral side in unilateral cryptorchidism is 8.0 and 1.6 in the contralateral
descended side. Early orchidopexy, before the age of 5 years, may decrease this risk
[24]. A Swedish study of 16,983 men who had been surgically treated for undescended
testis and followed for 209,984 person-years identified 56 cases of testicular cancer,
for which the relative risk in those operated on before 13 years was 2.23 (95% CI
1.58–3.06) as opposed to 5.40 (95% CI 3.20–8.53) in those treated at an older age [25].

Orchidopexy
Orchidopexy is important to prevent recurrent testicular torsion. If surgery in the inguinal
region is required, it is vital to avoid accidental, or unwitting, injury to the vas deferens or
testicular vessels because they can be a particular risk of inguinal herniorrhaphy.
Prophylactic Mumps, Measles, Rubella Vaccination

Mumps, Measles, Rubella (MMR) vaccination protects against the development of
mumps orchitis, a condition that, after puberty, may significantly affect spermatogen-
esis. Chickenpox also can cause a severe orchitis. Viral oophoritis is an uncommon
cause of female sterility; it is usually secondary to mumps and thus also should be
prevented by MMR vaccination in childhood.
Orchitis
If orchitis occurs, it is essential to try to minimise testicular atrophy, a condition that is
secondary to raised intratesticular pressure. Steroids should be administered (predniso-
lone at 40–60 mg/day); in those cases not responding to steroid treatment, surgery can
be p erformed to relieve pressure necrosis by placing incisions in the tunica albuginea.
Sexually Transmitted Diseases

Gonorrhoea causes irreversible obstruction of the spermatic ducts, but it is much less
prevalent in the West than it was 30–40 years ago. Chlamydia trachomatis is now
the most common sexually transmitted pathogen in developed countries, causing
urethritis and epididymitis. Young men and women should be advised about the use
of barrier methods of contraception, and men should be urged to use condoms until
they are in a stable relationship in which they want to start a family.
Injuries
Trauma to the testes can result in permanent damage and also increase the risk of the
subsequent production of antisperm antibodies. Men should therefore be advised to
wear appropriate protection when participating in contact sports.
Varicocele Ligation
In some countries, varicocele ligation is performed in teenagers to prevent subsequent
infertility. There is controversy surrounding the role of varicocele ligation in male
infertility; therefore, there is no justification to perform prophylactic ligation in
childhood or adolescence at the present time (see Chapter 12).
Occupational Factors
Men should be made aware if they have to work in the presence of environmental
toxins that can affect fertility. Some metals, such as lead, cadmium and mercury,

are toxic to spermatogenesis [22,26]. Metal welders have been observed to have
fertility problems, as have workers who are exposed to many other chemicals (e.g.
pesticides dibromochloropropane, chlordecone and ethylene dibromide; glycol ethers
used in inks, paint and adhesives).
Drugs
Although the effects of many drugs on spermatogenesis are reversible, some can
have a permanent effect; for example, spermatogenesis does not always make
a full recovery after therapy with sulfasalazine, a drug used in the treatment of
inflammatory bowel disease. Olsalazine can be used instead of sulfasalazine, and it
does not appear to have an adverse effect on fertility. Sometimes, the side effects of
drug therapy have to be weighed against their therapeutic benefits, but there are often
alternative p reparations. For example, many antihypertensives may cause impo-
tence (β-blockers, methyldopa, captopril), whereas others do not (calcium channel
blockers).
Chemotherapy and Radiotherapy

Men should be made aware of the possibility of freezing sperm before c hemotherapy
or radiotherapy. Alkylating agents (e.g. cyclophosphamide, procarbazine and
cisplatin) are particularly damaging to gonadal function. Unfortunately, we still see
cases where this risk has not been discussed before treatment. Men who are about to
undergo chemotherapy or radiotherapy are often severely debilitated and may have
difficulty producing a sperm sample. Furthermore, the quality of the sample may be
very poor. Since the advent of in vitro fertilisation (IVF) with intracytoplasmic sperm
injection (ICSI; see Chapter 14), it is now possible to provide treatment for men for
whom donor insemination was the only option in the past. Thus, any sperm that can
be produced before spermatotoxic therapy should be frozen for future use. An area of
active research is the potential for cryopreservation of spermatogenic stem cells taken
from the testes of pre-pubertal boys with cancer, an approach that also is controversial
because of difficulties in taking informed consent.
Advice about Impact of Age in Males and Females

Fecundity declines with age and is primarily related to the age of the woman. Men
have fathered children into their nineties, although there is an increase in the rate
of fresh genetic mutations with increasing paternal age that leads to dominantly
inherited congenital defects such as Marfan’s syndrome, Alpert’s syndrome and
achondroplasia. Sperm numbers and function do tend to decline with age, although
there is no predictable pattern [27,28]. A study from Bristol identified a correlation
between increased time to conception and paternal age, after taking into account
variables such as female age and other factors that affect fertility [29]. Although the
decline is most noticeable after 55 years of age, even men older than 35 have been
shown to have one-half the chance of achieving a pregnancy compared with men
younger than 25 [29]. The reasons for this difference are unclear but may be due to

a combination of factors, including declining testicular endocrine function, reduced

coital frequency and declining spermatozoal function [30,31].
Women are born with a fixed number of oocytes (approximately one million
per ovary), although fewer than 500 ovulate and the remainder degenerate. In the
Oxford Family Planning survey [32], it was found that parous women who stopped
contraception experienced a significant decline in fertility after the age of 37, whereas
in nulliparous women there was a significant decrease in fertility from the age of 28
onwards. Smoking accelerates the age of the menopause by up to 2 years (see Chapters
3 and 9) [33]. Nulliparity also brings forward the age of menopause. It is a decline in
oocyte quality rather than uterine receptivity that accounts for the age-related decline
in infertility, as evidenced by the high pregnancy rates that are achieved in older,
sometimes post-menopausal women, who undergo oocyte donation from women who
may be 10–30 years younger than themselves [34].
The decline in oocyte quality with age, accompanied by an increase in the rate
of chromosomal abnormalities, accelerates when the critical mass of follicles has
declined to approximately 10,000 per ovary, usually around the age of 37 years
[35]. A woman’s fertility is therefore thought to decline significantly after the age
of 37. Recent data have suggested that the decline in fertility starts much earlier,
with women aged 19–26 years having twice the chance of a spontaneous pregnancy
compared with women aged 35–39 years [36]. In this study, fertility also declined in
men after the age of 35 years [36].
It has been suggested that the increase in chromosomal abnormalities is not directly
due to the chronological age of the oocyte and its prolonged state of meiotic arrest but
that the normal oocytes are ovulated and selected first. This hypothesis would explain
why women who have premature ovarian failure have an increased risk of chromo-
somally abnormal fetuses as they near the end of their reproductive life [37]. The best-
known association between maternal age and aneuploidy is for trisomy 21, Down’s
syndrome, yet a full understanding of the mechanism(s) remains elusive and trisomic
chromosomal imbalance continues as a major cause of human genetic disease. To
facilitate wider understanding of aneuploidy, its incidence has been studied cytoge-
netically at different developmental time points, most commonly either on mature
gametes or on tissues from clinically recognised pregnancies.
With the widespread introduction of IVF programmes, many human cytogenetic
studies have been performed on metaphase II oocytes that have failed to fertilise
after insemination. Age-related increases in the incidence of aneuploidy have been
found by some but not all investigators (see the review by Nugent and Balen [38]).
It is thought that anomalies in chromosome segregation arise most commonly dur-
ing a dysfunctional first meiotic division [39]. Insights into potential mechanisms
have been provided by Angell and colleagues [40] using in vitro culture and donated
oocytes from women of different ages to examine the segregation of chromosomes
during first meiosis compared with observations on metaphase II oocytes. They found
that 64 of 179 meiosis II oocytes examined had an abnormal haploid complement,
but none involved a whole extra chromosome as would be predicted by the classical
model of non-disjunction. These results suggest that premature division of the centro-
mere at meiosis I may be the most important source of human trisomy.
Although observations on human oocytes from failed IVF are of interest, they may not
be an accurate reflection of the in vivo situation for a variety of reasons. These oocytes

have usually been collected after superovulation regimens, and they therefore include
oocytes from follicles otherwise destined to undergo atresia. Furthermore, they have
failed to fertilise after insemination, have undergone prolonged periods in culture
and have predominantly been donated by older women undergoing IVF for diverse
indications. Another factor that may influence interpretation of these studies is a signif-
icant inter-individual variation in non-disjunction, suggested by aneuploidy in multiple
oocytes from some patients. Embryonic chromosomal abnormalities are a major cause
of implantation failure and early pregnancy loss, thereby accounting for the relatively
low rates of human fertility in spontaneous and assisted conceptions [41].
Chromosomal aberrations for X, Y, 18 and 21 have been found in 70% of abnor-
mally developing monospermic donated embryos in IVF. Aneuploidy rates have been
reported at 13.5% for embryos from women below the age of 30 years, 19.8% for
those aged 30–34 years and 23.1% for those aged 35–39 years [42]. When fl uorescent
in situ hybridisation (FISH) was used, 3 and 1 of 64 embryos were aneuploid for
chromosomes 16 and 18, respectively, in patients more than 35 years of age [41].
These results suggest a relationship between maternal age and malsegregation of
certain chromosomes during female meiosis, although we should recognise that these
spare embryos may not be representative of the in vivo situation. With an increasing
number of studies becoming available, together with more reliable laboratory facili-
ties, further insight into aneuploidy should become clear. Furthermore, some clinics
are beginning to offer aneuploidy screening of pre-implantation embryos for older
couples who would not otherwise require IVF. However, there is considerable debate
as to whether this technique actually confers an increase in ongoing pregnancy rates
per cycle started (see Chapter 19). Another tantalising aspect of this debate is whether
embryos may be able to fix some genetic abnormalities later in their development but
early enough to prevent an effect on the fetus.
There is a higher rate of spontaneous abortion with increased maternal age.
Cytogenetic studies of several thousand first-trimester abortus from clinically
recognised pregnancies found a total aneuploidy frequency of 35%–40% [43]. Of
those aneuploidies analysed, trisomy 16 was the commonest, representing 20%–35%.
Aneuploidy of chromosomes 2, 13, 15, 18, 21 and 22 accounted for the remainder.
Effects of maternal age on aneuploidy vary, with chromosome 16 showing a lin-
ear increase with maternal age, whereas chromosome 21 shows an exponential rise
towards the end of the reproductive life span.
Young men and women should be made aware of these issues. Unfortunately, our
society encourages career development for men and women without providing suitable
flexibility for women and appropriate crèche facilities (see Chapter 1). See Table 2.1
for a summary of some of the issues.
Female Infertility
Contraception
Probably the most important advice that can be given to a young woman concerns
appropriate methods of contraception. Pelvic infection, most commonly caused by
Chlamydia trachomatis, results in severe tubal damage in 10%–30% of women after

TABLE 2.1
Prevention of Infertility
Male Female
Environmental – reduce oestrogenic pollutants Avoid unwanted pregnancies and termination of
pregnancy
Protect workers in chemical industries Care of pelvic organs with abdominal surgery
Undescended testes – orchidopexy surgery to
testis – avoid injury to vas deferens, testicular
vessels
Orchitis – MMR vaccination
Both
Avoid sexually transmitted diseases – barrier methods of contraception
Do not delay childbearing
Storage of sperm and oocytes (ovarian tissue) before chemoradiotherapy or radiotherapy
Reduce occupational exposure to pesticides and heavy metals such as lead
a first attack, 30%–60% after a second attack and 50%–90% after a third attack.
Chlamydial pelvic inflammatory disease (PID) is often silent, with the patient having
no notion that there was an infection until severe adhesions and pelvic damage are
noted at laparoscopy during infertility investigations.
The combined oral contraceptive pill (COCP) is the most efficacious contraceptive,
and it also provides some protection against PID, reducing the risk of hospitalisation
with PID by 50%. The mechanism is by the effect of progestogens on thickening
cervical mucus, thereby inhibiting penetration by spermatozoa and the bacteria
associated with them. The COCP does not however confer complete protection from
STDs, and barrier methods of contraception should be used in addition to the COCP,
especially by women who are not in a stable relationship.
However, the COCP has been associated with a doubling of the risk of cervical
cancer [44], whereas any barrier method of contraception that prevents STDs should
reduce the incidence of cervical dyscrasia and the consequent need for cone biopsy
of the cervix or diathermy loop excision of the abnormal area. Surgery to the cervix
can lead to disturbances in the production of cervical mucus or cervical stenosis and
hence infertility. In addition, it may result in cervical incompetence and miscarriage.
The intrauterine contraceptive device (IUCD) is thought to increase the risk of
developing a clinical PID by 50%–100% compared with non-users, and certainly
PID associated with the presence of an IUCD is often severe. The risk of PID is
mostly related to lifestyle, with a very low rate of PID in IUCD users who are in
long-term, stable, monogamous relationships. Of all the different types of IUCDs, the
progestogen-releasing IUCD (Mirena® Intrauterine System (IUS)) appears to mini-
mise the risk of infection by its effect on the cervical mucus. We do not generally
recommend the use of IUCDs in a nulliparous woman unless the woman anticipates
that she is in a long-term relationship – an IUS could, however, be offered.
A woman’s fertility is put at significant risk when she undergoes termination of a
pregnancy. Suction termination of pregnancy risks damage to the cervix, although this
risk is reduced by cervical preparation with intravaginal prostaglandins p reoperatively.
Damage to the uterus by perforation may occur, and pelvic infection, caused by

introduction of infection during the procedure or secondary to retained products of

conception, occurs after 5% of surgical terminations. There is debate about the rou-
tine use of antibiotic prophylaxis before termination of pregnancy, with conflicting
evidence about its benefit because of the possible risk of inducing antibiotic resis-
tance. The results of preoperative endocervical swabs are rarely a vailable by the time
of the procedure. On balance, we consider it prudent to offer prophylaxis (in the form
of a tetracycline and metronidazole or amoxicillin/clavulanic acid (Augmentin)) to
nulliparous women having a surgical termination of pregnancy. Medical termination
of pregnancy with the antiprogesterone mifepristone combined with a prostaglandin
such as misoprostol carries a 5% risk of retained products of conception and hence
risk for pelvic infection, although overall this drug combination probably leads to
slightly fewer cases of subsequent infertility than surgical termination of pregnancy.
General Health Screening

Issues relating to female health and pre-pregnancy screening are covered in Chapter 3.
Family planning clinics also should provide general health screening to discuss issues
such as weight, smoking and alcohol consumption.
Young women with erratic menstrual cycles, who are likely to have polycystic
ovary syndrome, or who might have stigmata of the syndrome, such as acne, should
be warned against excessive weight gain as obesity worsens the endocrine profile of
these women and increases the risk of infertility (see Chapters 7 and 8).
Chemotherapy and Radiotherapy

The oocyte is more vulnerable to freezing than spermatozoa, and current work on
oocyte cryopreservation has recently progressed from research to clinical practice.
To freeze oocytes, women have to undergo the same stimulation as women going
through IVF. The survival rate is relatively low, and subsequent fertilisation and
pregnancy are by no means guaranteed. On average, using standard stimulation regi-
mens, 8–12 mature oocytes are produced per cycle, a rate that currently provides
a modest live birth rate of 18.3%, much lower than the rate with conventional IVF
[45]. Cryopreservation of strips of ovarian cortex that contain oocytes has been used
before administration of sterilising chemotherapy for cancer [46]. However, up to
75% of oocytes are lost, as part of the freezing–thawing and grafting process [46];
therefore, this technique should be reserved for those women for whom there is no
other a lternative, particularly as usually a whole ovary is required. In addition to
oocyte cryopreservation, work is underway to try to preserve ovarian tissue for later
use, either for ovarian autografting or for the in vitro culture of follicles from which
oocytes can be obtained for IVF. This area of research is extremely exciting, and con-
siderable advances have taken place in the past 5 years (see Chapter 19).
Can Women Protect Fertility against Ageing?

The advent of new techniques to cryopreserve oocytes and ovarian tissue to pre-
serve fertility in the face of sterilising cancer treatment has raised interest in banking
oocytes. Banking oocytes at a young age has the potential to preserve fertility in

single women who are yet to find a partner or in women who wish to pursue a career.
Unfortunately, as already described, these techniques are still relatively inefficient.
Abdominal Surgery
Surgery for appendicitis should be performed swiftly and preferably before peritonitis
evolves. Pelvic structures should be left alone, and if peritonitis has occurred, p eritoneal
lavage should be performed and antibiotics administered for at least 2 weeks. General
surgeons should be trained to respect pelvic structures. If there is doubt about the
diagnosis before performing a laparotomy, a gynaecological opinion should be sought
and a laparoscopy performed, as all too often salpingo-oophorectomies have been
performed through extended grid-iron or mid-line incisions for benign ovarian cysts
that may have been managed conservatively. Gynaecologists should be all too well
aware of the care that should be taken when operating on young women to p reserve
fertility and avoid disrupting ovarian and tubal anatomy.
Environmental Pollutants
Environmental pollutants have not been considered to have an equivalent effect on
female fertility as they have on male fertility [47,48]. There is some evidence from
non-human primate studies that dioxins might induce endometriosis, but this o utcome
is unproven in humans. Occupational exposure to pesticides may be detrimental, but
it is difficult to implicate other occupational hazards based on evidence [22]. This
subject is a highly topical subject, and further research is required before firm conclu-
sions are drawn about the effects of environmental pollutants, other than cigarette
smoke (see Chapter 3), on reproductive health [48].
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3
Planning a Pregnancy
Introduction
Denial of fertility treatment because of problems with a couple’s health (usually the
woman’s) or because of unhealthy habits such as smoking is a contentious issue. The
debate concerns the reduced success of fertility treatments in couples with health
problems and the increased risks during pregnancy and to the subsequent health of
the newborn child. Although the welfare of the child is of paramount importance, it
is often argued by those seeking fertility treatment that fertile women with health
problems similar to their own are neither forbidden from conceiving nor advised to
terminate their pregnancy when they do conceive, although there is a strong move
towards improving pre-pregnancy advice to women who conceive naturally [1].
Why should we therefore be selective in our choice of who we treat? The two main
reasons given are as follows:
1. There are limitations on resources that encourage selection of those couples

who are likely to become pregnant quickly.
2. We are not very effective at preconception health screening and counselling
for couples who have health problems but who do not have subfertility.
In most cases, we advise deferring treatment until the patient’s health has improved,
rather than denying treatment. However, there are occasions where the risks to the
unborn child are such that we do not advise treatment (e.g. use of crack cocaine) or
where careful counselling and management are required (e.g. human immunodefi-
ciency virus (HIV) infection of the potential mother).
Other Issues
Patients who attend fertility clinics often have health problems in addition to the main
cause of their subfertility. Before treatment is started, such issues should be addressed
to optimise the chances of conception and to increase the probability of producing a
healthy child who is developmentally normal. Most women appreciate that changes
in lifestyle and diet are worthwhile if they are for the benefit of their unborn child.
However, one should try to avoid being too dogmatic or discriminatory, not least
because denial of treatment increases stress and is self-limiting in what it can hope
to achieve.

Weight
Women
Women who have a normal body mass index (BMI) are more likely to conceive and
to have a normal pregnancy than those who are not of the correct weight for their
height.
Women who are underweight become anovulatory and amenorrhoeic (see Chapter 7).
It is usually easy to induce ovulation in underweight women, who then conceive read-
ily. However, these pregnancies are more likely to miscarry or result in the p remature
delivery of growth-retarded babies. These babies are then at increased risk of problems
in later life, such as cardiovascular disease and diabetes, because of programming dur-
ing fetal life [2]. Thus, for the prospective mother, weight gain rather than ovulation
induction is the correct management.
Obesity is more of a problem in our society, and the United Kingdom has one of
the highest rates of obesity in Europe. Not only does obesity reduce fertility but also
obese women who conceive are at greater risk for many fetal and maternal complica-
tions. For a detailed discussion of obesity, see Chapter 4.
Men
Men who are significantly overweight also might be expected to have problems
as obesity in men is associated with reduced serum androgen concentrations and
elevated serum oestrogen concentrations. The hyperinsulinaemia of obesity results
in a fall in sex-hormone binding globulin (SHBG) levels, and so the free testosterone
concentration stays in the normal male range [3]. Most obese men are therefore
able to reproduce normally, provided there is no physical impediment to coitus or
erectile function [4]. However, extreme obesity in men is sometimes associated with
hypogonadotropic hypogonadism [5]. Furthermore, there is evidence of an associa-
tion between being overweight (BMI 25–30 kg/m2) and obesity and reduced sperm
numbers and function [6]. A higher incidence of sperm deoxyribonucleic acid (DNA)
fragmentation also has been observed in men with a moderately elevated BMI
(>25.9 kg/m2) [7]. However, careful scrutiny of the evidence summarised in a meta-
analysis has failed to demonstrate clear associations between male BMI and semen
parameters and calls for much larger studies to address these concerns [8].
Dietary Advice for Women Wishing to Conceive

Women attending a fertility clinic should be given general advice about diet (Tables 3.1
and 3.2; see Appendix) and exercise. A balanced diet should provide approximately
2000 kcal daily; a satisfactory range is 1500–2500 kcal. This daily requirement
increases by approximately 200 kcal during pregnancy. Some women like to have
very specific advice about diet, whereas others, if there are concerns, should be
encouraged to keep a record of what they eat over two separate days and then consult
a dietitian on how best to improve their diet. Specific diets have been recommended
for women with polycystic ovary syndrome (PCOS), and some women find them to be

Planning a Pregnancy 29
TABLE 3.1
Recommended Daily Requirements
Non-Pregnant Pregnant
Energy (kcal) 1940 2140
Protein (g) 45 51
Folate (μg) 300 400
Iron (mg) 15 15
Calcium (mg) 1200 1700
Zinc (mg) 7 7
Iodine (μg) 140 140
Carbohydrate (g) 250 275
TABLE 3.2
Energy Values of Main Energy-
Yielding Compounds
Energy Value
kJ/g kcal/g
Fat 9 37
Alcohol 7 29
Protein 4 17
Carbohydrate 3.75 16
advantageous, although overall it is an achievable, sustainable diet that is important.

In particular, we do not favour low-carbohydrate diets to the exclusion of all else, as
recommended by some. Furthermore, there is no evidence that women with PCOS
lose more weight with one type of diet rather than another [9]. A healthy diet requires
the right amounts of the four main food groups (see Appendix). In general, it is not
necessary to take vitamin supplements, as long as the diet contains fresh fruit; veg-
etables (preferably lightly cooked); dairy products; and some fish, lean meat or both.
The one exception is folic acid, which is now recommended for all women who are
trying to conceive.
Folic Acid (Folate)

Recent studies have shown that folate, available in many foods (Table 3.3), helps
to reduce the risk of babies developing neural tube defects. Women who are plan-
ning a pregnancy are advised to consume additional folate before conception and to
continue to do so during the first 12 weeks of pregnancy. The daily requirement is
400 μg. A higher dose, 5 mg, is advised to prevent recurrence of a neural tube defect
and for women on anti-epileptic drugs and overweight women with a BMI greater
than 30 kg/m 2. There are several tablets that contain both iron and folate, and these
tablets are often recommended during pregnancy. Many multivitamin tablets also
contain folate.

TABLE 3.3
Useful Sources of Folate in a Typical Serving
Source Folate
Boiled broccoli 30 μg
Boiled sprouts 100 μg
Boiled cabbage 25 μg
Boiled carrot 10 μg
Boiled cauliflower 45 μg
Boiled green beans 50 μg
Peas 30 μg
Potato 45 μg
Spinach 80 μg
Folate is lost by overboiling vegetables
Banana 15 μg
Grapefruit 20 μg
Orange 50 μg
Orange juice 40 μg
Bovril 95 μg/cup
Marmite 40 μg/serving
Milk 35 μg/pint
Boiled brown rice 15 μg
Boiled white rice 5 μg
Two slices of white bread 25 μg
Two slices of wholemeal bread 40 μg
Cornflakes (fortified) 100 μg
Note: Liver is rich in folate but should be avoided by those trying
to conceive because of the possible danger of consuming
too much vitamin A.
Special Diets for Sex Selection and Fertility

It has been suggested that changes in diet can both aid fertility and achieve sex selec-
tion, the latter by enhancing zona pellucida receptivity to either X- or Y-bearing
spermatozoa.
Sex Selection
Advocates of sex selection have advised special diets, vaginal douches of differing
pH or intercourse at different times around the time of ovulation. Not only are there
complete contrasts in opinion about these methods but also there are no prospective
randomised studies that support any of the practices. Similarly, whilst mechanical
separation of spermatozoa is practiced by some clinics, the results have not stood
up to scientific scrutiny. Sex selection to prevent the transmission of sex-linked
congenital disease is possible after pre-embryo biopsy in the context of in vitro
fertilisation (IVF) treatment or later in pregnancy by chorionic villus biopsy or
amniocentesis.

Fertility
Some minerals and vitamins have been used in the treatment of male infertility.
Zinc sulphate (120 mg twice daily) was found to increase sperm concentration and
serum testosterone concentrations in a small study of men with oligospermia and low
testosterone levels [10]. Vitamin E, because of its antioxidant properties, has been
advocated for use both orally (300–600 mg daily for at least 6 weeks) [11] and in vitro
[12] in men with asthenozoospermia. Vitamin B12 also has been used for the treatment
of oligozoospermia. However, there are insufficient data from prospective studies of
these therapies so, although not harmful, they are of uncertain benefit [13].
The Foresight programme in Britain, in addition to giving sensible preconception
advice about general health, advocates changes in diet to enhance fertility and reduce
miscarriage. Patients are asked to send their hair for analysis of minerals, metals
and trace elements, and advice is invariably given to take vitamin and mineral sup-
plements. We are not aware of prospective randomised studies that have shown this
approach to be of any clinical benefit; thus, we do not recommend it.
Acquired Infections
Listeriosis can cause miscarriage and may be acquired from cooked–chilled foods
that have not been adequately reheated. Cold meat pies, ready-to-eat poultry, unpas-
teurised milk and soft ripened cheeses (e.g. Brie, Camembert, blue vein types) should
be avoided by women who may be pregnant. When pregnant, women also should
avoid contact with sheep at lambing time and handling silage because of the risk of
contracting listeriosis, toxoplasmosis or chlamydiosis. Toxoplasmosis can be caught
from cats and dogs, so women should be advised to make sure that they wash their
hands thoroughly after handling pets or their food bowls.
Exercise
Regular physical exercise is an essential adjunct to a healthy diet and does not cause
problems for women who are either trying to conceive or are pregnant. Sudden
changes in exercise patterns can be detrimental and should certainly be avoided dur-
ing pregnancy. Excessive exercise can lead to hypothalamic dysfunction in women
and men, and weight loss can render women amenorrhoeic (see Chapter 7).
Alcohol
Alcohol has profound effects on Leydig cell function by reducing testosterone syn-
thesis, and acetaldehyde, a metabolite of alcohol, causes membrane damage and the
formation of Leydig cell autoantibodies, which persist long term. Excessive intake of
alcohol also disturbs hypothalamic–pituitary function, further worsening testicular
and sexual function. Impotence is a well-known effect of alcoholism, as are the signs
of hyperoestrogenism (e.g. gynaecomastia, female escutcheon), which is probably
secondary to disturbances of the metabolism of testosterones and oestrogens in the
cirrhotic liver. In a detailed assessment of all aspects of lifestyle, alcohol consump-
tion in the male partner of more than 20 units/week was associated with a significant
increase in infertility [14].

Alcoholism can lead to amenorrhoea and disorders of ovulation, probably by

c entral effects rather than by acting on the ovary. Alcohol consumption during early
pregnancy can lead to severe developmental abnormalities in the baby (e.g. growth
retardation, mental retardation, physical malformations). A sensible alcohol limit
while trying to conceive is less than 6 units/week. There is some evidence that com-
plete cessation of alcohol consumption is associated with improved fertility [15].
Alcohol also should be avoided during pregnancy, although small regular quantities
are preferable to binge drinking; some think binge drinking is the main cause of the
fetal alcohol syndrome.
In couples undergoing IVF treatment, it has been shown that alcohol consumption
by the woman was associated with an increased risk of not achieving a pregnancy
(odds ratio (OR) 2.86, 95% CI 0.99–8.24) and an increased risk of miscarriage (OR
2.21, 95% CI 1.09–4.49) [16]. Alcohol consumption in the male partner also caused a
two- to eight fold reduction in achieving an ongoing pregnancy [16].
Smoking
The metabolites of cigarette smoking are toxic to oocytes (causing oxidative damage
to mitochondria), sperm (causing a higher percentage of morphological abnormali-
ties) and embryos (causing miscarriage) [17]. Smoking reduces both the chance of
getting pregnant and the success of fertility treatments [14].
Lower Fertility
The Oxford Family Planning Association Database permitted observation of more
than 17,000 women in the United Kingdom, of whom more than 4000 stopped
contraception to become pregnant [17]. There was a highly significant trend of
decreasing fertility with increasing number of cigarettes smoked per day. It was esti-
mated that 5 years after stopping contraception, approximately 11% of women who
smoked more than 20 cigarettes a day, but only 5% of non-smokers, had yet to have
a baby. A systematic review of published studies reported that the overall OR for
the risk of infertility was 1.60 (95% CI 1.34–1.91) for smokers compared with non-
smokers [18]. The chance of conception in smokers undergoing IVF was 0.66 (95% CI
0.49–0.88) [19]. There is some evidence that ex-smokers can expect a return to normal
fecundity [18], although smoking brings forward the age of the menopause and so
appears to have a direct effect on ovarian function. Even passive smoking may have
an adverse effect on female fertility [20]. Although it used to be thought that smoking
had no effect on male fertility, recent studies have suggested otherwise [16,20].
Higher Risk of Miscarriage

Smoking during pregnancy doubles the risk of miscarriage, increases the risk of pre-
mature labour by 50%, doubles the rate of having a low birth weight baby and leads
to intrauterine growth retardation with an increased risk of perinatal mortality. There
have been reports of an increased rate of congenital limb abnormalities, with termi-
nal transverse defects, thought to be a result of vascular insufficiency. The restric-
tion of the normal growth of the baby may in turn cause both physical and mental

BOX 3.1 PLANNING A PREGNANCY

Optimise health: normal BMI, exercise
Diet: folate, appropriately prepared food
Restrict alcohol <6 units/week
Stop smoking
Optimise pre-existing medical conditions
Avoid teratogenic drugs
Prostaglandin synthetase inhibitors (e.g. indomethacin, mefenamic
acid, naproxen, diclofenac) may inhibit ovulation and result in an
increased chance of the formation of a luteinised unruptured follicle
(LUF). Beware!
developmental problems for the child in late life. Smoking also is associated with an
increased risk of sudden infant death syndrome.
Box 3.1 shows what steps should be taken when planning a pregnancy.
Medical Conditions and Drugs

It is beyond the scope of this book to give an exhaustive account of the medical
conditions that can occur in women of reproductive years. Any debilitating condi-
tion can lead to anovulatory infertility secondary to loss of hypothalamic pulsatility
of gonadotropin-releasing hormone (GnRH) or to weight loss. Some conditions may
be inherited, so prenatal genetic counselling would be appropriate (see Chapter 19).
We describe some of the disorders that can affect fertility and the drugs that should
be avoided because of teratogenicity. The period of greatest risk is the 3rd to 11th
week of pregnancy, at a time when many women are initially unaware that they have
conceived (although most women who are having fertility treatment perform a preg-
nancy test the day that their expected period is late). In general, it is advisable to avoid
taking any drugs unless their need is proven. Many drugs have warnings against use
in pregnancy because of the difficulties in testing new drugs during pregnancy. Thus,
caution about the avoidance of drugs during pregnancy may be due to lack of data
rather than proven teratogenicity.
Psychiatric Disorders
Infertility can cause psychological distress, sexual dysfunction and impotence, but
it is not thought to cause psychiatric disease as such. Psychiatric illness, in contrast,
can result in infertility. Women with schizophrenia may have menstrual disturbances
(often secondary to hypothalamic dysfunction or drug-induced hyperprolactinaemia),
and anorexia nervosa leads to weight-related amenorrhoea. Bulimia nervosa often
goes undetected and is usually denied by the patient, but it can be a significant con-
tribution to infertility because of its association with PCOS. Any psychiatric illness
can cause hypothalamic dysfunction and anovulatory infertility. Major tranquilizers
cause hyperprolactinaemia and may result in amenorrhoea.

Anxiety and Depression

Infertility causes profound anxiety and may lead to clinical depression. Management
should be in the form of supportive care with the aid of the clinic counsellor, and
drug therapy should be avoided. If a patient is on sedatives or antidepressants, she is
probably better deferring pregnancy until her psychological state is stable and she is no
longer taking drugs. These women are prone to post-natal depression, and when they
conceive, their obstetrician should be informed. Hypnotic drugs (e.g. b enzodiazepines)
should be avoided in women trying to conceive, although if absolutely necessary
the shorter acting preparations (e.g. loprazolam, lormetazepam, temazepam) can
be used in a single dose. Barbiturates also should be avoided. Antidepressants are
probably safe in pregnancy but, again, they should be avoided unless absolutely nec-
essary. Some antidepressants can interfere with sexual function (e.g. amitriptyline,
clomipramine, dothiepin, imipramine, mianserin) or cause menstrual irregularities
(e.g. amoxapine). Monoamine oxidase inhibitors should be avoided in women wishing
to conceive. Serotonin uptake inhibitors (e.g. citalopram, escitalopram, fluoxetine)
have become very popular in recent times and are used in the treatment of depres-
sion, as appetite suppressants (although a combination of diet and exercise is a better
approach in the management of obesity), and in the treatment of premenstrual syn-
drome. These drugs also should be avoided if there is a chance of a pregnancy because
of a slightly increased risk of congenital heart defects.
Psychosis
Antipsychotic drugs can cause anovulatory infertility by effects on the hypothalamus
and by causing hyperprolactinaemia. They also should be used with caution during
pregnancy as they can cause extrapyramidal signs in the neonate. Lithium, used in the
treatment of mania and in the prophylaxis of manic depression, can lead to hypothy-
roidism; it is also teratogenic and should be avoided.
Clinicians working in fertility clinics have an overriding responsibility to the health
of the unborn child. It is appropriate to hold a case conference with all the members
of the team who care for a patient with psychiatric disease before embarking upon
fertility treatment. It is therefore essential to liaise with the psychiatrist to help with
the psychodynamics of impending pregnancy and parenthood as well as to advise on
the use of specific medication (such as alternatives to lithium).
Neurological Disorders
Epilepsy
There is an increased risk of anomalies in the fetuses of epileptic women who are not
taking anti-epileptic drugs, possibly because of a genetic linkage between epilepsy
and some fetal anomalies, for example, facial clefts. Most anticonvulsant drugs are
teratogenic, so it is important to try to achieve adequate control of epilepsy in women
who are trying to conceive with the lowest dose of a single drug. There is an increased
risk of neural tube defects associated with the use of carbamazepine and sodium val-
proate, and patients should be counselled and advised to have antenatal screening.
Phenytoin increases the risk of facial clefts and can cause the fetal hydantoin syndrome

(small digits, congenital heart defects, facial clefts, abnormalities of head and mental
development). It is mandatory to seek the advice of a neurologist before a patient with
epilepsy commences fertility therapy. An increased dose of folic acid (5 mg daily) also
is recommended. Some anti-epileptic drugs reduce the efficacy of hormonal contracep-
tives, so unplanned pregnancy is a risk unless additional precautions are taken.
Myotonic Dystrophy
Myotonic dystrophy is an autosomal dominantly inherited condition that often pres-
ents with infertility, due to either anovulation or testicular atrophy. The obstetric and
genetic sequelae of this condition are so severe as to indicate caution before offering
treatment to these patients.
Endocrine Disorders
All of the endocrinopathies can affect gonadal function either directly or by effects
on the hypothalamic–pituitary axis. The common causes of anovulatory infertility
and their treatments are discussed in detail in Chapter 7. Women with prolactinomas
might not wish to conceive, but if they do fall pregnant it is important to know the size
and position of the tumour: lactotroph hyperplasia leads to a 10%–20% increase in
pituitary mass during pregnancy, although symptomatic expansion of treated macrop-
rolactinomas occurs in only 7% of cases and the risk with microprolactinomas (<1 cm
in diameter) is very small. Dopamine agonist therapy (e.g. bromocriptine, cabergoline)
is usually discontinued during pregnancy unless the patient has a macroprolactinoma
with suprasellar extension, in which case pregnancy should ideally be avoided (see
Chapter 7). Cabergoline is the drug of first choice for hyperprolactinaemia, but it
is not licenced for use in pregnancy; thus, patients wishing to conceive are usually
switched to bromocriptine therapy.
Polycystic Ovary Syndrome

Women with PCOS (see Chapters 7 and 8) who do not wish to conceive are often
prescribed anti-androgen therapy to suppress unwanted acne and hirsutism. Anti-
androgens such as cyproterone acetate are usually taken in combination with ethi-
nyl estradiol (usually as the preparation cyproterone acetate and ethinylestradiol
(Dianette®)), a contraceptive. If an accidental pregnancy should occur, anti-androgens
could theoretically affect development of the genitalia; although there have been more
than 16 million women-years of use of this contraceptive and approximately 40 preg-
nancies in which the preparation has been taken beyond the critical period of organ-
ogenesis; no adverse consequences have been reported. Strict contraceptive advice
should be given to women using other non-contraceptive anti-androgen preparations,
such as spironolactone, finasteride and flutamide.
Congenital Adrenal Hyperplasia

Congenital adrenal hyperplasia (CAH) encompasses many disorders of steroidogene-
sis of differing degrees of severity. Patients with salt-losing, 21-hydroxylase deficiency

commonly require replacement therapy with glucocorticoids and fl udrocortisone,

and this treatment should be continued during pregnancy, although pregnancy is
uncommon in women with CAH [21]. Furthermore, there is a subgroup of women
with CAH who have non-suppressible hypersecretion of progesterone that causes
infertility due to failure of endometrial thickening. The control of progesterone
secretion can be independent of the control of androgen levels, regardless of the type
of steroid therapy used, and adrenalectomy is sometimes indicated if standard sup-
pressive therapies do not restore a regular ovulatory cycle.
Cushing’s Syndrome
Cushing’s syndrome causes menstrual irregularities and subfertility. Pregnancy should
be avoided until the treatment for Cushing’s syndrome is complete, although if a preg-
nancy should occur, it has been suggested that termination is advisable because of the
potential risks of the disease to the mother (e.g. hypertension, diabetes). Fetal virilisa-
tion does not occur, little adrenocorticotrophin (ACTH) crosses the placenta and the
fetus is protected from cortisol as it is converted to cortisone by the placenta.
Acromegaly
Women with active acromegaly rarely conceive because of coexistent abnormali-
ties in prolactin and gonadotropin secretion, and most have PCOS. Bromocriptine
sometimes aids conception, and if pregnancy does occur, the fetus is not affected by
acromegaly.
Thyroid Disease
Thyroid disease is common in young women, occurring in 2%–3% of pregnant
women, and it is associated with adverse pregnancy outcome [22]. Approximately 5%
of women attending infertility clinics are found to have thyroid disease, so routine
screening is recommended. If there is evidence of biochemical thyroid dysfunction,
for example, elevated serum thyroid-stimulating hormone (TSH) concentration, then
it is useful to test for thyroid antibodies against thyroperoxidase (TPO-Ab) and thyro-
globulin (Tg-Ab), antibodies that are elevated in 8%–14% of women of reproductive
age [23]. Even in euthyroid women, the presence of thyroid autoantibodies is asso-
ciated with a significant risk for subfertility, miscarriage (sporadic and recurrent),
preterm birth and maternal post-partum thyroiditis [24], and treatment with thyroxine
may lower the risk for miscarriage and preterm birth [24].
Thyroid dysfunction may affect fertility by both hyper- and hypothyroidism causing
anovulatory cycles. The latter condition may be associated with hyperprolactinaemia.
Women with hyperthyroidism and amenorrhoea usually lose weight. Fertility is usually
restored once the patient is rendered euthyroid. The fetus cannot synthesise thyroxine
until 12 weeks’ gestation and is dependent on placental transfer. Hypothyroidism in the
first trimester can have a profound effect on fetal neurological development, so thyroid
replacement therapy should be vigorously adhered to, with close monitoring of mater-
nal TSH and free thyroid hormone concentrations. Hyperthyroidism has the poten-
tial to affect the fetus by transplacental passage of thyroid-stimulating autoantibodies

or TSH-receptor-binding antibodies rendering the fetus thyrotoxic or hypothyroid,

respectively, rather than as a result of high circulating concentrations of maternal thy-
roid hormones. Antithyroid drugs should be reduced to the lowest necessary dose, and
maternal thyroid function should be monitored regularly.
Pregnancy often ameliorates autoimmune thyroid disease, and drug therapy can
sometimes be discontinued. Thyroid function also should be monitored closely post-
partum because rebound thyroid disease can have a profound effect on maternal
health. Hyperthyroidism should be managed with antithyroid drugs and not radioio-
dine, if there is any risk of pregnancy. Propylthiouracil is preferred to carbimazole
as it inhibits peripheral conversion of thyroxine (T4) to tri-iodothyronine (T3) and
causes a smaller risk of blood dyscrasia, although both have been used safely during
pregnancy. Carbimazole rarely causes aplasia cutis in the neonate. Surgery should be
considered if thyrotoxicosis is not controlled with 20 mg of carbimazole or 300 mg
of propylthiouracil.
Diabetes
Both type 1 and type 2 diabetes are associated with disturbed ovarian function and
also reduced spermatogenesis. If diabetes is poorly controlled, anovulatory infertil-
ity may occur. Type 1 diabetes can affect hypothalamic–pituitary function and may
be associated with premature menopause due to ovarian autoimmunity. Women with
type 2 diabetes are hyperinsulinaemic, and insulin increases ovarian steroidogenesis,
leading to hyperandrogenism and PCOS. Thus, there is a close association between
diabetes and PCOS. Women with PCOS are prone to develop gestational diabetes,
especially if they are overweight. Women who are diabetic should be encouraged to
have tight control over their blood sugar concentrations to enhance their fertility and
to minimise the risks of congenital anomalies and pregnancy complications.
There have been conflicting reports about sexual dysfunction in women with dia-
betes and a suggestion of impaired sexual response, particularly in those women with
type 2 diabetes. Up to 25% of young men with long-standing (>10 years) diabetes
experience erectile dysfunction, due to both vascular and neurological sequelae of the
disease, and the rate increases to 75% by the age of 60. Retrograde ejaculation also
has been reported as a consequence of diabetic neuropathy. Diabetes also may have a
detrimental effect on spermatogenesis.
Gastrointestinal Disease
Celiac Disease
Men and women with gluten-sensitive enteropathy, or celiac disease, appear to have an
increased rate of infertility due both to abnormalities of the hypothalamic–pituitary
axis and, in men, impotence and disordered spermatogenesis. Gluten withdrawal
should correct most abnormalities, but it does not always improve sperm function.
Inflammatory Bowel Disease

Inflammatory bowel disease can impair fertility, but this impairment depends largely
on nutritional status, activity of the disease and drug therapy. Surgery can cause

pelvic damage, and care should be taken when performing laparoscopic evaluation
of the pelvis because of the risk of adhesions and damage to the bowel. Pyschosexual
difficulties also occur due to altered perceptions of body image, particularly after
resective surgery. Sulfasalazine may cause reversible oligospermia, but the alterna-
tive preparation olsalazine is thought not to affect spermatogenesis. These drugs are
probably safe in pregnancy although folate supplementation is recommended in the
third trimester.
Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is increasingly recognised in young women as a cause
of pelvic and generalised abdominal pain. Women with IBS are often of an anxious
disposition, and their symptoms might be exacerbated by concerns about subfer-
tility. Management is with a combination of high-fibre diets, stool-bulking agents
and antispasmodics (anticholinergic drugs), although the latter should be avoided in
pregnancy.
Peptic Ulcers
Peptic ulceration can be treated successfully with H2 receptor antagonists (e.g.
ranitidine, cimetidine), but these antagonists can cause gynaecomastia and impo-
tence in men (less so with ranitidine than cimetidine). Omeprazole, a proton pump
inhibitor, is thought to be safe, although lansoprazole should probably be avoided in
pregnancy.
Renal Disease
Adults with severe renal disease are unlikely to conceive.
Renal Disease in Males

Men with renal disease may have erectile dysfunction, primary hypogonadism
and irreversible histological changes in the testes, with hyalinisation of the tubular
basement membranes and reduced numbers of Leydig cells. Uremia also leads to
hypothalamic failure and hyperprolactinaemia; the latter condition is caused by both
pituitary overproduction and reduced renal excretion of prolactin. Hypothalamic
anovulatory infertility seems to respond better to haemodialysis than male infertility,
but both recover to a greater degree after successful renal transplantation.
Renal Disease in Females

Pregnancy should only be contemplated in a woman with renal disease if her
plasma creatinine concentration is less than 250 mmol/L and urea is less than
10 mmol/L. Pregnancy can significantly worsen renal function, and this possi-
bility, combined with the reduced life expectancy of these patients, must be dis-
cussed in-depth in the pre-pregnancy clinic. Optimally, women who have had a
renal transplant should have been in good health for 2 years, with no evidence of

graft rejection, proteinuria or hypertension. Immunosuppressive drugs should be

continued, and teratogenesis is unlikely at the doses usually required by women
who have stable renal function.
Cardiovascular Disease
Women with congenital or acquired heart disease should be evaluated by a cardiologist
before conception, and the risks of pregnancy should be discussed. Anti-arrhythmic
drugs are generally safe in women planning a pregnancy, and their b enefits out-
weigh the risks. Amiodarone can affect thyroid function and cause either hypo- or
hyperthyroidism and secondary subfertility; serum total thyroxine (T4) concentrations
can be elevated in the absence of hyperthyroidism, and it is necessary to measure tri-
iodothyronine (T3) and TSH. Disopyramide, flecainide and procainamide should be
used with caution in pregnancy, and it is sometimes appropriate to change the anti-
arrhythmic preparation before trying to conceive.
Hypertension can be managed safely with several drugs in early and late
pregnancy. Diuretics should be avoided not only because they affect electrolyte
homeostasis and can cause hypovolemia and renal failure but also because they
might reduce placental blood flow, particularly if the patient has pre-eclampsia. The
β-blockers appear to be safe although they have been associated with intrauterine
growth retardation. Adrenergic neurone blocking drugs, such as guanethidine, and
α-blockers, such as phenoxybenzamine, should be avoided in women trying to
conceive, and these drugs also can cause ejaculatory failure in men. Angiotensin-
converting enzyme (ACE) inhibitors are effective and widely used; they may cause
impotence in men and should not be given to women planning a pregnancy because
of concerns about teratogenicity. Calcium channel blockers also should be avoided
if there is a chance of pregnancy, as there are reports of teratogenicity in animals.
Women who require antihypertensive therapy should therefore be stabilised on a
preparation that is safe in pregnancy (e.g. methyldopa, labetalol) before trying to
conceive.
There are increasing numbers of women now reaching child-bearing age who
have severe cardiovascular disease and who in the past would have died at an early
age. Many will have had extensive surgery, and there are a few who have had heart
transplants or, in the case of cystic fibrosis, heart–lung transplants. These individuals
should be managed in conjunction with their cardiologists.
Respiratory Disease
Asthma
Asthma is the commonest respiratory disorder in women of reproductive years,
affecting approximately 1%. Pregnancy itself places relatively little stress on the
respiratory system, and the effect of pregnancy on asthma is variable and unpredict-
able, with some women noticing an improvement and others a deterioration. As emo-
tional stress affects asthma, infertility might cause a worsening of the condition, and
the condition can sometimes be cyclical. The β-sympathomimetic drugs, theophyl-
line, steroids and disodium cromoglycate are safe, whether taken by inhaler or orally.

Cystic Fibrosis
The prognosis for patients with cystic fibrosis has improved tremendously over the past
20 years, and many women with cystic fibrosis are now well enough to have a family. It
is important that these women are as fit as possible before embarking on a pregnancy as
they and their babies do better if they have good lung function and are free from chest
infections. Pancreatin and mucolytics, such as acetylcysteine, are safe during pregnancy.
Women with cystic fibrosis who conceive have a similar rate of miscarriage, but they
have an increased risk of perinatal mortality and maternal mortality compared with
healthy women, although the latter is no greater than in women with cystic fibrosis of
the same age who are not pregnant. Being underweight is probably the most significant
problem for women with cystic fibrosis with respect to both fertility and risks during
pregnancy. It has been reported that only 20% of women with cystic fibrosis are fertile
as the remainder have abnormal cervical mucus with increased viscosity. This mechani-
cal barrier to conception can in theory be overcome by intrauterine insemination (IUI).
Men with cystic fibrosis are usually, but not invariably, azoospermic due to abnor-
mal development of the mesonephric ducts. Spermatogenesis is usually normal, and
sperm collected from the epididymis or testis can be used to achieve IVF with the aid
of intracytoplasmic sperm injection (ICSI).
It is sensible to offer preconception genetic counselling to couples in which one or
both partners have cystic fibrosis.
Tuberculosis
In recent years, there has been an upswing in the incidence of tuberculosis, second-
ary to the immigration of non-immunised women of low socio-economic status and
to the immunosuppressive effects of HIV infection. Ethambutol and isoniazid appear
not to cause teratogenicity, and rifampicin appears to be safe but streptomycin should
be avoided.
Antibiotics and Anti-Infective Agents

Here, we have listed the antibiotics and anti-infective agents in common use in the
United Kingdom. When caution is expressed, it is sensible to advise the use of contra-
ception until the infection has been treated. Regardless, women with severe infections
and debilitating illness are unlikely to conceive until they are better.
Antibiotics
Antibiotics thought to be safe in early pregnancy include the following:
• Cephalosporin
• Erythromycin
• Fusidic acid
• Nitrofurantoin
• Penicillin

Antibiotics that should be used with caution include the following:
• Ciprofloxacin
• Clindamycin
• Gentamicin
• Metronidazole
• Nalidixic acid
• Ofloxacin
• Rifampicin
• Spectinomycin
• Vancomycin
Antibiotics that should be avoided include the following:
• Aminoglycosides (if absolutely necessary, gentamicin is probably the safest)

• Chloramphenicol
• Colistin
• Co-trimoxazole
• Dapsone
• Fosfomycin
• Sulfonamides
• Tetracyclines
There are many more recent antibiotics for which no clear information is available,
and as with all drug therapy, it is important to access the contemporary literature and
to determine whether any perceived benefits of therapy outweigh the possible risks
of the drug.
Live Vaccines
These include BCG for tuberculosis and vaccines for the prevention of yellow fever,
typhoid, cholera, measles, mumps, rubella and Sabin poliomyelitis and should not be
administered unless the risk of infection is so great as to outweigh any risk to the fetus.
Antifungals
An antifungal considered safe is nystatin; amphotericin, fluconazole, flucytosine,
griseofulvin, itraconazole, ketoconazole and terbinafine should be used with caution.
Antivirals
Aciclovir is probably safe but use only if necessary. Avoid ganciclovir, ribavirin and
podophyllin.

Human Immunodeficiency Virus

Women with HIV should be counselled carefully before they try to conceive
(see below). Combination therapy for HIV is recommended during pregnancy and
labour to reduce the risk of transmission of the virus to the baby. The various drugs
used in combination include antiretroviral agents, such as zidovudine, together with
two protease inhibitors (e.g. saquinavir, lopinavir, ritonavir, indinavir).
Amoebicides
An amoebicide considered safe is diloxanide; metronidazole should be used with
caution.
Antimalarials
The benefits of prophylaxis and treatment outweigh the risk. Antimalarials considered
safe include chloroquine, proguanil and pyrimethamine (with folate supplements).
Avoid Fansidar®, halofantrine, maloprim, mefloquine, primaquine and quinine.
Anthelmintics
Avoid mebendazole, piperazine and pyrantel.
HIV and Acquired Immunodeficiency Syndrome

Men with acquired immunodeficiency syndrome (AIDS) have an increased rate of tes-
ticular atrophy, testosterone deficiency and antisperm antibodies. It has been debated
whether infected men or women should be encouraged to procreate because of sexual
transmission of the virus and possible risks to offspring; however, life expectancy
with appropriate therapy has improved dramatically, and laboratory facilities are
available to provide safe treatments [25]. There are reports of pregnancies that have
not resulted in transmission of HIV to the mother after insemination with prepared
samples of semen, and now men on long-term antiretroviral therapy with an undetect-
able viral load (<50 copies/mL) may have intercourse timed with ovulation without
risking HIV transmission to their partner. If the plasma viral load is greater than
50 copies/mL, then semen can be assessed, and if less than 50 copies/mL, sexual
intercourse is probably safe [26,27]; if greater, then sperm washing or IVF should be
considered [28,29].
HIV seroprevalence amongst pregnant women in Europe is between 1.5 and 5.5
per 1000 in urban areas. Women with AIDS who are fit enough to be ovulating are
thought to have an approximately 15%–20% chance of transmitting the virus to their
child in utero. This risk does not appear to be increased if their partner is infected.
The risk of materno-fetal transmission appears to be reduced by a combination of drug
therapy (zidovudine (AZT) and/or didanosine or zalcitabine together with protease
inhibitors such as saquinavir, lopinavir, ritonavir and indinavir) with elective caesar-
ean section. Although the immunosuppressive effects of pregnancy might precipitate
deterioration of the disease, maternal prognosis has certainly improved dramatically

in recent years. In the past, children born to infected parents were likely to become
orphans in childhood or early adolescence, but current combination therapy signifi-
cantly reduces the likelihood of disease progression, and the disease can be main-
tained in a quiescent state – perhaps indefinitely. Worldwide, of course, the situation
varies greatly, with some developing countries experiencing an AIDS epidemic that
is spiralling out of control.
Of great importance is the issue of handling blood, semen and follicular fluid
with possible infection of laboratory staff. Couples who seek advice about becoming
pregnant where one or both partners have HIV should be counselled carefully. If
they maintain their wish to conceive, they should be advised to have unprotected
intercourse only around the time of ovulation. If the woman is HIV positive and the
man is HIV negative, his sperm can be inseminated, thus avoiding the risk of his
becoming infected. The converse situation requires IVF to minimise the risk to the
woman, although, as mentioned, there are reports of the use of prepared, washed
sperm from HIV-positive men being used to inseminate their partners without trans-
mission of the virus. The use of donated gametes by the non-infected partner also
can be considered.
The extent to which couples with HIV should be investigated and treated by fertil-
ity clinics should be decided on an individual basis. Nonetheless, the prognosis has
improved dramatically over the past 10 years. In the United Kingdom, screening for
HIV (and hepatitis B and C) is performed in all couples undergoing IVF because of
the putative risk of viral transmission (particularly hepatitis C) in liquid nitrogen dur-
ing embryo cryopreservation.
Haematological Problems
Anaemia
Anaemia is common and worsens in pregnant women who have reduced stores of
iron. The haemodilutional effect of pregnancy causes a physiological anaemia, but
there is also evidence that the diet of most women contains insufficient iron to meet
the demands of pregnancy and that many women of reproductive age lack storage
iron. Folic acid requirements also increase during pregnancy, and there is evidence
that folate supplementation reduces the risk of neural tube defects and other major
developmental abnormalities in the developing fetus. In addition to the routine use of
folic acid by all women wishing to conceive (see section Folic Acid (Folate) above),
some women have an increased demand for folate, for example, those women requir-
ing anti-epileptic drugs. Vitamin B12 deficiency is rare in young women.
It is useful to perform a full blood count on women attending a fertility clinic as
it is preferable not to become pregnant if anaemic, although anaemia itself does not
cause infertility.
Sickle Cell Anaemia

Women from high prevalence groups (Afro-Caribbean women and those from India
and the Mediterranean countries) should be screened at the fertility clinic for haemo-
globinopathies. They will already know whether they have sickle cell anaemia (HbSS).

Sickling crises are more frequent during pregnancy and can be fatal; there is also an
increased risk of miscarriage due to placental infarction. These patients should be
counselled by their haematologist about the risks of becoming pregnant. Women with
sickle cell trait (HbAS), in contrast, are healthy and rarely have problems during preg-
nancy. Their partners should be screened for HbAS, and the possibility of antenatal
diagnosis should be discussed.
Thalassemia
Prospective parents with thalassemia should receive genetic counselling and be
reviewed by a haematologist before they conceive. Women with α-thalassemia
(a1 or a2, i.e. with two or three α-globin molecules) and β-thalassemia minor require
close attention to iron and folate supplementation during pregnancy and should enter
pregnancy in as healthy a condition as possible. Patients with β-thalassemia major
often have severe problems and require regular blood transfusions throughout life.
This can lead to iron overload and haemochromatosis, with endocrine dysfunction
secondary to excess deposition of iron in the pituitary gland and gonads. Involvement
of the liver and pancreas can contribute to the hormonal disturbances, and these
patients have delayed puberty and hypogonadal infertility. Testicular biopsy may dem-
onstrate iron overload. Desferrioxamine can be used to chelate excess iron, although
therapy has to be commenced pre-pubertally to prevent pituitary dysfunction.
Thrombophilic Disorders
Women with thrombophilic disorders are at risk of thromboembolism during preg-
nancy, and those with a history of thrombosis are often prescribed prophylactic
anticoagulants for all or part of their pregnancy. The commonest practice is to
commence heparin in labour and continue for 6 weeks post-partum. Women with
prosthetic heart valves might be on long-term warfarin therapy and present particu-
lar dilemmas when trying to conceive. Warfarin should be avoided during the first
trimester because of the risk of chondrodysplasia punctata, a condition that results
in abnormal bone and cartilage formation. Prolonged use of heparin can cause
osteoporosis, and osteoporosis is of particular concern in women with infertility
secondary to long-standing ovarian failure, who might already have compromised
bone density caused by oestrogen deficiency. The risk of osteoporosis appears to be
reduced by the use of low-molecular-weight heparins, although these preparations
have not yet been licenced for use in pregnancy. Careful consideration should be
given to women at high risk of thromboembolism who are undergoing superovulation,
as the resultant high serum concentrations of estradiol might put them at an increased
risk of thrombosis and heparin prophylaxis is sometimes advisable. Therapy should
therefore be coordinated with the advice of a thrombosis expert.
Antiphospholipid Syndrome
Antiphospholipid syndrome is associated with recurrent miscarriage (see Chapter 21).
However, most women with the coagulation defects that constitute this disorder do
not have overt signs or symptoms of connective tissue disease.

Connective Tissue Disorders

Systemic Lupus Erythematosus
Women with systemic lupus erythematosus (SLE) should be advised against conceiv-
ing during active phases of the disease as pregnancy can cause severe flare-ups. There
is a high risk of miscarriage, perhaps in up to 40% of pregnancies, and miscarriage
can occur in the first or second trimesters. Strategies to prevent miscarriage include
the use of aspirin, heparin, corticosteroids and immunoglobulins.
Other connective tissue disorders, such as rheumatoid arthritis, do not appear to
increase the risk of miscarriage. Prenatal counselling is important to rationalise drug
therapy. Corticosteroids and chloroquine are safe in pregnancy, as is aspirin in low dose,
but paracetamol is preferable as an analgesic. Indomethacin and other non-steroidal anti-
inflammatory drugs should be avoided in pregnancy, as should gold and penicillamine.
Cyclooxygenase-2 inhibitors (e.g. meloxicam, rofecoxib, nimesulide) are a group
of non-steroidal anti-inflammatory drugs that affect prostaglandin synthesis and
may have a profound effect on fertilisation, decidualisation and implantation, so they
should be avoided in women trying to conceive [30].
Chemotherapy
Pregnancy should be avoided during chemotherapy.
Effect on Men
Regimens that contain alkylating agents (e.g. busulfan, carmustine, chlorambucil,
cyclophosphamide, estramustine, ifosfamide, lomustine, melphalan, mustine,
thiopeta, treosulfan) can severely affect gametogenesis, so men, if well enough,
should be advised to produce sperm for cryopreservation. Since the advent of ICSI,
this advice has assumed even greater importance (see Chapters 12 and 14). Men also
can be adversely affected by cytarabine, doxorubicin, procarbazine and vinblastine.
Chemotherapy predominantly affects seminiferous tubules, but Leydig cell function
also may be compromised.
Effect on Women
The effect of alkylating agents on women is variable. It is more dependent on age and
dose, with women over the age of 30 being more likely to have premature ovarian failure.
It is now becoming possible to freeze oocytes or ovarian biopsies containing primordial
follicles; in the meantime, it is not usually feasible for women to undergo IVF before
starting chemotherapy (see Chapter 19). Most other chemotherapeutic agents allow pres-
ervation of ovarian function once the patient has recovered from the underlying d isease.
Treatment with the oral contraceptive pill or GnRH analogues does not protect the
oocytes. It is fortunate that methotrexate, used to treat choriocarcinoma and some women
with ectopic pregnancy, does not affect fertility, although pregnancy should be avoided
for 3–6 months after administration. If radiotherapy of the pelvic region is required,
oophoropexy may reduce the dose of radiation to the ovaries, but cryopreservation of
ovarian tissue should provide the solution for these patients in the future.

REFERENCES
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2012; 344: 34–9.
2. Barker DJ. The fetal and infant origins of adult disease. BMJ 1990; 301: 111.
3. Amatruda JM, Harman SM, Pourmotabbed G, Lockwood DH. Depressed plasma
testosterone and fractional binding of testosterone in obese males. J Clin Endocrinol
Metab 1978; 47: 268.
4. Chung WS, Sohn JH, Park YY. Is obesity an underlying factor in erectile d ysfunction?
Eur Urol 1999; 36: 68–70.
5. Glass AR, Burman KD, Dahms WT, Boehm TM. Endocrine function in human
obesity. Metabolism 1981; 30: 89.
6. Kort HI, Massey JB, Elsner CW, et al. Men with high body mass index values present
with lower numbers of normal-motile sperm cells. Abstract no. P-355. Fertil Steril
2003; 80 (Suppl. 3): S238.
7. Kort HI, Massey JB, Witt MA, Mitchell-Leef D, Durrance MH, Roudebush WE.
Sperm chromatin integrity is related to body mass index: men presenting with high
BMI scores have higher incidence of sperm DNA fragmentation. Abstract no. P-333.
Fertil Steril 2003; 80 (Suppl. 3): S232.
8. MacDonald AA, Herbison GP, Showell M, Farquhar CM. The impact of body mass
index on semen parameters and reproductive hormones in human males: a systematic
review and meta-analysis. Hum Reprod Update 2010; 16: 293–311.
9. Norman RJ, Dewially D, Legro RS, Hickey TE. Polycystic ovary syndrome. Lancet
2007; 370: 685–97.
10. Schmid TE, Eskenazi B, Marchetti F, et al. Micronutrients intake is associated with
improved sperm DNA quality in older men. Fertil Steril 2012; 98: 1130–7.
11. Colagar AH, Marzony ET, Chaichi MJ. Zinc levels in seminal plasma are associated
with sperm quality in fertile and infertile men. Nutr Res 2009; 29: 82–8.
12. Aitken RH, Clarkson JS. Significance of reactive oxygen species and antioxidants in
defining the efficacy of sperm preparation techniques. J Androl 1988; 9: 367.
13. Wong WY, Mekus HM, Thomas CM, Menkveld R, Zielhuis GA, Steegers-Theunissen
RP. Effects of folic acid and zinc sulfate on male factor subfertility: a double blind,
randomized, placebo controlled trial. Fertil Steril 2002; 77: 491–8.
14. Hassan MA, Killick SR. Negative lifestyle is associated with a significant reduction
in fecundity. Fertil Steril 2004; 81: 384–92.
15. Jensen TK, Hjollund NHI, Henriksen TB, et al. Does moderate alcohol consumption
affect fertility? Follow up study among couples planning first pregnancy. BMJ 1988;
317: 505–10.
16. Klonoff-Cohen H, Lam-Kruglick P, Gonzalez C. Effects of maternal and p aternal
alcohol consumption on the success rates of in vitro fertilization and gamete
intrafallopian transfer. Fertil Steril 2003; 79: 330–9.
17. Howe G, Westhoff C, Vessey M, Yeates D. Effects of age, cigarette smoking and other
factors on fertility: findings in a large prospective study. BMJ 1985; 290: 1697–700.
18. Augood C, Duckitt K, Templeton AA. Smoking and female infertility: a systematic
review and meta-analysis. Hum Reprod 1998; 13: 1532–9.
19. Hughes EG, Brennan BG. Does cigarette smoking impair natural or assisted
fecundity? Fertil Steril 1996; 66: 679–89.
20. Hull MG, North K, Taylor H, Farrow A, Ford WC. Delayed conception and active
and passive smoking. Fertil Steril 2000; 74: 725–33.

21. Holmes-Walker DJ, Conway GS, Honour JW, Rumsby G, Jacobs HS. Menstrual
disturbance and hypersecretion of progesterone in women with congenital a drenal
hyperplasia due to 21-hydroxylase deficiency. Clin Endocrinol (Oxf) 1995;
43: 291–6.
22. Vissenberg R, van den Boogard E, van Wely M, et al. Treatment of thyroid disorders
before conception and in early pregnancy: a systematic review. Hum Reprod Update
2012; 18: 360–73.
23. Krassas GE, Poppe K, Glinoer D. Thyroid function and human reproductive health.
Endocr Rev 2010; 31: 702–55.
24. Thangaratinam S, Tan A, Knox E, Kilby MD, Franklyn J, Coomerasamy A.
Association between thyroid autoantibodies and miscarriage and preterm birth:
meta-analysis of evidence. BMJ 2011; 342: d2616.
25. Gilling-Smith C, Almeida P. HIV, hepatitis B and hepatitis C and infertility: reducing
risk. Hum Fertil (Camb) 2003; 6: 106–12.
26. Castilla J, Del Romero J, Hernando V, Marincovich B, Garcia S, Rodriguez C.
Effectiveness of highly active antiretroviral therapy in reducing heterosexual
transmission of HIV. J Acquir Immune Defic Syndr 2005; 40: 96–101.
27. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early
antiretroviral therapy. N Engl J Med 2011; 365: 493–505.
28. Bujan L, Hollander L, Coudert M, et al. Safety and efficacy of sperm washing in
HIV-1-serodiscordant couples where the male is infected: results from the European
CREAThE network. AIDS 2007; 21: 1909–14.
29. Kashima K, Takakuwa K, Suzuki M, et al. Studies of assisted reproduction
techniques (ART) for HIV-1-discordant couples using washed sperm and the nested
PCR method: a comparison of the pregnancy rates in HIV-1-discordant couples and
control couples. Jpn J Infect Dis 2009; 62: 173–6.
30. Norman RJ, Wu R. The potential danger of COX-2 inhibitors. Fertil Steril 2004;
81: 493–4.
FURTHER READING
Powrie R, Greene M, Camann W, eds. de Swiet’s Medical Disorders in Obstetric Practice,
5th edn. Chichester, Sussex, U.K.: Wiley-Blackwell, 2010. ISBN: 978-1-4051-4847-4.

4
Obesity and Reproduction
Introduction
Obesity is a common problem amongst women of reproductive years, with 60%
of women in the United Kingdom being either overweight or obese. Obesity has a
negative impact on natural conception, pregnancy, the risk of miscarriage, and the
long-term health of both mother and child due to both an increased rate of congenital
anomalies and also the possibility of metabolic disease in later life. Obesity also has
a negative impact on male fertility (see Chapter 3).
Women who are obese respond less to drugs that are used for ovarian s timulation
for the treatment of both anovulation and assisted conception, although this low-
ered response does not always equate with a reduction in ongoing pregnancy rates.
Furthermore, obesity may affect the safety of procedures, for example, the ability
to see ovaries on ultrasound scan or the provision of safe anaesthesia for laparos-
copy or oocyte retrieval. Obesity also has a major impact during pregnancy and at
delivery.
Defining Obesity and the Extent of the Problem

A normal body mass index (BMI) is considered to be 19–24.9 kg/m2, although
some would consider the lower limit of normal to be 20 kg/m2 (Figure 4.1). Being
underweight leads to hypothalamic amenorrhoea and increases risk to pregnancy if
conception does occur. For consistency, we refer to overweight as a BMI > 25 kg/m2
and obese as a BMI > 30 kg/m2.
In the United Kingdom, approximately one-third of men and women over the age
of 16 years are overweight and another one-third obese. The treatment of obesity
costs the nation at least £10 million annually, the long-term consequences of obesity
will cost £500 million and the overall impact on the economy is estimated at £2
billion.
The main cause of obesity is an excess of energy intake over expenditure, with
the majority of the population taking little exercise and eating an unhealthy diet [1].
Having obese parents increases the risk of obesity by fivefold. A survey in Glasgow of
women booking into the antenatal clinic observed a doubling of obesity from 9.4% in
1990 to 18.9% in 2004, despite no change in age [2].

Weight in stones
7.0 8.0 9.0 10.0 11.0 12.0 13.0 14.0 15.0
1.80 11
10
5´9
15
8
20
1.70 7
25 5´6
Height in metres
Ideal
Height in feet
weight 30
1.60 5´3
range
35
Severely
40 5´0
1.50 obese
Morbidly
8 obese
6
4´9
4
2
1.40
40 2 4 6 8 50 60 70 80 90 100
Weight in kilograms
FIGURE 4.1 BMI chart. Each diagonal line represents the BMI in kg/m2. (Chart originally devised
by Dr. G. Conway, University College Hospital, London.)
BOX 4.1 WHO DEFINITIONS OF BMI RANGES

Overweight ≥ 25 kg/m2
Pre-obese 25.0–29.9 kg/m2
Moderate obesity (class I) 30.0–34.9 kg/m2
Severe obesity (class II) 35.0–39.9 kg/m2
Very severe (morbid) obesity (class III) ≥ 40 kg/m2
BMI is a reproducible measurement that is easy to measure. However, in metabolic

terms, the distribution of body fat is more important than actual body weight. Visceral
fat is more metabolically active, and an increased waist circumference (or waist:hip
(W:H) ratio) correlates better with both metabolic risk and long-term disease.
Unfortunately, waist circumference is difficult to measure (i.e. subject to increased
error) in obese individuals, whereas BMI is more consistent (Box 4.1).
Insulin resistance is also an important correlate of BMI and is perceived as a
more accurate marker of the metabolic effect of obesity. There are also important
ethnic variations in the expression of insulin resistance. A BMI > 30 kg/m2 is usually
considered to confer increased risk in white Caucasians, whereas in those of South
Asian origin a BMI > 25 kg/m2 is sufficient to increase risk of metabolic defects [3].

Obesity and Reproduction 51
Insulin resistance is defined as a reduced glucose response to a given amount of

insulin and may occur secondary to resistance at the insulin receptor, decreased
hepatic clearance of insulin and/or increased pancreatic sensitivity. The measurement
of insulin resistance is an imprecise science without universally accepted guidelines.
Technical difficulties have given rise to many invasive tests, including the euglycemic
clamp method. This method is considered to be a ‘gold standard’, but it is complex
and expensive, as are the measurements of fasting insulin concentrations, which
combined with glucose can provide formulae for the homeostasis model assessment
(HOMA) and the quantitative insulin sensitivity check index (QUICKI) calculations
of insulin resistance. So, in practice, these tests are confined to the research setting
in the United Kingdom and have not become established in clinical practice in repro-
ductive medicine. Most clinicians resort to the standard 75-g oral glucose tolerance
test (Oral glucose tolerance test (OGTT); Table 4.1). Fasting glucose levels alone are
poorly predictive of 2-h levels in impaired glucose tolerance (IGT), suggesting that a
full OGTT should be conducted [4]. Between 20% and 40% of women with polycystic
ovary syndrome (PCOS) have IGT, a value that is significantly higher than the preva-
lence among age- and weight-matched pre-menopausal women [5].
In a U.K. study of pre-menopausal women with non-insulin-dependent diabetes
mellitus (NIDDM), almost 30% had PCOS and 82% had polycystic ovary (PCO)
morphology [6]. Women with PCOS are between three and seven times more likely
to develop NIDDM than control subjects [4,7]. Furthermore, the conversion rate
is potentially rapid. When 54 normoglycemic women and 13 women with IGT at
baseline with PCOS were followed for an average of 6.2 years, 9% of the former
group developed impaired tolerance and 8% developed frank NIDDM. Of the IGT
group, 54% had frank NIDDM at follow-up. BMI at baseline was an independent
significant p redictor of conversion. The speed of change suggests regular surveillance
is required, especially when BMI is high [8], yet this surveillance is far from becoming
part of standard U.K. healthcare for these women.
Although the insulin resistance may occur irrespective of BMI, the common
association of PCOS and obesity has a synergistic deleterious impact on glucose
homeostasis and can worsen both hyperandrogenism and anovulation. An assessment
of BMI alone is not thought to provide a reliable prediction of cardiovascular risk.
It has been reported that the association between BMI and coronary heart disease
almost disappeared after correction for dyslipidemia, hyperglycaemia and hyper-
tension [9]. Some women have profound metabolic abnormalities in the presence
TABLE 4.1
Definitions of Glucose Tolerance after a 75-g Glucose Tolerance Test
Impaired Glucose Impaired Fasting
Diabetes Mellitus Tolerance glycaemia
Fasting glucose (mmol/L) ≥7.0 <7.0 ≥6.1 and <7.0
2-h glucose (mmol/L) ≥11.1 ≥7.8 and <11.1 <7.8
Action Refer diabetic Dietary advice Dietary advice
clinic Check fasting Check fasting
glucose annually glucose annually
Consider metformin

of a normal BMI, whereas others have few risk factors despite an elevated BMI
[10,11]. Thus, rather than BMI itself, it is the distribution of fat that is important,
with android obesity being more of a risk factor than gynaecoid obesity. Hence, the
value of m easuring W:H ratio, or waist circumference, detects abdominal visceral
fat rather than subcutaneous fat. It is the visceral fat that is metabolically active, and
when increased, it results in increased rates of insulin resistance, type 2 diabetes, dys-
lipidemia, hypertension and left ventricular enlargement. Exercise has a s ignificant
effect on reducing visceral fat and reducing cardiovascular risk. There is a closer
link between waist circumference and visceral fat mass, as assessed by c omputed
tomography (CT) scan, than with W:H ratio or BMI [11]. Waist circumference should
ideally be less than 79 cm, whereas a measurement that is greater than 87 cm carries
a significant risk.
Effect of Obesity on Pregnancy

(Miscarriage, Maternal Health, Fetal Health)
Miscarriage rates appear to be increased with increasing maternal weight. In those
women who conceive naturally, there is an increased risk of miscarriage if they are
moderately overweight (BMI 25–27.9 kg/m2) [12]. This relationship also has been
demonstrated in women who conceive by in vitro fertilisation (IVF) [13,14] or who
are recipients of donated oocytes [15].
There is also an increased rate of insulin resistance in women with recurrent
miscarriage (27% compared with 9.5% in controls with ongoing pregnancies) [16].
This finding introduces the notion that it is the metabolically active fat, that is, visceral
fat, that is most important in predicting reproductive outcome. A possible mecha-
nism is via plasminogen activator inhibitor (PAI-1), a potent inhibitor of fibrinolysis
that is elevated in insulin resistance, PCOS and women who miscarry. There are
several other possible mechanisms, including adverse effects of insulin resistance on
follicular development, oocyte maturation and endometrial development.
Pregnancy carries significant risks for those women who are obese, with increased
rates of congenital anomalies, including neural tube (odds ratio (OR) 3.5), o mphalocele
(OR 3.3) and cardiac (OR 2.0) defects; miscarriage; gestational diabetes; hypertension
and problems during delivery [17,18].
The risks of congenital anomalies appear real, although there are also techni-
cal d ifficulties in assessing the fetus by ultrasound because adipose tissue attenu-
ates the signal. Pregnancy itself exacerbates any underlying insulin resistance; as
a result, women with PCOS, obesity or both have an increased risk of gestational
diabetes [19].
Obesity is associated with an increased risk to the mother during pregnancy. Risks
include increased incidence of hypertension, gestational diabetes and thromboembolic
disorders as well an increased cesarean section rate. Macrosomia, admission to
neonatal intensive care, birth defects, stillbirth and perinatal death are all increased
in the infants of women who are obese [20,21]. In a U.K. study of 287,213 singleton
pregnancies, 176,923 (61.6%) were of normal weight (BMI 20–24.9) and 31,276
(10.9%) were obese (BMI > 30) [2]. The ORs from this study [2] in those women who
were obese are shown in Table 4.2.

TABLE 4.2
Risk during Pregnancy in Obese Women
Condition Odds Ratio (95% Confidence Interval)
Gestational diabetes 3.6 (3.25–3.98)
Pre-eclampsia 2.14 (1.85–2.47)
Induction of labour 1.70 (1.64–1.76)
Cesarean section 1.83 (1.74–1.93)
Post-partum haemorrhage 1.39 (1.32–1.46)
Genital infection 1.3 (1.1–1.6)
Urinary tract infection 1.4 (1.2–1.6)
Wound infection 2.2 (2.0–2.6)
Macrosomia 2.36 (2.23–2.50)
Intrauterine death 1.4 (1.14–1.71)
Source: Kanagalingam MG et al., BJOG 112, 1431–3, 2005.
In a study of women with PCOS undergoing ovulation induction, of 270 with a

BMI > 35 kg/m2, there were only five pregnancies of which one was stillborn and
another had congenital anomalies [22]. The proposed mechanisms that increase the
stillbirth and congenital anomaly rate include insulin resistance and incipient or undi-
agnosed diabetes. Similar trends have been shown in an Australian population [21] of
women giving birth, with a doubling of birth defects from 1.9% in women with a BMI
of 30–40 kg/m2 to 4% in women with a BMI of > 40 kg/m2. There is also evidence that
obesity in pregnancy causes programming of the fetus to become obese in later life.
Pregnancy in obese women is therefore more costly because of increased cesarean
section rates, length of stay and admission to neonatal services. Overweight mothers
are more likely to have hypertension and thromboembolism, leading to a higher risk of
maternal mortality. In 2000–2002, of the 261 deaths reported to the U.K. Confidential
Enquiry into Maternal Health [23], 78 women (35%) were obese, compared with 23%
of women in the general population, and of these women more than one-quarter had
a BMI > 35 kg/m2.
A gain in weight between first and second pregnancies, even if maternal BMI
remains within the normal range, has been shown to significantly increase the risk of
gestational diabetes, pre-eclampsia and stillbirth [24].
Influence of Obesity on Natural Fertility

Body weight has a profound effect on the initiation of puberty in girls and their
subsequent natural fertility. A detailed account is beyond the scope of this book,
and there are some excellent reviews that include appraisals of the interrelationships
between centrally acting hormones and active products of adipose tissue [25,26].
Although most attention has been directed towards the effects of obesity on anovula-
tory infertility, there is evidence that being overweight can influence spontaneous
conception in women who are ovulating [27–29]. Again, it is central/visceral fat that
appears to be most significant.

TABLE 4.3
Waist:Hip (W:H) Ratio and Percent Pregnant
after 12 Cycles
W:H ratio % Pregnant after 12 Cycles
<0.70 63
0.7–0.75 51
0.76–0.8 47
0.81–0.85 41
>0.85 32
Source: Zaadstra BM et al., BMJ 305, 484–7, 1993.
TABLE 4.4
Body Mass Index (BMI) and Percent Pregnant
after 12 Cycles
BMI % Pregnant after 12 Cycles
<20.0 40
20.1–25 48
25.1–30 48
>30 18
Source: Zaadstra BM et al., BMJ 305, 484–7, 1993.
For example, a study from several years ago looked at 542 women attending for
donor insemination (DI) and found that a 0.1 unit increase in W:H ratio led to a
30% decrease in probability of conception per cycle (hazard ratio 0.705, 95% CI
0.562–0.887) [29]. The relationship with BMI was not linear, and the detrimental
effect was observed only with a BMI > 30 kg/m2 (Tables 4.3 and 4.4).
PCOS, Insulin Resistance, Metformin and

the Effect of Weight Loss
PCOS affects 20%–25% of women (see Chapter 8). Its prevalence appears to be
rising because of the current epidemic of obesity. PCOS accounts for 90%–95%
of women who attend infertility clinics with anovulation. At least 40% of women
with PCOS are obese [30], and they are more insulin resistant than weight-
matched individuals with normal ovaries. Increasing abdominal obesity is corre-
lated with reduced menstrual frequency and fertility together with greater insulin
resistance [31].
Several studies have shown that weight loss in women with PCOS improves the
endocrine profile, menstrual cyclicity, rate of ovulation and likelihood of a healthy
pregnancy [32]. Even a modest loss of 5%–10% of total body weight can achieve a 30%
reduction of central fat, an improvement in insulin sensitivity and restore ovulation.

Lifestyle modification is clearly a key component for the improvement of reproductive

function for overweight, anovulatory women with PCOS.
Weight loss should therefore be encouraged before ovulation induction treat-
ments, such as clomifene citrate or gonadotropin therapy, to improve the likeli-
hood of ovulation and to enhance ovarian response. Monitoring treatment is
also harder in the obese as visualisation of the ovaries is more difficult, raising
the risk of multiple ovulation and multiple pregnancy. National guidelines in the
United Kingdom for the management of overweight women with PCOS advise
weight loss, preferably to a BMI < 30 kg/m 2, before commencing drugs for ovarian
stimulation [33].
A study by Clark et al. [34] looked at the effect of a weight loss and exercise
programme on women with a BMI > 30 kg/m2 and anovulatory infertility who were
clomifene resistant. The emphasis of the study was a realistic exercise schedule
combined with positive reinforcement of a suitable eating programme over 6 months.
Thirteen out of the 18 women enrolled completed the study, reinforcing the difficulties
some individuals have in sustaining even moderate changes in lifestyle. Weight loss
had a significant effect on endocrine function, ovulation and the chance of p regnancy.
Fasting insulin and serum testosterone concentrations fell, and 12 of the 13 subjects
resumed ovulation; 11 becoming pregnant – 5 naturally and the remainder became
responsive to clomifene. Thus, with appropriate support, patients may ovulate natu-
rally without medical therapy. An extension of this study, in women with a variety of
diagnoses, demonstrated that in 60 out of 67 subjects weight loss resulted in spontane-
ous ovulation with lower than anticipated rates of miscarriage and a significant saving
in the cost of treatment [35].
Weight loss among obese women with anovulatory PCOS is therefore associated
with significant improvements in the menstrual pattern (from 40% to 89%) and
spontaneous resumption of regular ovulatory cycles (from 33% to 55%) [31,36,37].
Lifestyle modification is clearly a key component for the improvement of reproduc-
tive function in overweight women with anovulation and PCOS. It is likely that
starting to lose weight, by being in negative calorific balance, will provide early
benefit.
The use of insulin-lowering or sensitising agents has excited much interest in the
management of PCOS, but drugs such as metformin appear to be ineffective for
women with anovulation and extreme obesity (see Chapters 7 and 8). It is logical
to assume that therapy that achieves a fall in serum insulin concentrations should
improve the symptoms of PCOS. Many studies have now been carried out to e valuate
the reproductive effects of metformin in patients with PCOS. However, most of the
initial studies were observational, and any randomised studies involved a small
number of participants. The largest appropriately powered, prospective randomised,
double-blind, placebo-controlled multicentre study has recently been published. It
aims to evaluate the combined effects of lifestyle modification and metformin on
obese anovulatory women (BMI > 30 kg/m2) with PCOS [38]. All the patients had
an individualised assessment by a research dietitian to set a realistic goal that could
be sustained for a long period of time with an average reduction of energy intake of
500 kcal/day. Both the metformin-treated and placebo groups lost weight, but the
amount of weight reduction did not differ between the two groups. An increase in

menstrual cyclicity was observed in those who lost weight, but again the increase did
not differ between the two arms of the study.
The very variable findings from the published studies on the use of metformin
reflect the large differences in study populations, particularly with respect to body
weight. Insulin sensitivity decreases (or insulin resistance increases) with BMI [39]. It
has been shown that non-obese women with PCOS respond better to metformin than
obese women to metformin. One might expect metformin to have a greater effect in
those with the greater insulin resistance; however, there may be either underdosing
or resistance to the effects of metformin at the doses used. Furthermore, metformin
does not appear to enhance the outcome of ovulation induction with clomifene citrate
(see Chapter 7) [39].
The thiazolidinedione derivatives, although potentially more effective than
metformin for improving insulin sensitivity, are inappropriate for use in those s eeking
fertility, and they also have the unwanted effect of actually increasing weight.
Effect of Obesity on Treatment of Anovulatory Infertility

A study of 1880 infertile women and 4023 control women [40] showed that anovu-
latory infertility was three times more common in those with a BMI > 27 kg/m 2.
Overweight women also require higher doses of clomifene and gonadotropins.
It is difficult to accurately monitor women who are overweight by transvaginal
ultrasound scan and it has been shown that they are at greater potential risk of
overresponse [41]. In this study, there was no significant influence of BMI on the
rate of ovulation or pregnancy (as assessed by positive human chorionic gonadotro-
pin (hCG), clinical pregnancy rate and ongoing pregnancy rate). The group with a
BMI > 30 produced more small f ollicles (p = .005) and fewer intermediate follicles
(p < .036) than the less overweight and normal weight patients, despite a higher
antral follicle count. Those women with a BMI < 25 kg/m 2 had a better chance of a
unifollicular response. An increasing BMI is associated with more treatment days,
a higher total dose and a higher threshold dose of gonadotropins [41].
Many studies have historically excluded women with a BMI > 35, or in some cases
30 kg/m2, based on general algorithms for the provision of ovulation induction. Some
studies have included very obese women, for example, in a cohort of 270 women with
PCOS who received either clomifene citrate or gonadotropins for ovulation induction,
the ovulation rate at 6 months was 79% in women with a BMI of 18–24 kg/m2, 15.3%
in women with a BMI of 30–34 kg/m2 (p < .001) and 12% in women with a BMI ≥
35 kg/m2 (p < .001) [22].
A meta-analysis of 13 studies confirmed a positive association between
degree of obesity and amount of gonadotropin required, with a weighted mean
difference of 771 international units (IU) more needed (95% CI 700–842) and
also a higher rate of cycle cancellation in the obese (pooled OR 1.86, 95% CI
1.13–3.06) [42].
There was also a reduction in ovulation rate associated with obesity compared
with non-obese (OR 0.44, 95% CI 0.31–0.61). Although there was no difference
in pregnancy rates associated with obesity, there was a negative association with
insulin resistance (pooled OR 0.29, 95% CI 0.10–0.80). Thus, the combination of

obesity and insulin resistance appears to be the most significant determinant for the
outcome of ovulation induction therapy, with degree of insulin resistance being more
important.
Laparoscopic ovarian diathermy is an alternative to gonadotropin therapy for
clomifene citrate-resistant anovulatory PCOS (see Chapter 7). However, those

women who are most likely to respond are slim with elevated serum-luteinising hor-
mone (LH) concentrations rather than overweight women [43]. Furthermore, obesity
presents additional hazards during general anaesthesia.
Effect of Obesity on IVF and Related Treatments

There is evidence that women who are extremely overweight have a higher chance
of failure to conceive with assisted reproductive technology (ART) cycles. Several
studies have reported that very obese women have up to one-half the chance of
conceiving with ART compared with women with a normal BMI range [14,44,45],
although a few studies suggest no effect of body weight [46,47]. As with publications
on the outcome of ovulation induction, there are few women with extreme obesity in
the study cohorts.
Obese women have been shown to require a higher dose of gonadotropins and
to have fewer growing follicles, less frequent oocyte retrievals and fewer oocytes
retrieved. Relative to their lean counterparts, obese women have been reported to
have lower embryo quality and lower implantation rates, higher early pregnancy
loss rates and, as a result, lower live birth rates. However, often, the intensity of the
hormonal stimulation may be sufficient to overcome some of the disadvantages of
obesity and permit reasonable clinical pregnancy rates [46].
A retrospective study of the records of 5019 IVF/intracytoplasmic injection of
sperm (ICSI) cycles in 2660 couples found that compared with a BMI < 25 kg/m2,
those women with a BMI > 30 kg/m2 had an OR of a live birth of 0.75 (95% CI
0.57–0.98, p < .05) and of a miscarriage of 1.69 (95% CI 1.13–2.51, p < .003) [44].
In another analysis of 3586 women who had ART in Adelaide, South Australia, of
whom 25% had PCOS, a logistic regression analysis confirmed an independent effect
of body weight, with linear reduction in fecundity with obesity (p < .001) [14]. The
percentage of women achieving at least one pregnancy in different BMI groupings is
shown in Table 4.5 [14].
TABLE 4.5
Percentage of Women Achieving at Least One Pregnancy in Different BMI Groupings
BMI (kg/m2) % Achieving One Pregnancy OR 95% CI
<20 45 0.81 0.65–1.01
20–24.9 48 1.0
25–29.9 42 0.81 0.68–0.97
30–34.9 40 0.73 0.57–0.95
>35 30 0.50 0.32–0.77
Source: Wang JX et al., BMJ 321, 1320–1, 2000.

Thus, women with a BMI > 35 kg/m2 have a significantly reduced chance of
c onceiving compared with women of a normal weight. Furthermore, this group also
reported a significant correlation between body weight and miscarriage after ART
[48]; this correlation was even significant in the overweight group and highly so in
women with a BMI between 30 and 35 kg/m2.
Attempts have been made to determine the reasons for reduced outcome during
ART treatments. These reasons may relate to the absorption and distribution of
the administered drugs or to the effects of hyperinsulinaemia and other endocrine
abnormalities on ovarian response, follicular growth and oocyte maturation. There
appears to be more of a negative effect on pregnancy rates in women with central
obesity but less correlation with BMI, indicating that the effect may be due to hyper-
insulinaemia and a hyperandrogenic hormonal milieu adversely affecting the growing
follicle, oocyte quality or endometrial maturation [49].
There is also evidence that women who receive donated eggs have a significantly
lower chance of implantation, ongoing pregnancy and a greater risk of miscar-
riage if they have a BMI > 30 kg/m 2, irrespective of the BMI of the donor [15].
However, on the contrary, there are data that showed no effect of obesity in egg
recipients [50].
A recent meta-analysis confirmed the adverse effects of obesity on the outcome
of IVF with respect to the need for higher doses of gonadotropins, the production
of fewer oocytes leading to the likelihood of lower pregnancy rates [46] – although
the latter was not conclusively proven. Miscarriage rates were generally increased,
although overall the study failed to find a significant effect of extreme obesity on live
birth rates [46]. However, few studies reported live birth rates, and the actual numbers
of treatment cycles studied was small.
Consideration should be given to the safety of providing treatment and the
availability of appropriate facilities (for safe monitoring of treatment and provision of
anaesthesia for operative procedures including oocyte retrieval) [51].
Provision of Support in Achieving Weight Loss

There is ample evidence that weight loss will improve reproductive function, so
support needs to be given to overweight women to improve their fertility and
chance of a healthy pregnancy. Although much has been written about differ-
ent diets, there is little evidence that one is better than another with respect to
enhancing reproduction. However, it is clear that participating in a supervised
weight loss p rogramme or a group programme including support in addition to
diet and exercise helps reduce weight, increase ovulatory frequency and improve
pregnancy rates.
Women should be provided with assistance to lose weight, including psychological
support, dietary advice (see Chapter 3) and exercise classes. Drug therapy, such as
orlistat, has minimal, if any, long-term benefit. In contrast, bariatric surgery – gastric
banding or bypass – has been shown to be very effective in restoring reproductive
function, provided there is appropriate nutritional support and pregnancy does not
occur until weight loss has stabilised (Box 4.2) [52].

BOX 4.2 KEY POINTS

• Consideration should be given to the safety of providing treatment
and the availability of appropriate facilities.
• BMI is a reliable, reproducible and easy measurement and remains
useful in clinical practice. Waist circumference and a more detailed
measure of metabolic risk are advisable in women at high risk of
insulin resistance.
• Women should be informed about the association between increased
weight and adverse aspects of fertility treatment.
• Women should aim to reduce their BMI to less than 35 kg/m2 and
preferably to less than 30 kg/m2 before starting any form of fertility
treatment.
• Even a moderate loss of 5%–10% of body weight can be sufficient to
restore fertility and improve metabolic parameters.
• Practitioners should be aware of and inform their patients that mater-
nal obesity is associated with an increased risk of maternal, fetal and
neonatal complications.
• Women should be provided with assistance to lose weight, including
psychological support, dietary advice, exercise classes and, where
appropriate, bariatric surgery.
• Metformin should not be prescribed as a weight reduction agent.
• Obesity also has an adverse effect on male fertility and long-term
health. Couples usually share lifestyle habits and should be encouraged
as couples to improve their general health and reproductive health.
NOTE
Much of the content of this chapter was produced by the author for the British Fertility
Society’s Guidelines on the Impact of Obesity on Female Reproductive Health (Balen
AH, Anderson RA. Human Fertility 2007; 10: 195–206).
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5
Investigating Infertility
Introduction
ertility investigations should normally be instigated as soon as the couple seeks
help. Even if they have been trying for less than a year, it is worthwhile asking some
general questions to ensure that major problems, such as irregularities of the men-
strual cycle, a history of pelvic surgery, or orchidopexy, have not been ignored. If the
couple’s medical history is normal, the expected cumulative chance of conception
over a period of time should be explained, and investigations should be deferred until
they have been trying for a year. When the female partner is aged 35 years or older,
monthly fecundity is significantly reduced, but I do not believe that investigations
should be delayed p roportionately because of the concomitant age-related decline in
the success of treatment (see Chapter 1).
Once the decision has been taken to investigate a couple, it should be possible
to perform the basic screening tests within 3–4 months and provide them with a
management plan that may involve reassurance, more detailed investigations or
treatment. A pragmatic approach should be taken. Infertility is rarely absolute, and
treatment options may be discussed to enhance a couple’s fertility even in the absence
of a clear diagnosis. To quote from The ESHRE Capri Workshop Group, ‘Both old
and new diagnostic tests must be considered, but to what degree is diagnostic cer-
tainty necessary? The science of infertility is uncertain and it is not a life-threatening
condition. Testing until uncertainty vanishes may delay treatment (and if the delay is
long enough, the female patient will become menopausal)’ [1].
Couples usually attend the infertility clinic together, but there are sometimes
secrets between them that might yield clinically relevant information. We suggest
that the physical examination of the individual is performed with their partner out
of the room, as this separation provides a good opportunity to uncover c onfidential
information about previous pregnancies, illnesses or sexually transmitted diseases.
It is essential to remember that one is dealing with both the couple and with two
individual patients who often have separate general practitioners (GPs). It is of para-
mount importance not to convey confidential information to the wrong GP, as the
issues that surround infertility are extremely sensitive. It is our practice to send
patient’s copies of correspondence so that they have a written record of what has been
discussed. Not only does this practice help to avoid confusion, but it also increases
confidence that everyone is included in the communication loop.

General Investigations
The fertility clinic should be used for general health screening and preconception
counselling. Particular attention should be paid to body weight, blood pressure, uri-
nalysis, cervical cytology and rubella immunity. Some clinics ascertain h epatitis B, C
and human immunodeficiency virus (HIV) status before offering assisted conception
– this practice has become routine in the United Kingdom because of the putative risk
of viral contamination of cryopreserved embryos via liquid nitrogen.
Investigating the Female Partner

Examination
A calculation of the body mass index (BMI) is made from the height and weight (kg/m2)
– the normal range is 20–25 kg/m2 (see Chapter 4 and Figure 4.1). The patient’s gen-
eral appearance may give clues about either systemic disease or endocrine problems.
The presence of normal secondary sexual characteristics should be noted.
Signs of Endocrine Disorder

Signs of hyperandrogenism (e.g. acne, hirsutism, balding) are suggestive of polycys-
tic ovary syndrome (PCOS), although biochemical screening helps to differentiate other
causes of androgen excess. Hirsutism can be graded and given a Ferriman Gallwey
Score (Figure 5.1). It is useful to monitor the progress of hirsutism, or its response to
treatment, by making serial records, either using a chart such as the one illustrated or by
taking photographs of affected areas of the body. It is important to d istinguish between
hyperandrogenism and virilisation (Table 5.1), which is associated with high circulat-
ing androgen levels and causes deepening of the voice, increase in muscle bulk, breast
atrophy and clitoromegaly. Virilisation suggests a more profound d isturbance of andro-
gen secretion than usually seen with PCOS and indicates the need to exclude androgen-
secreting tumours, congenital adrenal hyperplasia (CAH) and Cushing’s syndrome.
One should be aware of the possibility of Cushing’s syndrome in women with stig-
mata of the PCOS and obesity as it is a disease of insidious onset and dire conse-
quences; additional clues are the presence of central obesity, moon face, plethoric
complexion, buffalo hump, proximal myopathy, thin skin, bruising and abdominal
striae, which alone are a common finding in obese individuals.
Acanthosis nigricans is a sign of profound insulin resistance and is usually visible
as hyperpigmented thickening of the skin folds of the axilla and neck; it is associated
with PCOS and obesity (Figure 5.2a and b).
Amenorrhoeic women may have hyperprolactinaemia and galactorrhoea. It is
important, however, not to examine the breasts before taking blood as the serum
prolactin concentration may become falsely elevated. Generally, vaginal and breast
examinations and stress can all cause a temporary elevation in serum prolactin
concentration. If there is suspicion of a pituitary tumour, the patient’s visual fields
should be checked, as bitemporal hemianopia secondary to pressure on the optic
chiasm requires immediate attention.

Investigating Infertility 65
1 Upper lip
2 Face
3 Chin
Jaw and
4
neck
Upper
5 back
Lower
6 back
7 Arm
8 Thigh
9 Chest
Upper
10 abdomen
Lower
11 abdomen
12 Perineum
FIGURE 5.1 Ferriman Gallwey Score: each area is given a score from 1 to 4 (1 = mild, 2 =
moderate, 3 = complete light coverage, 4 = heavy coverage).

TABLE 5.1
Hyperandrogenism versus Virilisation
Hyperandrogenism Virilisation
Acne Acne
Hirsutism Hirsutism
Male pattern balding Male pattern balding
Increased muscle mass
Deep voice
Clitoromegaly
Breast atrophy
Thyroid disease is common, and the thyroid gland should be palpated and signs
of hypothyroidism (e.g. dry thin hair, proximal myopathy, myotonia, slow-relaxing
reflexes, mental slowness, bradycardia) or hyperthyroidism (e.g. goiter with bruit,
tremor, weight loss, tachycardia, hyperreflexia, exophthalmos, c onjunctival oedema,
ophthalmoplegia) determined.
General Examination
It is important to perform a general physical examination, including examination of
the breasts (Box 5.1). Remember that the patient might require an anaesthestic as part
of investigations, so consideration of fitness for anaesthesia is important.
Pelvic Examination
A pelvic examination should be performed. Endometriosis is suggested by the
presence of nodules in the vagina, thickening of the posterior fornix, tenderness and
fixity of the pelvic organs. If the examination is painful, be alerted to the possibility
of pelvic pathology and include a laparoscopy early in the course of investigations.
Adnexal masses should be investigated by ultrasound in the first instance.
Chlamydia Detection
A controversial subject is the routine swabbing of the cervix for Chlamydia tra-
chomatis. Chlamydial DNA has been recovered from 50% of women with tubal
infertility compared with approximately 12% in pregnant women or women with
non-tubal infertility. Chlamydia infection is the commonest cause of tubal infertility
in developed countries, and it is the commonest sexually transmitted pathogen in the
United Kingdom. It is thought that at least 1 in 20 women in the United Kingdom
between the ages of 18 and 25 years may have undiagnosed infection. Chlamydia
trachomatis causes urethritis and epididymitis in men and cervicitis, salpingitis and
endometritis in women, although symptoms can be mild and non-specific. Indeed, the
majority of Chlamydia-infected individuals are asymptomatic and remain untreated,
raising the debate about population screening [2].
Chlamydia has both intracellular and extracellular forms and requires prompt
transfer to the laboratory in a special transport medium for tissue culture. The antigen

(a)
(b)
FIGURE 5.2 Acanthosis nigricans, as seen typically in the axilla or skin of the neck. (a) Axilla.
(b) Close-up, demonstrating hypertrophic and pigmented skin.

BOX 5.1 EXAMINATION (FEMALE PARTNER)

Signs of endocrine disorders: acne, hirsutism, balding
Acanthosis nigricans
Virilisation
Visual field defects
Goiter, signs of thyroid disease
BMI
Blood pressure
Fitness for possible anaesthetic
Urinalysis
Breast examination – lumps, galactorrhoea
Cervical smear if required
Abdominal examination masses, scars, striae, hirsutism
Pelvic examination
Developmental anomalies
Vaginal nodules of endometriosis
Tenderness
Mobility of uterus
Masses
Endocervical swab
Rectal examination if indicated
can be detected in endocervical swabs or urine by enzyme-linked immunosorbent

assay (ELISA) or the nucleic acid amplification test (NAAT), the latter of which is
more sensitive. Chlamydia antibody testing using micro-immunofluorescent tests
appears to be the most accurate method for determining past infection and for predict-
ing tubal pathology. The presence of chlamydial antibodies correctly predicts tubal
damage in 90% of cases, of whom more than one-half have no history of pelvic inflam-
matory disease (PID) [3]. We advise the use of Chlamydia screening to help identify
patients whose tubal status should be tested early in the investigative process. There
is evidence, however, that screening tests may be negative in the presence of infection
in the upper genital tract, so there is rationale for prophylactic antibiotics before any
procedure that involves instrumentation of the cervix (e.g. doxycycline, azithromycin).
In recent years, it has been suggested that pelvic infection with Mycoplasma
hominis or Ureaplasma urealyticum accounts for some cases of tubal infertility.
However, finding these organisms on routine swabs does not predict infertility because
of their high prevalence in fertile women. Bacterial vaginosis causes up to 50% of
vaginal infections, yet it often goes unrecognised. The organisms responsible for
bacterial vaginosis include Gardnerella vaginalis; Mycoplasma hominis; Mobiluncus
spp.; anaerobic Gram-negative rods of the genera Prevotella, Porphyromonas and
Bacteroides; and Peptostreptococcus spp. Co-infection with Chlamydia, gonorrhoea
and Trichomonas is common. Bacterial vaginosis is associated with infective com-
plications after gynaecological surgery, first- and second-trimester miscarriage and
premature labour/delivery. There is also an increased risk of miscarriage after in vitro

fertilisation (IVF) in women found to have bacterial vaginosis. Screening in the infer-
tility clinic and treatment may therefore be of benefit. Many clinics take a pragmatic
approach and give antibiotic prophylaxis during IVF treatment, although there is no
evidence of benefit from randomised trials.
We recommend taking both a high vaginal and endocervical swab from all new
patients attending for investigation and if positive, onward referral to the genitourinary
medicine clinic for further screening of partner and contacts.
Diagnosis of Anovulatory Infertility

Determining the cause of anovulatory infertility is the key to treatment as correction
of the cause will result in cumulative conception rates that mimic those expected for
normal women of the same age.
It is first necessary to ascertain whether ovulation is occurring. Patients with
anovulatory infertility will have oligomenorrhoea or amenorrhoea and a low luteal-
phase progesterone. Progesterone should only be secreted by the corpus luteum after
ovulation, and of course, the only test that an egg was released is if a pregnancy
occurs! A progesterone concentration of greater than 30 nmol/L suggests ovulation,
but it can be difficult to know when to take the blood if the patient has an erratic
cycle – and impossible if she is amenorrhoeic. If the progesterone concentration is
15–30 nmol/L, it is likely that ovulation has occurred but that the timing may have
been incorrect. It is then necessary to check the timing of the blood test to subsequent
menstruation and repeat the test in the following cycle; sometimes two progesterone
measurements in the same cycle are helpful. The optimal way to assess ovulation in
women with irregular cycles is by a combination of serial ultrasound scans and serum
endocrine measurements, that is, measuring follicle-stimulating hormone (FSH) and
luteinising hormone (LH) in the follicular phase and progesterone in the luteal phase.
Basal body temperature (BBT) charts (Figure 5.3) provide an overview of the
regularity of a woman’s cycle and an assessment of coital frequency, as the couple
are requested to encircle days when they have intercourse. Temperature charts are,
however, a source of considerable stress, and they do not provide a prospective indica-
tion of the day of ovulation. The rationale behind the use of BBT measurements is that
progesterone will raise the BBT by 0.2–0.4°C, although between 10% and 75% of ovu-
latory cycles fail to show an adequate rise in BBT. A flat chart therefore does not neces-
sarily indicate anovulation. We no longer recommend the use of temperature charts.
Some women are aware of changes in the consistency of their cervical mucus and
can assess for themselves when the mucus is receptive (the so-called Billing’s method
of family planning). Oestrogenised cervical mucus will stretch either between the fin-
gers of an individual who wishes to assess her own mucus or between two microscope
slides at the time of a post-coital test (PCT) (Spinnbarkeit). This stretching can then
be measured in centimetres (see Cervical Mucus Penetration and the PCT and Figures
5.4 and 5.5). This outdated test is no longer recommended in clinical practice.
Commercially available kits that indicate the presence of LH in the urine are
expensive, and they also may become a cause of stress. Women with PCOS and a
high serum concentration of LH can have false-positive results. The kits also can
be affected by variations in ambient temperature. Women who are having regular

70
Shortest known cycle 27 Route of temperature O V R

Length of this cycle 28 Time of taking temperature 7 a.m.
Month April May
Date 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 8 9 10
37.5 37.5
37.4 37.4
37.3 37.3
37.2 37.2
37.1 37.1
37.0 37.0
36.9 36.9
36.8 36.8
36.7 36.7
36.6 36.6
36.5 36.5
KEY 36.4 36.4
P Period or blood loss 36.3 36.3
D Dry day 36.2 Virtually 36.2
Possibly fertile Fertile Virtually infertile
M Mucus 36.1 infertile 36.1
F Fertile-type mucus 36.0 36.0
Peak day 35.9 35.9

35.8 35.8
35.7 35.7
35.6 35.6
35.5 35.5
Sexual intercourse
Days of the menstrual cycle 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
P P P P P P
D D D M M M M F F M M M D D D D D D D D M M D
Mucus – sensation
Appearance
Stretch
Moist white
Moist thick
Stretchy wet
Stretchy wet
Thick moist
Sticky curdy
Sticky curdy
Sticky
Wet cloudy
Moist thick
Moist thready
Cyclical
symptoms P P B B B B B B B B
Cervix – rising
Opening
Softening H H H H H S S S S H H H H
Tilt
FIGURE 5.3 A rise of 0.2–0.5°C, secondary to progesterone secretion by the corpus luteum, suggests that ovulation has occurred.
Infertility in Practice
At ovulation
Before ovulation After ovulation
Cervix
Mucus
Cervix is closed
Cervix is fully open
FIGURE 5.4 Production of cervical mucus at different times in the cycle.
Ovulatory mucus
Viscous, non-ovulatory mucus
FIGURE 5.5 Self-assessment of Spinnbarkeit.

menstrual cycles (frequency of 23–35 days, with no more than 2–3 day variation each
month) have a greater than 95% chance that they are ovulating, and up to 75% of
women with an erratic cycle also are found to be ovulating. Women with regular
cycles should be reassured, and for them, the value of BBT charts or urinary LH kits
can be questioned. If they are aware of pelvic discomfort (Mittleschmerz) or cervical
mucus changes around the time of ovulation, then these conditions can be used as a
guide for when to have intercourse.
The optimal frequency of intercourse is every 2–3 days in the follicular phase of the
cycle, and, if possible, daily for 2–3 days at the predicted time of ovulation. Abstinence
until the day of ovulation can be detrimental to sperm function (see Chapter 12). It is
therefore important to advise couples about the frequency of intercourse and try to
diffuse the tensions that often result from timed intercourse to order.
The timing of sexual intercourse in relation to ovulation has a strong influence
on the chance of conception (Figure 5.6). The precise number of fertile days in a
woman’s menstrual cycle is uncertain, and it has been estimated that conception
only occurs when intercourse has taken place during a 6-day period that ends on
the day of ovulation. It has been shown that the probability of conception was 10%
when intercourse occurred 5 days before ovulation and 33% when it took place
on the day of ovulation [4]. The fertile period appears to last for 6 days and ends
on the day of ovulation. The rapid decline in the probability of conception after
this time is due either to a short survival time of the oocyte or to a swift change
in the nature of the cervical mucus. This information has important implications
for some fertility treatments that rely upon insemination after ovulation has been
identified by using temperature charts. Furthermore, if commercially available kits
for detecting the mid-cycle surge of LH in the urine are used to focus a couple to
have intercourse on the day of the LH surge and the following day, they may be
missing three or four fertile days before this time and thus reducing their chance
of conception. With respect to the precise timing of the fertile window in the
menstrual cycle, the window occurs between days 10 and 17 in only approximately
30% of women [4]. Even in women with regular menstrual cycles, the timing of
the fertile window can be highly variable. Wilcox et al. [5] estimated that 2% of
women were in their fertile period by day 4 of their cycle, 17% by day 7 and 54%
by day 12. Most women appear to reach their fertile window early in the cycle,
although a proportion do so much later, even past day 35. The fertile window may
last between 1 day and 5 days and the chance of natural pregnancy is signifi-
cantly greater the longer it lasts [6]. For example, when the fertile window is only
1 day, the fecundability ratio is 0.11 (95% CI 0.03–0.45) compared with 2.4 (95%
CI 1.1–5.2) when it lasts for 5 days [6].
Wilcox et al. [5] also found that 94% of pregnancies were attributed to sperm that
were 1 or 2 days old, although sperm can retain their capacity to fertilise in vitro for 5
days, and they can survive in oestrogenised cervical mucus for 7 days. There is no evi-
dence that closely spaced ejaculations are detrimental to fertility; in fact, the opposite
applies in some cases [7] (see Chapter 12). It is suggested that normal couples wishing
to conceive should have intercourse frequently during the first part of the menstrual
cycle up to the day of ovulation.
The luteal phase of the cycle normally lasts for between 10 days and 17 days,
and the concept of luteal-phase deficiency (LPD) is controversial. Probably, the

(a)
Day 1
Day 2
Day 3
Follicular growth
Day 5
Ovulation Day 6–7
Corpus luteum
(b)
FIGURE 5.6 (a) Passage of sperm through the genital tract. (b) Ovulation, fertilisation and
implantation.

most convincing argument against the phenomenon of LPD is the failure of luteal
support – with either progesterone or human chorionic gonadotropin (hCG) – to
improve pregnancy rates in natural pregnancies. Endometrial biopsy has been used
to assess the quality of ovulation further by equating histological changes with serum
progesterone levels. Histological dating is however an unreliable indicator of the
endometrial response to hormonal stimulation, and it is open to considerable bio-
logical variability and observer error. We do not recommend endometrial biopsy for
determining whether the patient has ovulated.
Endocrine Profile
A baseline endocrine profile is optimally performed during the first 3 days of the
cycle, when measuring the gonadotropins. The recent advent of assessing anti-
Müllerian hormone (AMH) as a measure of ovarian reserve, however, is not cycle
dependent (see below). It is essential to be aware of the normal reference range for the
assay in the laboratory in which it is being performed. Reference ranges vary from
laboratory to laboratory and can be quite different if different types of assay are used;
for example, radioimmunoassays and immunoradiometric assays give very different
results for gonadotropin measurements. There are a variety of recent advances in
assay technology, including chemiluminescence assays and mass spectrometry, par-
ticularly for testosterone measurement. It is therefore important to have knowledge of
normal ranges for the assays used by your laboratory and also to ensure that they are
appropriately calibrated for your normal population.
It is essential that the date of the blood test is recorded carefully, as it is not
uncommon for all hormones to be measured on the day of the luteal-phase progester-
one measurement, usually day 21, and such timing can be very misleading (Box 5.2).
For example, if the patient has a 35-day cycle, ovulation might be occurring on day
21, and the gonadotropin levels will be perceived to be in the menopausal range,
because of the mid-cycle surge, whereas the progesterone will not yet have begun to
rise (Figure 5.7).
BOX 5.2 ASSESSMENT OF OVULATION

Ovulation can only be confirmed with certainty if a pregnancy occurs
Mittelschmerz
Thinning of cervical mucus
Mid-cycle bleed
Regular cycle with cycle variation no more than ±2 days −95% likely to
be ovulatory
Mid-luteal serum progesterone > 30 nmol/L (see text) (day important –
not necessarily day 21, ideally 7 days before next menses)
Ultrasound monitoring of folliculogenesis and ovulation
Basal body temperature (stressful)
Detection of LH surge in urine (hard to use prospectively)

Gonadotropic Fertilisation and

hormones Luteinising implantation
hormone No Yes
Follicle-stimulating
hormone
High levels of
chorionic
gonadotropin
Ovulation
Ovarian Corpus
activity luteum
persists
Oestrogen
Ovarian
hormones
Progesterone
Embryo
Endometrium embeds
in
decidua
Menses Proliferation Secretion Menses No menstruation
Days 5 14 28
One menstrual cycle
FIGURE 5.7 Schematic diagram of menstrual cycle.
If the patient has amenorrhoea or oligomenorrhoea, a random blood sample has to

be taken, and it is best repeated a week later to get an impression of the underlying
pathology. I usually give the patient a form for a further to test when she next
menstruates. An assessment of endocrine status in these cases can usefully be per-
formed in conjunction with a pelvic ultrasound scan to assess ovarian activity and
endometrial thickness.
Progesterone
Progesterone should be measured in the mid-luteal phase, 7 days after ovulation and
7 days before the next expected period. An ovulatory concentration is considered
greater than 30 nmol/L; although if >10 nmol/L, or certainly >20 nmol/L, there is a
strong suggestion that ovulation has occurred but that the blood test was mistimed.
It is essential to know when the test was performed in relation to both the preceding
and subsequent menstrual period. If there is doubt, the test should be repeated the
following month, and it is occasionally beneficial to measure the progesterone two
or three times in the luteal phase. A combination of serum endocrinology with ultra-
sound monitoring of follicular growth and ovulation will provide the best reflection of
ovarian function. An interesting finding is that ovaries ovulate on alternate sides more
often in young women, whereas women more than 40 years of age are more likely to
have successive ovulations from the same ovary [8].

Follicle-Stimulating Hormone
Historically, the favoured indicator of ovarian function in routine practice has been
a measurement of the baseline serum FSH concentration. This measurement is
being replaced by an assessment of AMH, when the assay is available (see below).
An elevated FSH level indicates reduced ovarian reserve and, generally, if FSH
is greater than 10 IU/L on more than one occasion, the ovaries are unlikely to
be o vulating regularly and also will be resistant to exogenous stimulation. When
the serum concentration of FSH is greater than 15 IU/L, the chance of releas-
ing a fertile oocyte is slim, and levels greater than 25 IU/L are suggestive of
the m enopause or premature ovarian failure/insufficiency. Even if ovulation is
occurring in the presence of an elevated serum FSH concentration, the fertility
potential of the oocyte within the follicle is significantly impaired, and in the
unlikely event of fertilisation taking place, there is an increased likelihood of a
chromosomally abnormal embryo d eveloping and consequent risk of miscarriage
and fetal chromosomal abnormality.
Ovarian Reserve Tests

It is natural for a woman to wish to have an idea of her potential fertility.
A measurement of serum FSH concentration taken during days 1–3 of menstruation
is still the most commonly used test of ‘ovarian reserve’ – a term that refers both to
the (unmeasurable) number of oocytes within the ovary and to their fertility potential.
In practice, a baseline serum FSH concentration on day 3 of the cycle usually suffices,
and if it is elevated, it should be repeated on at least one occasion. An elevated FSH
level indicates that fertility treatment should proceed without delay, and there is no
advantage in repeatedly testing FSH and waiting to commence treatment in a cycle
when it may be lower than that measured previously [9] (see Chapter 14).
Ovarian reserve, or the number of releasable oocytes, declines with ovarian age
and does not always equate with the age of the woman. Additional measurements can
be made to increase the positive predictive value of FSH, including an assessment
of ovarian volume and the number of visible antral follicles on ultrasound scan,
serum inhibin B and AMH [10]. It has even been suggested that these tests may help
determine a woman’s future fertility over forthcoming years, although the evidence
for longer term predictions is still to be obtained, and there is debate about the wide-
spread use of ovarian reserve testing outside of the context of planning infertility
treatment [11].
Chronological age, as mentioned, is the major determinant of ovarian reserve,
although there is considerable variability in the rate of ovarian ageing, from
the transition from normal fertility, to subfertility, sterility and then menopause
(Figure 5.8) [12]. The response of the ovary to stimulation by gonadotropins is the
essential test of ovarian function, but it provides only a retrospective analysis rather
than a prospective indication of the likely response to treatment that can be used to
determine the starting dose or stimulation regimen in a patient undergoing assisted
conception treatment. Women with a normal ovarian reserve should develop 8–10
follicles, with a corresponding number of oocytes, during routine stimulation for
IVF [11].

A B C D
100
75
Cumulative %
50
25
0
21 31 41 51 61
Age (years)
FIGURE 5.8 (See colour insert.) This figure represents the changes that occur with reproductive
ageing, with curve A representing the variation of age as women become subfertile, curve B repre-
senting the age of sterility, curve C as menstrual regularity is lost and curve D the age of menopause.
(Reproduced with permission from te Velde ER, Pearson PL, Hum Reprod Update 8, 141–54, 2002.)
Antral Follicle Count

The number of antral follicles in the ovary, as assessed by pelvic ultrasound (see
below), has been reported as a good predictor of poor ovarian response to stimula-
tion for IVF and similar to a measurement of AMH. Indeed, it is the number of small
antral follicles, 2–6 mm in diameter, that declines significantly with age, whereas
there is little change in the larger follicles of 7–10 mm [13]; these larger follicles
are still below the size at which growing follicles have been recruited. A reduced
ovarian volume is a poor surrogate for antral follicle number [14], contrary to the
role of increased ovarian volume in the assessment of the polycystic ovary (see below
and Chapter 8). In the prediction of a clinical pregnancy occurring, however, neither
antral follicle count (AFC) nor ovarian volume performs well, and it is essential to
standardise the methodology of the ultrasonographic assessment [14].
Inhibin B
Inhibin B is thought to be the ovarian hormone that has the greatest influence on
pituitary secretion of FSH. Assays for inhibin B can detect the dimeric peptide
hormone and do not cross-react with free subunits, as was the problem with earlier
assays. It used to be thought that serum concentrations of inhibin B might provide
better quantification of ovarian reserve than serum FSH concentrations. However,
it appears that basal FSH concentration and age are better predictors for clinical
endpoints such as cancellation of an IVF cycle or ongoing pregnancy [15,16], and
measurement of inhibin B is no longer performed.

Anti-Müllerian Hormone
AMH is another dimeric glycoprotein and member of the transforming growth
factor-β (TGF-β) superfamily, which is best known as a product of the testes during
fetal development that suppresses the development of Müllerian structures (formerly
known as Müllerian-inhibiting substance). AMH also is produced by the granulosa
cells of pre-antral and antral follicles and appears to be a more stable predictor of the
ovarian follicle pool, as it does not fluctuate through the menstrual cycle [16]. Indeed,
it has been reported that higher AMH concentrations are associated with increased
numbers of mature oocytes, embryos and clinical pregnancies during IVF treatment
[17]. Assays for AMH are now available for routine use, and it is this hormone that
currently offers greatest promise for future assessment of ovarian reserve and func-
tion [18]. Caution is required when interpreting historical results as there were big
variations in the assays used; these variations should soon be resolved by Beckman
Coulter, who have produced a unifying Generation II assay. The great advantage of
AMH measurement compared with AFC is the removal of operator dependence.
AMH also has potential uses in the biochemical assessment of the polycystic ovary
(see Chapter 8) and as a long-term predictor of ovarian reserve and reproductive
health [18].
Stimulation Tests (Ovarian Challenge Tests)

Stimulation tests have been evaluated with the aim of enhancing the predictability of
ovarian response to superovulation. Clomifene citrate (100 mg) can be administered
from day 5 to day 9, and the serum FSH concentration can be measured on days 3 and
10. It is thought that in response to clomifene, the day-10 FSH rises before there is a
rise in the basal day-3 FSH concentration. The clomifene challenge test appears to be
more useful in predicting reduced ovarian reserve when abnormal than in p redicting
normal ovarian function when the test is normal. Ovarian reserve also can be assessed
by stimulation with a gonadotropin-releasing hormone (GnRH) agonist. If these tests
are used, normal ranges need to be developed for patients of different ages. These
tests, moreover, are dependent upon normal pituitary function and are an indirect
measure of ovarian responsiveness that is best assessed by the direct administration
of FSH/LH-containing preparations. We do not therefore recommend their use.
In summary, there are many ways of assessing ovarian reserve, which in turn
is a reflection of oocyte quality. These tests may help predict ovarian response to
stimulation for treatments such as IVF and help in determining the correct stimulation
protocol and dose (see Chapter 14). Ovarian responsiveness does not necessarily
correlate with the chance of having an ongoing pregnancy, which is, of course, all
that matters to the patient. Furthermore, despite some enthusiastic publicity, ovarian
reserve tests have not yet been proven to be able to reliably predict long-term fertility
and its projected rate of future decline in an individual.
Luteinising Hormone
Luteinising hormone (LH) is the second gonadotropin, which, like FSH, is released
by the gonadotropes in the anterior pituitary gland, under the influence of pulsatile

TABLE 5.2
Endocrine Parameters in Common Clinical Scenarios
Follicle-Stimulating Luteinising
Hormone Hormone Oestradiol Diagnosis
Normal Elevated Usually normal Polycystic ovary syndrome
Normal Low Low Weight-related amenorrhoea
Low Low Low Hypogonadotropic hypogonadism,
functional or organic
Elevated Elevated Low If oligo-/amenorrhoeic: ovarian failure
Elevated Elevated High If mid-cycle, think of mid-cycle surge
release of GnRH. The differential control of FSH and LH secretion relies upon the
need for priming of the pituitary by oestradiol before it will become responsive to
GnRH and release LH. FSH secretion, in contrast, is more under tonic inhibitory
control by inhibin acting in a negative feedback loop from the ovaries. Therefore, in
times of oestrogen deficiency, for example, weight-related amenorrhoea, LH concen-
trations in the circulation are lower than those of FSH, whereas the mid-cycle surge
that is primed by rising oestradiol secretion from the ovary results in a greater release
of LH than FSH.
An elevated serum concentration of LH in the follicular phase of the cycle suggests
that the patient has PCOS – usually associated with a level greater than 10 IU/L in the
early to mid-follicular phase of the cycle. In a series of more than 1700 women with
PCOS, we found that approximately 40% of patients had an elevated serum concen-
tration of LH that was associated with a significantly higher risk of infertility than
those with normal LH levels [19]. Other causes of an elevated LH are the mid-cycle
surge and ovarian failure.
The association of amenorrhoea with very low levels of FSH and LH (usually
<2 IU/L or below the range of the assay) suggests pituitary failure or hypogonado-
tropic hypogonadism. Gonadotropin measurements are best interpreted together with
the findings of a pelvic ultrasound scan as the combination of ovarian morphology,
endometrial thickness (as a reflection of oestrogenisation) and serum oestradiol levels
provides the diagnosis in most cases (Table 5.2).
Androgens
The normal female range for total serum testosterone (T) is 0.5–3.5 nmol/L,
although the few clinics that use mass spectroscopy report the upper limit of normal
as 1.8 nmol/L. The most usual cause of an elevated serum T is PCOS. Most women
with PCOS, however, have a normal total serum T concentration (approximately
70% in our experience). Measurement of the sex-hormone-binding globulin concen-
tration (SHBG; normal range 16–119 nmol/L) will permit the calculation of the free
androgen index (FAI) ((T × 100)/SHBG), the value of which should be less than 5.
Women who are obese may have high circulating levels of insulin that reduce syn-
thesis of SHBG by the liver so that the FAI is often elevated when the total T is in
the normal range.

TABLE 5.3
Diagnosis of Non-Classical Congenital Adrenal Hyperplasia (NCAH)
1. Measure 17-OHP, early morning, early follicular phase:
<6 nmol/L (2 ng/mL) excludes NCAH, >12 nmol/L (4 ng/mL) diagnostic
2. ACTH stimulation (250 μg) test if basal > 6 nmol/L:
Post-stimulation > 30–36 nmol/L (10–12 ng/mL) diagnostic NCAH,
>50–60 nmol/L diagnostic classical CAH
There are physiological variations in serum T concentrations, with higher levels in

the morning, luteal phase of the cycle and summer compared with winter; furthermore,
levels decline gradually with age.
If the T is greater than the 95th percentile (e.g. 5 nmol/L with standard assays), it is
necessary to exclude other causes of hyperandrogenaemia: late onset CAH, Cushing’s
syndrome and androgen-secreting tumours. Women with the most common form of
CAH (21-hydroxylase deficiency) will have an elevated serum 17-hydroxyprogesterone
concentration (17-OHP > 20 nmol/L) and an exaggerated response to an intravenous
bolus of adrenocorticotropic hormone (ACTH) (250 mg of tetracosactrin will cause
an elevation of 17-OHP, usually between 50 and 470 nmol/L).
Late onset or non-classical CAH, although rare, may present in a similar way as
PCOS. Prevalence varies and is more common in some Mediterranean populations
and Ashkenazi Jews. A simple algorithm for investigation can be seen in Table 5.3.
In Cushing’s syndrome, the 24-h urinary free cortisol is elevated (>400 nmol/24 h).
The normal serum concentration of cortisol is 140–700 nmol/L at 8 a.m. and less than
140 nmol/L at 12 a.m. In normal people, a low-dose dexamethasone suppression test
(0.5 mg 6 hourly for 48 h) will cause a suppression of serum cortisol by 48 h. A simpler
screening test is an overnight suppression test, using a single midnight dose of dexa-
methasone (1 or 2 mg if obese) and measuring the serum cortisol concentration at 8 a.m.
when it should be less than 140 nmol/L. If Cushing’s syndrome is confirmed, a high-dose
dexamethasone suppression test (2 mg 6 hourly for 48 h) should suppress serum cortisol
by 48 h if there is a pituitary ACTH-secreting adenoma (Cushing’s disease). Failure of
suppression suggests an adrenal tumour or ectopic secretion of ACTH; further tests and
detailed imaging are then required, and the opinion of an endocrinologist is essential.
The measurement of other serum androgen levels can be helpful. Dehydroepian-
drosterone sulfate (DHEAS) is primarily a product of the adrenal androgen pathway
(normal range 3–10 μmol/L). If the serum androgen concentrations are greatly ele-
vated, the possibility of an ovarian or adrenal tumour should be excluded by ultrasound
or computed tomography scans. A serum T concentration of greater than 5 nmol/L
associated with a normal DHEAS suggests an ovarian source, whereas if combined
with an elevated DHEAS the source is likely to be adrenal. Androstenedione (normal
range 2–10 nmol/L), secreted by both ovaries and adrenals also may be mildly
elevated in women with PCOS.
Thyroid Function
Thyroid disease is common in women, affecting approximately 5% of reproduc-
tive years, and subtle disturbances of thyroid function may have a profound effect

on fertility. Although the National Institute for Health and Clinical Excellence (NICE)
Guidelines on the Investigation of Infertility suggest that routine a ssessment of t hyroid
function is not necessary (see Further Reading), we found that 5% of women a ttending
our infertility clinic had thyroid dysfunction – often in the absence of symptoms – so,
we still recommend what is a cheap and simple screening test, particularly in view of
the importance of normal circulating thyroxine levels for the developing fetus [20].
A measurement of thyroid-stimulating hormone (TSH; range 0.5–4.0 U/L) is the most
sensitive test of thyroid function with an elevation suggesting hypothyroidism. The
additional measurement of free thyroxine (T4; range 9–22 pmol/L) may be helpful.
If hyperthyroidism is suspected, a suppressed TSH and elevated free T4 will usually
reveal the diagnosis; if the free T4 is normal, then measure free tri-iodothyronine (T3;
range 4.3–8.6 pmol/L). The measurement of total thyroxine (60–160 nmol/L) and T3
(1.2–3.1 nmol/L) rarely provides additional i nformation. Thyroid a utoantibodies should
be measured because of the risk of their transplacental passage. Hypothyroidism is
sometimes associated with a mild elevation in serum prolactin levels. It is essential
that thyroid disease is treated and that thyroid function be stabilised before conception.
Hypothyroidism, in particular, is very bad for the developing baby (see Chapter 3).
Prolactin
Mild elevations in serum prolactin concentration are associated with stress and
may occur simply as a result of having blood taken. Prolactin measurements vary
day to day, and if elevated to more than 1000 mU/L, the test should be repeated
before imaging of the pituitary gland is arranged (see Chapter 6). Fifteen percent of
women with PCOS have hyperprolactinaemia, of which approximately 50% have a
micro-adenoma. It used to be thought that as stress can lead to a slight elevation in
serum prolactin concentration, stress might itself cause subfertility. The treatment
of o vulatory women with mild hyperprolactinaemia with dopamine agonists such as
bromocriptine, however, does not enhance fertility.
Oestrogen
Oestrogen is of little value in pre-treatment evaluation of infertile women. Sometimes,
an early follicular-phase measurement of oestradiol can be useful as, in the normal
cycle, FSH remains fairly constant from day 1 to day 3, whereas oestradiol starts
to rise on day 3 with follicular growth. Furthermore its measurement can aid in the
interpretation of levels of FSH to confirm that the sample was taken at the correct time
in the cycle and in the absence of a follicle or oestrogen-producing cyst. It has been
suggested that a relationship between serum FSH and oestradiol concentrations can
be used to enhance the prediction of ovarian reserve, although this has not become
generally adopted in clinical practice (see Ovarian Reserve Tests).
Glucose Tolerance
Women who are obese, and also many slim women with PCOS, may have insulin resis-
tance and elevated serum concentrations of insulin (usually <30 mU/L fasting). We
suggest that a 75-g oral glucose tolerance test (GTT; Table 5.4) be performed in women

TABLE 5.4
Definitions of Glucose Tolerance after a 75-g Glucose Tolerance Test
Diabetes Impaired Glucose Impaired Fasting
Mellitus Tolerance glycaemia
Fasting glucose (mmol/L) ≥7.0 <7.0 ≥6.1 and <7.0
2-h glucose (mmol/L) ≥11.1 ≥7.8, <11.1 <7.8
Action Refer diabetic Dietary advice check Dietary advice check
clinic fasting glucose fasting glucose annually
annually
with PCOS and a BMI > 30 kg/m2, with an assessment of the fasting and glucose con-
centration. It has been suggested that South Asian women should have an assessment
of glucose tolerance if their BMI is greater than 25 kg/m2 because of the greater risk of
insulin resistance at a lower BMI than that seen in the Caucasian population.
Other Investigations
Chromosomal Analysis
It is sensible to study the chromosomes of women with infertility and any dysmorphic
features, women with recurrent miscarriage (and their partners; see Chapter 21) and
those with premature ovarian insufficiency/failure (see Chapter 9). Men with severe oli-
gospermia (<5 million/mL) also should have a chromosomal analysis (see Chapter 12).
Autoantibodies
Women with premature ovarian failure sometimes have ovarian autoantibodies or
signs of other autoimmune disease (e.g. thyroid disease, pernicious anaemia, diabetes
mellitus, systemic lupus erythematosus (SLE)) (see Chapter 9). The presence of autoan-
tibodies alerts one to the risk that these conditions may become manifest in the future.
Anticardiolipin Syndrome
Women with recurrent miscarriage might have elevated levels of lupus anticoagu-
lant and anticardiolipin antibodies and may benefit from a full thrombophilia screen
(see Chapter 21).
Pelvic Ultrasound
When first scanning the pelvis, many radiographers and radiologists suggest per-
forming a transabdominal scan to first obtain an overview of the pelvic organs, and
second to assess the kidneys and renal tract if indicated. Subsequently, a transvaginal
ultrasound examination (Figure 5.9) of the pelvic organs is preferred to the transab-
dominal approach as it not only obviates the need for a full bladder with its associated

Transvaginal
probe
Abdominal
probe
FIGURE 5.9 Ultrasound machine with transabdominal and transvaginal probes.
discomfort but also allows high-frequency probes (5–7.5 MHz) to be used so that higher
resolution and greater precision in measurements of the pelvic structures, follicular
diameters and endometrial thickness can be achieved. It is especially advantageous in
patients who are undergoing assisted conception as they commonly have lower abdom-
inal scars that impair the penetration of ultrasound; furthermore, periadnexal adhe-
sions may tether the ovaries deep in the pelvis and limit the elevation of these structures
that normally occurs when the bladder is filled for a transabdominal scan. A study

comparing transabdominal with transvaginal scanning demonstrated that the mar-

gins of the follicles were more sharply defined in 90% of cases when the transvaginal
approach was used compared with only 41% with a transabdominal approach [21]. The
same study found that the numbers and sizes of the dominant follicles correlated better
with the serum oestradiol concentrations when transvaginal scanning was used.
An ultrasound assessment of ovarian volume and AFC in the early follicular phase
has been used as a predictor for ovarian response before IVF treatment, with small-
volume ovaries indicating reduced ovarian reserve (see above) [22].
Ovarian Morphology
We recognise in the ovary three distinct morphological appearances: normal
(Figure 5.10), polycystic (Figure 5.11) and multicystic (Figure 5.12). Multicystic
ovaries are characteristically observed in pubertal girls and women recovering from
weight-loss-related amenorrhoea. These multicystic (or multifollicular) ovaries are
normal in size or slightly enlarged and contain six or more cysts that are 4–10 mm
in diameter [23]; in contrast to women with polycystic ovaries (PCOs), the stroma is
not increased. The multicystic ovary appears to develop as a consequence of reduced
hypothalamic secretion of GnRH, resulting in subnormal stimulation of the ovaries
by the g onadotropins. The multicystic ovary has a normal response to exogenous
FIGURE 5.10 Transabdominal ultrasound scan of a normal ovary.

(a)
(b)
FIGURE 5.11 (a) Transabdominal ultrasound scan of a polycystic ovary. (b) Transvaginal
ultrasound scan of a polycystic ovary.

(c)
FIGURE 5.11 (Continued) (c) Transvaginal ultrasound scan of a polycystic ovary.
s timulation, by either pulsatile GnRH or gonadotropins, and the ultrasound appearance

of the ovary usually reverts to normal.
Polycystic ovaries are a separate entity and have a distinct response to induction of
ovulation and ovarian stimulation for IVF. The association of enlarged, sclerocystic
ovaries with amenorrhoea, infertility and hirsutism was first described by Stein and
Leventhal in 1935 [24], and it is now known as PCOS. Since then, it has become
apparent that polycystic ovaries may be present in women who are non-hirsute and
who have regular menstrual cycles [25]. Thus, a clinical spectrum exists between the
typical Stein–Leventhal picture (PCOS) and the symptomless (PCO). Even patients
described as having the PCOS exhibit considerable heterogeneity [19] (see Chapter 8).
Differentiating between PCO and PCOS

It is important to differentiate between PCO and the PCOS. PCO describes the
morphological appearance of the ovary, whereas PCOS is only appropriate when PCOs
are found in association with a menstrual disturbance (amenorrhoea or, more com-
monly, oligomenorrhoea) and/or the complications of hyperandrogenism (acne and
hirsutism) [25]. PCOS also is associated with endocrinological abnormalities and, in
particular, with elevated serum concentrations of androgens (T, androstenedione) and
LH. As with the clinical picture, these changes are variable, and patients with PCOS
may have normal endocrine concentrations (see Chapter 8 for further discussion).

(a)
(b)
FIGURE 5.12 (a) Transabdominal scan of a multicystic ovary. (b) Transvaginal ultrasound scan of
a multicystic ovary.

The diagnosis of PCO is therefore best made not on the clinical presentation but
rather on the ovarian morphology. With the advent of high-resolution ultrasound, iden-
tification of PCO is simple, and ovarian biopsy is an unnecessary and o utdated proce-
dure, as it is invasive and possibly damaging to future fertility. Ovaries were i nitially
described by transabdominal ultrasonography as being polycystic if there were 10
or more cysts, 2–8 mm in diameter, arranged around a dense stroma or scattered
throughout an increased amount of stroma [23]. There have been many attempts to
redefine the morphological appearance of the PCO by using transvaginal ultraso-
nography (Figure 5.11), three-dimensional transvaginal ultrasonography (Figure 5.13)
and magnetic resonance imaging (MRI; Figure 5.14). Ovarian stromal volume has
been correlated with serum T concentrations and may provide more useful informa-
tion than the volume of the cysts. Furthermore, ovarian volume c orrelates well with
stromal volume as a marker of hyperandrogenism and is easier to measure in practice
than stromal volume [26]. Ovarian volume is usually greater than 10 mL, compared
with the normal ovarian volume of 5 mL.
The latest international consensus definition for the ultrasound assessment of the
PCO is as follows [26]:
1. The polycystic ovary should have at least one of the following: either 12 or
more follicles measuring 2–9 mm in diameter or increased ovarian volume
(>10 cm3). If there is evidence of a dominant follicle (>10 mm) or a corpus
luteum, the scan should be repeated the next cycle.
2. The subjective appearance of polycystic ovaries should not be substituted
for this definition. The follicle distribution should be omitted as well as
FIGURE 5.13 Three-dimensional transvaginal ultrasound scan of a polycystic ovary. (Courtesy of

Dr. A Kyei-Mensah.)

FIGURE 5.14 MRI of a pelvis, demonstrating two polycystic ovaries (closed arrows) and a hyper-
plastic endometrium (open arrow).
the increase in stromal echogenicity and/or volume. Although the latter

is specific to PCO, it has been shown that the measurement of the ovarian
volume is a good surrogate for the quantification of the stroma in clinical
practice.
3. Only one ovary fitting this definition or a single occurrence of one of
the above-mentioned criteria is sufficient to define the PCO. If there is
evidence of a dominant follicle (>10 mm) or corpus luteum, the scan
should be repeated the next cycle. The presence of abnormal cysts or ovar-
ian asymmetry, perhaps suggesting a homogeneous cyst, necessitates fur-
ther investigation.
4. This definition does not apply to women taking the oral contraceptive pill, as
ovarian size is reduced, even though the polycystic appearance may persist.
5. A woman having PCO in the absence of an ovulation disorder or hyperan-
drogenism (asymptomatic PCO) should not be considered as having PCOS,
until more is known about this situation.
6. In addition to its role in the definition of PCO, ultrasound is helpful to pre-
dict fertility outcome in patients with PCOS (response to clomifene citrate,
risk for ovarian hyperstimulation syndrome (OHSS), decision for in vitro
maturation of oocytes). It is recognised that the appearance of PCOs may
be seen in women undergoing ovarian stimulation for IVF in the absence of
overt signs of the PCO syndrome. Ultrasound also provides the opportunity
to screen for endometrial hyperplasia.

7. The following technical recommendations should be respected:

• State-of-the-art equipment is required and should be operated by
appropriately trained personnel.
• Whenever possible, the transvaginal approach should be preferred,
particularly in obese patients.
• Regularly menstruating women should be scanned in the early follicular
phase (days 3–5). Oligo-/amenorrhoeic women should be scanned either
at random or between days 3 and 5 after a progestogen-induced bleed.
• If there is evidence of a dominant follicle (>10 mm) or a corpus luteum,
the scan should be repeated the next cycle.
• Calculation of ovarian volume is performed using the simplified f ormula
for a prolate ellipsoid (0.5 × length × width × thickness).
• Follicle number should be estimated both in longitudinal and
anteroposterior cross-sections of the ovaries. Follicle size should be
expressed as the mean of the diameters measured in the two sections.
Since this consensus was published in 2003, there have been further debates about
the threshold number of follicles and appropriate size, with the suggestion that it is the
smaller follicles (2–5 mm) that are more relevant and that a PCO should have at least
19 per ovary; furthermore, an AMH concentration of >35 pmol/L might be a better
and more consistent discriminator [27].
Prevalence
The prevalence of PCOs in women with ovulatory disorders has been well docu-
mented. Using high-resolution ultrasound, it has been shown that as many as 87% of
patients with oligomenorrhoea and 26% with amenorrhoea have PCOs [23]. We also
have identified PCOs in women with hypogonadotropic hypogonadism who attended
our ovulation induction clinic, and although these patients had no endogenous
production of gonadotropins, they responded to stimulation in a characteristically
polycystic manner with a sudden growth of multiple follicles [28]. PCOs also have
been found in 33% of normal young women [29] (see Chapter 8). The prevalence in
patients referred for IVF is not well known. We studied more than 500 patients who
underwent IVF and found 34% to have ultrasound-detected PCO [30].
Ovarian Cysts
Besides making a careful assessment of ovarian morphology, it is necessary to perform
a baseline ultrasound scan of the ovaries before commencing ovarian stimulation to
detect the presence of ovarian cysts (Figures 5.15 through 5.17). It is obviously necessary
to record the presence of any cystic structures before commencing ovarian stimula-
tion to accurately monitor the development of new follicles. There remains controversy
as to the effect of ovarian cysts on the treatment cycle (see Chapter 14). Although it has
been suggested that the presence of ovarian cysts reduces the success of the subsequent
IVF cycle [31,32], other studies have failed to confirm this conclusion [33,34]. It is also
necessary to distinguish between cysts that are present before the administration of

FIGURE 5.15 Transabdominal ultrasound scan of a simple, functional cyst.
FIGURE 5.16 Transvaginal ultrasound scan of a mucinous cystadenoma.

FIGURE 5.17 Transvaginal ultrasound scan of a benign cystic teratoma (dermoid cyst).
hormonal agents and those cysts that might arise as a result of hormonal stimulation
because of the exaggerated release of the gonadotropins that occurs when GnRH ago-
nist therapy is commenced (e.g. pre-treatment with the combined oral contraceptive pill
reduces the occurrence of such GnRH agonist-stimulated cysts).
The situation is slightly different in patients who are undergoing ovulation induction
for anovulatory infertility. In such patients, cysts are usually functional and secrete
oestrogens or progesterone. If a cyst is detected on a baseline ultrasound scan, the
usual policy is to commence ovarian stimulation only after the patient has had a
spontaneous menstrual bleed, indicating that the endogenous secretion of ovarian
hormones has returned to baseline levels. Further confirmation of this baseline return
is provided by a thin endometrium (<5 mm). Simple ovarian cysts that are less than
5 cm in diameter rarely require surgical intervention. If there is any doubt about the
nature of a cyst, then tumour markers should be measured (e.g. CA125) and surgi-
cal removal considered to make a histological diagnosis before commencing ovarian
stimulation. If the patient is known to have endometriosis, it is important to avoid
aspirating the cyst, either before ovarian stimulation is commenced or during the
oocyte retrieval procedure itself because of the risk of infection (see Chapter 14). An
endometrioma has the characteristic hazy, echodense appearance of blood in a cyst.
Inadvertent, or unavoidable, aspiration of an endometrioma necessitates full antibiotic
cover. Dermoid cysts (mature cystic teratoma) are sometimes seen in women of repro-
ductive age and may be difficult to distinguish from endometriomas, as both may be

bilateral with a hazy, homogeneously echodense appearance of lipid matter in der-

moids and blood in endometriomas. Dermoid cysts can sometimes be differentiated
by brightly echogenic areas caused by the presence of solid components.
All but obviously simple cysts should be treated with caution as ovarian m alignancy
may occur in young women. Therapeutic stimulation of the ovaries should not be
performed until complex ovarian cysts have resolved, either naturally or surgically.
The baseline ultrasound scan also permits inspection of the other pelvic structures
and might reveal the presence of hydrosalpinges, fibroids (Figure 5.18) – sub-mucus
fibroids are of particular importance – or even an elusive intrauterine contraceptive
device, which on removal should cure the patient’s subfertility [35]. A patient with
hydrosalpinges visible on ultrasound should be counselled to consider salpingectomy
to improve the outcome of IVF (see Chapter 11).
The resolution of transvaginal and transabdominal scans is 2–3 mm and 3–5 mm,
respectively, so small follicles can be visualised easily as echo-free structures that are
usually towards the periphery of the more echogenic ovarian tissue [36]. The internal
diameter of the follicle should be measured in three planes and the mean value should
be calculated [37]. In one study, the intra-observer standard deviation of transabdomi-
nal follicular measurement was reported to be 0.6 mm and the interobserver standard
deviation 1.2 mm, irrespective of the follicular diameter [38]. The 95% confidence
limits for any particular measurement would therefore be ±2.4 mm. One would expect
transvaginal measurements to confer greater precision. In natural cycles, therefore,
the small follicles can generally be visualised approximately 10 days before the day
FIGURE 5.18 Transabdominal ultrasound scan of a serous fibroid.

of ovulation (day 4). By day 5, there is usually a dominant follicle that then grows at
a rate of approximately 2–3 mm daily until the day of ovulation. For illustration of
ultrasound scans of follicular growth, see Figure 7.22.
Plasma oestradiol concentrations correlate quite well with follicular diameter in
natural cycles but not in superovulated cycles, when not only is there great variation but
also differential effects of the different drug regimens that may be used. The increase in
circulating oestrogen levels results in an increase in the overall uterine size and a thicken-
ing of the endometrium, thereby serving as a useful bioassay for oestrogen production.
It may be helpful to perform an ultrasound scan in the mid-luteal phase in both natural
and stimulated cycles for IVF. The corpus luteum may have various a ppearances,
being either ovoid or irregular in outline with either a cystic, echo-free interior or it
may have a hazy, echodense appearance because of the presence of c ellular debris and
blood (see Chapter 7). The combination of a corpus luteum seen on ultrasound and
an elevated serum progesterone concentration provides the best possible evidence of
ovulation, although only a pregnancy will confirm that an oocyte was released from
the follicle. Occasionally, there is no follicular rupture and a cystic structure persists
in the luteal phase of the cycle associated with an elevated serum progesterone con-
centration. This process is referred to as luteinised unruptured follicle (LUF) [39].
There is some debate about the incidence of the LUF syndrome. It occurs in less than
5% of cycles of patients undergoing ovulation induction therapy, and it does not tend
to be a recurrent phenomenon [40].
Endometrial Assessment
Endometrial changes can be seen clearly using pelvic ultrasound (Figures 5.19 and
5.20). In the early follicular phase, when the endometrium is thin, there is a single
hypoechogenic line produced by the opposed walls of the endometrial cavity. In the
periovulatory phase, the oestrogenised endometrium takes on a characteristic triple
line appearance (see Figure 7.24). In the luteal phase, the functional layer becomes
hyperechogenic because of stromal oedema. The endometrial thickness in the early
follicular phase is 4–6 mm, by the time of ovulation, it is approximately 8–10 mm
and in the mid-luteal phase it may reach 14 mm. It has been suggested that there is
a reduced chance of pregnancy if the triple line appearance is absent or if the pre-
ovulatory endometrial thickness is less than 7 mm [41,42].
Doppler Ultrasound in Assisted Conception

The combination of transvaginal ultrasound with colour Doppler measurements can
provide a detailed picture of follicular events around the time of ovulation, and it
allows assessment of the uterine blood flow to predict endometrial receptivity. The
precise uterine requirements for successful implantation have yet to be fully eluci-
dated. The probability of a pregnancy occurring during assisted conception procedures
depends on embryo quality and uterine receptivity. Methods to improve our ability
to assess endometrial receptivity for implantation might help prevent the transfer of
precious pre-embryos in cycles that are virtually doomed to failure. The embryos
could then be frozen and transferred later, in a cycle that is judged to be optimal
for implantation, perhaps after hormonal manipulation of the endometrial response.

FIGURE 5.19 Transabdominal ultrasound scan demonstrating endometrial hyperplasia (30 mm in

diameter) in an amenorrhoeic woman with PCOS.
FIGURE 5.20 Transvaginal ultrasound scan demonstrating an endometrial polyp.

Until recently, the only way to assess endometrial receptivity was by endometrial
biopsy. Doppler ultrasound has been suggested as a valuable, non-invasive method
that provides an instantaneous picture of uterine blood flow [43].
Blood flow through the uterine and ovarian arteries has been extensively
investigated in spontaneous and stimulated cycles [44]. Doppler studies of the ovarian
circulation are still at the research stage. It was reported in one study of natural cycles
that resistance to arterial flow was lower on the side bearing the dominant follicle. In
gonadotropin-stimulated cycles, it was reported that ovarian impedance was inversely
proportional to the number of follicles greater than 15 mm in diameter [45]. It also
has been reported that, in IVF cycles, there was a lower ovarian impedance 3 days
after embryo transfer in those patients who conceived compared with those who did
not [46]. In practice, blood flow studies tend still to be performed only in centres with
a research interest and have not gained widespread use.
Assessment of Tubal Patency and the Uterine Cavity

Hysterosalpingography
Tubal infertility is diagnosed in between 15% and 50% of couples presenting with
subfertility. X-ray hysterosalpingography (HSG) (Figures 5.21 through 5.26) p rovides
a delineation of both the uterine cavity and the fallopian tubes. An HSG is the sim-
plest preliminary test for the assessment of the uterine cavity and fallopian tubes and
has few complications [1].
FIGURE 5.21 HSG performed using a digital system. The iodine-based X-ray contrast medium
appears black. In this picture, free spill into the peritoneal cavity can be seen flowing from each
fallopian tube. In this procedure, a metal cannula was used.

FIGURE 5.22 Plastic Malmstrom–Westerman vacuum suction cup. The cup fits over the cervix,
and negative pressure is applied by a hand-driven pump. Once the cup fits snugly over the cervix,
contrast is injected through the central channel.
FIGURE 5.23 X-ray HSG demonstrating free spill from the left fallopian tube, but there is
obstruction of flow through the right tube by an intrauterine lesion that was later found to be an
endometrial polyp (large arrow). For this procedure, a balloon catheter (see Figure 5.24) was used,
and the inflated balloon can be seen occupying the lower portion of the uterus (small arrows).

FIGURE 5.24 Balloon catheter. The catheter is inserted gently through the cervix, and the balloon
is inflated within the uterine cavity. Gentle traction is applied to prevent backward flow of contrast.
FIGURE 5.25 X-ray HSG of a uterus didelphys that is acutely anteflexed. An older style metal
Leisch–Wilkinson cannula has been used and a conventional X-ray system in which the contrast
appears white.
It is important that the procedure is performed by an experienced radiologist who

is able to position the cannula over or into the cervical canal and gently inject the
contrast medium while imaging the pelvis to get a dynamic view of the passage of
dye. There are many different cannulae, ranging from the old-style metal Leisch–
Wilkinson or Green–Armytage cannula, which may have to be virtually screwed

FIGURE 5.26 Conventional X-ray HSG demonstrating Ashermann’s syndrome, with intrauterine

synechiae. There is no flow of contrast through the right tube, although thickening of the cornual end
of the tube suggests the possibility of tubal spasm. There is flow to the end of the left fallopian tube,
but no free spill into the peritoneal cavity, raising the possibility of sacculated adhesions around the
fimbrial end of the tube.
into the cervix, to the more modern plastic Malmstrom–Westerman vacuum suction
cup that fits over the cervix, or balloon catheters that either fit into the endocervi-
cal canal or are passed into the uterine cavity itself. We prefer to use the latter two
techniques.
A water-soluble contrast medium is usually used and will be absorbed after 1 h.
Although there is reported to be up to a 90% concordance between HSG and lapa-
roscopic findings, a false-positive diagnosis of unilateral tubal blockage also has
been reported in up to two-thirds of cases of apparently blocked tubes by using
either method. In a meta-analysis of 20 studies comparing HSG and laparoscopy, it
was found that for tubal patency, the sensitivity of HSG was 0.65 and the specificity
0.83 (95% CI 0.77–0.88) [47]. If obstruction is suggested by HSG, it is confirmed
at laparoscopy in 38% of cases. In contrast, if the tubes are patent at HSG, this
condition is confirmed laparoscopically in 94% of cases. In women with risk fac-
tors for tubal pathology, the sensitivity of HSG is highest [48], although it could be
argued that these patients should proceed straight to laparoscopy (see below). HSG
has generally been found to be unreliable for the detection of peritubular adhesions.

Sometimes, the cause of an apparent blockage is a mucus plug, which might be

flushed through the tube by the contrast medium. Thus, there are reports of an
increased chance of pregnancy in the 2 or 3 months that follow either an HSG or
laparoscopic insufflation of the tubes.
Oil-based contrast media are more irritant than water-soluble media and have gone
out of favour because of the risk of venous intravasation of contrast and subsequent
embolism in the immediate post-menstrual phase of the cycle. Fluoroscopic control of
the procedure should ensure that this serious complication does not happen. Oil-based
media are absorbed slowly and can cause granuloma formation when trapped within
a hydrosalpinx. Interestingly, oil-based media are thought to unblock more tubes than
water-based media. Indeed, a meta-analysis of 10 studies indicated that spontaneous
pregnancy rates were significantly higher after oil-based contrast media were used
than after the use of water-soluble agents [49]. This benefit was greatest for patients
with unexplained infertility, suggesting the possibility of tubal plugs as a cause. We
also have recently reported a therapeutic benefit in a randomised controlled trial in
couples with unexplained infertility [50]. A similar beneficial effect has been reported
after falloposcopic flushing of the tube or transcervical fallopian tube catheterisation.
Despite these findings, it is unclear whether oil-based media will return to favour
as not only is their use more painful but also the high viscosity leads to a prolonged
injection time and the need, in some cases, for an image to be taken 24 h after the
procedure.
Timing
An HSG should be performed optimally within 10 days of a menstrual period when
there should be no risk of a pregnancy. It should not be performed when the patient
is bleeding. We advise that contraceptive precautions should be used during the cycle
in which the HSG is performed. If a woman is oligo-/amenorrhoeic, we induce a
withdrawal bleed with a progestogen after a negative pregnancy test. If there is erratic
bleeding or any doubt about the possibility of an early pregnancy, the procedure
should be delayed and a pregnancy test should be performed.
The HSG can be uncomfortable, especially if there is either tubal spasm or a tubal
obstruction. We advise patients to take an analgesic (e.g. mefenamic acid, naproxen,
diclofenac) 30–45 min before the procedure. Preparation for the HSG takes approxi-
mately 5 min, and the average length of time spent screening for the flow of contrast is
40 s. Tubal spasm can occur and antispasmodics have been used (e.g. glucagon, diaz-
epam, hyoscine) with varying success. Probably, the best way to avoid tubal spasm,
however, is by slow injection of contrast.
Antibiotic Prophylaxis
If there has been a history of PID, antibiotic prophylaxis should be given (either a
3- or 5-day course of doxycycline and metronidazole or amoxicillin and clavulanate
(Augmentin)), although patients with a history of pelvic infection are probably bet-
ter assessed by laparoscopy than HSG. Although HSG will have been performed in
aseptic conditions, patients should be warned to report immediately of severe pelvic
pain or pyrexia in the 24–48 h after the procedure, as admission to hospital is then

required to administer intravenous antibiotics. Because of silent pelvic infection, in

particular via Chlamydia, we advocate routine antibiotic prophylaxis for all proce-
dures that involve instrumentation of the cervix (see Chapter 2).
Characteristic Findings
Small filling defects can be caused by air bubbles and small polyps that can r epresent
normal endometrium in the premenstrual phase of the cycle. The cavity of the
body of the uterus is usually triangular, sometimes with a concave or convex fun-
dus. The diameter of the cornual portion of the uterus is approximately 35 mm. The
fallopian tubes are 5–6 cm in length, and free spill of contrast into the peritoneal
cavity should be seen. Hydrosalpinges appear as large sacculated structures that are
often either convoluted or retort shaped. One of the criticisms of HSG is that it is not
possible to detect peritubular adhesions that can interfere with oocyte pick-up by the
fimbrial end of the tube. A convoluted distal tube may however suggest the presence
of peritubular adhesions, and the contrast medium tends to be immobile at the end of
the tube rather than continue to spill freely into the peritoneal cavity.
If there is tubal blockage, the commonest histological finding after surgical
excision of the occluded portion of the tube is obliterative fibrosis, followed

by salpingitis isthmica nodosa (Figures 5.27 and 5.28), chronic inflammation
and intramucosal endometriosis. Salpingitis isthmica nodosa is seen on an HSG as
multiple small (2-mm diameter) diverticula of the proximal 2 cm of the fallopian
tubes; the condition is bilateral and the tubes are often blocked. The appearance of
tubal damage after tuberculous salpingitis differs in that there is a ragged outline,
FIGURE 5.27 (See colour insert.) X-ray HSG demonstrating salpingitis isthmica nodosum (small
arrows) in the right tube.

FIGURE 5.28 (See colour insert.) Laparoscopy of salpingitis isthmica nodosum of right tube
(same case as in Figure 5.27). Blue dye appears in the herniation through the serosal layer of the tube.
often with multiple strictures and a beaded appearance; occasionally, the tube is
rigid, with a pipe stem appearance. Pelvic tuberculous may lead to calcification that
can be seen on an X-ray.
A proximal tubal occlusion may be cannulated by selective salpingography, using
guide wires, balloons and catheters under fluoroscopic control in an attempt to
unblock the obstruction (see Chapter 11, tubal disease).
Asherman’s Syndrome
Asherman’s syndrome is a condition in which intrauterine adhesions prevent normal
growth of the endometrium. This condition may be the result of a too vigorous
endometrial curettage affecting the basalis layer of the endometrium or adhesions
may follow an episode of endometritis. Oestrogen deficiency may increase the risk
of adhesion formation in breast-feeding women who require a curettage for retained
placental tissue. Typically, amenorrhoea is not absolute, and it may be possible to
induce a withdrawal bleed by using a combined oestrogen/progestogen preparation.
Intrauterine adhesions may be seen on an HSG (Figure 5.26). Alternatively, hystero-
scopic inspection of the uterine cavity will confirm the diagnosis and enable treatment
by adhesiolysis. After surgery, a 3-month course of cyclical progesterone/oestrogen
should be given. The insertion of an intrauterine contraceptive device for 2–3 months
may prevent the recurrence of adhesions, and intrauterine anti-adhesion gels are also
available.

Ultrasound Contrast Hysterosalpingography or

Hysterosalpingo-Contrast Sonography (HyCoSy)
It is now possible to perform an HSG by using ultrasonography (Figures 5.29
through 5.33) and an ultrasound contrast medium that contains galactose
m icroparticles (Echovist®) (Figure 5.34) and is therefore free of the possible risks of
radiation. The procedure should be conducted in a similar manner and at a similar
time in the cycle as conventional HSG. Not only can tubal patency be assessed but
also, before the contrast is injected, ultrasound enables the visualisation of ovarian
morphology and soft tissue abnormalities, such as fibroids or congenital anomalies
of the uterus and cervix. Fibroids are not seen on X-ray HSG unless they are calci-
fied or the uterine cavity is distorted, and then the cause will not usually be apparent.
Sub-mucosal fibroids can cause tubal obstruction (usually at the cornual end) and
can sometimes disrupt implantation and be associated with recurrent miscarriage.
It is still debated as to whether myomectomy improves matters, in the absence of a
tubal blockage [33] (see Chapter 11). There is increasing evidence that intramural
fibroids affect implantation, even when there is no deformation of the uterine cavity.
One report found that the presence of fibroids of less than 5 cm in diameter reduced
ongoing pregnancy rates by one-half after assisted conception [51]. Myomectomy
is a major procedure with potential risks to the integrity and v iability of the uterus.
There has yet to be a randomised controlled study of myomectomy before assisted
conception. Less invasive procedures are being evaluated for the management of
fibroids, including magnetic resonance imaging (MRI)–guided laser coagulative
necrosis or high-intensity focused ultrasound for the destruction of fibroids. The
place of these techniques in the management of infertility is still being evaluated.
The much publicised technique of uterine artery embolisation is not suitable for
FIGURE 5.29 Ultrasound HyCoSy. Transvaginal ultrasound scan showing negative contrast
(saline) outlining a smooth endometrial cavity.

FIGURE 5.30 Transvaginal ultrasound HSG with saline demonstrating an endometrial polyp
(small arrows). Note the transcervical balloon catheter (open arrows).
FIGURE 5.31 Transabdominal ultrasound HSG showing a sub-mucosal fibroid (large arrow).
There is also an intramural fibroid (open arrows).

FIGURE 5.32 Transvaginal ultrasound HSG, using positive contrast medium (Echovist) that has
increased echogenicity on ultrasound. The two cavities of a uterus didelphys are seen (same patient
as Figure 5.25).
women wishing to conceive because of an adverse effect on uterine and ovarian

blood supply.
HyCoSy provides a good alternative to conventional X-ray HSG and appears to
have an 80%–90% concordance with laparoscopy and dye insufflation. Some have
used saline as an alternative ultrasound contrast medium, with similar success rates,
particularly if a Doppler gate is placed over the fallopian tube to observe forward flow
of the medium. Furthermore, the uterine cavity can be reconstructed using three-
dimensional imaging techniques to facilitate the diagnosis of uterine anomalies and
to differentiate between septate and bicornuate uteri.
Disadvantages of the HyCoSy procedure are that it takes longer than a conventional
HSG (10–15 min) because of the additional time spent performing the transvaginal
assessment of the pelvis, both the ultrasound transducer and catheter are in the vagina
at the same time, and only one fallopian tube can be visualised at a time. HyCoSy
requires trained personnel, and we are not convinced that it will become adopted
widely. We are certainly advocates of ultrasound assessment of ovarian and uterine
morphology and consider that it should be performed by a skilled ultrasonographer.
Then, if indicated, a conventional X-ray HSG should be performed separately by a
radiologist.
Selective Salpingography and Falloposcopy

Transcervical cannulation of the tube can be performed using ultrasound guidance
– selective salpingography – or with a falloposcope (Figure 5.35; see Chapter 11).
Selective salpingography might allow passage of the catheter through a ste-
notic region of the tube or permit flushing of inspissated mucus or fibrinous

FIGURE 5.33 Three-dimensional reconstruction of the image obtained in Figure 5.32 of the uterus

didelphys to show the relationship between the two cavities.
deposits [52,53]. Balloon tuboplasty can be achieved under fluoroscopic guidance.

Falloposcopy, in contrast, allows visualisation of the tubal lumen (Figure 5.36)
and enables tuboplasty to be performed. The linear everting falloposcope elimi-
nates the need for a hysteroscope and appears to be less traumatic to the tube [54].
The visualisation of mucosal abnormalities might lead one to guide the patient to
IVF sooner than if the architecture of the recannulated tube appeared normal. The
salpingoscope, inserted laparoscopically [55], provides clear visualisation of the
ampullary segment of the tube that should normally have three to five major folds
(4 mm in height) and several minor folds (1 mm in height). These anatomical folds
are not easily seen during salpingography, so salpingoscopy may enable a more
appropriate decision to be made about whether to proceed with tubal surgery or
IVF. Although these are attractive techniques, they have yet to be adopted in routine
practice, largely because the optical systems have considerable limitations, particu-
larly for falloposcopy.

(a)
(b)
FIGURE 5.34 Transabdominal ultrasound HSG using Echovist. The fundus of the uterus is
visualised with a Doppler gate over the intramural portion of the fallopian tube. Flow is readily
detected on the left (a) when the intrauterine contrast medium is injected, whereas there is no flow
on the right (b).

FIGURE 5.35 The falloposcope is inserted transcervically, usually via a channel in a hysteroscope

(not shown). Also see Figure 11.9.
FIGURE 5.36 Schematic diagram of normal ciliated mucosa of the fallopian tube.

Laparoscopy and Hysteroscopy

It is our current practice to include a hysteroscopic evaluation of the uterine cavity
whenever we perform a laparoscopy in the investigation of a woman with infertil-
ity (Figure 5.37). Although it is uncommon to detect significant uterine anomalies,
the procedure is simple and safe. The hysteroscopy can be performed while carbon
dioxide is being instilled into the peritoneal cavity for the laparoscopy and need not
lengthen the procedure if two gynaecologists are available. Although carbon dioxide
can be used to distend the uterine cavity, we prefer to use saline. It is important to
visualise both tubal ostia and make note of any intrauterine adhesions that can usually
be divided quite easily and to remove polyps, although we accept that the effect of
endometrial polyps on fertility is uncertain. Congenital anomalies of uterine develop-
ment occur in approximately 4% of women. Depending upon their nature, they may
affect fertility and also predispose to an increased risk of miscarriage and premature
delivery [56]. For example, an arcuate uterus appears to have little effect on fertility
or miscarriage risk, whereas the presence of a septum, unicornuate and bicornuate
uteri may affect both [56].
It is not our routine practice to perform an endometrial biopsy unless the endome-
trium appears abnormal, as endometrial dating is of little diagnostic value.
Just as with hysterosalpingographic assessment of tubal patency, it is important
to ensure that there is no risk of the patient being pregnant before undertaking the
procedure. Laparoscopic assessment of the pelvis (Figure 5.38) should include care-
ful inspection of the peritoneal surface of the uterus, bladder and bowel. The area
around the appendix should be visualised to check for occult inflammation, and the
FIGURE 5.37 Diagnostic videolaparoscopy.

FIGURE 5.38 Hysteroscopy can be performed with rigid or flexible instruments and is often pos-
sible as an outpatient procedure with minimal analgaesia.
sub-diaphragmatic s urface of the liver should be inspected for adhesions, which might
indicate chlamydial or gonococcal PID in the past, that is, the Fitz-Hugh–Curtis syn-
drome (Figure 5.39).
The ovaries should be inspected for signs of follicular activity and ovulation,
abnormal morphology and endometriosis, which often occur on the undersurface of
the ovary or in the ovarian fossa. Endometriosis elsewhere in the pelvis should be
noted carefully. Endometriosis can take on several appearances (see Chapter 10), and
the pelvis should be inspected in a careful and systematic way (Figure 5.40). There is
evidence that even mild endometriosis may adversely affect fertility and so ablation,
with diathermy or laser, can be performed during the initial diagnostic procedure.
Thus, it is our practice to consent all patients undergoing diagnostic laparoscopy for
treatment of mild endometriosis or adhesiolysis, which should not prolong the proce-
dure by more than 15–20 min.
It helps to make drawings of the laparoscopic findings and also to take still
photographs that can be placed in the patient’s notes. Video/DVD recordings of endo-
scopic procedures require careful cataloguing and it is our experience that they are
rarely viewed and so of less practical value than still photographs – unless being
used for demonstrations and teaching purposes. Nonetheless, some suggest keeping
a video record of operative procedures both as a personal record and for medicolegal
purposes. Also, some patients are interested in viewing the images themselves.
Methylene blue dye is injected transcervically, and the fimbrial ends of the fallopian
tubes are observed for spill (Figure 5.41). If there is unilateral spill, the isthmic part

(a)
(b)
FIGURE 5.39 (See colour insert.) Laproscopic views of the liver and undersurface of the
diaphragm to illustrate the importance of assessing this area. (a) Fitz-Hugh–Curtis syndrome.
(b) Endometriosis.

FIGURE 5.40 Laparoscopic view of pelvis.
FIGURE 5.41 (See colour insert.) Laparoscopy with intubation of methylene blue dye. There is
bilateral cornual obstruction to flow and, on the right, the dye can be seen suffusing the myometrium
and vessels of the broad ligament. Externally the pelvic structures appear normal.

of the patent tube can be compressed gently to encourage the flow of dye through the
contralateral tube. Fine periovarian and peritubular adhesions can often be broken
down at the time of the initial laparoscopy. If, however, a more complicated adhe-
siolysis or tubal surgery is required, it is our practice to inform the patient and plan an
elective procedure, unless there is a high index of suspicion because of a past history
of PID, for example, in which case we would schedule a longer time for the diagnostic
procedure.
Ovarian cysts should have been detected by preoperative ultrasonography. Simple
cysts can be aspirated but endometriotic or complicated cysts should be removed
carefully. If there is doubt about the diagnosis, a laparotomy should be performed
together with either a careful cystectomy or even an oophorectomy if there is a strong
suspicion of malignancy. These possibilities must be discussed in detail with the
patient before surgery, and the appropriate consent must be obtained.
Every patient should be warned that there is a possibility of a laparotomy because
of the risks of perforation of viscera or accidental intraperitoneal haemorrhage. It
should be remembered that diagnostic laparoscopy carries a mortality of 1:12,000, so
the less invasive diagnostic methods (see above) should be considered first.
Transvaginal Hydroculdoscopy/Hydrolaparoscopy/Salpingoscopy
Transvaginal salpingoscopy is a technique that has been developed to visualise p elvic
anatomy and tubal architecture [52]. The procedure may be performed with the patient
awake. A small incision is made high in the vagina in the posterior cul-de-sac, and the
pouch of Douglas is filled with warm Hartmann’s solution. A fine 4-mm scope may
then be inserted to inspect the underside of the ovaries and the fimbrial ends of the
fallopian tubes that are beautifully demonstrated by hydroflotation. Tubal patency is
assessed, salpingoscopy may be undertaken and minor operative procedures also are
performed (e.g. adhesiolysis and ovarian diathermy for PCOS).
Choosing between HSG and Laparoscopy

HSG is recommended as a first-line screening test for women who have no history
suggestive of pelvic pathology. A laparoscopy is preferred when there is a possibil-
ity of a problem, and then the aim should be to see and treat as part of the same
procedure (see Chapter 11). This approach would apply therefore to women with a
history of abdominal surgery, for example, for peritonitis associated with appendici-
tis or surgery for inflammatory bowel disease. A history of dysmenorrhoea, dyspa-
reunia or pelvic pain might suggest the presence of endometriosis, although in this
condition symptoms often do not correlate with severity (see Chapter 10). It has been
suggested that women who have had a previous emergency caesarean section may
be at greater risk of tubal subfertility than those who have had an elective caesarean
[57]. It also has been suggested that avoidance of pregnancy is voluntary in 69% of
women after caesarean section and may be related to experience of the previous birth
[58], as is also the case for those women who deliver vaginally (spontaneously or with
instrumental assistance). The factors that influence this choice are also complicated

by the observation that women with infertility are more likely to be delivered by
caesarean in the first place, so there is a complex relationship between operative
delivery and subfertility [59].
MRI/Computed Tomography/Scans
MRI of the pituitary fossa is indicated in cases of persistent hyperprolactinaemia, in
patients with hypogonadotropic hypogonadism and Cushing’s disease (see Chapter 7).
Imaging of the adrenal glands might additionally be required if Cushing’s syndrome
or androgen-secreting tumours are suspected. An MRI scan of the pelvis is useful
when there is doubt about the development of the internal genitalia and ultrasonogra-
phy has been uninformative (e.g. when there are complex uterine anomalies or to look
for testes in women with androgen insensitivity syndromes). MRI provides beautiful
images of the ovaries, although it is rarely required for routine practice (Figures 5.14
and 11.11). We find MRI of the pelvis of greatest use when assessing the position of
fibroids before myomectomy and in assessing congenital uterine anomalies.
Investigating the Male Partner

Examination
The general examination (Figures 5.42 and 5.43 and Box 5.3) should include an
assessment of BMI, blood pressure, secondary sexual characteristics and the abdo-
men and genitalia. Some chest diseases are associated with infertility (e.g. congeni-
tal absence of the vas, spermatic duct obstruction (see Chapter 12) and Kartagener’s
syndrome with dextrocardia) and might be elicited at the time of the examination. An
absent or deficient sense of smell in patients with hypogonadotropic hypogonadism
gives the diagnosis of Kallman’s syndrome and saves a lot of further tests.
Men with androgen deficiency of pre-pubertal origin may have a high-pitched
voice, small soft testes and a small penis, lack of adult hair and decreased mus-
cle mass. They are often tall, with a large arm span that exceeds their height. If
hypogonadism d evelops after puberty, the skin becomes fine and both body hair
and beard growth diminish. There may be gynaecomastia, as in Klinefelter’s syn-
drome. Gynaecomastia also may occur with hyperthyroidism, liver disease, oestrogen
or hCG-producing tumours or with some drugs (most notably anti androgens such
as cimetidine, s pironolactone, digitalis). Transient gynaecomastia is normal during
puberty. Other signs of endocrine disease (e.g. Cushing’s syndrome, thyroid disease,
pituitary tumour) also should become evident on the general examination. A full neu-
rological examination is required when there are problems with sexual function.
Abdominal Examination
Abdominal examination should reveal the presence of abnormal masses and herniae.
Scars from herniorrhaphy in childhood should be sought as often the history is either
forgotten or unknown and damage to the vas deferens or testicular blood supply may

Bladder
Ampulla and
seminal vesicle
Vas deferens
Ejaculatory duct
Prostate gland
Bulbo-urethral
Urethra
gland
Epididymis
Testis
(a)
Bladder
Ampulla
Seminal vesicle
Prostate gland Ejaculatory duct
Bulbo-urethral
glands Urethra
Caput
Ducti efferentes
Corpus Epididymis
Seminiferous
tubule
(b) Cauda
FIGURE 5.42 (a, b) Male reproductive tract.
follow surgery. Similarly, a history of orchidopexy in childhood may not be revealed

and has important implications for future fertility.
Genital Examination
The penis should be inspected for the location of the urethral opening and the foreskin
retracted if possible. Congenital deformities of the penis or hypo-/epispadias may

Vas deferens
Ducti efferentes
Tunica vaginalis
Rete testis
Seminiferous
tubule
Epididymis
Tunica albuginea
FIGURE 5.43 Testis and vas deferens.
BOX 5.3 EXAMINATION OF THE MALE

General: weight, blood pressure, urinalysis
Secondary sexual characteristics
Muscle bulk
Signs of endocrine disease (see text)
Gynaecomastia
Abdominal examination: masses, liver, scars, herniae
Genital examination
Urethral meatus
Testicular volume, masses
Epididymis
Varicocele
Rectal examination of prostate
cause problems with semen deposition. Testicular size should be assessed using an
orchidometer and is considered normal if more than 15 mL. Small testes that are
soft are usually associated with gonadotropin deficiency, as in hypopituitarism or
Kallman’s syndrome. Small testes that are firm, implying fibrosis, are usually associ-
ated with severe and permanent destruction of germinal epithelium (as in Klinefelter’s
syndrome), whereas androgenisation may be normal. The plane of the testis has no
bearing on fertility, but testes that lie in a horizontal plane are more likely to tort
than those that lie more vertically. Testicular masses or asymmetry warrant further
investigation by ultrasound in the first instance. Scrotal swellings are best palpated

with the patient standing. It is then easier to palpate the epididymis and vas deferens
and to ascertain the presence of cysts, thickening and tenderness, conditions that are
all associated with infection.
A varicocele may be palpated with the patient standing in the upright position
because the valves are incompetent and the varicocele fills with venous blood due
to increased intra-abdominal pressure. Varicoceles are more common on the left,
because of the differential venous drainage between left and right, and they can be
graded depending whether they (1) fill only during a Valsalva manoeuver, (2) are
detectable by palpation or (3) are clearly visible [60].
Rectal Examination of Prostate

If indicated, the prostate should be palpated by rectal examination and undue ten-
derness suggests infection. Prostatic massage may produce a urethral secretion that
should be sent for microscopy and culture; a urine specimen also should be sent after
prostatic massage. Some men are aware of changes of seminal colour or smell in asso-
ciation with infection of the epididymis, prostate or seminal vesicles, and the semen
should be sent for microscopy and culture.
Semen Analysis
The specimen of semen should be produced by masturbation into a clean, dry con-
tainer and delivered to the laboratory within 30 min of its production. There should
have been a period of abstinence of 3 days. A fixed period of abstinence not only
improves the standardisation of the test but also more than 5 days of abstinence is
associated with a decrease in motility despite an increase in sperm number. A large
study of more than 9000 semen samples found that men with normal sperm param-
eters had similar semen characteristics when the period of abstinence ranged from
1 day to 10 days, after which they declined [7], whereas men with oligospermia had
better samples after shorter periods of abstinence (i.e. <3 days and in many cases 1
day of abstinence was preferable) [7].
There can be large swings in semen parameters in healthy, fertile sperm donors,
so the results of a single semen analysis should be viewed with caution and repeated
on two or more occasions, 3 months apart [57]. The results of four samples should
provide average values that are within 1 SD of the mean, although in most cases
two semen analyses will suffice. There may be regional differences in semen qual-
ity dependent both on ambient temperature (with counts being higher in winter) and
environmental exposures or lifestyle differences [61]. Sperm production by the testis
takes 10–12 weeks (Figures 5.44 and 5.45), so an abnormal semen specimen is a
reflection of testicular function 3 months previously. Thus, to assess the effects of
therapy, it is necessary not to be too hasty before repeating the analysis.
The conventional semen analysis has been criticised in the past for providing poor
prognostic information about male fertility, and the criteria defined by earlier versions
of the World Health Organization (WHO) manual on semen analysis were dismissed
by some authorities as providing minimal values that are well into the fertile range.
There is also considerable intra- and interobserver variation of semen assessment,
both within and between laboratories. The recent WHO criteria has provided revised

Stem cells (2N)
Spermatogonia (2N)
Spermatocytes
(4N) (2N)
Spermatids (1N)
(1N)
FIGURE 5.44 Spermatogenesis. Stem cells proliferate to become spermatogonia. The DNA is then
replicated to produce the first spermatocytes, after which two meiotic reduction divisions produce
the spermatids. These spermatids undergo spermiogenesis to produce mature spermatozoa.
parameters, and these revisions appear to be better accepted [62,63] (Table 5.5).
Semen samples from more than 4500 men from 14 countries were obtained from
prospective and retrospective studies on fertile men and those with unknown fertility
status. Reference ranges were then established for those whose partners with a time
to pregnancy of 12 months or less. It is important to appreciate that the different

Spermatogonium Primary
spermatocyte Acrosome
Head
Stem cell Nucleus
Neck Centriole
Axial filaments
Sertoli cell Secondary
spermatocyte
Middle Mitochondrial
Spermatid piece sheath
Plasma
Spermatozoon
membrane
Lumen of
seminiferous tubule Tail
FIGURE 5.45 Spermatogenesis within the seminiferous tubule.
TABLE 5.5
Normal Semen Parameters
Standard Tests Lower Reference Limit (95% CI)
Volume ≥1.5 mL (1.4–1.7)
pH 7.2–8.0
Sperm concentration ≥15 × 106/mL (12–16)
Total sperm count ≥39 × 106/ejaculate (33–46)
Motility (within 60 min ≥25% with rapid progression (category a)
of ejaculation) ≥40% with forward progression (38–42)
(categories a and b)
Vitality ≥75% live (categories a, b and c)
<25% dead (category d)
Morphology ≥4% normal forms (3.0–4.0)
White blood cells <1 × 106/mL
Immunobead test <50%
Mixed antiglobulin reaction <50%
Additional possible tests
Fructose ≥13 mmol/ejaculate
Acid phosphatase ≥200 U/ejaculate
α-Glucosidase ≥20 mU/ejaculate
Zinc ≥2.4 mmol/ejaculate
Citric acid ≥52 mmol/ejaculate
Source: Cooper TG et al., Hum Reprod Update 16, 231–45, 2010.

parameters should not be taken in isolation, and most laboratories approach the semen
analysis with a view to seeing what the likelihood is of natural conception or concep-
tion with either insemination treatments (IUI) or assisted conception (IVF or intracy-
toplasmic sperm injection (ICSI)) [64].
Reduced Sperm Concentration (Oligozoospermia)

The chance of natural conception falls significantly when the motile sperm
concentration is less than 5 × 106/mL. When the total count is low, there is often a
corresponding reduction in motility. The concentration of progressively motile sperm
consistently appears to be the most predictive factor with regard to outcome for both
natural conception and artificial insemination.
Impaired Sperm Morphology (Teratozoospermia)

Sperm morphology remains confusing with a lack of standardisation across centres,
ever stricter scoring criteria and changing reference values [64]. Using the strict
assessment of sperm morphology, developed by Kruger and Coetzee [65], the definition
of a normal spermatozoon is one that is oval, with a smooth contour; an acrosome
comprising 40%–70% of the distal part of the head; a normal neck, mid-piece and tail;
and no large cytoplasmic droplets (Figure 5.46). The normal size of the sperm head
is 5–6 × 2.5–3.5 μm. Assessment of sperm morphology, although not strictly a sperm
function test, is still thought by many to provide a good reflection of sperm function.
The lack of objectivity in the morphological assessment of sperm has led to the devel-
opment of automated computer morphology analysers that are expensive and so not
widely used. The acceptable percentage of normal sperm has decreased dramatically
in recent years to its current level of 4%. It is now felt that isolated teratozoospermia
has no influence on fertilisation, pregnancy or live births, and a recent meta-analysis
has shown that the use of ICSI does not improve the outcome compared with IVF alone
[66]. Recent advances in sperm morphology analysis include the use of intracytoplas-
mic morphologically selected sperm injection (IMSI), a high-powered morphological
examination of organellar morphology in motile sperm [64].
Globozoospermia (roundheaded spermatozoa) is often missed and requires a
skilled andrology technician to make the diagnosis. There is no acrosome in these
spermatozoa, so fertilisation cannot occur. IVF/ICSI might be a possibility for these
patients, although very few cases have been successful.
There is evidence to suggest that sperm possessing the hyaluronic acid (HA) recep-
tor are more mature and have improved morphology, reduced DNA fragmentation
and fewer DNA aneuploidies and that these findings have led to the launch of a com-
mercial hyaluronan binding assay (HBA). Further research is required before this
approach can be adopted into routine practice [64].
Reduced Sperm Motility (Asthenozoospermia)

If most of the sperm are immotile, the method of collection should be scrutinised and
the sample should be repeated, ensuring that there is no delay between production and
arrival at the laboratory and that sperm has been delivered directly into a pot and not

Normal
Head and
size variations
Immature
Mid-piece anomalies
Cytoplasmic droplets
Tail anomalies
FIGURE 5.46 Sperm morphology.

into a condom, which might contain lubricating or spermicidal agents. It is important

that the man does not use lubricating jelly, soap or water, all of which can cause sperm
death. Good hygiene when producing the specimen also prevents contamination, so
the patient should be advised to wash his hands and penis first. If the man has dif-
ficulties producing a specimen, there are inert silicon condoms that can be used to
collect sperm during vaginal intercourse. In these situations, it is sensible to consider
cryopreservation of sperm as a backup for use in future assisted conception cycles in
case there is a complete inability to produce a sample on the day that it is required
for treatment.
True immotility can be caused by infection, superoxide production by leukocytes,
antisperm antibodies or defects in the microtubules and dynein arms of the sperm tail.
Sperm agglutination is often due to infection rather than antisperm antibodies, and
the appropriate tests should be performed (see below).
A precise analysis of sperm motility can be obtained using a computerised image
analysis system that tracks motile sperm and provides data on several parameters,
including forward velocity, curvilinear velocity and amplitude of lateral head
displacement. Not only is forward movement required for sperm to reach their
target but also there must be adequate lateral head displacement for penetration
of the cervical mucus. Hyperactivation also can be observed, that is, the process
of increasing beat amplitude that occurs with capacitation of the sperm in the
female reproductive tract as the sperm prepares to penetrate the zona pellucida.
Computerised assessment of sperm motility and action correlates well with its
in vitro fertilising ability, and these techniques are now used by many large centres
that can afford the equipment.
Cause of Sperm Dysfunction

Sperm function can be impaired by lipid peroxidation in the sperm plasma mem-
brane. Oxidative stress correlates with reduced motility and a decreased capacity
for oocyte fusion. Reactive oxygen species (ROS) initiate lipid peroxidation, and
they are produced either within the dysfunctional spermatozoa or by leukocytes.
An end product of lipid peroxidation is malondialdehyde, and malondialdehyde can
be measured to give an index of oxidative stress. Luminometry uses very expensive
equipment to measure ROS, and it differentiates between those released from sperm
and leukocytes. Hydrogen peroxide appears to be the most important cytotoxic oxy-
gen metabolite. Seminal plasma contains a rich concentration of antioxidants, and
removal of sperm from seminal plasma during preparative procedures for assisted
conception can expose the sperm to damaging ROS; antioxidants in the media used
for the preparation of sperm may help to counterbalance this damage.
A matter of some concern is the notion that ROS are well-known mutagens and
sperm-derived genetic damage to embryos might occur through chromosomal break-
age, whereas oocyte-derived damage occurs through chromosomal rearrangement. It
has been suggested that spermatozoa that have been exposed to ROS are at increased
risk of carrying chromosomal breakages.
Sperm activation and the acrosome reaction are dependent upon the influx of
calcium before the sperm fuses with the oocyte. Progesterone appears to play a
role in this process, although progesterone receptors have been found on only 10%

of spermatozoa, the significance of which is unknown. It is difficult to assess the

acrosome reaction in vitro as it cannot be visualised by light microscopy, so the acro-
some has to be labelled with fluorescent monoclonal antibodies or lectins that attach
to the acrosome membrane. The acrosome reaction occurs spontaneously in only
approximately 5%–10% of sperm in vitro, so the normal range is very low. All sperm
that have bound to the zona are acrosome reacted.
Sperm DNA damage testing has been proposed for several years as a useful sup-
plementary investigation for the subfertile man, and it has been suggested by some
to be more robust than conventional semen parameters as a predictor of outcome.
Although there may be some merits in developing some form of sperm DNA damage
test, several of differing methodologies have been described and there is, as yet, no
consensus as to their benefit [64]. The literature to date does not clearly identify a
particular clinical indication for sperm DNA testing nor does it identify how patients
should be managed should the test outcome be unfavourable. The strongest evidence
to date relates DNA damage with pregnancy loss, but this outcome still does not
clearly identify the most appropriate test or a clear clinical threshold at which clinics
might advise patients that treatment is inadvisable [64,67].
Leukospermia
It is difficult to distinguish leukocytes from immature germ cells by microscopy, and
semen culture rarely yields a positive result, even in the presence of a significant con-
centration of leukocytes. Sometimes bacteria are visualised by direct microscopy or
can be grown in culture. Bacteria are most often thought to arise from contamination
at the time of sperm production as repeat analysis usually fails to reveal an underlying
infection. If a lower genital tract infection is suspected, a Stamey–Meares test should
be performed. This test involves collecting three small samples of urine in succes-
sion. The first sample indicates urethral infection; the second sample (a mid-stream
specimen) urinary infection; and the third sample, collected after prostatic massage,
prostatic infection.
Cervical Mucus Penetration and the PCT

The parameters of sperm movement correlate well with its ability to penetrate
cervical mucus. The PCT was been traditionally used to assess sperm survival
in cervical mucus. A PCT should be performed mid-cycle, when the oestrogenised
cervical mucus is most receptive to sperm. The couple should be asked to have
intercourse the night before the test, and the woman should refrain from wash-
ing inside the vagina afterward. A sample of cervical mucus is aspirated from the
cervical os and placed on a microscope slide for examination under high power.
The characteristics of the cervical mucus should be recorded, including its cellu-
larity, viscosity, Spinnbarkeit and ferning pattern when allowed to dry on the slide
(Figure 5.47). A cervical score can be obtained by quantifying each of these charac-
teristics from 0 to 3; a score of less than 5 indicates cervical hostility, a score greater
than 10 satisfactory and a score of 15 maximal. A score of 3 is obtained if the volume
is at least 0.3 mL, no cellularity (i.e. no white cells), normal viscosity, Spinnbarkeit
of at least 9 cm and a ferning pattern with tertiary and quaternary stems (Table 5.6).

(a) (b)
FIGURE 5.47 Ferning pattern of (a) ovulatory (oestrogenised) cervical mucus that has dried on a
microscope slide, contrasted with (b) non-ovulatory mucus.
TABLE 5.6
Cervical Scoring
0 1 2 3
Quantity (mL) 0 0.1 0.2 ≥0.3
Viscosity Thick Intermediate Mildly viscous Normal
Cellularity ≥11 cells/HPF 6–10 cells/HPF 1–5 cells/HPF 0 cells/HPF
Ferning No crystallisation Atypical pattern 1° and 2° stems 3° and 4° stems
Spinnbarkeit (cm) <1 1–4 5–8 ≥9
Note: HPF, high-power field.
Couples often find the PCT very stressful, and precise timing at mid-cycle is often
difficult to achieve. It is seen to be an invasion of their privacy by focusing on the
most intimate part of their relationship, which is under close enough scrutiny in any
case when attending the fertility clinic. In addition, it is necessary to have the facility
to perform the test on every week day. And although the finding of motile sperm is
reassuring, their absence does not necessarily indicate a problem, providing inter-
course has taken place. The methodology of performing the PCT varied enormously
between centres. It has been suggested that the only useful parameter is the presence
of a single sperm as any number above this one sperm does not correlate better with
fertility. The PCT is therefore outmoded and rarely used in routine practice.
An alternative to the PCT is the observation of the distance travelled by sperm over
a period through HA polymers, which serve as an artificial substitute for c ervical
mucus. The results correlate very well with those observed in aspirated cervical
mucus but can be better controlled and quantified. Furthermore, the test is not depen-
dent on the stage of the woman’s cycle. It has been suggested that this assay, combined
with a measurement of antisperm antibodies, should replace the PCT, although even
then there is no consensus and in reality this test is rarely performed.

Antisperm Antibodies
The effects of antisperm antibodies on outcome do not appear to be independent
of other semen parameters (e.g. motility, agglutination), bringing into question the
need for routine testing of all infertility patients. Immunoglobulin (Ig)G antisperm
antibodies (ASABs) are found in the serum, whereas those in the cervical mucus are
IgA, and both classes of antibody are found in the seminal fluid. There are several
of different assays for the measurement of antisperm antibodies, and the cut-off lev-
els for a significant concentration of antibody vary depending on the assay and the
laboratory’s normal range. A survey of U.K. practice found tremendous variation, and
confusion, about appropriate tests for ASABs and their interpretation [68].
• Sperm agglutination tests (tray agglutination test): sperm agglutinate if

bound to bivalent antibodies, agglutination can occur due to non-immune
causes, based on serum antibodies, quantitative; poor specificity and poor
correlation with fertility
• Mixed agglutination reaction (MAR) test: sperm agglutinate with sensitised
rhesus-positive red cells in the presence of anti-IgG antiserum, detects
antibodies bound to sperm in semen, measures IgG and IgA only, good
specificity, non-quantitative
• Sperm immobilisation test: antibody binding activates complement to immobil-
ise sperm, good specificity for complement fixing antibodies, poor sensitivity
• ELISA: enzyme-linked antibody reacts with antisperm antibody, quantitative;
requires fixation or homogenisation and exposes internal antigens so
irrelevant antigens might be detected, good specificity, poor sensitivity
• Indirect immunofluorescence: fluorescent-labelled antibody reacts with
antisperm antibody, both IgA and IgG detected, high false-positive rate,
good sensitivity
• Radiolabelled antiglobulin assay: radiolabelled antibody reacts with anti-
sperm antibody, both IgA and IgG detected, quantitative, good specificity
and sensitivity
• Immunobead binding test (IBT): polyacrylamide beads with bound antibody
react with antisperm antibody, both IgA and IgG detected, good specificity
and sensitivity
The IBT appears to be the best test as it also detects the binding loci (i.e. head, mid-
piece or tail) on living sperm, which can be viewed by light microscopy. This detec-
tion is important as head-bound antisperm antibodies have the most serious impact on
fertility. The levels of antisperm antibodies are considered to be significant when more
than 50% of the motile sperm are affected. A recent meta-analysis failed to find any
significant link between the presence or level of ASABs and pregnancy in IVF or ICSI
[69]. However, they did concede that the most commonly used laboratory methods
(i.e. immunobead test or Sperm Mar) were crude at best and were unable to determine
the exact function of the immunoglobulin being detected. There remains no protocol
which is either standardised or universally accepted as the standard method [64].

Serum Endocrinology in the Male

An endocrine profile should be performed in men with oligospermia (counts
<5 × 106/mL) or if there are signs or symptoms suggestive of either androgen defi-
ciency or endocrine disease.
Testosterone Levels
Serum testosterone levels undergo diurnal variation, with the highest levels in the
morning. The time of the test – and its comparison with measurements performed on
other days – may be important if the result is borderline. The normal range is 10–35
nmol/L.
FSH and LH
Normal serum concentrations of gonadotropins FSH and LH are less than 10 IU/L,
although it is important to know the normal range for the individual laboratory.
The combination of azoospermia with normal-sized testes and normal levels of T,
FSH and LH suggests a mechanical obstruction to the passage of sperm. An elevated
serum concentration of FSH indicates germinal cell insufficiency or primary t esticular
failure if combined with an elevated serum LH concentration; and the serum testos-
terone level will be low. The combination of azoospermia and an elevated serum FSH
concentration has, until recently, been taken as an indication of no spermatogenesis.
However, cases have been reported of a few spermatozoa being found during testicu-
lar aspiration/biopsy that have then been used to perform IVF/ICSI. Thus, unless the
testes are absolutely tiny (i.e. <2 mL), some andrologists now suggest that all men
with an elevated serum FSH concentration should be offered a testicular biopsy, with
an option for cryopreservation of any retrieved spermatozoa at the same time.
Low serum concentrations of all three hormones indicate hypothalamic or pituitary
insufficiency, a condition that may be amenable to hormonal therapy.
Inhibin
Serum inhibin concentrations have not shown any correlation with spermatogenic
activity, and they have no role in the current investigation of the infertile male.
Prolactin and Thyroid Function

These hormones should be measured to provide a complete endocrine profile when
serum testosterone levels are low or when there is gynaecomastia or thyroid disease.
Pituitary imaging and further investigation by an endocrinologist may be required
if there are abnormalities of the hypothalamic–pituitary–gonadal axis.
Chromosomal Analysis
Both men and women with primary gonadal failure should undergo karyotyping
to aid diagnosis and to enable the provision of appropriate genetic counselling in

cases when gonadal failure is not absolute because there might be the possibility of
extracting a few spermatozoa for IVF/ICSI. A karyotype is indicated in azoosper-
mia and for men with severely impaired semen parameters, because of an increased
risk of structural chromosomal anomalies and sex chromosomal anomalies (e.g.
Klinefelter’s syndrome 47XXY). Furthermore, microdeletions on the long arm of the
Y chromosome have been causally linked to anomalies in spermatogenesis, and these
microdeletions may be passed on to the male offspring of men who undergo IVF/
ICSI. These microdeletions are often at the azoospermia factor (AZF) locus at q11.23
of the Y chromosome and may be found in 7% of infertile men and 2% of normal men
[70] (see Chapters 12, 14 and 17). Congenital bilateral absence of the vas deferens
(CBAVD) is associated with mutations in the cystic fibrosis gene, so when CBAVD is
detected both partners should be screened.
Imaging in Male Infertility

Varicoceles can be investigated by a combination of ultrasonography (± Doppler
flow studies), nuclear scintigraphy, thermography or venography. The patient can
be asked to perform a Valsalva manoeuver to accentuate the varicocele. As the
diagnostic s ignificance of a varicocele is debatable, its classification by these methods
is imprecise, particularly as the size of varicocele does not correlate with the degree
of impairment of spermatogenesis [71].
A vasogram can be performed if an obstruction is suspected. Sometimes this is
done in the operating theatre at the time of testicular exploration (Figure 12.1).
Testicular Exploration and Biopsy

Testicular exploration is indicated if the sperm density is less than 1 × 106/mL and the
serum FSH concentration is normal. If an obstruction is found, it may be bypassed
during the same procedure (see Chapter 12). Facilities should be available for sperm
cryopreservation whenever surgery is performed on the testis and collecting system
and sperm stored in case the procedure is unsuccessful (see Chapter 12).
A testicular biopsy aids in the diagnosis of severe oligospermia or azoosper-
mia (Box 5.4). If there is obstructive azoospermia, spermatogenesis is normal
but there may be sloughing of the superficial layers of the seminiferous epithe-
lium. Absent spermatogenesis suggests the diagnosis of the Sertoli-cell-only (del
Castillo) s yndrome, whereas after orchitis there might be hyalinisation and tubular
atrophy.
The degree of spermatogenesis can be scored using the mean Johnsen score
(Box 5.4), a score that is obtained after the examination of several tubules. A score of
8–10 is normal, a score of 2 indicates the Sertoli-cell-only syndrome and intermedi-
ate scores suggest varying degrees of disordered spermatogenic or maturation arrest.
When cells of increasing maturity are seen, all of the preceding stages also are seen
in the biopsy.
See Box 5.5 for a summary of the investigation and treatment of infertility, with
suggestions for tests that can be initiated by the GP.

BOX 5.4 JOHNSEN SCORE

1. No cells in the tubule
2. Sertoli cells only
3. Spermatogonia only
4. Few spermatocytes
5. Only spermatocytes
6. Few spermatids
7. Only spermatids
8. Few spermatozoa
9. Many spermatozoa, central sloughing, no lumen
10. Many spermatozoa with central lumen
BOX 5.5 SUMMARY OF INVESTIGATION

AND TREATMENT OF INFERTILITY
Scheme for the investigation of infertility
General practitioner
Semen analysis – twice if first abnormal
Rubella status
Baseline endocrine profile (FSH, LH, TSH, ± prolactin, testosterone)
Luteal-phase progesterone
Hysterosalpingogram
Infertility clinic
Baseline pelvic ultrasound scan
Laparoscopy and dye/hysteroscopy
More detailed endocrinology if indicated
Further investigation of endocrine disorders
More detailed sperm function tests
Scheme for the treatment of infertility

General practitioner
General health and sexual advice
Folic acid
Cervical smear
Rubella immunisation
Referral for preconception counselling if other health concerns,
drug therapy, older age group, family history of genetic
disease
Infertility clinic
All ovulation-inducing agents (including clomifene citrate) with
appropriate monitoring
Laparoscopic surgery
Assisted conception

Male treatments
Collaborative clinics with endocrinologist, urologist, pyschosex-
ual counsellor
General counselling
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FURTHER READING
NICE. Fertility: assessment and treatment for people with fertility problems. London: DoH
& RCOG, 2013.

6
Counselling
Introduction
The counsellor in a fertility clinic should be versatile both in dealing with the
psychological stresses of couples with subfertility and with the special ethical and
social dilemmas that need to be confronted when certain treatments are contemplated.
The counsellor therefore has to be compassionate in understanding the particular
emotional strains of subfertility and have knowledge of the various treatments and
the law as it applies to them.
Infertility
Many couples feel that they are infertile rather than subfertile. They do not see an end
to their problem or believe that a pregnancy can ever occur. The woman’s menstrual
period is a monthly reminder that pregnancy has not occurred, and this reminder can
compound what is already a low point of the month psychologically. Infertility treat-
ments have attained a high profile since the advent of in vitro fertilisation (IVF). This
waiting can aggravate the stresses felt by couples who are undergoing the early stages
of investigation and treatment because they sometimes perceive that they are embark-
ing on a long track before they are offered high-tech and, supposedly, higher success
therapies. It is important to try and place a couple’s investigations in the context of
their expected chance of conception over the next 6–12 months and to provide a pro-
posed plan of management so that they can see how their treatment is envisaged by
the clinician.
Society expects young couples to start a family – and many do. The couple with
subfertility sees relatives and friends expanding their families, whereas their own
pregnancy seems never to happen. Their working lives take over, and they become
more involved in work, both to fill time otherwise spent with a family and as an
excuse to others for not starting a family. This process can sometimes result in tre-
mendous isolation, especially if the couple also avoids contact with others who have a
young family. Sometimes, particularly with professional couples, childrearing is not
a consideration until the female partner is in her mid- to late thirties, when the natural
and assisted chance of conception declines quite rapidly. It has been suggested that we
should freeze oocytes from young professional women until a time when they want to
start a family. Currently, oocyte freezing is exciting much interest, although a large

pool of oocytes from many IVF stimulation cycles is required to provide a realist
chance of a pregnancy in the future (see Chapter 19). In the meantime, these women
require support and are not to be blamed for waiting.
Usually, one partner is more affected psychologically than the other. This
difference might be because they are going through the process of grieving at
different times. Thus, it is common for the male to be denying that there is a p roblem
while the woman is feeling angry and distressed. Sometimes, there is a feeling of
guilt, exacerbated if there has been a history of pregnancies in other relationships
that might have resulted either in abortion or in the birth of a child or children that
are now with an ex-partner or that have been adopted. It is common for women, but
not usually men, to disclose information about previous pregnancies to the clinic but
to wish to keep this information from their partners. If the woman has had p elvic
infection leading to tubal damage, or if the man has had a sexually transmitted
disease that has impaired his fertility, these issues might not have been discussed
previously and may come to light for the first time in the clinic. Guilt also has been
described in subfertile couples in relation to normal activities such as premarital sex
and masturbation.
Although infertility is not thought to cause psychiatric illness, there is no doubt that
psychological distress and psychosexual problems are commonly found in couples
attending fertility clinics. This attendance does not mean that couples with i nfertility
are more prone to personality disorders or anxiety than the fertile population. In
fact, patients with subfertility appear to have a lower incidence of serious psychiatric
disorders than the rest of the population. There is no difference in the overall rates of
psychological problems and those in the general population, perhaps because subfer-
tile individuals tend to be in an older age group and usually in stable relationships.
This is not to say that infertility does not cause psychological morbidity. Indeed, as
some couples with unexplained infertility conceive after they have adopted a baby,
it has been suggested that stress might have accounted for their infertility. Although
this outcome might sometimes be true, the rates of conception are low (between 2%
and 4% overall) and no higher than in couples with unexplained infertility who do
not adopt.
Couples with infertility have a tendency to become increasingly isolated and
avoid family gatherings and friends who have young families. Leisure time becomes
focused on activities that do not involve children – and this focus can sometimes
cause problems when the long-awaited child is born.
Some psychological disorders are relatively more common in young women,
such as disordered eating habits. Bulimia, for example, is associated with ovarian
dysfunction and polycystic ovary syndrome, and it may be difficult to detect, particu-
larly if the patient is of normal body weight – as is often the case. Chronic stress can
lead to alcohol and drug abuse, and such abuse has important implications not only
for ovarian and testicular function but also for teratogens.
Women appear to differ from men in the ways in which they are affected by
infertility, and the gap tends to widen as treatment progresses. Many women absorb
infertility as a part of their identity, as opposed to men, who see infertility as a
problem to be dealt with. Women become very preoccupied with their problem and
often talk only with their partners. A study from Nottingham found that only 75% of
women had told their mothers by the end of a year of attending the clinic, and by this

Counselling 137
time, 47% had given up their jobs. Particular treatments bring their own stresses, for
example, the humiliation that can sometimes be caused by having a postictal test or
the use of donor gametes. Fertility drugs, such as clomifene, the gonadotropins and
gonadotropin-releasing hormone (Gnarl) agonists, also can have profound effects on
a patient’s psychological well-being.
After the failure of one IVF treatment cycle, as many as 25% of women are thought
to have clinical depression, and this rate rises with repeated failures. Men, in contrast,
tend to have more clinical anxiety (38% compared with 10% in the community),
although the rate does not worsen with repeated treatment cycles – and may some-
times improve. As time goes on, women begin to feel frustrated and more reliant
on their partner; they become guilty, feel greater responsibility and have a need to
talk. Men, in contrast, become fed up with the constant focus on their wives’ ovarian
function and throw themselves into other activities as a distraction; they become more
introverted and less able to talk with their partners about their infertility and other
personal issues.
Psychosexual Problems
Couples who are trying for a pregnancy tend to have sexual intercourse less
frequently than those who have no concerns about fertility. The reasons for this
difference include the mistaken notion that long periods of abstinence improve
the sperm and that the days around ovulation are the only time when intercourse
should take place. Women become very aware of their cycle and sometimes become
obsessive about recording dates of menstruation and keeping temperature charts
or testing urine for luteinising hormone (LH) surges. Their partners often feel that
they are required to perform to order rather than make love for pleasure and affec-
tion, so excuses are made, intercourse does not take place and tensions increase.
Furthermore, the couple knows that when they are next seen in the clinic, they will
be asked about frequency of intercourse, or they will be requested to have a p ostictal
test (albeit rarely these days) or told to make love on a particular day during an
ovulation induction cycle.
Major psychosexual problems and impotence account for less than 5% of cases of
subfertility, but they require careful counselling and expert advice. However, most
couples with subfertility have varying degrees of stress placed upon their sex lives,
and it is necessary to be sensitive to these issues and to try to demedicalise this
most personal part of a couple’s relationship. A careful explanation about the opti-
mum frequency of intercourse will help a couple to appreciate that it is not necessary
to have long periods of abstinence before the day of ovulation and that intercourse
every 2–3 days in the follicular phase of the cycle will result in satisfactory numbers
of motile sperm in the fallopian tube on the day of ovulation (see Chapter 5). This
approach should diffuse the pressure associated with a monthly focus on the middle
part of the cycle. Indeed, it has been reported that up to 10% of men having f ertility
treatment have sexual difficulties mid-cycle and that 35% of couples have sexual
problems during fertility treatment. One of the few benefits of keeping a temperature
chart for a few months is the record of the frequency of intercourse, which can be
noted by the physician.

In caring for couples with subfertility, it is essential not to overmedicalise sexual

performance so that the loving and enjoyable aspects of love-making are not lost. It
is also important to talk about these issues openly with an acknowledgement of the
problems to break the chain of silence.
How to Deal with Work

A major source of stress for women is the logistical difficulties of fitting repeated vis-
its to the clinic into the working week. Although many employers are cooperative and
understanding, because fertility treatment is aimed at getting the woman pregnant, it
may inevitably result in the need for maternity leave and maternity pay. It is not sur-
prising that many women try to hide their reasons for repeated absences from work.
The clinic can help by trying to perform scans early in the morning, at lunchtime and
after work, although this has implications for the staffing of the unit.
Another factor is the attention paid to a couple undergoing fertility treatment
by their friends and family. The couple feels under pressure to succeed, even
though success is really out of their hands. They are confronted by continual
requests for progress reports, making the lack of a pregnancy all the more hard
to bear. Couples should be advised to discuss their treatment only with those who
they know will be discreet so as not to increase the pressures already on them.
This necessity to be selective about whom to talk to unfortunately perpetuates the
mystique of fertility treatments and the ability of those who are affected to talk
openly about the need for an improved service. Thus, the topic remains relatively
taboo on an individual level, despite the publicity that surrounds the scientific
breakthroughs.
Special Needs of the Male Partner

The male partner should certainly be encouraged to become involved in the
investigations and treatments. His role in fertility therapy is relatively easy,

irrespective of whether there are male factors in the couple’s subfertility. As

treatment centres largely around the female partner, the man can sometimes feel left
out and guilty, particularly if there is nothing specifically wrong with his partner
and she is undergoing stressful treatment with potentially dangerous side effects.
Although couples should be encouraged to confront feelings of guilt and emotional
difficulties to help each other cope better with fertility treatment, many feel unable
to communicate either with a counsellor or, more importantly, with each other.
Furthermore, research that has been conducted in this area is limited because of not
being able to include those who do not attend the clinic or those who will not see a
counsellor. We also can only guess at the number of couples who never present for
investigation because they are unable to address their infertility, and couples who
actually make it to the clinic might be those better able to cope with the stresses of
infertility and its management.

Counselling 139
Adjustment to Parenthood
Couples who have experienced infertility can have difficulties adjusting to parent-
hood. They may have been together as a couple for a long time, and the intrusion of
a baby can disrupt their daily regime. The female partner may have to give up work
after many years of building up a career. She may resent her baby and at the same
time feel guilty about such feelings. There is an increased rate of post-natal depres-
sion among women who have experienced subfertility, which rises with the duration
of marriage.
Before conception, there is a tremendous focus on conceiving; yet, after the birth
of the baby, life has to assume normal dimensions, although interestingly women still
see themselves as being infertile. Multiple births bring with them additional stresses
and difficulties with parenting. Not only do the parents find it difficult to relate to each
of the babies, they often avoid close affection to prevent favouritism. Furthermore,
pre-existing children are at the risk of being excluded because so much time has to be
spent with the babies.
How to Tell Children of Donated Gametes

All couples who undergo donor insemination (DI) or oocyte donation (OD) have to
undergo counselling both as an essential part of the treatment and as a prerequi-
site of the U.K. Human Fertilisation and Embryology Authority (HFEA). They need
to understand how the donors are selected, how they are screened and the limita-
tions of accurate matching. The counsellor also should describe the law with respect
to the legal position of the child and the parents to the child and also the rules
governing confidentiality and anonymity, which in the United Kingdom now allows
donor-conceived adults to identify their genetic parents. At present, sperm donors
are invariably anonymous at the time of donation. However, oocyte donors are often
provided by the recipient couple, sometimes by the sister of the patient. If the donor
is known to the recipient couple, it is virtually impossible to prevent the child from
knowing his or her genetic origins. In DI, the choice lies with the parents, who need
not tell anyone if they do not wish to. The parents’ names go on the child’s birth
certificate, so no one need ever know that donated gametes were used. If the parents
choose to tell their child, then they will need guidance about when and how. It is
suggested that they tell the child in stages, initially with a simple explanation of how
medical help was needed for conception, gradually expanding over the years and
always emphasising that the child was very much wanted and all the more so because
of his or her special beginning. If the couple decides not to tell their child, it is impor-
tant that they are advised not to tell anyone else, as the worst scenario is for the child
to find out as the result of an accidental slip of the tongue.
More recipients of donated eggs are thought to tell their children than those who
conceive through DI, with only 20% in the United Kingdom and 30% in the rest of
Europe informing their children of their origins [1]. There is a move towards greater
openness, although this openness can potentially bring with it another set of problems,

as many children who discover that they were conceived using donated gametes then
want to discover more about the gamete donor, and the implications of this must be
appreciated.
Surrogacy
Surrogacy involves a host mother carrying a pregnancy for a couple in which the
woman is unable to go through a pregnancy, usually because she does not have a
uterus or because she has a serious medical condition that makes it unwise for her to
conceive. Natural surrogacy involves the host donating her egg as well as lending her
uterus, and it is achieved by artificial insemination with the recipient father’s sperm
or by intercourse with the recipient father. These forms of surrogacy are performed
by private arrangement and not usually by fertility clinics. IVF surrogacy, in contrast,
involves the host receiving embryos that have been conceived in vitro by using the
recipient parents’ gametes. IVF surrogacy is offered by a few assisted conception
clinics in the United Kingdom. The ethical aspects of surrogacy are considerable,
and the host, her family and the recipient couple require extensive counselling before
embarking upon treatment.
Problems of Different Cultural Groups in the United Kingdom

Some cultures associate infertility with impotence and, for example, some African
men will only marry a woman once she has borne his child. If a conception fails to
occur, the woman might still be blamed for the couple’s infertility, even if the man is
found to be azoospermic.
Here, we give a simplified account of the teachings of the major religions – the
reader involved in these transcultural problems is encouraged to consult priests and
teachers of the religions concerned.
The Christian Church

The Anglican Church is fairly open minded about fertility treatment, as does
Buddhism. The Roman Catholic Church considers that infertility is predestined and
has suggested that infertile couples should spend their energies usefully by adopting
or helping other families, or by helping poor or handicapped children. Furthermore,
the Catholic Church considers life to begin at the time of fertilisation. This can pose
a dilemma for couples who decide to undergo IVF, as they may only permit two or
three eggs to be exposed to sperm, so if more than three oocytes are collected, they
have to be disposed of rather than allow the possibility of the disposal of pre-embryos.
The freezing of surplus oocytes in this situation is gaining popularity as technology
improves. This prevents the selection of the best quality pre-embryos for transfer and
might cause problems if there is poor fertilisation. In some South American, pre-
dominantly Catholic, countries, all embryos that are generated during IVF have to be
frozen, irrespective of their quality; if they are not transferred in a subsequent cycle
at a time when a conception could occur, they have to be placed in the uterus during

Counselling 141
the luteal phase, thus returning the embryo to the site of its origin, even though a
conception could not occur. Catholics do not favour the use of donated sperm, eggs or
embryos which all run contrary to the concept of the unity of marriage and the child’s
right to be born in marriage.
The Jewish Faith

The Jewish faith varies depending on the degree of orthodoxy, with the most ortho-
dox groups forbidding masturbation and hence any treatment that requires the pro-
duction of sperm outside the woman’s body because there should be no destruction
of germ cells. Thus, laparoscopic ovarian diathermy also is forbidden. A semen anal-
ysis can usually be obtained by ejaculation into a condom (free of spermicides) dur-
ing intercourse, or alternatively a post-coital test can be performed. Contraception
is banned, and intercourse is permitted during the most fertile time of the cycle, so
the size of Jewish families tends to be large. A couple without children therefore
feels immense pressure and distress in such a procreation-oriented society. However,
it is our experience that most couples who are intent upon seeking treatment seem
to be able to find a Rabbi who will give them a special exemption and bless their
treatment.
It has been suggested that sperm could be retrieved post-coitally from the wife
of an orthodox Jew and then prepared for either conventional IVF, if the number
of sperm is sufficient, or for IVF–intracytoplasmic sperm injection (ICSI), if only a
few sperm are retrieved [2]. This approach would require the couple to have inter-
course before oocyte retrieval at a time when the stimulated ovaries are enlarged and
possibly tender. Post-coital assisted conception (PC–IVF or PC–ICSI) provides the
possibility of fertility without the need for masturbation, semen collection devices or
coitus interruptus.
The use of donated spermatozoa is forbidden by Jewish law, which does not permit
the insemination of a married woman with spermatozoa that are not her husband’s.
The main issue is that of incest, as the father of the child is an unknown sperm donor,
although some have got round this law by using the sperm from a non-Jewish donor.
If donated sperm has been used, the owner of the sperm is considered to be the legal
father of the child.
Muslims and Hindus

Many Muslims and Hindus tend to live in close-knit, family-oriented communities, so
subfertility brings with it particular stresses. In the United Kingdom, many families
are first-generation immigrants, and the women often have a poor grasp of English
and thus become isolated within their community. They also have difficulty in know-
ing where to go for help. Although the men are often better integrated because they
are usually employed, they, too, have difficulty in accessing help and relationships can
become highly stressed. Islamic law prohibits the use of donated gametes and states
that infertility should be accepted rather than engaging in adulterous treatments. The
Hindu faith, in contrast, will permit DI by using spermatozoa from a close relative
of the husband, provided all other treatments have failed. Buddhism allows relative
freedom.

Emotional Support for Clinic Staff

Dealing with stress is stressful in itself, and it is important for nurses, doctors, embry-
ologists and administrative staff to be able to meet and defuse tensions that have been
absorbed during the course of difficult consultations and encounters. Some patients
latch on to an individual member of staff, who might not be the appropriate person
to deal with their medical problems or be able to cope with the constant demands
made upon them. For example, a particular nurse or doctor might be requested always
to perform a couple’s insemination treatment or embryo transfer after a successful
attempt resulted in a pregnancy that then miscarried. The couple might have an unre-
alistic belief that that nurse or doctor is the only member of the clinic who can help
them to achieve a pregnancy, yet with each failed attempt, the pressure on the nurse or
doctor increases to an unreasonable level. Some consultations can be extremely tense
and emotions can run so high as to make communication impossible. Tensions are
transmitted to the staff, and it is sometimes necessary to ask another member of staff
to take over either for the present or, sometimes, in all future consultations.
It is important that there is a forum to discuss all consultations at the end of the
clinic or at the end of the week, not only as an educational forum but also so that
concerns about the emotional problems of the patients can be aired. Each member of
staff also should be able to talk in confidence to a colleague about personal concerns
and difficulties, and even the counsellor sometimes needs a counsellor!
It is inevitable that some members of the clinic staff will themselves experience
infertility or miscarriage and may even require treatment at the unit where they work.
This need may create immense tensions, with a combination of factors, including
lack of privacy and a feeling of being in the spotlight during treatment. If therapy
can be offered elsewhere, the situation might be made easier, although geographical
constraints often render this option impractical.
Infertility Counsellor
The HFEA requires that each assisted reproduction clinic has access to a counsellor.
Furthermore, an infertility clinic can barely survive without a suitably trained coun-
sellor who is able to help couples deal with the emotional and ethical issues of modern
fertility treatment. The clinic nurse has traditionally fulfilled the role of counsellor,
but it is now recognised that patients should be able to communicate in confidence
with the counsellor and that the counsellor should not be involved with the patients’
treatment. There are now several courses for counsellors with an interest in infertil-
ity, and a British Infertility Counsellors’ Association (BICA) now has unified training
and accreditation for fertility counselling. Counsellors in the clinic should be trained
and also should receive regular supervision from a senior colleague, who might not
necessarily work in the fertility unit.
The counsellor has to support couples through the acceptance of their fertility
problem(s) and in making the right decisions for themselves as an individual couple
about whether to have treatment. The couple should be aware that in any one cycle of
treatment, whether by DI, ovulation induction or IVF, the greater chance is that they will
not be pregnant and that they may need support through several attempts. Some months,

Counselling 143
there will be pitfalls in the treatment, for example, lack of ovarian response to stimulation
or a cancelled cycle because of ovarian overstimulation. The counsellor therefore needs
to have a detailed understanding of the clinic’s protocols and should be able to help to
clarify the expectations of the couple. If a pregnancy occurs, there is still the possibil-
ity of miscarriage, ectopic pregnancy and problems later in pregnancy, particularly if a
multiple pregnancy has occurred. Whatever the outcome of the treatment, counselling
aims to help the couple to accept their situation and feel comfortable with their emotions.
The counsellor may work in a variety of ways but must be familiar with the likely
procedures and patterns of experience that present in a fertility clinic and the dilem-
mas, grief and joy that these bring. He or she should be able to detect major depression
and other severe psychiatric disorders and be able to recognise when the couple’s dif-
ficulties are beyond personal expertise. He or she should be familiar with the psycho-
logical processes of adjustment, the process of grief, and the resilience of the mind
and its defences.
Counsellors also can help to educate the rest of the team about psychological issues
and communication skills. Some counsellors work very closely with their nursing and
clinical colleagues, whereas others keep the entire contents of their sessions confiden-
tial. Patients should, of course, have the right to complete confidentiality if they wish,
but they should also be made aware of the fact that a summary of the counselling
sessions in the clinical notes would be helpful. The detailed content of counselling is
not usually required by the gynaecologist but where misunderstandings or grief have
been engendered, further emotional upheaval can be avoided by the sensitive involve-
ment of the gynaecologist in the relevant psychological concerns. A well-informed
team works best all-round, and if good communication does not occur between the
counsellor and clinical staff, patients may find themselves splitting the staff and
directing woe or anger against individuals.
Counsellors need to be able to accept non-judgementally the decisions that couples
make about treatment and should be aware how their own psychological dilemmas
interact with those of the patient and the gynaecologist. It is my experience that coun-
sellors contribute enormously to the successful operation of a clinic, and those that
I have met are able to empathise with the patients and take a genuine interest in their
concerns (Box 6.1).
BOX 6.1 KEY POINTS OF COUNSELLING

• Counselling is an integral part of the management of infertility.
• Subfertile men and women have different needs and approach their
problems in different ways.
• It is important to be conscious of the needs of different religious and
cultural societies.
• Working in a fertility clinic can be mentally and emotionally e xhausting;
special consideration should be given to the needs of the staff.
• Counsellors should be properly trained and selected.
• Counselling subfertile patients requires different skills and knowledge
to general counselling.

REFERENCES
1. Golombok S, Brewaeys A, Cook R, et al. The European study of assisted reproduction
families: family functioning and child development. Hum Reprod 1996; 10: 2324–31.
2. Hirsh A. Post-coital sperm retrieval could lead to the wider approval of assisted con-
ception by some religions. Hum Reprod 1996; 11: 101–3.
FURTHER READING
Appleton T. The distress of infertility: some thoughts after 22 years of infertility c ounseling.
In: Brinsden PR, ed. Textbook of In Vitro Fertilization and Assisted Reproduction,
3rd edn. Abingdon, U.K.: Taylor & Francis, 2005: 579–88.
Demyttenaere K. Coping with infertility. In: Templeton AA, Cooke I, O’Brien PMS, eds.
Evidence Based Fertility Treatment. London: RCOG Press, 1998: 345–53.

7
Anovulatory Infertility and
Ovulation Induction
Introduction
The principles of the management of anovulatory infertility are as follows: first,
to correct any underlying disorder (e.g. nutritional deficiency in hypogonadotropic
patients who are underweight); second, to optimise health before commencing t herapy
(e.g. women with polycystic ovary syndrome (PCOS) who are overweight); and third,
to induce regular unifollicular ovulation.
A semen analysis should be performed before ovulation induction (OI) therapy is
commenced. We recommend that tubal patency should be assessed by either hystero-
salpinography (HSG) or laparoscopy before embarking upon gonadotropin therapy.
There are some who believe that if there are no firm indications (e.g. past history of
pelvic infection, pelvic pain), a test of tubal patency can be delayed until there have
been up to three or six ovulatory cycles. However, to minimise the risks of therapy
(see Chapter 18) and also to ensure a cost-effective approach to treatment, we feel that
an assessment of tubal patency is appropriate in every woman before commencing
therapy.
Before considering the management of specific disorders of anovulation, we p resent
a classification of primary and secondary amenorrhoea. Of course, not all women
with anovulatory infertility are amenorrhoeic – some have oligomenorrhoea, particu-
larly those with PCOS. The classification still holds, and the diagnosis is made by
following the steps described in Chapter 5.
Pituitary and Hypothalamic Causes of Anovulation

The causes of primary and secondary amenorrhoea are listed in Tables 7.1 and 7.2.
Pituitary and hypothalamic aetiologies occur after surgery for pituitary tumours,
pituitary ablation in addition to Kallmann’s syndrome and idiopathic hypogonad-
otropic hypogonadism (Tables 7.3 and 7.4). Initial clues to the presence of a pitu-
itary tumour can be seen on a skull X-ray (Figures 7.1 and 7.2), although magnetic
resonance imaging (MRI) and computed tomography (CT) are preferred nowadays
(see below).

TABLE 7.1
Classification of Primary Amenorrhoea
Uterine causes Müllerian agenesis (e.g. Rokitansky syndrome)
Ovarian causes Polycystic ovary syndrome
Premature ovarian insufficiency (formerly known as premature
ovarian failure) (usually genetic, e.g. Turner’s syndrome)
Hypothalamic causes Weight loss
(hypogonadotropic Intense exercise (e.g. track athletes, ballerinas)
hypogonadism) Genetic (e.g. Kallmann’s syndrome)
Idiopathic
Delayed puberty Constitutional delay or secondary (see text)
Pituitary causes Hyperprolactinaemia
Hypopituitarism
Causes of hypothalamic/ Tumours (craniopharyngiomas, gliomas,
pituitary damage germinomas, dermoid cysts)
(hypogonadism) Cranial irradiation, head injuries (rare in young girls)
Systemic causes Chronic debilitating illness, often associated with weight loss
Endocrine disorders (e.g. thyroid disease, Cushing’s syndrome)
TABLE 7.2
Classification of Secondary Amenorrhoea
Uterine causes Asherman’s syndrome, cervical stenosis
Ovarian causes Polycystic ovary syndrome
Premature ovarian insufficiency (formerly known as premature
ovarian failure: genetic, autoimmune, infective, radio- and
chemotherapy)
Hypothalamic causes Weight loss
(hypogonadotropic Exercise
hypogonadism) Chronic illness
Psychological distress
Idiopathic
Pituitary causes Hyperprolactinaemia
Hypopituitarism
Sheehan’s syndrome
Causes of hypothalamic/pituitary Tumours (e.g. craniopharyngiomas)
damage (hypogonadism) Cranial irradiation
Head injuries
Sarcoidosis
Tuberculosis
Systemic causes Chronic debilitating illness
Weight loss
Endocrine disorders (e.g. thyroid disease, Cushing’s syndrome)

Anovulatory Infertility and Ovulation Induction 147
TABLE 7.3
Aetiology of Primary Amenorrhoea in
90 Consecutive Patients in an Endocrine Clinic
Aetiology %
Premature (primary) ovarian failure 36
Hypogonadotropic hypogonadism 34
Polycystic ovary syndrome 17
Hypopituitarism 4
Hyperprolactinaemia 3
Weight-related amenorrhoea 2
Congenital abnormalities 4
TABLE 7.4
Aetiology of Secondary Amenorrhoea in
570 Patients Attending an Endocrine Clinic
Aetiology %
Polycystic ovary syndrome 36.9
Premature ovarian failure 23.6
Hyperprolactinaemia 16.9
Weight-related amenorrhoea 9.8
Hypogonadotropic hypogonadism 5.9
Hypopituitarism 4.4
Exercise-related amenorrhoea 2.5
FIGURE 7.1 Lateral skull X-ray of a patient with a pituitary macroadenoma. The pituitary fossa is
enlarged and the floor of the sella turcica is eroded (black arrows).

FIGURE 7.2 Magnified view of the pituitary fossa, in a different patient with a macroadenoma,
showing an eroded floor of the sella with asymmetrical ballooning (open arrow). The anterior clinoid
processes are eroded from beneath and appear pointed (closed arrow).
Hypogonadotropic Hypogonadism
One should suspect hypogonadotropic hypogonadism if the gonadotropin concentra-
tions are subnormal (<5 IU/L) in the presence of oestrogen deficiency. The cause may
be at the level of the pituitary or hypothalamus. Luteinising hormone (LH) levels are
often suppressed more than follicle-stimulating hormone (FSH) with hypothalamic
amenorrhoea of secondary causes, such as underweight or overexercise. Stimulation
with gonadotropin-releasing hormone (GnRH) does not help in distinguishing
between a hypothalamic and pituitary aetiology, as there is great heterogeneity in
the response to a single 100-μg dose of GnRH. In our centre, we therefore no longer
perform the GnRH test [1]. The diagnosis of Kallmann’s syndrome is made if the
patient has hyposmia or anosmia associated with hypogonadotropic hypogonadism.
Radiology of the hypothalamus and pituitary is otherwise indicated with CT or MRI.
Pulsatile LHRH or GnRH

Ovulation is optimally induced in women with intact pituitary function by a pplication
of pulsatile GnRH, administered subcutaneously or intravenously by a miniaturised
infusion pump (Figures 7.3 and 7.4). The injections are given at intervals of 90 min
at a dose of either 15 μg subcutaneously or 5–10 μg intravenously [2,3]. This therapy

Emotion and
external stimuli
Hypothalamus
GnRH
Hypophyseal
portal circulation
Pituitary
gland
FSH LH
Positive and negative feedback
Ovary
Steroid hormones
(oestradiol, progesterone)
Ovulation
Non-steroidal hormones
(inhibin family)
FIGURE 7.3 Hypothalamic–pituitary–ovarian axis.
Syringe driver
Reservoir
Battery casing
and controls
Subcutaneous needle
FIGURE 7.4 Mini-infusion GnRH (LHRH) pump.
provides the most physiological correction of the primary disturbance with little risk of
multiple pregnancy or ovarian hyperstimulation. Ultrasound monitoring can be kept to a
minimum, and cumulative conception and live birth rates (LBRs) equal those expected
of normal ovulating women (see also Figure 7.8) [4–6]. Some women with hypogo-
nadotropic hypogonadism also have polycystic ovaries that are suppressed because they

FIGURE 7.5 Transabdominal ultrasound scan of suppressed polycystic ovaries in patient with
hypogonadotropic hypogonadism before stimulation.
have not been exposed to cyclical stimulation by gonadotropins. These small polycystic
ovaries are usually larger than normal ovaries in patients with hypogonadotropic hypo-
gonadism, and they can be identified before stimulation transabdominally (Figure 7.5)
or transvaginally (Figure 7.6). However, sometimes they are first recognised after stim-
ulation (Figure 7.7). If overstimulated, these ovaries behave in a typically polycystic
manner. It is also interesting to note that when stimulated with pulsatile GnRH, these
patients often develop abnormally elevated serum LH concentrations [7].
If pulsatile GnRH cannot be used (e.g. if the patient is unhappy with the equipment
or if a pump is not available), then women with hypogonadotropic hypogonadism,
of whatever cause, respond better to human menopausal gonadotropin (hMG) than
to purified FSH, because the former contains the LH that is necessary to stimulate
androgen steroidogenesis – the substrate for oestrogen biosynthesis [8]. Sadly, pulsa-
tile GnRH is nowadays seldom administered as few practitioners are trained in their
use, and the combination of pump and drugs is much more expensive than hMG.
Furthermore the product has recently been withdrawn from the UK market and so is
no longer readily available. Gonadotropin therapy is described on p. 175.
Adjuvant Therapy
Adjuvant therapy with recombinantly derived human growth hormone has been shown
to be of benefit to some women with hypogonadotropic hypogonadism who respond
poorly to gonadotropin therapy [9]. The optimum dose has not been clearly defined.
We suggest alternate-day injections of 12 IU over 2 weeks. Growth hormone appears
to be of particular benefit to women with prolonged oestrogen deficiency or pitu-
itary failure. Growth hormone deficiency can be diagnosed by a negative response of

FIGURE 7.6 Transvaginal ultrasound scan of suppressed polycystic ovaries in patient with hypo-
gonadotropic hypogonadism before stimulation.
FIGURE 7.7 Transvaginal ultrasound scan of suppressed polycystic ovaries in patients with hypo-
gonadotropic hypogonadism after stimulation.

growth hormone to clonidine, which stimulates growth-hormone–releasing h ormone

secretion and thus assesses the growth-hormone–secreting capacity of the pituitary.
Baseline measurements of growth hormone are less useful. Growth hormone has been
used in combination with several treatment regimens and does not appear to be of
benefit to women with PCOS or hypergonadotropic ovarian failure; it also has been
used in IVF regimens with little benefit.
Weight-Related Amenorrhoea
A body mass index (BMI) of less than 20 kg/m2 is subnormal (Figure 7.8) [4]. It is also
necessary to achieve a BMI >19 kg/m2 before the menarche for puberty to progress
normally. Fat seems to be the critical component, and it has been estimated that for
the maintenance of ovulatory cycles, fat should make up at least 22% of body weight.
The gonadotropin deficiency seen with weight loss is greater for LH than FSH, as is the
diminished response to stimulation with exogenous GnRH. Subnormal secretion of
gonadotropins, particularly an impairment of the pulsatility of gonadotropin secretion,
may result in a multicystic pattern in the ovary [10], as demonstrated by ultrasonog-
raphy. This ovarian appearance is characteristic of normal puberty (see Figure 5.12).
The endocrine link between nutrition and reproduction involves several factors,
including the secretion of leptin from white fat cells. Leptin is thought to signal satiety by
suppressing the activity of the central neurotransmitter neuropeptide Y (NPY). NPY, as
well as stimulating appetite and eating behaviour, controls GnRH activity, and therefore
reproduction, as well as adrenocorticotropic hormone (ACTH) and thyroid-stimulating
100
80
60
CCR (%)
40
20
0
0 2 4 6 8 10 12 14
Cycles of treatment
FIGURE 7.8 Cumulative conception rates (CCRs) over successive cycles in normal women (tri-
angle) and 20 patients with weight-related amenorrhoea (square) and 77 with hypogonadotropic
hypogonadism (diamond) who have undergone ovulation induction. (From Balen AH et al., Hum
Reprod 9, 1563–70, 1994.)

hormone (TSH) secretion, thereby modifying metabolism and the response to stress.
Leptin levels are low in starvation, resulting in heightened NPY activity, a voracious
appetite, with elevated ACTH and cortisol concentrations and low TSH and thyroxine
concentrations, as typically seen in patients with severe anorexia nervosa. As weight is
regained, leptin secretion resumes, NPY activity falls and GnRH secretion resumes,
permitting the return of fertility as nutrition returns to normal. It is thought that leptin
also plays an important role in the initiation of puberty, along with other hormones that
are involved in the regulation of GnRH secretion such as kisspeptin.
There are many other hormones that interlink nutrition with reproduction to pre-
vent fertility and preserve vital bodily functions during times of famine and to facili-
tate a return to fertility when the body is nutritionally able to cope with a pregnancy.
Ghrelin, secreted from the stomach, has been described as the hunger hormone. It is
released during food deprivation, causing an increase in appetite, and it also inhib-
its GnRH secretion both directly and via an increase in secretion of corticotropin-
releasing hormone (CRH). Conversely, Peptide YY, from small bowel, secreted when
nutritionally replete, suppresses appetite and stimulates GnRH pulsatility.
Not all women who attain a normal BMI resume regular menstruation. In some
cases, resuming menstruation is dependent on levels of exercise, in which case the
serum LH concentration may still be low. Approximately 20% of women have PCOS
(see Chapters 5 and 8), a condition which is also associated with an increased rate of
eating disorders. Women with PCOS will be prone to oligomenorrhoea or amenor-
rhoea irrespective of their BMI.
Anorexia nervosa accounts for between 15% and 35% of patients with amenor-
rhoea. It is now recognised that there is a spectrum of psychosomatic dysfunction
from anorexia nervosa to bulimia and that menstrual disturbances are invariably
associated. Although the extreme forms of dietary abuse are more readily recognised
now than in the past, there are many women with weight-related amenorrhoea who
have an appropriate body image perception and a lesser degree of weight loss than that
seen in classic anorexia nervosa. It should be appreciated that these groups may form
part of a continuum, with the possibility of an apparently innocent dieting pattern
leading eventually to true anorexia. Many of these women will have presented with
either amenorrhoea or infertility without perceiving that they have a problem related
to weight. It is essential to encourage weight gain as the main therapy, and a careful
explanation of the cause of their amenorrhoea will help in this aim. Women with
anorexia nervosa should be managed in collaboration with a psychiatrist, and women
with less severe dieting problems usually benefit from counselling or psychotherapy.
The prescription of an oral contraceptive, while inducing an artificial cycle, masks
the underlying problem by allowing the denial of weight loss as the aetiological factor.
In contrast, the degree of osteopenia caused by oestrogen deficiency may be so great
that the benefits of oestrogen replacement therapy outweigh any putative psychiatric
risks. Oestrogen and leptin deficiency, reduced calcium and protein intake, reduced lev-
els of vitamin D and elevated cortisol levels can all contribute to osteoporosis, so oes-
trogen therapy alone does not always rectify the problem. The age of onset of anorexia
nervosa is also important, as prolonged amenorrhoea before the normal age at which
peak bone mass is obtained (approximately 25 years) increases the likelihood of severe
osteoporosis. Pregnancy and lactation make significant demands on the skeleton’s cal-
cium reserves, so conception when significantly osteoporotic carries additional risks.

Although ovulation may be readily induced with either GnRH or exogenous gonad-
otropins, treatment of infertility in the underweight patient is not necessarily in the
baby’s best interest as embarking upon a pregnancy when severely underweight results
in a significant risk of intrauterine growth retardation and neonatal problems. In our
experience, few women have difficulty in perceiving and accepting that being under-
weight poses an avoidable risk to the unborn child and that, consequently, weight
gain is an essential prelude to conceiving [11]. Furthermore, because three-quarters
of the cell divisions that occur during pregnancy take place during the first trimester,
it is essential that nutritional status is optimised before conception. In an increas-
ing number of studies, low birth weight also is being related to an increased risk of
cardiovascular disease, obstructive lung disease and other illnesses in adult life [12].
Thus, it seems that fetal nutritional status determines the pattern of adult disease. It is
therefore the duty of the fertility specialist to provide a holistic approach to the patient
and her desire for a family, with appropriate involvement of other healthcare profes-
sionals (e.g. dietitian, nutritionalist, counsellor, psychiatrist) in providing support both
before and after pregnancy.
Worldwide, involuntary starvation is the commonest cause of reduced reproduc-
tive ability, resulting in delayed pubertal growth and menarche in adolescents and
infertility in adults. Acute malnutrition, as seen in famine conditions and during and
after World War II, has profound effects on fertility and fecundity. Ovulatory function
usually returns quickly on restoration of adequate nutrition. The chronic malnutrition
common in developing countries has less profound effects on fertility but is associ-
ated with small and premature babies.
Systemic Disorders Causing Secondary

Amenorrhoea and Anovulation
Chronic disease may result in menstrual disorders as a consequence of the general
disease state, weight loss or by the effect of the disease process on the h ypothalamic–
pituitary axis. Furthermore, a chronic disease that leads to immobility, such as
chronic obstructive airways disease, may increase the risk of amenorrhoea-associated
osteoporosis.
In addition, certain diseases affect gonadal function directly. Women with chronic
renal failure have a discordantly elevated LH, possibly as a consequence of impaired
clearance. Prolactin also is elevated in these women, due to failure of the normal
dopamine inhibition. Diabetes mellitus may result in functional hypothalamic–
pituitary amenorrhoea and be associated with an increased risk of PCOS. Liver
disease affects the level of circulating sex-hormone-binding globulin and thus
circulating free hormone levels, thereby disrupting normal feedback mechanisms.
Metabolism of various hormones, including testosterone, is also liver dependent;
both menstruation and fertility return after liver transplantation. Endocrine disor-
ders such as thyrotoxicosis and Cushing’s syndrome are commonly associated with
gonadal dysfunction. Management of these patients should concentrate on the under-
lying systemic problem and on preventing complications of oestrogen deficiency. If
fertility is required, it is desirable to achieve maximal health and, where possible, to
discontinue teratogenic drugs.

Studies have failed to demonstrate a link between stressful life events and
a menorrhoea of longer than 2 months. However, stress may lead to physical debility
such as weight loss that may then cause menstrual disturbance.
Exercise-Related Amenorrhoea
Menstrual disturbance is common in athletes undergoing intensive training. Between
10% and 20% of such athletes have oligomenorrhoea or amenorrhoea, compared
with 5% in the general population. Amenorrhoea is more common in athletes under
30 years of age, and it is particularly common in women involved in the endurance
events, such as long-distance running. Up to 50% of competitive runners training
80 miles/week may be amenorrhoeic [13]. Studies of women who train for competitive
sport have reported rates of oligomenorrhoea/amenorrhoea of 16%–79% in dancers,
47% in gymnasts, 24%–50% in runners and 12% in swimmers and cyclists [14,15].
The main aetiological factors are low weight and low percentage body fat content,
but other factors also have been postulated. Physiological changes are consistent with
those associated with starvation and chronic illness. To conserve energy, there may
be a fall in TSH, a reduction in tri-iodothyronine (T3) and an elevation of the inactive
reverse-T3. Exercise also leads to a fall in circulating insulin and insulin-like growth
factor 1 (IGF1) and therefore decreases their stimulation of the pituitary and ovary.
Amenorrhoea occurs when percentage body fat falls below a threshold of 17% and
when serum LH concentrations are less than 5 IU/L.
Female ballet dancers provide an interesting and much studied subgroup of sports
women, because their training begins at an early age. They have been found to have
a significant delay in menarche (15.4 vs. 12.5 years) and a retardation in pubertal
development that parallels the intensity of their training. Menstrual irregularities are
common and up to 44% have secondary amenorrhoea [16]. In a survey of 75 dancers,
61% were found to have stress fractures and 24% had scoliosis; the risk of these patho-
logical features was increased if menarche was delayed or if there were prolonged
periods of amenorrhoea. These findings may be explained by delayed pubertal matu-
ration resulting in attainment of a greater than expected height and a predisposition to
scoliosis, as oestrogen is required for epiphyseal closure.
Exercise-induced amenorrhoea has the potential to cause severe long-term
morbidity, particularly with regard to osteoporosis. Studies on young ballet dancers
have shown that the amount of exercise undertaken by these dancers does not com-
pensate for these osteoporotic changes. Oestrogen is also important in the formation
of collagen, and soft tissue injuries are also common in dancers. Whereas moderate
exercise has been found to reduce the incidence of post-menopausal osteoporosis,
young athletes may be placing themselves at risk at an age when the attainment of
peak bone mass is important for long-term skeletal strength.
It is sometimes difficult to unravel the interaction between desire to exercise and
an eating disorder, as undereating and overexercising are mutually reinforcing and
self-perpetuating behaviours [17]. The psyche of the young athlete is affected not
only by pressure to compete against peers but also by parents and coaches. Stresses
– mental as well as physical – may be immense, and some athletes are found to be
abusing performance enhancing drugs at a young age. Appropriate advice should be

given, particularly regarding improving diet, vitamin, calcium and iron supplements,
and the use of a cyclical oestrogen/progestogen preparation should be considered.
If possible, the amount of exercise itself should be reduced, for which the support of
parents and coaches is essential. Unfortunately, the long-term health of the young girl
is often overridden by the ambitions of those around her.
Hyperprolactinaemia
There are many causes of a mildly elevated serum prolactin concentration, including
stress and a recent physical or breast examination. If the prolactin concentration is
greater than 1000 mU/L, then the test should be repeated, and if still elevated, it is nec-
essary to image the pituitary fossa (usually by MRI) [18]. Hyperprolactinaemia may
result from a prolactin-secreting pituitary adenoma or from a large non-functioning
disconnection tumour in the region of the hypothalamus or pituitary that disrupts
the inhibitory influence of dopamine on prolactin secretion. Large non-functioning
tumours are usually associated with serum prolactin concentrations of less than
3000 mU/L (Figure 7.9), whereas prolactin-secreting macroadenomas usually result
(a) (b)
FIGURE 7.9 Craniopharyngioma. Cranial MRI. (a) Coronal T1-weighted section after gadolinium
enhancement. (The tumour signal intensity is reduced on the T1 image, and only part of the periphery
of the tumour enhances.) The carotid arteries have a low signal intensity (black arrows) due to the
rapid flow within them and are deviated laterally and superiorly by the mass, which arises out of the
pituitary fossa (P). (b) Axial T2-weighted section, without enhancement, made just above the level
of the pituitary gland and through the chiasmatic cistern. There is a high signal in the suprasellar
extension of the tumour (arrowed).

TABLE 7.5
Causes of Hyperprolactinaemia
Physiological Pregnancy, lactation, neonatal period, stress
Hypothalamic Tumours, transection pituitary stalk, cranial irradiation
Pituitary Adenoma, acromegaly, Cushing’s disease, tumours compressing pituitary stalk,
empty sella syndrome
Miscellaneous Primary hypothyroidism, PCOS, chronic renal failure, cirrhosis, ectopic
prolactin secretion (bronchogenic carcinoma, hypernephroma), seizures;
hypersecretion of biologically less active isoforms of prolactin
(e.g. big-prolactin)
Drugs SSRIs: citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
Classic neuroleptics: perphenazine, fluphenazine, flupentixol, thioridazine,
promazine, haloperidol, loxapine, chlorpromazine, sulpiride
Atypical neuroleptics: amisulpride, sertindole, risperidone
Anti-emetics: metoclopramide, domperidone
Cardiovascular drugs: verapamil, reserpine, methyldopa
Oestrogens: high-dose oral contraceptives
Opiates
Miscellaneous: bezafibrate, omeprazole, trimethoprim,
histamine H2 antagonists
in concentrations of 4000 mU/L or more, and the figures may rise to 50,000 mU/L.
Other causes of mild hyperprolactinaemia include hypothyroidism, PCOS (occurs in
15%; up to 2500 mU/L) and several drugs (e.g. the dopaminergic antagonist pheno-
thiazines, selective serotonin reuptake inhibitors (SSRIs), domperidone and meto-
clopramide). In fact, the SSRIs are now the most common cause of drug-induced
hyperprolactinaemia (Table 7.5) [19].
If the prolactin concentration is slightly to moderately elevated in the presence
of regular menstruation, there is no evidence that treatment to suppress prolactin
will improve fertility. Some people secrete biologically inactive prolactin molecules
(big-prolactin and big-big-prolactin) that are detected by the standard prolactin assays
and give an incorrect impression of a problem.
In women with hyperprolactinemic amenorrhoea, the main symptoms are usu-
ally those of oestrogen deficiency (e.g. vaginal dryness, dyspareunia), and libido is
usually reduced, irrespective of oestrogen status. Prolonged oestrogen deficiency may
result in osteoporosis, and although in many cases there will be an improvement of
trabecular bone mineral density with resumption of regular menses, full recovery
is not seen in all patients. In contrast, when hyperprolactinaemia is associated with
PCOS, the syndrome is characterised by adequate oestrogenisation, polycystic ova-
ries on ultrasound scan and a withdrawal bleed after a progestogen challenge; the
bone mineral density is usually normal. Galactorrhoea may be found in up to one-
third of hyperprolactinemic patients, although its appearance is not correlated with
prolactin levels or with the presence of a tumour [18]. Approximately 5% present with
visual field defects.
A prolactin-secreting pituitary microadenoma (Figure 7.10) is usually associated
with a moderately elevated prolactin (1500–4000 mU/L) and is unlikely to result in
abnormalities on a lateral skull X-ray. Conversely, a macroadenoma (Figure 7.11),

FIGURE 7.10 Pituitary microadenoma. Cranial MRI. A coronal section T1-weighted spin echo
sequence after intravenous gadolinium. The normal pituitary gland is hyperintense (bright), whereas
the tumour is seen as a 4-mm area of non-enhancement (grey) in the right lobe of the pituitary,
encroaching up to the right cavernous sinus. It is eroding the right side of the sella floor (arrow).
associated with a prolactin typically greater than 4000–8000 mU/L, and by defini-
tion greater than 1 cm in diameter, may cause typical radiological changes, that is, an
asymmetrically enlarged pituitary fossa, with a double contour to its floor and erosion
of the clinoid processes. In practice, X-ray imaging is seldom performed these days
as CT and MRI allow detailed examination of the extent of the tumour, and, in par-
ticular, identification of suprasellar extension and compression of the optic chiasma
or invasion of the cavernous sinuses. Prolactin is an excellent tumour marker, so the
higher the serum concentration, the larger the size of the tumour expected on the MRI
scan. In contrast, a large tumour on the scan with only a moderately elevated serum
prolactin concentration (2000–3000 mU/L) suggests a non-functioning tumour com-
pressing the pituitary stalk with disconnection from the hypothalamus.
Management
The management (Table 7.6) of hyperprolactinaemia centres around the use of a
dopamine agonist (ergot-derived bromocriptine and cabergoline and the non-ergot
quinagolide). Bromocriptine is still the most widely used preparation, despite caber-
goline being today’s drug of choice (see below). Of course, if the hyperprolactinae-
mia is drug induced, the relevant preparation should be discontinued. However, this
discontinuation may not be appropriate if the cause is a psychotropic medication,

(a)
(b)
FIGURE 7.11 Pituitary macroadenoma. Cranial MRI. T1-weighted sections made after gadolinium
enhancement. (a) Mid-line sagittal section. (b) Coronal section at the level of the pituitary stalk
(white arrows). There is a macroadenoma that enhances to a considerably lesser degree than the
normal pituitary substance within and expanding from the left lobe of the pituitary gland into the left
cavernous sinus. The tumour bulges the pituitary diaphragms superiorly and deviates the pituitary
stalk towards the right side.

TABLE 7.6
Drug Therapy for Hyperprolactinaemia
Drug Dosage Maintenance
Bromocriptine 2.5–20 mg daily, divided doses Usually 5–7.5 mg/day
Cabergoline 0.25–1 mg twice weekly Usually 1 mg/week
Quinagolide 25–150 μg daily, divided doses Usually 75 μg/day
for example, a phenothiazine being used to treat schizophrenia. In these cases, it is

reasonable to continue the drug and, after imaging the pituitary fossa, to prescribe
a low-dose combined oral contraceptive to counteract the symptoms of oestrogen
deficiency. Serum prolactin concentrations must then be carefully monitored to ensure
that they do not rise further. Sometimes, it is possible to change to an alternative drug,
such as an atypical neuroleptic. The use of a dopamine agonist combined with an
antipsychotic may lower serum prolactin concentrations, but it also may antagonise
the therapeutic effects of the antipsychotic agent. Furthermore, dopaminergic drugs
can occasionally induce or worsen psychotic symptoms (probably more so with bro-
mocriptine than the longer acting cabergoline), so they should only be used with great
caution in patients with pre-existing psychotic illness and in conjunction with input
from a psychiatrist [19].
Most patients show a fall in prolactin levels within a few days of commencing dopa-
mine agonist therapy and a reduction of tumour volume within 6 weeks (Figures 7.12
through 7.14).
Bromocriptine
Bromocriptine should be commenced at a dose of half a tablet at night (1.25 mg) and
increased gradually every 3–5 days to 2.5 mg at night and then 1.25 mg in the morn-
ing with 2.5 mg at night until the daily dose is 7.5 mg (in two or three divided doses).
The maintenance dose should be the lowest that works and is often lower than that
needed at first to initiate a response. Side effects (e.g. nausea, vomiting, headache,
postural hypotension) can be troublesome and are minimised by commencing the
therapy at night for the first 3 days of treatment and taking the tablets in the middle
of a mouthful of food. Longer term side effects include Raynaud’s syndrome, consti-
pation and psychiatric changes, especially aggression, that can occur at the start of
treatment [18].
Quinagolide and Cabergoline

Longer acting preparations (e.g. quinagolide or twice-weekly cabergoline) may be
prescribed to those patients who develop unacceptable side effects. Cabergoline gen-
erally appears to be better tolerated and more efficacious than bromocriptine, and it is
now the drug of choice for hyperprolactinaemia, although it is not licenced for women
who want to conceive; so, the current recommendation is to switch to bromocriptine if
fertility is desired (although there is some debate as to whether this is still appropriate
advice). Both quinagolide and cabergoline are highly effective in suppressing pro-
lactin secretion, although the latter drug appears more effective in reducing tumour

(a)
(b)
FIGURE 7.12 Pituitary macroadenoma. (a) CT scan of the pituitary fossa with coronal reconstruc-
tions. A 1.3-mm slice taken after contrast enhancement showing a mixed density tumour (arrow)
with suprasellar extension. (b) The same patient after treatment with bromocriptine showing con-
siderable shrinkage of the tumour, with no suprasellar component but evidence on this section of
erosion of the floor of the sella into the sphenoid sinus (arrow).
volume [19]. Bromocriptine and cabergoline have been associated with p ulmonary,
retroperitoneal and pericardial fibrotic reactions, so e chocardiography is r ecommended
before starting treatment to exclude valvulopathy, and echocardiography should be
repeated after 3–6 months and then annually, although young patients are less at
risk than older patients who may be prescribed higher doses for the management of
Parkinson’s disease.
Dopamine agonist therapy may be discontinued for a trial period after a variable
period of time, usually 1–5 years; approximately 25% of patients will remain
normoprolactinemic [20].

FIGURE 7.13 MRI scan of a pituitary macroadenoma before bromocriptine therapy. T1-weighted

image after gadolinium enhancement demonstrating a macroadenoma with a large central cystic
component (large arrow). There is suprasellar extension with compression of the optic chiasm
(small arrows).
Surgery
Surgery, in the form of a transsphenoidal adenectomy, is reserved for cases of drug
resistance and failure to shrink a macroadenoma or if there are intolerable side
effects from the drugs (the most common being indication). Non-functioning tumours
should be removed surgically and are usually detected by a combination of imaging
and a serum prolactin concentration of less than 3000 mU/L. These tumours may
expand with invasion of the cavernous sinus or compression of the optic chiasma
(with impairment of vision). Occasionally, such tumours are subject to haemorrhage
(pituitary apoplexy). When the prolactin level is between 3000 and 8000 mU/L, a
trial of bromocriptine is warranted, and if the prolactin level falls, it can be assumed

FIGURE 7.14 MRI scan of a pituitary macroadenoma after bromocriptine therapy. The tumour has
almost completely resolved, and there is tethering of the optic chiasm (arrow) to the floor of the sella.
that the tumour is a prolactin-secreting macroadenoma. Operative treatment is also

required if there is suprasellar extension of the tumour that has not regressed during
treatment with bromocriptine and a pregnancy is desired. With the current skills of
neurosurgeons in transsphenoidal surgery, it is seldom necessary to resort to pitu-
itary irradiation, which offers no advantages. Furthermore, long-term surveillance is
required after irradiation to detect the inevitable hypopituitarism, a condition that is
immediately apparent if it occurs after surgery.
Women with a microprolactinoma who want to conceive should be prescribed bro-
mocriptine, as there are limited safety data for the use of cabergoline in pregnancy,
albeit reassuring [20]. Bromocriptine may be discontinued when pregnancy is diag-
nosed and no further monitoring is required, as the likelihood of significant tumour
expansion is very small (<2%). In contrast, if a patient with a macroprolactinoma is
not treated with bromocriptine, the tumour has a 25% risk of expanding during preg-
nancy. This risk is probably also present if the tumour has been treated but has not
shrunk, as assessed by CT or MRI scan.

The first-line approach to treatment of macroprolactinomas is therefore with cab-

ergoline combined with barrier methods of contraception. In cases with suprasellar
expansion, a follow-up CT (or MRI) scan should be performed after 3 months of
treatment to ensure tumour regression before it is safe to embark upon pregnancy.
The patient should be switched to bromocriptine if she is trying to conceive; this drug
can be discontinued during pregnancy, although if symptoms suggestive of tumour
re-expansion occur, an MRI scan should be performed. If there is continuing supra-
sellar expansion, it is necessary to recommence bromocriptine therapy. The patient
also requires expert assessment of her visual fields during pregnancy.
If the serum prolactin is found to be elevated and the patient has a regular men-
strual cycle, no treatment is necessary unless the cycle is anovulatory and fertility is
desired. Amenorrhoea is the bioassay of prolactin excess and should be corrected for
its sequelae, rather than for the serum level of prolactin.

A detailed description of the definition of PCOS, its pathophysiology, and long-term
sequelae is given in Chapter 8. Here, we deal with PCOS in the context of anovula-
tory infertility, of which, in the developed world, it is the commonest cause. Various
factors influence ovarian function, and fertility is adversely affected by an indi-
vidual being overweight, usually with hyperinsulinaemia or having elevated serum
concentrations of LH (Figure 7.15). Strategies to induce ovulation include weight
100
80 Cycle disturbance
60
%
40
Infertility
20
0
1–2 3–4 5–6 7–8 9–10 11–12 13–14 15–16 17–18 19–20 21–22 23–24 25–26
LH (IU/L)
FIGURE 7.15 Relationship of serum luteinising hormone (LH) concentration to rate of infertility

and cycle disturbance.

loss, oral anti-oestrogens (principally clomifene citrate (CC)), aromatase inhibitors,

parenteral gonadotropin therapy and laparoscopic ovarian surgery. There have been
no adequately powered randomised studies to determine which of these therapies
provides the best overall chance of an ongoing pregnancy when used as first-line ther-
apy. Women with PCOS are at risk of ovarian hyperstimulation syndrome (OHSS) and
multiple pregnancy, so OI has to be carefully monitored with serial ultrasound scans.
The realisation of an association between hyperinsulinaemia and PCOS has resulted
in the use of insulin-sensitising agents such as metformin. Early studies indicated that
metformin may ameliorate the biochemical profile and improve reproductive func-
tion, but large randomised clinical trials (RCTs) and recent systematic reviews have
not found significant benefit (see below).
Newer therapeutic approaches include aromatase inhibitors and the potential use
of in vitro maturation (IVM) of oocytes collected from unstimulated (or minimally
stimulated) polycystic ovaries. There has been an unfortunate shift away from mono-
follicular OI (Figure 7.16) to the use of IVF, based on a false premise of greater cumu-
lative conception rates (CCRs) and appropriate concerns about multiple pregnancy.
Superovulation for IVF presents significant risks for women with polycystic ovaries,
namely, the potentially life-threatening complication of OHSS. Carefully conducted
and monitored OI can achieve good CCRs; furthermore, multiple pregnancy rates can
be minimised with strict adherence to criteria that limit the number of follicles that
are permitted to ovulate.
PCOS accounts for approximately 80%–90% of women with anovulatory infertil-
ity. There are many interlinking factors that affect expression of PCOS [21]. A gain
in weight is associated with a worsening of symptoms, whereas weight loss will
FIGURE 7.16 Stimulation of a single mature follicle in a polycystic ovary (transvaginal

ultrasound scan).

ameliorate the endocrine and metabolic profile and symptomatology [22]. Feedback
from the polycystic ovary to both the pituitary and hypothalamus appears to be
disturbed due to abnormalities in the secretion of ovarian steroid hormones and –
probably more importantly – of non-steroidal hormones, for example, inhibin and
related proteins [23,24]. Normal ovarian function relies upon the selection of a fol-
licle that responds to an appropriate signal (e.g. FSH) to grow, become dominant and
ovulate. This mechanism is disturbed in women with PCOS, resulting in multiple
small cysts (follicles), most of which contain potentially viable oocytes but within
dysfunctional follicles.
Hypersecretion of LH is found in 40% of women with PCOS and is associated with
a reduced chance of conception and an increased risk of miscarriage, possibly through
an adverse effect of LH on oocyte maturation [23]. Elevated LH concentrations are
more often found in slim women with PCOS, whereas those who are overweight
are more likely to be hyperinsulinaemic. Genetic studies to date have demonstrated
abnormalities in both the steroidogenic pathway for androgen biosynthesis and the
regulation of expression of the insulin gene. Elevated serum concentrations of insulin
are more common in both lean and obese women with PCOS than in weight-matched
controls. Indeed, it is hyperinsulinaemia that many feel is the key to the pathogenesis
of the syndrome as insulin stimulates androgen secretion by the ovarian stroma and
appears to affect the normal development of ovarian follicles, by the adverse effects
of androgens on follicular growth and possibly also by suppressing apoptosis and
permitting the survival of follicles otherwise destined to disappear (see Chapter 8).
OI has traditionally involved the use of CC and then gonadotropin therapy or lap-
aroscopic ovarian surgery in those who are clomifene resistant. The principles of
management of anovulatory infertility are first to optimise health before commenc-
ing therapy, for example, weight loss for those who are overweight, and then induce
regular unifollicular ovulation while minimising the risks of OHSS and multiple
pregnancy.
Endocrine and Metabolic Factors in Anovulation

Hypersecretion of LH is particularly associated with menstrual disturbances and
infertility (Table 7.7 and Figure 7.15) [21]. Indeed, it is this endocrine feature that
appears to result in reduced conception rates and increased rates of miscarriage in
TABLE 7.7
Serum Luteinising Hormone Concentrations with
Respect to Fertility Status
Fertility Status Serum LH Concentrations (IU/L)
Proven fertility 7.2 ± 2.1
Untested fertility 7.4 ± 2.2
Primary infertility 11.0 ± 2.2a
Secondary infertility 9.0 ± 2.0b
Source: Balen AH et al., Hum Reprod 10, 2107–11, 1995.
a Different from proven fertile and secondary infertile groups.
b Different from proven fertile group.

both natural and assisted conception [23]. The finding of a persistently elevated early
to mid-follicular-phase LH concentration in a woman who is trying to conceive sug-
gests the need to suppress LH levels by either pituitary desensitisation, with a GnRh
agonist, or laparoscopic ovarian diathermy (LOD). However, there are no large pro-
spectively randomised trials that demonstrate a therapeutic benefit from a reduction
in serum LH concentrations during OI protocols. The assessment of serum LH con-
centration in the mid-follicular stage of the stimulated cycle is helpful in predicting
the likelihood of a successful outcome – particularly in the context of CC therapy
(see below).
The patient’s BMI correlates with both an increased rate of cycle disturbance and
infertility [25], secondary to disturbances in insulin metabolism [26]. Even moderate
obesity (BMI > 27 kg/m2) is associated with a reduced chance of ovulation [27], and
a body fat distribution leading to an increased waist:hip ratio appears to have a more
important effect than body weight alone. Monitoring treatment is also harder in obese
women because their ovaries are more difficult to see on ultrasound scans, thus rais-
ing the risk of missing multiple ovulation and multiple pregnancy. National guidelines
in the United Kingdom for managing overweight women with PCOS advise weight
loss, preferably to a BMI of less than 30 kg/m2, before commencing drugs for ovarian
stimulation [28].
Obese women (BMI > 30 kg/m2) should therefore be encouraged to lose weight
(see Chapter 4). A study some years ago in Australia [22] looked at the effects of a
weight loss and exercise programme on women with anovulatory infertility, clomi-
fene resistance and a BMI > 30 kg/m2. The emphasis of the study was a realistic exer-
cise schedule combined with positive reinforcement of a suitable eating programme
over a 6-month period. Thirteen out of the 18 women enrolled completed the study.
Weight loss had a significant effect on endocrine function, ovulation and subsequent
pregnancy. Fasting insulin and serum testosterone concentrations fell, and 12 of the
13 subjects resumed ovulation; 11 became pregnant (five naturally and the remainder
became sensitive to clomifene). Thus, with appropriate support, patients may ovulate
spontaneously without medical therapy. An extension of this study, in women with a
variety of diagnoses, demonstrated that in 60 out of 67 subjects weight loss resulted in
natural (spontaneous) ovulation with lower than anticipated rates of miscarriage and a
significant saving in the cost of treatment [29].
Even a modest loss of 5% of total body weight can achieve a reduction of central
fat, an improvement in insulin sensitivity and restoration of ovulation. Lifestyle modi-
fication is clearly a key component for the improvement of reproductive function in
overweight women with anovulation and PCOS. As the considerable risks in preg-
nancy associated with obesity are not usually appreciated when patients with PCOS
attend clinics and request fertility treatment, we posed the questions as to whether it is
appropriate to offer treatment or to insist on weight loss [30]. Or does any overweight
woman have the right to receive treatment, irrespective of the possible outcome? (see
Chapter 4.) We suggest that women with obesity and PCOS should try to attain a BMI
< 30 kg/m2 before commencing OI. Consideration of age is of course important; yet,
ultimately, the main consideration should be for the potential health of the pregnancy
and any children born.
Looking at all of the data together, lifestyle modification certainly achieves an
improvement in metabolic and endocrine parameters, although can be very hard to

sustain long term and there is a high rate of dropout [31]. Nonetheless, the incentive of
a much wanted pregnancy can be sufficient stimulus for many women with obesity-
related subfertility.
Clomifene Citrate Therapy

Anti-oestrogen therapy with CC or tamoxifen has traditionally been used as first-
line therapy for anovulatory PCOS (Box 7.1 and Figure 7.17). CC has been avail-
able for many years, and its use has tended not to have been closely monitored.
A meta-analysis has confirmed that clomifene is effective in increasing pregnancy
BOX 7.1 PROTOCOL FOR CC THERAPY

Pre-treatment investigations: semen analysis, assessment of tubal patency. If
BMI > 30 kg/m2, advise weight loss
Monitoring of therapy:
• serial ultrasound scans until response is confirmed

• standard would be ultrasound monitoring for each cycle
• luteal-phase progesterone each cycle
• mid-follicular-phase (day 8) LH in first cycle of a new dose
Dose: start with 50 mg, increase to 100 mg if no response and drop to 25 mg

if overresponse.
80
70
60
50
40
%
30
20
10
0
0 1 2 3 4 5 6 >6
Cycles
FIGURE 7.17 Use of clomifene citrate in induction of ovulation. (From Kousta E et al., Hum
Reprod Update 3, 359–65, 1997.)

rates compared with placebo as first-line therapy (fixed odds ratio (OR) 5.8, 95% CI
1.6–21.5; number needed to treat (NNT) 5.9, 95% CI 3.6–16.7) [32]. Nonetheless,
clomifene is associated with an approximately 11% risk of multiple pregnancy [33],
so careful monitoring with ultrasound to assess ovarian response is recommended.
Anti-oestrogen therapy is usually commenced on day 2 of the cycle and given for
5 days. If the patient has oligo/amenorrhoea, it is necessary to exclude pregnancy
and then induce a withdrawal bleed with a short course of a progestogen, such as
medroxyprogesterone acetate 5–20 mg/day for 5–10 days. The starting dose of CC
is 50 mg/day, for 5 days beginning on days 3–5 of the menstrual cycle (the first day
of bleeding is considered day 1 of the cycle). If the patient has not menstruated by
day 35 and she is not pregnant, a progestogen-induced withdrawal bleed should be
initiated. The dose of CC should only be increased if there is no response after three
cycles as, of those women who will respond to 50 mg/day, only two-thirds will do so
in the first cycle. Doses of 150 mg/day or more appear not to be of benefit. If there
is an exuberant response to 50 mg/day, as in some women with PCOS, the dose can
be decreased to 25 mg/day. Discontinuation of CC therapy should be considered if
the patient is anovulatory after the dose has been increased up to 100 mg/day. If the
patient is ovulating, conception is expected to occur at a rate determined by factors
such as the patient’s age.
CC may cause an exaggeration in the hypersecretion of LH and have anti-oestrogenic
effects on the endometrium and cervical mucus. All women who are prescribed CC
should be carefully monitored with a combination of endocrine and ultrasonographic
assessment of follicular growth and ovulation because of the risk of multiple pregnan-
cies. Clomifene therapy should therefore be prescribed and managed by specialists in
reproductive medicine.
An ovulatory trigger in the form of parenteral administration of hCG is very rarely
required and should only be given if there has been repeated evidence of an unrup-
tured follicle, by ultrasound and serum progesterone monitoring. Women with PCOS
should have LH measured on day 8 in a cycle that follows an ovulatory cycle; if the
LH is greater than 10 IU/L, the chance of conception is reduced and risk of miscar-
riage is elevated [34]. In this case, the options include LOD or gonadotropin therapy.
Other factors associated with treatment failure include obesity, elevated androgens
and hyperinsulinaemia (see below).
CC induces ovulation in approximately 70%–85% of patients. It is recommended
that at least the first cycle of treatment, if not all cycles, should be monitored with a
combination of serial ultrasound scans and serum endocrinology. In a large series of
167 patients treated with CC, there was a cumulative conception rate of 67.3% over
6 months in women who had no other subfertility factors, which continued to rise up
to 12 cycles of therapy (Figure 7.17) [33]. These investigators reported a multiple preg-
nancy rate of 11%, similarly to that described in other series and a miscarriage rate of
23.6%, with those who miscarried tending to have a higher serum LH concentration
immediately after CC administration. If a pregnancy has not occurred after 10–12
normal ovulatory cycles, it is then appropriate to offer the couple assisted conception.
The hormonal profiles were studied in a series of 41 women treated with CC, of
which 28 ovulated [34]. In those women who ovulated, 17 exhibited normal patterns
of hormone secretion and five conceived, whereas 11 exhibited an abnormal response,
characterised by significantly elevated serum concentrations of LH from day 9 until

the LH surge, together with premature luteinisation and higher E2 levels throughout
the cycle; none of the patients with this abnormal response conceived. This fi nding
strengthens the argument for careful monitoring of therapy and discontinuation if
the response is abnormal. Due to its anti-oestrogenic effect, CC also may inhibit
adequate endometrial thickening that may affect implantation. In addition, reduction
in cervical mucus may affect sperm penetration.
A useful approach for clomifene-resistant patients is the administration of
progesterone before CC treatment [35], which at an intramuscular dose of 50 mg
over 5 days caused a suppression of FSH and LH secretion. LH levels fell in 7 out
of 10 women treated with progesterone; all became responsive to clomifene (those
whose LH levels were not suppressed remained unresponsive), and three conceived in
the first cycle of treatment.
Side effects of clomifene include visual disturbances (stop drug immediately),
multiple pregnancy (in approximately 10%), abdominal distension, ovarian cysts, hot
flushes, breast tenderness, dizziness and nausea. Some women who experience trou-
blesome side effects with clomifene benefit from tamoxifen (20–40 mg, days 2–6).
Monitoring should be the same as for clomifene.
Clomifene is currently licenced for only 6 months’ use in the United Kingdom.
as the initial application for the licence was only made for 6 months. It has been
suggested that there is an association between clomifene and ovarian cancer with
more than 12 months’ therapy, although in most cases of prolonged use the indication
was unexplained infertility rather than anovulation [36]. It would seem reasonable
that patients should be counselled about the possible risks if treatment is to continue
beyond 6 months. If pregnancy has not occurred after 10–12 normal ovulatory cycles,
it is then appropriate to offer the couple assisted conception.
Approximately 15% of women do not respond and are considered to be clomifene
resistant. Patients with anovulatory infertility who are resistant to anti-oestrogens
may be prescribed parenteral gonadotropin therapy or treated with laparoscopic ovar-
ian surgery. The term clomifene resistance strictly speaking refers to a failure to ovu-
late rather than failure to conceive despite ovulation and should be termed clomifene
failure.
Aromatase Inhibitors
Aromatase inhibitors have been proposed as an alternative treatment to CC therapy
as the discrepancy between ovulation and pregnancy rates with CC has been attrib-
uted to its anti-oestrogenic action and oestrogen receptor depletion. The aromatase
inhibitors suppress oestrogen production and thereby mimic the central reduction
of negative feedback through which CC works. Inhibition of the aromatase enzyme
decreases the aromatisation of androgens to oestrogens that in turn releases the
hypothalamic–pituitary axis from negative feedback of oestrogen. Adverse effects on
the endometrium and cervical mucus are considerably less than CC. There are reports
of good pregnancy rates with a lower incidence of multiple pregnancies [37].
Despite the potential advantages over CC, the use of letrozole for OI was discour-
aged after a report at a meeting (report has not been published in a peer-reviewed
journal) [38] that suggested a significant increase in congenital cardiac and bone
malformations in newborns in letrozole-treated pregnancies compared with controls.

However, another trial comparing letrozole versus CC regarding newborns’ safety did
not support the teratogenic effect of letrozole [39]. Therefore, more research is needed
to assess the safety and efficacy of aromatase inhibitors for OI before any recommen-
dation for its clinical use.
Gonadotropin Therapy
Gonadotropin therapy is indicated for women with anovulatory PCOS who have been
treated with anti-oestrogens if they have failed to ovulate or if they have a response to
clomifene that is likely to reduce their chance of conception (e.g. persistent hyperse-
cretion of LH or anti-oestrogenic effect on cervical mucus).
To prevent the risks of overstimulation and multiple pregnancy, the traditional
standard step-up regimens (when 75–150 IU are increased by 75 IU every 3–5 days
have been replaced by either low-dose step-up regimens [40] or step-down regimens
(Figure 7.18) [41]. The low-dose step-up regimen uses a starting dose of 25–50 IU
that is only increased after 14 days if there is no response and then by only half an
ampoule every 7 days. Treatment cycles using this approach can be quite long – up to
28–35 days – but the risk of multiple follicular growth is lower than with conventional
step-up regimens. With the step-down protocol, follicular recruitment is achieved
using 150–225 IU daily for 3 or 4 days before decreasing the dose to 50–75 IU to
maintain follicular development.
Experimental studies have indicated that initiation of follicular growth requires a
10%–30% increment in the dose of exogenous FSH and the threshold changes with
follicular growth, due to an increased number of FSH receptors, so that the concentra-
tion of FSH required to maintain growth is less than that required to initiate it [42].
In all the above-mentioned OI regimens, gonadotropins are used alone, without a
background of pituitary desensitisation, which does not confer any advantage.
Furthermore, the different gonadotropin preparations appear to work equally well.
It can be extremely difficult to predict the response to stimulation of a woman
with polycystic ovaries – indeed, stimulation is the greatest therapeutic challenge in
all OI therapies. The polycystic ovary is characteristically quiescent, at least when
viewed by ultrasound, before often exhibiting an exuberant and explosive response to
stimulation (Figure 7.19). It can be very challenging to stimulate the development of a
single dominant follicle, and although attempts have been made to predict a multifol-
licular response by looking at mid-follicular endocrine profiles and numbers of small
follicles, it is harder to do so before commencing ovarian stimulation and hence deter-
mine the required starting dose of gonadotropin [43]. To prevent OHSS and multiple
pregnancy, however, the strategy of cancelling cycles on day 8 of stimulation if there
are more than seven follicles (≥8 mm) seems to be reasonable [43].
White and colleagues [44] reported their extensive experience of the low-dose
regimen in 225 women over 934 cycles of treatment, resulting in 109 pregnancies
in 102 women (45%). Of the cycles, 72% were ovulatory (<5% of patients failed to
ovulate) and 77% of these patients were uniovulatory. The multiple pregnancy rate
was 6%. Despite using a low-dose protocol, 18% of cycles were abandoned because
more than three large follicles developed – a further reminder of the sensitivity of
the polycystic ovary even when attempts are made to reduce the response. At the
start of their series, the initial starting dose was 75 IU but this dose was reduced

Gonadotropin regimens
Step-up
Low-dose step-up
Step-down
(a)
Step-up
Starting dose 75 IU
increase by 75 IU after 7 days
and then every 3–5 days until response
(b)
Low-dose step-up
Start with 25–50 IU

do not increase for 14 days (first cycle)
or 7 days (subsequent cycles)
Increments of 25–37.5 IU every 7 days until ‘threshold’
(GnRH agonists not used)

(c)
Step-down
Dominant follicle becomes more sensitive to

lower concentration of FSH
Decrease when follicle recruited

may decrease again 3 days later until day of hCG
(d)
FIGURE 7.18 Gonadotropin regimens. (a) All options. (b) Step-up. (c) Low-dose step-up. (d) Step-
down. FSH, follicle-stimulating hormones; GnRH, gonadotropin-releasing hormone; hCG, human
chorionic gonadotropin.

FIGURE 7.19 Transvaginal ultrasound scan of an overstimulated polycystic ovary. Both ovaries

are likely to have this appearance, and the treatment must be discontinued to minimise the risk of
multiple pregnancy and ovarian hyperstimulation syndrome.
to 0.7 of an ampoule (i.e. 52.5 IU) for the last 429 cycles of treatment to reduce
further the rate of multiple follicle development (84% of cycles with the lower starting
dose were uniovulatory). Interestingly, their previously reported miscarriage rate of
35% when the higher starting dose was used fell to 20% when they used the 52.5 IU
starting dose. Again, it was noted that the only factor that influenced the outcome
significantly was the patient’s BMI. Those with a BMI > 25 kg/m 2 had a higher rate of
abandoned cycles (31% vs. 15% in those of normal weight) and a lower cumulative
conception rate over six cycles (46.8% vs. 57% for the whole group) and a miscarriage
rate of 31%. We reported the cumulative conception and LBRs in 103 women with
CC-resistant PCOS (Figure 7.20) [4]. Although the cumulative conception and LBRs
after 6 months were 62% and 54%, respectively, and after 12 months 73% and 62%,
respectively, the rate of multiple pregnancy was 19%, and there were three cases of
moderate to severe OHSS [4]. We found that the rate of multiple pregnancy fell to 4%
after the introduction of real-time transvaginal ultrasound monitoring of follicular
development, which now of course is routine in all centres. These data emphasise the
central role of effective surveillance in programmes of OI.
Dosage
Because of the sensitivity of the polycystic ovary to stimulation by hormones, it
is important to start with low doses of gonadotropins and very carefully monitor
follicular development by ultrasound scans. Close monitoring should enable treatment
to be suspended if three or more follicles develop, as the risk of multiple pregnancy

90
80
70
60
50
%
40
30
20
10
0
0 1 2 3 4 5 6 7 8 9 10 11 12
Cycles
FIGURE 7.20 Gonadotropin therapy in 103 women with PCOS. (From Balen AH et al., Hum
Reprod 9, 1563–70, 1994.)
obviously increases [45]. We suggest the algorithm for gonadotropin therapy shown
in Figure 7.21.
Treatment with gonadotropins should be commenced within the first 5 days of a
natural or induced menstrual bleed, when a pelvic ultrasound examination indicates
that the endometrium is thin (<5 mm in depth) and that there are no ovarian cysts. The
initial dose, usually 50 IU of FSH, is increased by 25 IU/day after 14 days in the first
cycle of treatment, and 7 days in subsequent cycles, if there is an inadequate response,
as assessed by ultrasound scan. There is no value in increasing the initial dose before
the fifth day (at the earliest) as recruitment of follicles takes between 5 days and
15 days. Further increases are made at 4- to 7-day intervals. In subsequent cycles, the
starting dose is determined by the patient’s previous response and can be reduced in
some cases to 25 IU and increased in others to 100 IU or even 150 IU/day.
Several pre-stimulation protocols have been used to suppress endogenous p ituitary
gonadotropin secretion and ovarian activity before commencing gonadotropin
therapy. These protocols include treatment for 2–3 months with the combined oral
contraceptive pill or with a GnRH agonist for 6–8 weeks. In my view, this approach
simply prolongs the treatment cycle, resulting in fewer ovulations and hence chances
of conception in a given period of time without conferring a significant benefit on the
pregnancy rates. The use of GnRH agonists also increases the requirement for FSH.
A role for GnRH antagonists in OI has yet to be found.
Ovulation is triggered with a single injection of human chorionic gonadotropin
(hCG) 5000 units (intramuscular or subcutaneous). The inclusion criterion for hCG
administration should be the development of at least one follicle of at least 17 mm in
its largest diameter.
To reduce the risks of multiple pregnancy and OHSS, the exclusion criteria for
hCG administration are the development of a total of three or more follicles larger

Ovulation induction with gonadotropins

Start day 1
50 IU
Day 8
A B C D
No response At least one 1–4 follicles 4 follicles

follicle 10 mm 14 mm 15 mm
Same dose Same dose Decrease

4 days: C, D or 2 days dose** and
no change* scan in
No change* D 2 days
First cycle: Subsequent 1–4 follicles

same dose cycles ↑ by 15 mm
7 days 50 IU 5 days
B C D No change
2 days
No change*, D
same dose
B,C,D 1–3 follicles 15–16 mm:

E: No change No change*
same dose 2 days
by 25 IU
for 7 days 1–2 follicles >17 mm, no
Give hCG
more than 3 follicles >14 mm
B,C,D If still E, either increase for one

E: ↑ by 25 IU more week or stop and start
for 7 days at higher dose next cycle
B, C,D
1–3 follicles 1–2 follicles More than 2 follicles
15–16 mm: >17 mm, 18 mm and/or
same dose no more than 4 follicles 14 mm
No change*
2 days 3 follicles > 14 mm
1–2 follicles
>17 mm, Give hCG Cancel cycle
no more than
3 follicles >14 mm
*No change/suboptimal response:
if 2–4 days since last scan, continue same dose and rescan in 2 days.
if 7+ days since last scan, increase dose (see text).
**Decrease dose by 25 IU or by 50 IU if on 75–100 IU.
FIGURE 7.21 Ovulation induction with gonadotropin protocol. hCG, human chorionic
gonadotropin.

than 14 mm in diameter. In overstimulated cycles, hCG is withheld, and the patient is
counselled about the risks and advised to refrain from sexual intercourse (Figures 7.22
through 7.24).
Because gonadotropin therapy is usually reserved for those who are CC resistant,
and then these patients still have good cumulative conception rates, it has been pos-
tulated that the use of gonadotropin OI might be better than CC as first-line therapy.
To this end, a recent multicentre RCT on first-line CC versus gonadotropins in ther-
apy-naive anovulatory women with PCOS reported higher clinical pregnancy rate
with gonadotropins [46]. Pregnancy rates with gonadotropin therapy were almost
double in the first cycle compared with CC. In this study, 302 infertile women with
PCOS-related anovulation, without prior OI treatment, were randomised to OI with
either CC (50–150 mg/day for 5 days) or with recombinant FSH (starting dose 50 IU)
(a)
(b)
FIGURE 7.22 Ovulation induction in a polycystic ovary, transvaginal ultrasound monitoring.

(a) On day 5, the largest follicle has a diameter of 7 mm. (b) By day 12, this follicle is 15 mm in
diameter.

(c)
(d)
FIGURE 7.22 (Continued) Ovulation induction in a polycystic ovary, transvaginal ultrasound

monitoring. (c) Two days later, the diameter of the follicle is 23 mm, and ovulation can be triggered
using human chorionic gonadotropin (hCG) 5000 units. (d) Seven days later, a corpus luteum should
be visualised (between arrows).
for up to three cycles of treatment. Reproductive outcome was superior after OI with
FSH than after OI with CC with respect to pregnancy rate (PR) per first cycle (30%
vs. 14.6%, 95% CI 5.3–25.8, p = .003), PR per cycle (26.4% vs. 17.4%, 95% CI 2.4–
15.6, p = .008), PR per woman, (58% vs. 44% of women, 95% CI 1.5–25.8, p = .03),
LBR per woman (52% vs. 39%, 95% CI 0.4–24.6, p = .04), cumulative PR (52.1%
vs. 41.2%, p = .021) and cumulative LBR (47.4% vs. 36.9%, p = .031) within three
cycles of OI. Therefore, it appears that pregnancies and live births are achieved

FIGURE 7.23 Transvaginal ultrasound scan of luteinised unruptured follicles (LUF). In this case,
four large cysts are seen 7 days after human chorionic gonadotropin (hCG) administration. Although
it is often assumed that cysts represent failure of ovulation, the only actual proof of ovulation is the
subsequent fertilisation of the egg. An oocyte can be released from a follicle that becomes cystic
subsequently.
more effectively and faster after OI with low-dose FSH than after OI with CC. This
result has to be balanced by convenience and cost in favour of CC.
If conception has failed to occur after six ovulatory cycles in a woman younger
than 25 years or age or after 12 ovulatory cycles in women older than 25 years of age,
then it can be assumed that anovulation is unlikely to be the cause of the couple’s
infertility (Figures 7.25 and 7.26) [4]. The couple should have been comprehensively
investigated by this stage with a laparoscopy ± hysteroscopy or hysterosalpingogra-
phy and sperm function tests. If no other explanation has been found for their infertil-
ity, assisted conception (usually IVF) is now indicated.
Complications of Ovulation Induction

Women with PCOS are at an increased risk of developing OHSS. This condition
occurs if many follicles are stimulated, leading to ascites, pleural and sometimes
pericardial effusions with the symptoms of abdominal distension, discomfort, nausea,
vomiting and difficult breathing. Hospitalisation is sometimes necessary for intrave-
nous fluids (colloids preferable to crystalloids), and heparin may be given to prevent
dehydration and thromboembolism. Although this condition is rare, it is a potentially

(a)
(b)
FIGURE 7.24 Monitoring of endometrial development during ovulation induction (OI) (transvagi-

nal ultrasound). (a) Early follicular, thin endometrium (4.5 mm). (b) Mid-follicular (7 mm).

(c)
(d)
FIGURE 7.24 (Continued) Monitoring of endometrial development during ovulation induc-

tion (OI) (transvaginal ultrasound). (c) Pre-ovulatory (9.6 mm). (d) Mid-luteal, post-ovulation
(13 mm).
fatal complication and should be avoidable with appropriate monitoring of treatment

(Figure 7.19 and Chapter 18).
Multiple pregnancy is the other undesirable side effect of fertility therapy, first
because of the increased rates of perinatal morbidity and mortality and second
because of the devastating effects on the family of caring for many babies. High-
order multiple pregnancies (quadruplets or more) result almost exclusively from
OI therapies (Figures 7.27 and 7.28). Gonadotropins should be given in low doses
to women with anovulatory infertility and strict criteria should be used before the
administration of the ovulatory trigger.

100
80
60
CCR (%)
40
20
0
0 2 4 6 8 10 12 14
Cycles of treatment
FIGURE 7.25 Cumulative conception rates (CCRs) over successive cycles in normal women (tri-
angles) and 103 patients with anovulatory polycystic ovary syndrome (circles) who have undergone
ovulation induction (OI). (From Balen AH et al., Hum Reprod 9, 1563–70, 1994.)
Source of Gonadotropins
Gonadotropins are available in the form of urinary-derived hMG or FSH (Table 7.8).
The gonadotropins are glycoprotein hormones. Biological activity is determined by
the ability of the hormone to bind to its receptors on granulosa cells and its persistence
(half-life) in circulation. After the protein structure of the hormone is assembled in the
pituitary cell, the hormone is glycosylated, that is, carbohydrate moieties are applied
to the molecule. These carbohydrate components determine whether the molecule is
positively or negatively charged. People in fact secrete a mixture of isoforms, that is,
molecules of the same peptide structure but with a different carbohydrate component;
therefore, they have different acidity and alkalinity. Preparations of gonadotropins
that have a preponderance of alkaline isoforms bind well to the receptor but disap-
pear rapidly from the circulation, whereas those with a low pH (acidic) persist in the
circulation well and are thought to have a high total in vivo biopotency. The pituitary
secretes a range of FSH and LH isoforms, the distribution of which depends on cir-
culating oestrogen concentrations and other factors. Post-menopausal women secrete
highly glycosylated gonadotropins with a long half-life, and it is these g lycosylated
gonadotropins that are purified from the urine of post-menopausal women to provide
the preparations that are in current use. Because of the variation in bioactivity of the
urinary-derived gonadotropins, the allowable range in each ampoule is 20% on either
side of the mean – thus, between 60 and 94 units of activity in a 75-unit ampoule
(a potential variation of up to 64% between ampoules from different batches).

100
80
60
%
40
20
0
0 2 4 6 8 10 12 14
Cycles of treatment
FIGURE 7.26 Cumulative live birth rate (CLBR) after one course of ovulation induction (OI) treat-
ment for patients with polycystic ovary syndrome (PCOS) (H17034; n = 103), hypogonadotropic
hypogonadism (H17005; n = 77) and weight-related amenorrhoea (H11623; n = 20). (From Balen
AH et al., Hum Reprod 9, 1563–70, 1994. With p ermission.) The miscarriage rates were similar
for patients with PCOS and hypogonadotropic hypogonadism, but they were higher in women with
weight-related amenorrhea, leading to similar CLBRs for all three groups. Patients with weight-
related amenorrhoea should ideally be managed by encouraging weight gain rather than gonadotro-
pin administration to correct their anovulatory infertility.
The original preparations of hMG were administered intramuscularly, whereas

more purified preparations can now be given by subcutaneous injections that can be
self-administered and are tolerated better by the patient.
Recombinantly derived FSH, hCG and LH are synthesised by transfecting the
human gonadotropin genes into Chinese hamster ovary cell lines and are now widely
available for therapeutic use. These preparations have far greater purity and homo-
geneity than the urinary-derived gonadotropins. There is heterogeneity between the
different recombinantly derived preparations; thus, there is no single physiological
preparation of FSH.
Hypersecretion of LH appears to have a significant effect on conception and miscar-
riage. Initial, non-randomised reports of GnRH agonist therapy in PCOS described
encouraging rates of pregnancy, but prospective randomised studies have indicated
that using GnRH agonists during OI regimens provide no benefit over hMG therapy
alone and, in particular, do not reduce the tendency of the polycystic ovary to multi-
follicular development, cyst formation or OHSS. The purified and recombinant FSH
preparations or those with a reduced LH content confer no therapeutic advantage over
hMG as the LH content in hMG is trivial compared with the endogenous secretion
of LH [45].

Response to treatment
100%
*
80%
60%
40%
+
20%
0%
PCOS HH WRA
603 503 121
Number of cycles
Overstimulated
* P = .012
+ P = .003
Inadequate
Anovulatory
Ovulatory
FIGURE 7.27 (See colour insert.) Response to treatment: patients with polycystic ovary s yndrome
were less likely to have anovulatory cycles, with the usual reason being the need to abandon the cycle
because of an overexuberant response and the production of too many follicles. HH, hypogonado-
tropic hypogonadism; WRA, weight-related amenorrhoea. (From Balen AH et al., Hum Reprod 9,
1563–70, 1994.)
Insulin-Sensitising Agents
It is logical to assume that therapy that achieves a fall in serum insulin concentra-
tions should improve the symptoms of PCOS. The biguanide metformin inhibits the
production of hepatic glucose, thereby decreasing insulin secretion and also enhances
insulin sensitivity at the cellular level. The efficacy of metformin in PCOS was first
described almost 20 years ago, and in the last decade many studies have been carried

7 B Scanner Real-time scanner Transvaginal US

6
5
Number
2
1
0
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
Twins Triplets Quadruplets
FIGURE 7.28 Distribution of multiple pregnancies. With the advent of real-time and then trans-
vaginal ultrasonography (US), the rate of multiple pregnancy fell due to the increased accuracy of
monitoring and detection of each follicle. (From Balen AH et al., Hum Reprod 9, 1563–70, 1994.)
TABLE 7.8
Gonadotropins Available in the United Kingdom (2013)
Preparation Trade Names Route Urinary Proteins
hCG Choragon, Pregnyl i.m./s.c. ++
Dose per ampoule 5000 units
Recombinant hCG: choriogonadotropin α Ovitrelle s.c. 0
Dose per ampoule 6500 units = 250 μg
hMG Menopur, Merional s.c. +
(FSH:LH ~ 1:1)
Urofollitropin (FSH) Fostimon s.c. +
(FSH:LH = 75:<1)
Recombinant FSH: Gonal-F s.c. 0
Follitropin α
Multiple-dose cartridges
Follitropin β Puregon s.c. 0
Multiple-dose cartridges
Recombinant LH: lutropin α Luveris s.c. 0
Note: i.m., intramuscular; s.c., subcutaneous.
out to evaluate the reproductive effects of metformin in patients with PCOS [4]. Most
of the initial studies, however, were observational, and any randomised studies pub-
lished involved only a few participants.
Initial studies appeared to be promising, suggesting that metformin could improve
fertility in women with PCOS. However, more recent large RCTs have observed
that the beneficial effects of metformin first-line therapy for the treatment of the

anovulatory patient with PCOS is significantly less than with CC. In a multicentre
trial of 20 Dutch hospitals, 228 women with PCOS were treated either with CC
plus metformin or CC plus placebo [47]. The ovulation rate in the metformin group
was 64% compared with 72% in the placebo group, a non-significant d ifference.
There were no significant differences in either rate of ongoing pregnancy (40%
vs. 46%) or rate of spontaneous abortion (12% vs. 11%). A significantly larger
proportion of women in the metformin group discontinued treatment because of
side effects (16% vs. 5%). The investigators concluded that metformin is not an
effective addition to CC as the primary method of inducing ovulation in women
with polycystic ovary syndrome.
The Pregnancy in Polycystic Ovary Syndrome (PPCOS) trial, sponsored by the
National Institutes of Health (NIH), noted that as first-line therapy for the treat-
ment of anovulatory infertile PCOS women metformin alone was significantly less
effective than CC alone and that the addition of metformin to CC produces only
marginal benefits [48]. This multicentre study enrolled 676 infertile PCOS women
(diagnosed by elevated testosterone levels and oligomenorrhoea) who were seeking
pregnancy [4]. All were off confounding medications and in otherwise good health,
aged 18–39 years, and they had no other obvious infertility factors, with at least one
patent fallopian tube, normal uterine cavity and partner with sperm concentration
of 20 million/mL in at least one ejaculate. After a progestogen withdrawal, these
women were randomised to three different treatment arms for a total of 6 cycles
or 30 weeks: (1) metformin 1000 mg twice daily plus placebo, (2) CC 50 mg every
day for 5 days (day 3–7 of cycle) plus placebo, or (3) combined metformin 1000
mg twice daily plus CC 50 mg/day for 5 days (day 3–7). Overall, LBRs were 7.2%
(15/208), 22.5% (47/209) and 26.8% (56/209), respectively, with the metformin-
alone group being significantly lower than the other two groups. Pregnancy loss
rates tended to also be higher in the metformin-alone group (40.0% vs. 22.6% and
25.5%, respectively).
We set out to evaluate the combined effects of lifestyle modification and metformin
on obese anovulatory women (BMI > 30 kg/m2) with PCOS [49] in a prospective ran-
domised, double-blind, placebo-controlled multicentre study. All the patients had an
individualised assessment by a research dietitian to set a realistic goal that could be
sustained for a long time, with an average reduction of energy intake of 500 kcal/day.
As a result, both the metformin-treated and placebo groups managed to lose weight,
but the amount of weight reduction did not differ between the two groups. An increase
in menstrual cyclicity was observed in women who lost weight but again did not differ
between the two arms of the study 49, thus confirming reduction as the key to enhanc-
ing reproductive function.
The thiazolidinediones, such as troglitazone, also appeared to significantly
improve the metabolic and reproductive abnormalities in PCOS, although this
product was withdrawn because of reports of fatal liver damage. The new gen-
eration of thiazolidinediones (rosiglitazone, pioglitazone) may be of benefit to the
older woman with PCOS, but they can be associated with weight gain and are
not recommended for women wishing to conceive because of an uncertain safety
profile in pregnancy and also because of concerns of myocardial infarction and
cardiovascular death in recent studies on the use of rosiglitazone in type 2 diabetic
patients.

The latest Cochrane review by analysing 2537 women with PCOS in 31

RCTs explored the role of metformin and other insulin-sensitising agents (e.g.
pioglitazone and rosiglitazone) in PCOS. In this systematic review, no evidence
was found that metformin improved LBRs whether it is used alone (pooled
OR = 1.00, 95% CI 0.16–6.39) or in combination with CC (pooled OR = 1.05,
95% CI 0.75–1.47) [50]. There may be a small benefit for women who are resistant
to CC compared with using metformin in combination with CC. Despite some
improvement in ovulation and clinical PRs with metformin, these benefits were
not translated into i mprovement in LBRs, perhaps attributable to higher incidence
of miscarriage and adverse pregnancy outcomes in obese women with PCOS. In
addition, the review did not demonstrate the usefulness of metformin in improving
weight loss, insulin sensitivity or lipid profiles in women with PCOS; thus, empha-
sising the importance of weight loss and lifestyle modification in management of
women with PCOS.
In summary, the very variable findings from the published studies on the use
of metformin reflect the large differences in study populations, particularly
with respect to body weight. Although the initial studies appeared p romising,
subsequent large, randomised, controlled trials have not demonstrated the antici-
pated beneficial effects of metformin as a first-line therapy for the treatment of
the anovulatory patient with PCOS. The primary aim for overweight women with
PCOS is to make lifestyle changes with a combination of diet and exercise, to
lose weight and to improve ovarian function. The role of insulin-sensitising and
insulin-lowering drugs in the management of PCOS is limited and should be
reserved for women who have impaired glucose tolerance or type 2 diabetes and
also, perhaps, for women who are resistant to clomifene, when the two can be used
in combination. In conclusion, the position of metformin in the management of
PCOS is by no means clear, and on current evidence it is not the first-line treat-
ment of choice.
Surgical Ovulation Induction

An alternative to gonadotropin therapy for clomifene-resistant PCOS is laparo-
scopic ovarian surgery (Box 7.2 and Figures 7.29 through 7.31) that has replaced the
more invasive and damaging technique of ovarian wedge resection. Laparoscopic
ovarian surgery is free of the risks of multiple pregnancy and ovarian hyperstimu-
lation, and it does not require intensive ultrasound monitoring. Furthermore, ovar-
ian d iathermy appears to be as effective as routine gonadotropin therapy in the
treatment of clomifene-insensitive PCOS. In addition, laparoscopic ovarian sur-
gery is a useful therapy for anovulatory women with PCOS who fail to respond to
clomifene and who persistently hypersecrete LH, or need a laparoscopic assess-
ment of their pelvis, or who live too far away from the hospital to be able to attend
for the intensive monitoring required in gonadotropin therapy. Surgery does, of
course, carry its own risks and must be performed only by fully trained laparo-
scopic surgeons.
After laparoscopic ovarian surgery, with restoration of ovarian activity serum
concentrations of LH and testosterone fall. A fall in serum LH concentrations both
increases the chance of conception and reduces the risk of miscarriage. Whether

BOX 7.2 INDICATIONS FOR LOD

Anovulatory PCOS: CC resistance
Persistent hypersecretion of LH
Repeated overresponse to CC or gonadotropins
Patients who find it difficult to travel for regular scans
No value for therapy of long-term effects of PCOS (e.g. hirsutism, obesity)
(a)
(b)
FIGURE 7.29 (See colour insert.) (a) Laparoscopic ovarian diathermy. The needle enters the
ovarian capsule while the ovarian ligament is held steady, with the ovary supported on the front of
the uterus. (b) At the end of the procedure, the ovary has been diathermised at four sites.

FIGURE 7.30 Laparoscopic ovarian diathermy.
FIGURE 7.31 Laparoscopic ovarian diathermy (see Figure 7.29).

patients respond to LOD appears to depend on their pre-treatment characteristics,

with patients with high basal LH concentrations having a better clinical and endo-
crine response. Indeed, neither the pre-treatment testosterone level, BMI nor
ovarian volume could be used to predict outcome. We performed a small pro-
spective study in which we randomised women to receiving either unilateral or
bilateral LOD [51]. We found that unilateral diathermy restored bilateral ovarian
activity, with the contralateral, untreated ovary often being the first to ovulate
after the diathermy treatment. We also found that the only significant difference
between the responders and non-responders was a post-diathermy fall in serum LH
concentration.
Although the mechanism of OI by LOD is uncertain, it appears that minimal dam-
age to an unresponsive ovary either restores an ovulatory cycle or increases the sensi-
tivity of the ovary to exogenous stimulation. Furthermore, the finding of an attenuated
response of LH secretion to stimulation with GnRH suggests an effect on ovarian–
pituitary feedback and hence pituitary sensitivity to GnRH. Our study went one step
further by demonstrating that unilateral diathermy leads to bilateral ovarian activity,
suggesting that ovarian diathermy achieves its effect by correcting a perturbation of
ovarian–pituitary feedback. Our own hypothesis is that the response of the ovary
to injury leads to a local cascade of growth factors and those such as IGF1, which
interact with FSH, result in stimulation of follicular growth and the production of the
hormone gonadotropin surge attenuating/inhibitory factor (GnSAF/GnSIF) that leads
to a fall in serum LH concentrations [52].
Commonly used methods for laparoscopic surgery include monopolar electrocau-
tery (diathermy) and laser, whereas multiple biopsy alone is no longer used. In the
first reported series, ovarian diathermy resulted in ovulation in 90% and conception
in 70% of the 62 women treated [53]. Several subsequent studies have produced simi-
larly encouraging results, although the techniques used and degree of ovarian damage
vary considerably.
Gjönnaess [53] cauterised each ovary at five to eight points, for 5–6 s at each
point with 300–400 Watts. Naether et al. [54] treated 5–20 points per ovary, with
400 Watts for approximately 1 s. They found that the rate of adhesions was 19.3%
and 16.6%, respectively, when peritoneal lavage with saline was used. In an earlier
study, Naether et al. [55] found that the post-diathermy fall in serum testosterone
concentration was proportional to the degree of ovarian damage, with up to 40 cau-
terisation sites being used in some patients. The greater the amount of damage to
the surface of the ovary, the greater the risk of periovarian adhesion formation.
This finding led Armar et al. [56] to develop a strategy of minimising the number
of diathermy points to 4 per ovary for 4 s at 40 Watts; it is this last technique that
we favour. The high PR (86% of those with no other pelvic abnormality) indicates
that the small number of diathermy points used leads to a low rate of significant
adhesion formation.
Wedge resection of the ovaries resulted in significant adhesions – in 100% of cases
in some published series. The risk of adhesion formation is far less after LOD (10%–
20% of cases), and the adhesions that do form are usually fine and of limited clini-
cal significance. Our technique involves instilling 1000-mL Adept® solution into the
pouch of Douglas, which, by cooling the ovaries, prevents heat injury to adjacent tis-
sues and reduces the adhesion formation. The risk of periovarian adhesion formation

may be further reduced by abdominal lavage and early second-look laparoscopy, with
adhesiolysis if necessary.
It is suggested that a minimum amount of ovarian destruction should result.
Furthermore, a combined approach may be suitable for some women where low-dose
diathermy is followed by low-dose ovarian stimulation. Ostrzenski [57], for example,
commenced all his patients on either clomifene or FSH therapy immediately after
laser wedge resection, and Farhi et al. [58] demonstrated an increased ovarian sensi-
tivity to gonadotropin therapy after LOD.
An additional concern is the possibility of ovarian destruction leading to
ovarian failure, an obvious disaster in a woman wishing to conceive. Cases of ovarian
failure have been reported after both wedge resection and laparoscopic surgery. An
unfortunate vogue has developed whereby women with p olycystic o varies who have
overresponded to superovulation for IVF are subjected to o varian diathermy as a
way of reducing the likelihood of subsequent OHSS [59]. If one accepts that appro-
priately performed ovarian diathermy works by s ensitising the ovary to FSH, then
one could extrapolate that ovarian diathermy before s uperovulation for IVF should
make the ovary more and not less likely to overstimulate. The amount of ovarian
destruction that is required to reduce the chance of overstimulation is therefore
likely to be considerable. We would urge great c aution before proceeding with such
an approach because of concerns about permanent ovarian atrophy.
Laser treatment seems to be as efficacious as diathermy, and it has been sug-
gested that it may result in less adhesion formation, although the only study to
compare the two techniques was non-randomised. It reported similar ovulation and
PRs and did not examine adhesion formation [60]. Various types of laser have been
used, from the CO2 laser to the Nd:YAG and KTP lasers. As with the use of laser in
other spheres of laparoscopic surgery, whether laser or diathermy is used appears
to depend upon the preference of the surgeon and the availability of the equipment.
After laparoscopic ovarian surgery, with restoration of ovarian activity, serum con-
centrations of LH and testosterone fall. Whether patients respond to LOD appears
to depend on their pre-treatment characteristics, with patients with high basal LH
concentrations having a better clinical and endocrine response.
Ovarian diathermy appears to be as effective as routine gonadotropin therapy
in the treatment of CC-insensitive PCOS [61]. The largest RCT to date is the
multicentre study performed in the Netherlands in which 168 patients resistant to
CC were randomised to either LOD (n = 83) or OI with recombinant FSH (rFSH,
n = 85) [61]. The initial cumulative PR after 6 months was 34% in the LOD arm
versus 67% with rFSH. Those women who did not ovulate in response to LOD were
then given first CC and then rFSH; so by 12 months, the cumulative PR was similar
in each group at 67%. Thus, women treated with LOD took longer to conceive and
54% required additional medical OI therapy [61]. The greatest advantage for LOD
appears to be the need for less monitoring and that multiple PRs are considerably
reduced.
IVF in Women with Polycystic Ovaries

In vitro fertilisation is not the first-line treatment for PCOS, but many patients
with the syndrome may be referred for IVF, either because there is another reason

for their infertility or because they fail to conceive despite ovulating (whether
spontaneously or with assistance), that is, their infertility remains unexplained.
Furthermore, approximately 30% of women have polycystic ovaries as detected
by ultrasound scan [62]. Many will have little in the way of symptoms and may
present for assisted conception treatment because of other reasons (e.g. tubal f actor
or male factor). When stimulated, these women with asymptomatic polycystic ova-
ries have a tendency to respond sensitively and are at increased risk of developing
OHSS.
The response of the polycystic ovary to stimulation in the context of OI aimed
at the development of unifollicular ovulation is well documented and differs
significantly from that of normal ovaries. The response tends to be slow, with
a significant risk of ovarian hyperstimulation. Conventional IVF depends on
inducing multifollicular recruitment, and again the response of the polycystic
ovary differs from the normal, with a potentially explosive response, based
on the presence of many partially developed follicles present in the polycystic
ovary. Thecal hyperplasia (in some cases with raised levels of LH and/or insu-
lin) provides large amounts of androstenedione and testosterone, which act as
substrates for oestrogen production. Granulosa cell aromatase, although defi-
cient in the resting polycystic ovary, is readily stimulated by FSH. Therefore,
normal quantities of FSH act on large amounts of substrate (testosterone and
androstenedione) to produce large amounts of intraovarian oestrogen. Ovarian
follicles, of which there are too many in polycystic ovaries, are increasingly
sensitive to FSH (receptors that are stimulated by high local concentrations of
androgens and oestrogen), and as a result, there is multiple follicular develop-
ment associated with very high levels of c irculating o estrogen. In some cases,
this condition may result in OHSS, to which patients with polycystic ovaries are
particularly prone.
In addition, insulin acts as a cogonadotropin and augments theca cell production
of androgens in response to stimulation by LH and granulosa cell production of in
response to stimulation by FSH. Also, there is widespread expression of vascular
endothelial growth factor (VEGF) in polycystic ovaries. VEGF is an endothelial
cell mitogen that stimulates vascular permeability; hence, its involvement in the
pathophysiology of OHSS. VEGF is normally confined in the ovary to the blood
vessels and is responsible there for invasion of the relatively avascular Graafian
follicle by blood vessels after ovulation. The increase of LH at mid-cycle leads to
expression of VEGF, which has been shown to be an obligatory intermediate in
the formation of the corpus luteum. It has been shown that, compared with women
with normal ovaries, women with polycystic ovaries or PCOS have increased serum
VEGF [63].
The above-mentioned data serve to remind us of the close relationship of
polycystic ovaries with OHSS and also provide a possible explanation for the mul-
tifollicular response of the polycystic ovary to gonadotropin stimulation. One of
the mechanisms that underpins the unifollicular response of the normal ovary
is diversion of blood flow within the ovaries, first from the non-dominant to the
dominant ovary, and second, from cohort follicles to the dominant follicle. This
diversion results in diversion of FSH away from the cohort follicles and permits
them to undergo atresia. The widespread distribution of VEGF in polycystic ovaries

may prevent this diversion of blood flow, leaving a substantial number of small-
and intermediate-sized follicles in suspended animation and ready to respond
to gonadotropin stimulation. The distribution of VEGF in the polycystic ovary
therefore helps to explain one of the fundamental features of the polycystic ovary,
namely, the loss of the intraovarian autoregulatory mechanism that permits unifol-
licular ovulation to occur.
Case control studies of the outcome of IVF in women with polycystic ovaries
compared with control patients with normal ovaries have consistently shown the
development of more follicles, higher serum estradiol concentrations, more eggs but
often lower fertilisation rates. Rates of OHSS are significantly higher than controls at
5%–10% compared with the expected rate of 1%.
A long-running debate in OI for women with PCOS is whether the use of FSH alone
has any benefit over hMG – Is the hypersecretion of LH responsible for the exagger-
ated response to stimulation of the polycystic ovary? Does minimising circulating LH
levels by giving FSH alone improve outcome? The consensus from a combination of
meta-analyses suggests that there is no difference in outcome whether hMG, urinary-
FSH or recombinant FSH is used.
The recent introduction of schedules of gonadotropin stimulation that i ncorporate
treatment with GnRH antagonists holds promise for patients with polycystic ovaries
and PCOS. GnRH antagonists do not activate the GnRH receptors and produce a
rapid suppression of gonadotropin secretion within hours. These protocols have
been associated with a reduction in the rates of OHSS (see Chapter 14) that also
has been shown with the use of metformin for the first 4 weeks of an IVF treatment
cycle [64].
IVM of Oocytes
In recent years, IVM has attracted a lot of interest as a new assisted reproductive
technique. The immature oocytes are retrieved from antral follicles of unstimu-
lated (or minimally stimulated) ovaries via the transvaginal approach. The oocytes
are subsequently matured in vitro in a special formulated culture medium for
24–48 h. The mature oocytes are fertilised, usually by intracytoplasmic sperm
injection (ICSI), and the selected embryos are transferred to the uterus 2–3 days
later. Although IVM is labour-intensive compared with conventional IVF treat-
ment, there are several clinical advantages by the avoidance of large doses of
exogenous gonadotropins, most importantly by avoiding the risk of OHSS. Since
patients with PCOS have more antral follicles and a higher risk of developing
OHSS compared with women without PCOS, IVM may be a promising alternative
to conventional IVF.
Significantly more immature oocytes are retrieved from polycystic ovaries than
from normal ovaries, and the overall oocyte maturation and fertilisation rates are
similar among the two groups. The subsequent pregnancy and LBRs per trans-
fer are then significantly higher in patients with polycystic ovaries because of
a greater choice in the embryos selected for transfer. IVM yields significantly
fewer mature oocytes than IVF cycles and therefore fewer embryos per retrieval;
i mplantation rates are still lower in IVM compared with IVF cycles, which may be

due to a reduced oocyte potential or a reduced endometrial receptivity. Continuous

improvements in the culture medium and synchrony between endometrial and
embryonic development will hopefully result in better IVM success rates in the
future.
Summary
The underlying principle of all methods of OI for women with PCOS must always
be to use the lowest possible dose (of drug or surgery) to achieve unifollicular
ovulation and thereby avoid the significant risks of multiple pregnancy and OHSS
(Table 7.9 and Figure 7.32). CC remains the first-line medical therapy for anovula-
tory PCOS, although studies comparing gonadotropin therapy with CC as first-line
treatment show the former to be more efficacious, although more labour-intensive
and costly (Box 7.3). The use of aromatase inhibitors may increase with the con-
clusion of a large RCT that is currently underway. Compared with medical OI
with gonadotropins for the CC-resistant patient, the advantage of LOD is that it
need only be performed once, and intensive monitoring is not required as there
is no danger of multiple ovulation or ovarian hyperstimulation. We are, however,
still unsure of the right dose of diathermy to stimulate reliably the resumption of
ovulatory cycles. Neither are we certain about the degree of permanent damage
done to the ovary by different amounts (duration, power, number of sites) of treat-
ment. Gonadotropin therapy appears to provide similar long-term CCRs as LOD,
although time to p regnancy is quicker.
Unifollicular OI requires a subtle approach, particularly in women with PCOS.
Gonadotropin therapy is still the mainstay of most forms of fertility therapy
and adds appreciably to the cost of assisted reproduction therapies; indeed,
the costs of the preparations have risen four-fold over the past 10 years. Other
costs have to be counted in terms of the successful outcome of treatment with
a low rate of m iscarriage and the birth of healthy, preferably singleton, babies,
with no health risks to their mothers. Advances in recombinant DNA technology
have resulted in the development of long-acting FSH preparations, a single shot
of which might be sufficient to induce unifollicular ovulation [65]. We also may
expect to see orally active agents. The results of current trials are awaited with
interest.
TABLE 7.9
Strategy for Ovulation Induction in Anovulatory PCOS
Slim Patient Obese Patient (BMI > 30 kg/m2)
1. CC therapy 1. Lifestyle changes to achieve weight
2. LOD if LH elevated reduction (defer OI if BMI > 35 kg/m2)
3. Gonadotropin therapy or LOD if CC
resistant
4. IVF if no pregnancy after 9–12 ovulations

Primordial
follicle
50 µm
Pre-antral
follicle
200 µm
Basement
Zona
membrane Granulosa
pellucida
cells
Theca
Antral
follicle
Oocyte
500 µm
Antrum
Pre-ovulatory
Blood vessel follicle
Smooth
muscle LH
20 mm
Plasmin LH
collagenase
FSH
LH
Progesterone
Plasmin
PG
Collagenase
Progesterone
FIGURE 7.32 Schematic diagram to illustrate the principal steps in follicular development
primordial follicle through to ovulation. Meiosis is arrested within the oocyte by maturation inhibitor
(OMI) until the time of the LH surge.

BOX 7.3 KEY POINTS – OVULATION INDUCTION

• Correction of the cause of anovulatory infertility leads to cumulative
conception rates that approach those expected for the female patient’s
age.
• It is important to optimise health, confirm tubal patency and check
the partner’s semen analysis before commencing treatment.
• Hypogonadotropic hypogonadism is optimally treated with pulsatile
GnRH subcutaneously, but if gonadotropins are required use hMG
rather than FSH.
• PCOS should be treated first with CC, and if this treatment fails,
gonadotropin therapy and LOD are equally efficacious.
• Insulin-sensitising agents, such as metformin, now appear to have a
limited role in the management of PCOS.
• CC therapy should be carefully monitored. Doses greater than 100 mg
confer no benefit, and if ovulation is occurring, it is reasonable to con-
tinue for at least six but no more than 12 months.
• Gonadotropin therapy requires tight monitoring with serial ultra-
sound scans. The main risks are multiple pregnancy and OHSS.
• Laparoscopic ovarian diathermy is a single treatment that works well
in selected patients; excellent results can be achieved using four-point
diathermy on each ovary (4 s with 40 Watts).
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K. Laparoscopic electrocoagulation of the ovarian surface in infertile patients with
polycystic ovarian disease. Fertil Steril 1993; 60: 88–94.
55. Naether O, Weise HC, Fischer R. Treatment with electrocautery in sterility patients
with polycystic ovarian disease. Geburtsh Frauenheilk 1991; 51: 920–4.
56. Armar NA, McGarrigle HH, Honour J, Holownia P, Jacobs HS, Lachelin GC.
Laparoscopic ovarian diathermy in the management of anovulatory infertility in
women with polycystic ovaries: endocrine changes and clinical outcome. Fertil Steril
1990; 53: 45–9.
57. Ostrzenski A. Endoscopic carbon dioxide laser ovarian wedge resection in resistant
polycystic ovarian disease. Int J Fertil 1992; 37: 295–9.
58. Farhi J, Soule S, Jacobs H. Effect of laparoscopic ovarian electrocautery on ovarian
response and outcome of treatment with gonadotropins in clomifene citrate resistant
patients with PCOS. Fertil Steril 1995; 64: 930–5.
59. Rimmington MR, Walker SM, Shaw RW. The use of laparoscopic ovarian electro-
cautery in preventing cancellation of in-vitro fertilization treatment cycles due to
risk of ovarian hyperstimulation syndrome in women with polycystic ovaries. Hum
Reprod 1997; 7: 1443–7.
60. Heylen SM, Puttemans PJ, Brosens LH. Polycystic ovarian disease treated by lapa-
roscopic argon laser capsule drilling: comparison of vaporization versus perforation
technique. Hum Reprod 1994; 9: 1038–42.

61. Bayram N, van Wely M, Kaaijk EM, Bossuyt PMM, van der Veen F. Using an
electrocautery strategy or recombinant FSH to induce ovulation in polycystic ovary
syndrome: a randomised controlled trial. BMJ 2004; 328: 192–5.
62. MacDougall JM, Tan SL, Balen AH, Jacobs HS. A controlled study comparing
patients with and without polycystic ovaries undergoing in-vitro fertilization and the
ovarian hyperstimulation syndrome. Hum Reprod 1993; 8: 233–7.
63. Agrawal R, Sladkevicius P, Engman L, et al. Serum vascular endothelial growth
factor concentrations and ovarian stromal blood flow are increased in women with
polycystic ovaries. Hum Reprod 1998; 13: 651–5.
64. Tang T, Glanville J, Barth JH, Balen AH. Metformin in patients with polycystic ovary
syndrome (PCOS) undergoing IVF. A randomised, placebo-controlled, double-blind
study. Hum Reprod 2006; 6: 1416–25.
65. Balen AH, Mulders A, Fauser B, et al. Pharmacodynamics of a single low dose of
long-acting recombinant FSH (FSH-CTP, corifollitropin alfa) in women with WHO
Group II anovulatory infertility. J Clin Endocrinol Metab 2004; 89: 6297–304.
FURTHER READING
Balen AH, Conway G, Homburg R, Legro R, eds. Clinical Management of Polycystic
Ovary Syndrome. London: Taylor & Francis, 2005: 234.
Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Consensus
on infertility treatment related to polycystic ovary syndrome. Hum Reprod 2008; 23:
462–77.

8
Introduction
The polycystic ovary syndrome (PCOS) is the commonest endocrine disturbance
affecting women and comprises a heterogeneous collection of signs and symptoms
that gather together to form a spectrum of a disorder with a mild presentation in
some women and a severe disturbance of reproductive, endocrine and metabolic
function in others [1]. The pathophysiology of the PCOS appears to be multifactorial
and p olygenic. The definition of the syndrome has been much debated. Key features
include menstrual cycle disturbance, hyperandrogenism and obesity. There are many
extra-ovarian aspects to the pathophysiology of PCOS, yet ovarian dysfunction is cen-
tral. Terminology is important, and it is gratifying to see a shift away from the term
polycystic ovarian disease to the more commonly accepted PCOS. There have been
calls by some to change to a yet new term that encompasses the metabolic components
of the condition, although we feel comfortable with PCOS and the recognition that it
is a multifaceted condition.
Until recently, there was no international consensus either on the definition of the
syndrome or, indeed, on what constitutes a polycystic ovary. At a joint European
Society of Human Reproduction and Embryology (ESHRE)/American Society for
Reproductive Medicine (ASRM) consensus meeting in Rotterdam in 2003, a refined
definition of the PCOS was agreed upon, namely, the presence of two out of the fol-
lowing three criteria: (1) oligo-ovulation and/or anovulation; (2) hyperandrogenism
(clinical and/or biochemical); and (3) polycystic ovaries, with the exclusion of other
aetiologies [2]. These Rotterdam criteria have since been debated by other bodies but
nonetheless have gained fairly widespread acceptance. The morphology of the poly-
cystic ovary also was redefined as an ovary with 12 or more follicles measuring 2–9
mm in diameter and/or increased ovarian volume (>10 cm3) [3]. Again, this definition
has been refined further (see below).
There is considerable heterogeneity of symptoms and signs among women with
PCOS, and for an individual these may change over time (1). Polycystic ovaries can
exist without clinical signs of the syndrome, expression of which may be precipitated
by various factors, most predominantly increase in body weight. We tend to take
a pragmatic approach to the management of an individual’s symptoms and needs,
which may change over time. Hence, an argument could be made that a precise defini-
tion of the condition does not help when providing therapy. Yet, we feel that, although
having practical relevance, this argument is flawed because it is necessary to evaluate
scientifically the outcomes of treatment. It is then only possible to compare outcomes

if the same starting points are used. Furthermore, although PCOS is a familial
condition, it is proving difficult to establish the genetic basis for the syndrome with-
out a clear view of the phenotype – another reason to aim for a consensus in defining
PCOS and its subphenotypes.
What Is PCOS?
Polycystic ovaries are commonly detected by pelvic ultrasound, with estimates of the
prevalence in the general population being in the order of 20%–33% [4–6]. However,
not all women with polycystic ovaries demonstrate the clinical and b iochemical
features that define PCOS. These features include menstrual cycle disturbances,
hirsutism, acne and alopecia; and abnormalities of biochemical profiles including
elevated serum concentrations of luteinising hormone (LH), testosterone (T) and
androstenedione. Obesity and hyperinsulinaemia are associated features, although
only 40%–50% of women with PCOS are overweight. Presentation of the syndrome
is so varied that one, all, or any combination of the aforementioned features may be
present in association with an ultrasound picture of polycystic ovaries (Figure 8.1 and
Table 8.1) [7].
There is considerable heterogeneity of symptoms and signs among women
with PCOS and for an individual, these symptoms and signs may change over
time. PCOS is familial and various aspects of the syndrome may be differentially
inherited. Polycystic ovaries can exist without clinical signs of the syndrome but
then may become expressed over time. There are several interlinking factors that
affect expression of PCOS [8]. A gain in weight is associated with a worsening of
symptoms, whereas weight loss ameliorates the endocrine and metabolic profile and
symptomatology [9]. Although weight reduction does not necessarily normalise the
FIGURE 8.1 Symptoms, signs and endocrine disturbances in the PCOS can occur either together
or separately but require the presence of polycystic ovarian morphology, as seen here by transvaginal
ultrasound.

Polycystic Ovary Syndrome 203
TABLE 8.1
Spectrum of Clinical Manifestations of PCOS
Symptom Serum Endocrinology Possible Late Sequelae
Obesity Diabetes mellitus
↑ Androgens (T and androstenedione)
Dyslipidemia
Menstrual disturbance ↑ LH Hypertension
Infertility ↑ Fasting insulin Cardiovascular disease
Hyperandrogenism ↓ Sex-hormone-binding globulin (SHBG) Endometrial carcinoma
Asymptomatic ↑ Oestradiol, oestrone Breast cancer?
situation, it certainly improves response to therapy, whether for fertility or other

aspects of the syndrome.
The pathogenesis of polycystic ovaries and the associated syndrome is still being
elucidated, but the heterogeneity of presentation of PCOS suggests that a single cause
is unlikely. Some genetic studies have identified a link between PCOS and disordered
insulin metabolism, and they indicate that the syndrome may be the presentation of
a complex genetic trait disorder [10]. The features of obesity, hyperinsulinaemia and
hyperandrogenaemia, commonly seen in PCOS, are also known to be factors that
confer an increased risk of cardiovascular disease and non-insulin-dependent diabe-
tes mellitus (NIDDM) [11]. There are studies that indicate that women with PCOS
have an increased risk for these diseases, thus posing long-term risks for health, and
this evidence has prompted debate as to the need to screen women for polycystic
ovaries. There are also associations between the presence of PCOS and some cancers
(see below). For studies of the long-term risks, it is also essential to have a clear view
of the definition.
Definitions
Historically, the detection of the polycystic ovary required visualisation of the
ovaries at laparotomy with histological confirmation after biopsy [12]. As further
studies identified the association of certain endocrine abnormalities in women with
histological evidence of polycystic ovaries, biochemical criteria became the mainstay
for d iagnosis. Raised serum levels of LH, T and androstenedione in association
with low or normal levels of follicle-stimulating hormone (FSH) and abnormali-
ties of oestrogen secretion described an endocrine profile that many believed to be
diagnostic of PCOS [13]. Well-recognised clinical presentations included menstrual
cycle disturbances (oligomenorrhoea/amenorrhoea), obesity and hyperandrogenism
manifesting as hirsutism, acne or androgen-dependent alopecia. These definitions
proved inconsistent, h owever, as clinical features were noted to vary considerably
between women, and indeed some women with h istological evidence of p olycystic
ovaries consistently failed to display any of the common symptoms. There are also
significant ethnic variations in the presentation of the syndrome. Likewise, the
biochemical features associated with PCOS are not consistent in all women. Thus,
consensus on a single biochemical or clinical d efinition for PCOS was thwarted by
the heterogeneity of presentation of the disorder.

The advent of high-resolution ultrasound scanning provided a non-invasive

technique for the assessment of ovarian size and morphology. Good correlation has
since been shown between ultrasound diagnoses of polycystic morphology and the
histopathological criteria for polycystic ovaries by studies examining ovarian tissue
obtained at hysterectomy or after wedge resection [14,15]. The histopathological cri-
teria have been defined as the observation of increased numbers of follicles, hyper-
trophy and luteinisation of the inner theca cell layer and thickened ovarian tunica.
Transabdominal and/or transvaginal ultrasound have since become the most com-
monly used diagnostic methods for the identification of polycystic ovaries. And an
attempt has been made to provide the ultrasound criteria for the diagnosis of polycys-
tic ovaries (see Chapter 5, page 90) [3]. In essence, the polycystic ovary should have at
least one of the following: either 12 or more follicles measuring 2–9 mm in diameter
or increased ovarian volume (>10 cm3) [3]. With improvements in the resolution of
ultrasound technology, it has more recently been suggested that the threshold number
of follicles to define a polycystic ovary should be 19 and that the biochemical marker
of anti-Müllerian hormone (AMH) may be even more precise than ultrasound with a
threshold serum concentration greater than 35 pmol/L [16].
The innovation of three-dimensional ultrasound and the use of colour and pulsed
Doppler ultrasound are techniques that may further enhance the detection of
polycystic ovaries and that may be more commonly used in time (Figure 8.2) [17,18].
The use of magnetic resonance imaging (MRI) for the visualisation of the structure of
pelvic organs has been claimed to have even greater sensitivity than ultrasound for the
detection of polycystic ovaries. However, the substantial cost and practical problems
involved with this imaging technique limit its use.
FIGURE 8.2 (See colour insert.) Colour Doppler studies of a polycystic ovary. Transvaginal
ultrasound (5 MHz) with superimposed pulsed Doppler demonstrating a typical ovarian stromal
flow velocity waveform. In the early follicular phase, the normal velocity is <0.1 m/s. (With thanks
to Dr. J. Zaidi.)

The term polycystic ovary in some respects adds to the confusion that surrounds
its diagnosis. The cysts are not cysts in the sense that they do contain oocytes. So,
truly it should be called a polyfollicular ovary, to reflect the finding that the cysts are
actually follicles whose development has been arrested. Indeed, the prerequisite of a
certain number of cysts may be of less relevance than the volume of ovarian stroma,
which has been shown to correlate closely with serum T concentrations. In addition, it
has been suggested that an ultrasound assessment of the ratio of ovarian stromal area
to total ovarian area gives the greatest sensitivity and specificity for the diagnosis of
PCOS [19].
Although it is now clear that ultrasound provides an excellent technique for the
detection of polycystic ovarian morphology, identification of polycystic ovaries by
ultrasound does not automatically confer a diagnosis of PCOS. Controversy still
exists over a precise definition of the syndrome and whether the diagnosis should
require confirmation of polycystic ovarian morphology. In North America in 1990,
the National Institutes of Health conference on PCOS recommended that diagnostic
criteria should include evidence of hyperandrogenism and ovulatory dysfunction,
in the absence of non-classic adrenal hyperplasia, and that evidence of polycystic
ovarian morphology is not essential [20]. This definition results in the mystifying
condition of PCOS without polycystic ovaries! However, the more generally accepted
theory in the United Kingdom and Europe is that a spectrum exists, ranging from
women with polycystic ovarian morphology and no overt abnormality to women with
polycystic ovaries associated with severe clinical and biochemical disorders; hence,
the ESHRE/ASRM Consensus of 2004 [2]. Nevertheless, it is widely recognised in
the United States that positive ovarian findings predominate and there is consider-
able overlap between the European and U.S. definitions (Table 8.2). Debate continues
regarding the reliability and reproducibility of the various tests that we have at our
disposal [21].
TABLE 8.2
Definitions of PCOS
Source Criteria
NIH [20] To include all of the following:
1. Hyperandrogenism and/or hyperandrogenaemia
2. Oligo-ovulation
3. Exclusion of related disorders
ESHRE/ASRM To include two of the following, with the exclusion of related disorders:
(Rotterdam) [2] 1. Oligo-ovulation or anovulation
2. Clinical and/or biochemical signs of hyperandrogenism
3. Polycystic ovaries redefined as an ovary with 12 or more follicles measuring
2–9 mm in diameter and/or increased ovarian volume (>10 cm3)3
Androgen To include all of the following:
Excess Society 1. Hirsutism and/or hyperandrogenaemia
[22] 2. Oligo-anovulation and/or polycystic ovaries
3. Exclusion of androgen excess or related disorders

It is important also to appreciate that in vitro studies have demonstrated that

theca cells from ovulatory women with polycystic ovaries produce increased andro-
gens compared with normal ovaries, strengthening the argument for a fundamen-
tal dysfunction of ovarian steroidogenic activity [23,24]. Using a combination of
clinical, ultrasonographic and biochemical criteria, the diagnosis of PCOS is usu-
ally reserved for women who exhibit an ultrasound picture of polycystic ovaries and
who display one or more of the clinical symptoms (menstrual cycle disturbances,
hirsutism, obesity, hyperandrogenism), and/or one or more of the recognised bio-
chemical disturbances (elevated T, androstenedione, LH or insulin). This definition
of PCOS requires the exclusion of specific underlying diseases of the adrenal or pitu-
itary glands (e.g. hyperprolactinaemia, acromegaly, congenital adrenal hyperplasia,
Cushing’s syndrome, androgen-secreting tumours of the ovary or adrenal gland) that
could predispose to similar ultrasound and biochemical features (see Chapter 5).
Heterogeneity of PCOS
A few years ago, we reported a large series of women with polycystic ovaries
detected by ultrasound scan [1]. All of the 1871 patients had at least one symptom of
the PCOS (see Table 8.1). Thirty-eight percent of the women were overweight (body
mass index (BMI) > 25 kg/m 2).
Obesity was significantly associated with an increased risk of hirsutism, menstrual
cycle disturbance and an elevated serum T concentration (Figure 8.3) [1]. Obesity also
was associated with an increased rate of infertility. Twenty-six percent of patients
with primary infertility and 14% of patients with secondary infertility had a BMI >
30 kg/m2. Approximately 30% of the patients had a regular menstrual cycle, 50% had
oligomenorrhoea and 20% had amenorrhoea. In this study, the classical endocrine
features of raised serum LH and T were found in only 39.8% and 28.9% of patients,
respectively [1]. Ovarian volume was significantly correlated with serum LH and
with T concentrations. Other studies have reported that markers of insulin resistance
correlated with ovarian volume and stromal echogenicity that, in turn, have been
correlated with androgen production [24].
Many other groups have similarly reported heterogeneity in their populations
with PCOS. Franks’s series, also from England [25], related to 300 women recruited
from a specialist endocrine clinic. Some years earlier, Goldzieher [26] compiled a
comprehensive review of 1079 cases of surgically proven polycystic ovaries. The
frequency of clinical symptoms and signs in these series was similar (Tables 8.3
and 8.4).
Clinical phenotyping of PCOS involves determining the presence of clinical and/or
biochemical androgen excess (hyperandrogenism), while excluding related disorders.
The primary clinical sign of androgen excess is the presence of hirsutism. However,
at the ESHRE/ASRM consensus meeting [2], it was agreed that normative data in
large populations are still lacking, the assessment of hirsutism is relatively subjective,
and few physicians in clinical practice actually use standardised scoring methods.
There are also significant racial differences, with hirsutism being significantly less
prevalent in hyperandrogenic women of Eastern Asian origin and more so in those
from Southern Asia.

120 4
*
100 * * *
*
* * * * *
3
80
* *
* *
nmol/L
60 2
%
*
+
+
40 + + +
+
+ 1
+ + + +
20
+ +
+
0 0
17–18
19–20
21–22
23–24
25–26
27–28
29–30
31–32
33–34
35–36
37–38
39–40
41–42
43–44
45–46
47–48
BMI
+ Infertility Hirsutism
* Testosterone
FIGURE 8.3 Relationship of BMI to rate of hirsutism and T concentration. (From Balen AH et al.
Hum Reprod 10, 2107–11, 1995.)
The sole presence of acne is also felt to be a relatively good indicator of hyperan-
drogenism, although studies are somewhat conflicting regarding the exact prevalence
of androgen excess in these patients. The sole presence of androgenic alopecia as an
indicator of hyperandrogenism has been less well studied. However, it appears to be a
relatively poor marker of androgen excess, unless present in the oligo-ovulatory patient.
In our study of more than 1700 women with PCOS, we found that one-third had an
elevated serum total T concentration and that the 95th percentile for total T was 4.8
nmol/L, using the traditional radioimmunoassay [1]. We therefore used this value in
practice as the cut-off for screening for other causes of androgen excess. If the value
is greater than 4.8 nmol/L, it is only then necessary to assess the androgen profile in
greater detail to exclude other causes such as androgen-secreting tumours of the ovary
or adrenals (in which case the clinical history of hyperandrogenism is usually of more
acute onset), late onset congenital adrenal hyperplasia (CAH) or Cushing’s syndrome.

TABLE 8.3
Clinical Symptoms and Signs in Women with PCOS
Frequency of Symptom or Sign
Goldzieher [26]
Balen et al. [1] Franks [25]
n = 1079
n = 1741 n = 300
Symptom or Sign % % % No. of Casesa
Menstrual cycle disturbance:
Oligomenorrhoea 47 52 29b (n = 547)
Amenorrhoea 19 28 51 (n = 640)
Hirsutism 66 64 69 (n = 819)
Obesity 38 35 41 (n = 600)
Acne 34 27 – –
Alopecia 6 3 – –
Acanthosis nigricans 2 <q – –
Infertility(primary/secondary) 20 42 74 (n = 596)
Note: –, feature not recorded.
a In the Goldzieher study, clinical details were not available for the entire 1079 women; thus, the
number of cases which were used to determine the frequency of each symptom is stated.
b In this series, any abnormal pattern of uterine bleeding was included.
TABLE 8.4
Biochemical Features of Women with PCOS
% Frequency
Balen et al. [1] Franks [25]
n = 1741 n = 300
Elevated serum LH 39.8 51
Elevated serum T 28.9 50
Elevated serum prolactin 11.8 7
The measurements of free T or the free T (free androgen) index (FAI) are thought
to be sensitive methods of assessing for hyperandrogenaemia. As SHBG production
by the liver is suppressed by hyperinsulinaemia, overweight women with clinical
hyperandrogenism may have a normal total T but an elevated free T as less is bound to
SHBG. Some measure SHBG as a surrogate for the degree of insulin resistance. The
availability of mass spectrometry probably provides the most accurate method for the
assessment of T, and we now have an upper limit of normal set at 1.8 nmol/L [21].
High serum LH concentrations are associated with infertility or menstrual cycle
disturbances. In the study by Balen et al. [1], high serum T levels were associated
with an increased risk of hirsutism, infertility and cycle disturbances. Serum LH
concentrations are elevated in approximately 40%–60% of women with PCOS. This
elevation is due to an increased amplitude and frequency of LH pulses. An elevated
serum LH concentration has been associated with a reduced chance of conception
and an increased risk of miscarriage [8]. LH levels are influenced by the temporal

relation to ovulation, which transiently normalises LH due to the suppressive effect of

progesterone and by body weight, being higher in lean women with PCOS. Although
an elevation in serum LH concentration is pathonemonic of PCOS (in the absence
of the mid-cycle pre-ovulatory LH surge or the menopause transition), a measured
elevation of LH is not required to make the diagnosis. No longer either is an elevated
LH-to-FSH ratio required or useful [2].
In general, it appears that an elevated LGH is responsible for driving the ovary
to overproduce androgens in slim women with PCOS, whereas in obese women
insulin acts as a co-gonadotropin, augmenting the effect of LH and amplifying the
hyperandrogenism.
Population-Based Studies
Estimates of the prevalence of PCOS are greatly affected by the nature of the popu-
lation that is being assessed. Populations of women who are selected on the basis of
the presence of a symptom associated with the syndrome (e.g. hirsutism, acne and
menstrual cycle disturbances) would be expected to demonstrate a prevalence greater
than that which exists in the general population.
In a study of 173 women presenting with anovulation or hirsutism, Adams et al.
[27] found the prevalence of polycystic ovaries (using ultrasound criteria for diagno-
sis) to be 26% in women with amenorrhoea, 87% in women with oligomenorrhoea
and 92% in women with hirsutism and regular cycles. We have recently assessed 70
women presenting with features of PCOS, 20 from infertility, 17 from gynaecology, 17
from dermatology and 16 from endocrine clinics [28]. Participants were assessed for
symptoms and signs of PCOS and underwent a full endocrine and metabolic profile
and a pelvic ultrasound scan. All subjects had experienced menstrual problems, 81%
were overweight, 86% had polycystic ovaries on ultrasound, 56% had hirsutism, 53%
had acne, 23% had acanthosis nigricans, 16% had alopecia and 38% had previously
undiagnosed impaired glucose tolerance (IGT) or diabetes. A significant difference
between the four clinic groups existed with regard to frequency distribution of present-
ing symptoms as might have been expected with, for example, patients in the derma-
tology clinic having more hirsutism and patients in the gynaecology clinic a greater
frequency of menstrual disturbance. It was striking, however, that 34% had previously
undiagnosed IGT and 9% were found to be diabetic. This study emphasises the impor-
tance of understanding the full spectrum of PCOS as it presents to different specialty
clinics. Not only is the syndrome underdiagnosed but so too are the significant associ-
ated morbidities such as IGT and type 2 diabetes.
The prevalence of PCOS in the general population has not been definitively deter-
mined and appears to vary considerably between populations that have been stud-
ied. A cross-sectional study by Knochenhauer et al. [29] examined the prevalence
of PCOS in a population of American women and determined a prevalence rate of
4%, but this study applied the U.S. definition of PCOS and did not include polycystic
ovarian morphology on ultrasound as part of the defining criteria. Several studies
have been performed to attempt to determine the prevalence of polycystic ovaries in
the general population, as detected by ultrasound alone, and they have found remark-
ably similar prevalence rates in the order of 17%–22%. The study designs and results
are summarised in Table 8.5. All of the studies used transabdominal ultrasound for

210
TABLE 8.5
Prevalence of Polycystic Ovaries in the General Population
Polson Clayton Farquhar Botsis Cresswell Michelmore
Authors et al. [4] Tayob et al. [31] et al. [32] et al. [5] et al. [33] et al. [30] et al. [6]
Study Volunteers Volunteers Volunteers Volunteers Volunteers Volunteers Volunteers from
population recruited from using a low-dose born between recruited from recruited from born between 1952 Oxford (mainly
clinical and combined OCP, 1952 and 1969 two electoral women and 1953 colleges and
secretarial recruited from recruited from a rolls in presenting to recruited from GP practice),

staff at St. routine clinics at the list of a Group Auckland an outpatient records of the recruited into
Mary’s Margaret Pyke Practice in New Zealand, clinic for Jessop Hospital, Population
Hospital, Centre and the Royal Harrow, London, by random routine pap Sheffield, by study of
London Free Hospital, by Random postal smear invitation and women’s
(n = 257) London postal invitation invitation (n = 1078) personal interview health
(n = 120) (n = 190) (n = 183) (n = 235) (n = 226)
Response rate (%) Unknown Unknown 18 16 Unknown 68 Unknown
Age range (years) 18–36 18–30 18–36 18–45 17–40 40–42 17–26
(mean = 24) (mean = 33)
Prevalence (%) 22 22 22 21 17 21 33
95% CI 17–27 14–30 16–28 14–27 14–19 16–26
the diagnosis of polycystic ovaries, except for Cresswell et al. [30], who converted to
a transvaginal scan if the transabdominal picture was unclear.
The study populations recruited by Polson et al. [4], Tayob et al. [31] and Botsis
et al. [33] were subject to selection bias because they recruited women from hospital
populations and not from the general population, although Polson’s study recruited
hospital workers and not patients. The low response rates achieved in the community-
based studies by Clayton et al. [32] and Farquhar et al. [5] might reduce confidence
in the validity of their estimates of prevalence, but reassuringly, Cresswell et al.
[30], who achieved a much higher response rate in their sample, determined a very
similar prevalence. In the absence of a large, cross-sectional population-based study,
the prevalence rates detected above provide the best estimates of the occurrence of
polycystic ovaries in the normal population. The pooled prevalence is 19%, indicat-
ing that polycystic ovaries (as defined by their ultrasound appearance) are extremely
common. The frequency of symptoms and signs identified in women with and without
polycystic ovaries is summarised in Table 8.6. The inconsistencies between these
studies may be due in part to differences in the definitions used for each symptom or
sign that was recorded.
Comparison of hormone levels between women with and without polycystic ovaries
was further complicated by the high proportion of women using the oral contracep-
tive pill (OCP) in these populations. This use necessitated division of the normal and
polycystic ovary groups of women into further subgroups dependent upon their oral
contraceptive status. The women with polycystic ovaries tended to have disturbed
biochemistry, with elevated serum T concentrations and also sometimes elevated LH
levels compared with women who had normal ovaries.
We studied 224 normal female volunteers between the ages of 18 and 25 years
and identified polycystic ovaries by using ultrasound in 33% of participants [6]. Fifty
percent of the participants were using some form of hormonal contraception, but the
prevalence of polycystic ovaries in users and non-users of hormonal contraception
was identical. Polycystic ovaries in the non-users of hormonal contraception were
associated with irregular menstrual cycles and significantly higher serum T concen-
trations compared with women with normal ovaries; however, only a small propor-
tion of women with polycystic ovaries (15%) had elevated serum T concentrations
outside the normal range. Interestingly, there were no significant differences in acne,
hirsutism, BMI or body fat percentage between women with polycystic and normal
ovaries and hyperinsulinism and reduced insulin sensitivity were not associated with
polycystic ovaries in this group.
In our study, the prevalence of PCOS was as low as 8% using the NIH definition for
PCOS or as high as 26% if the broader ESHRE/ASRM Rotterdam Consensus criteria
were applied.
However, features included in the Rotterdam Consensus criteria (menstrual irregu-
larity, acne, hirsutism and also a BMI > 25 kg/m2, raised serum T or raised LH) were
found to occur frequently in women without polycystic ovaries, and 75% of women
with normal ovaries had one or more of these attributes. Subgroup analyses of women
according to the presence of normal ovaries, polycystic ovaries alone, or polycys-
tic ovaries and features of PCOS revealed greater mean BMI in women with PCOS
but also indicated lower fasting insulin concentrations and greater insulin sensitivity
in polycystic ovary and PCOS groups compared with women with normal ovaries.

212
TABLE 8.6
Frequency of Clinical Symptoms and Signs in Women with and without Polycystic Ovaries
Frequency (%)
Polson et al. [4] Clayton et al. [32] Farquhar [5] Botsis et al. [30] Cresswell et al. [30]
PCO Norm. PCO Norm. PCO Norm. PCO Norm. PCO Norm.
n = 33a n = 116a n = 43 n = 165 n = 39 n = 144 n = 183 n = 823 n = 49 n = 186

Menstrual cycle disturbance 76 1 29b 27 46 20 80 − 41 27
Hirsutism − − 14 2 23 4 40 10 14 2
Obesity − − 33 29 23 19 41 10 35 48
Infertilityc − 12 10 26 11 − − 16 15
(primary/secondary)
Note: –, feature not recorded.
a Value includes only non-OCP users with PCO.
b Percentage calculated for non-OCP users with PCO where n = 34.
c Includes only women who have tested their fertility.

This finding is in contrast to studies of older women [34]. These interesting findings

were difficult to interpret in the light of current understanding of PCOS, but they
lead us to consider the possibility that this young, mainly non-overweight population
might reflect women early in the natural history of the development of PCOS and that
abnormalities of insulin metabolism might evolve after weight gain in later life.
National and Racial Differences in Expression of PCOS

The highest reported prevalence of PCO has been 52% among South Asian
immigrants in Britain, of whom 49% had menstrual irregularity [35]. Rodin et al.
[35] demonstrated that South Asian women with polycystic ovaries had a comparable
degree of insulin resistance to controls, with established type 2 diabetes mellitus.
Generally, there has been a paucity of data of the prevalence of PCOS among women
of South Asian origin, both among migrant and native groups. Type 2 diabetes and
insulin resistance have a high prevalence among indigenous populations in South
Asia, with a rising prevalence among women. Insulin resistance and hyperinsulinae-
mia are common antecedents of type 2 diabetes, with a high prevalence in South
Asians. Type 2 diabetes also has a familial basis, inherited as a complex genetic trait
that interacts with environmental factors, chiefly nutrition, commencing from fetal
life. We also have assessed the hypothesis that ethnic variations in the overt features
of PCOS (symptoms of hyperandrogenism, menstrual irregularity, and obesity) in
women of South Asian descent are linked to the higher prevalence and degree of
insulin resistance in South Asians. We have shown that South Asians with anovular
PCOS [36] have greater insulin resistance and more severe symptoms of the syn-
drome than anovular white Caucasians with PCOS. Furthermore, we have found that
women from South Asia living in the United Kingdom appear to express symptoms at
an earlier age than their white Caucasian British counterparts [36].
So, is there evidence that the syndrome that we are discussing varies either in its
prevalence or in its presentation around the world or in different racial groups within
the same country? Michelmore et al. [6] demonstrated that 80% of women with
polycystic ovaries (26% of those from the community) had features of PCOS based
on the Rotterdam Consensus definition of PCOS in their post-menarchal years (i.e.
18–24 years). However, using the much more stringent North American criteria that
do not use ovarian morphology, the prevalence rate for PCOS ranged from 4.5% to
11.2% from an unselected group of white Caucasian and blacks in a population-based
study in Alabama [29] to 9% in Greece [37] and 6.5% in Spain [38]. Generally, ethnic
differences in the prevalence of PCOS have not been well explored. Dunaif et al. [39]
reported an increased rate of PCOS among Caribbean Hispanic women. However,
Knochenhauer et al. [29] in a sample of 195 black women and 174 white women in the
United States found the prevalence of PCOS among black women to be comparable
with that among white women (3.4% vs. 4.7%). There also may be ethnic varia-
tion in overt features of PCOS when the prevalence of biochemical manifestations
is similar across the races [40]. A study carried out comparing women with PCOS
from the United States, Japan and Italy reported less obesity in Japanese women, yet
comparable rates of androgen excess and insulin resistance [41]. The question remains
as to whether differences in expression of the syndrome are due to dietary and life-
style factors or to genetic variations in hormone actions, such as polymorphisms in

gonadotropin subunits or receptor function (affecting the expression of androgens,

gonadotropins or insulin). A full discussion of the genetics of PCOS is beyond the
scope of this chapter, and there are several candidate genes that have been proposed.
It may be that some families or racial groups have genetic differences that affect the
expression or presentation of PCOS.
Pathophysiology of PCOS
In understanding the pathophysiology of the PCOS, one has to consider both the
nature of the dysfunction within the ovary and the external influences that prevail to
modify ovarian behaviour.
Ovarian Biochemistry
Women with the classical syndrome have the highest levels of androgens, although
even women with polycystic ovaries and mild or no symptoms have mean serum
concentrations of T that are higher than in those with normal ovaries. The bulk of
evidence points to the ovary being the source of excess androgens, which appears to
result from an abnormal regulation (dysregulation) of steroidogenesis [42].
The ovary and adrenal cortex share the bulk of the steroid biosynthesis pathways,
by making equal contributions to the circulating concentrations of androstenedione
and T, in a normal pre-menopausal woman. Both glands secrete androstenedione in
significantly greater quantities than T, whereas 50% of circulating T is derived from
the peripheral metabolism of androstenedione [43]. Androgen production in the ovary
is by the theca interna layer of the ovarian follicle, whereas the zona fasciculata of
the adrenal cortex synthesises adrenal androgens. The enzymes used in the formation
of androstenedione from the initial substrate cholesterol are similar in both glands,
under the endocrine control of LH in the ovary and adrenocorticotropic hormone
(ACTH) in the adrenal glands.
The initial step in the biosynthesis of all steroid hormones is the conversion of
cholesterol to pregnenolone, by a two-stage process involving cholesterol side chain
cleavage enzyme and the acute steroidogenic regulatory protein. Pregnenolone is
then converted to dehydroepiandrosterone (DHEA) by a two-step process along the
Δ5-steroid pathway, with the conversion being catalysed by cytochrome P450c17a.
Progesterone undergoes a parallel transformation to androstenedione in the Δ4-steroid
pathway. In humans, the cytochrome P450c17 gene product seems to play a minor
role in terms of 17,20-lyase activity in the Δ4-pathway. In the adrenal gland,
17-hydroxyprogesterone is either converted to cortisol or sex hormones, depending
on whether it undergoes 21-hydroxylation to cortisol or 17,20-lysis to be converted
to 17 ketosteroids. The action of 17β-hydroxydehydrogenase on the 17-ketosteroids
is essential for their conversion to T, dihydrotestosterone and oestradiol (Figure 8.4).
Androgen secretion in normal women undergoes approximately two-fold episodic,
diurnal and cyclic variation. The rate-limiting step in steroidogenesis is the forma-
tion of pregnenolone from cholesterol that is regulated by trophic hormones. The
rate-limiting step in androgen formation is the gene expression of P450c17, which
is absolutely dependent on trophic hormones, LH in the ovary and ACTH in the

Cholesterol
STAR Side-chain cleavage
17α-Hydroxylase 17,20-Lyase (desmolase)
Pregnenolone 3β 17-Hydroxy- Dehydroepiandrosterone 3β
pregnenolone (DHEA)
3β-Hydroxysteroid 3β-Hydroxysteroid 3β-Hydroxysteroid
dehydrogenase dehydrogenase dehydrogenase
DHEAS-SO
17α-Hydroxylase 17,20-Lyase (desmolase)
Progesterone 17-Hydroxy- Androstenedione
progesterone
21-Hydroxylase 21-Hydroxylase
Deoxycorticosterone
11-Deoxycortisol
11β-Hydroxylase 17β-Hydroxysteroid dehydrogenase
11β-Hydroxylase
Corticosterone Testosterone
1β-Oxydase Cortisol
CMO-I 5α-Reductase
CMO-II
Aldosterone Dihydrotestosterone
FIGURE 8.4 Steroidogenic pathway.
adrenal cortex. The steroidogenic response to the trophic hormones is modulated by

an array of small peptides, including insulin and insulin-like growth factors (IGFs).
A certain amount of intraovarian androgens are essential for normal follicular
growth and for the synthesis of oestradiol. Nonetheless, when the synthesis of
androgens is not coordinated with the needs of a developing follicle, and is in excess,
poor follicle maturation and increased follicular atresia result. In the normal ovary,
LH acts on theca–interstitial–stromal cells, whereas FSH acts on granulosa cells.
According to the two gonadotropin, two cell theory of oestrogen biosynthesis, the
thecal compartment secretes androgens in response to LH, and the androstenedi-
one thus formed is converted in the granulosa cell to oestrogens, by the action of
aromatase, that, in turn, is under the influence of FSH. When a dominant follicle
emerges, the oestrogen content dominates over androgens and is not driven by long
loop negative feedback effects. The intraovarian modulation of androgen synthesis
by LH plays a critical regulatory role. As LH stimulation increases, a homologous
desensitisation sets in. Overstimulation with LH in a time- and dose-dependent man-
ner, causes down-regulation of LH receptors, reduces cholesterol side chain cleavage
activity, 17,20-lyase activity and finally that of 17-hydroxylase activity. Thus, the ratio
of 17-hydroxyprogesterone to androgen increases [44].
Autocrine, paracrine and hormonal factors modulate the coordination of thecal
and granulosa cell function, in terms of androgen synthesis. Androgens and oes-
trogens are negative modulators of LH effects, whereas IGFs play a positive mod-
ulator role. Insulin also augments LH-stimulated androgen production, either via
its own receptors or via IGF-1 receptors. Inhibin promotes androgen synthesis,
whereas androgens in turn stimulate inhibin production. Activin opposes the effects
of inhibin. Furthermore, prostaglandins and angiotensin also play a promoter role,
whereas corticotropin-releasing hormone, transforming growth factor-β, epidermal

growth factor, tumour necrosis factor and cytokines play an inhibitory role in andro-
gen biosynthesis.
Granulosa cell development, and thereby the increase of aromatase activity, also
determines androgen production. A healthy follicle that is 8 mm or more in diam-
eter converts androstenedione to oestradiol efficiently. Conversely atretic and/or cys-
tic follicles have a high androstenedione-to-oestradiol ratio. The action of FSH on
granulosa cells determines the growth of healthy follicles that are greater than 2–5
mm in diameter, partly mediated by the IGF system and insulin in physiological con-
centrations, all of which stimulate the production of oestradiol. IGF-binding proteins
inhibit FSH bioactivity and are markedly expressed in atretic follicles. Transforming
growth factor and epidermal growth factor inhibit aromatase, whereas activin pro-
motes granulosa cell oestrogen production while inhibiting thecal a ndrogen secretion.
Nearly one-half of the circulating T in normal adult women is derived from the
peripheral conversion of androstenedione, and the remainder is derived from the ovary
and adrenal cortex. The important tissues in which this conversion takes place are the
lung, liver, adipose tissue and skin. Adipose tissue also forms oestrone from andro-
stenedione, thus explaining the mild oestrogen excess of obesity. Plasma dihydrotes-
tosterone is produced virtually entirely by 5α-reductase activity in the periphery, with
plasma androstenedione being its major precursor.
Ovarian Function in PCOS

The presence of enlarged polycystic ovaries suggests that the ovary is the p rimary
site of endocrine abnormality, particularly the hyperandrogenism. In 1990,
Rosenfield et al. [42] suggested that derangement of P450c17a activity played a
central role in excess ovarian androgen production. This derangement was sub-
sequently confirmed by other workers who assessed the response of the pituitary
and ovary to a single dose of the gonadotropin-releasing hormone (GnRH) ago-
nist (GnRHa) nafarelin in hyperandrogenemic women with PCOS in whom adre-
nal androgen production had been suppressed by administering dexamethasone
[45]. The observations were that GnRHa yielded a significant elevation of andro-
stenedione and 17-hydroxyprogesterone. Franks et al. [46] extended this study to
anovulatory and ovulating hyperandrogenemic women, and they reported a small
but significant increase in androstenedione levels in both groups in response to
GnRHa, and a similar response in 17-hydroxyprogesterone, which was signifi-
cantly higher in the anovulatory women. They also demonstrated that there was
no significant rise in these two hormones in response to ACTH injection, which
excluded a significant role of adrenal androgen production. These data indicate
that hyperandrogenemia, in both ovulatory and anovulatory women with PCOS,
is predominantly of ovarian origin. This finding also confirmed that the primary
cause of excess androgen production by the polycystic ovary was not due to hyper-
secretion of LH alone and that it was reasonable to conclude that the intrinsic
defect was due to an ovarian theca–interstitial cell dysfunction, or other stimula-
tory influences such as insulin or IGF-1.
Further research confirmed that women with classic PCOS when injected with
a single dose of GnRHa had a surge of FSH and LH of pre-ovulatory magnitude;
a hyperresponsive secretion of 17-hydroxyprogesterone; and to a lesser extent, of

androstenedione, T, oestrone and oestradiol [45]. This finding is highly suggestive of

a generalised dysregulation of ovarian androgen secretion, and currently P450c17 is
the favoured route for this dysfunction.
Both in vivo and in vitro data confirm that the theca cells of PCOS patients have a
generalised overactive steroidogenesis. PCOS patients have a tendency to an excess of
oestradiol at all stages of follicular maturation. This excess steroidogenesis is partly
due to availability of excess androgen substrate for aromatase activity, as well as an
excessive response of follicle development and oestradiol secretion to FSH. Granulosa
cells from PCO in vitro also have been reported to lose FSH responsiveness, and they
produce low amounts of progesterone [47].
LH excess is considered the cause of ovarian hyperandrogenism of PCOS, in view
of the stimulatory effect of LH on theca cells. Nevertheless, some women with PCOS
have normal LH levels while being hyperandrogenic, but yet others who had down-
regulation of LH as secretion with long-term GnRHa displayed hyperresponsiveness
of 17-hydroxyprogesterone to human chorionic gonadotropin (hCG) injection (i.e.
challenge with LH, as hCG is a surrogate for LH activity). These findings argue
against a sole role of LH in the androgen excess of PCOS. They favour the the-
ory that theca cells of PCOS women hyperrespond to gonadotropins and produce
excess androgens due to an escape of their normal down-regulation to gonadotro-
pins, thereby linking this dysregulation to excess of insulin and IGF-1. Prelevic and
colleagues [48] supported this theory by demonstrating that suppression of insu-
lin secretion by a somatostatin analogue lowers serum LH and androgens in PCOS
women. Indeed, insulin acts as a co-gonadotropin and also amplifies the effects of T
by suppressing SHBG.
Inhibin is an FSH-inducible factor that is capable of interfering with the down-
regulation of steroidogenesis. Plasma inhibin and androstenedione concentrations
correlate, and women with PCOS have elevated serum inhibin B [49]. This finding
helps to explain the relatively low serum concentrations of FSH compared with LH
in anovulatory women with PCOS. Because inhibin stimulates androgen production,
and androgens, in turn, stimulate inhibin secretion, there is a potential for the devel-
opment of a vicious cycle within the ovary that would inhibit follicle development.
Alternatively, a defect in the IGF system could cause an alteration of the set point for
the response of the granulosa cell to FSH. Mason et al. [47] suggested that LH acts on
granulosa cells in the presence of insulin, thereby leading to premature luteinisation,
maturational arrest and excess androgen production.
In summary, as a consequence of dysregulation of androgen synthesis within the
ovary, women with PCOS have ovarian hyperresponsiveness to gonadotropins: that of
thecal cells to LH explaining the excess androgens and that of granulosa cells to FSH
leading to increased oestrogens.
Hypothalamic–Pituitary–Ovarian Axis
The pituitary gonadotrope is central to reproductive function – its production and
secretion of FSH and LH are directly stimulated by hypothalamic GnRH and are also
influenced by integrated feedback mechanisms. FSH provides the initial stimulus for
follicular development and also promotes granulosa cell conversion of androgens to
oestrogens by stimulating the aromatase enzymes. LH, classically known for its role

in the luteal phase by promoting progesterone secretion, also has a vital role in the
follicular phase, inducing androgen production by thecal cells (the substrate for oes-
trogen synthesis) and initiating oocyte maturation at mid-cycle.
A single hypothalamic decapeptide, GnRH, stimulates the release of both LH
and FSH from the gonadotrope. Pulsatile GnRH stimulation is required to maintain
gonadotropin secretion, whereas the continuous exposure of the pituitary to GnRH
results in desensitisation and a suppression of gonadotropin secretion. Changes in
the pulsatility of GnRH are thought to alter the ratio of secretion of the two pituitary
gonadotropins throughout the menstrual cycle. When GnRH pulsatility is slow, FSH
secretion predominates and when rapid, LH secretion predominates. The action of
GnRH is modulated at the level of the pituitary, thereby resulting in differential
production and secretion of the two gonadotropins. GnRH both causes release of
LH and FSH and has a self-potentiating effect on the gonadotrope. The primary
release of gonadotropins and their secondary synthesis and storage have been termed
the first and second pools of gonadotropins, respectively. Pituitary responsiveness
to GnRH is increased by the self-priming action of GnRH, defined as the protein
synthesis-dependent increase in GnRH-stimulated gonadotropin secretion caused by
previous exposure of the pituitary gland to GnRH. Inhibin is another key modulator
of gonadotropin secretion, with FSH being held in check by inhibin release from
the ovary. The multiple small follicles of the polycystic ovary increase the relative
amount of inhibin, thereby suppressing FSH in relation to LH and preventing the
intercycle rise of FSH that initiates normal follicular development. Abnormalities of
inhibin secretion have long been implicated in the pathogenesis of PCOS, with the
notion that hypersecretion of inhibin B by the ovary suppresses pituitary secretion
of FSH to cause the relative imbalance in gonadotropin concentrations observed in
these patients.
The sensitivity of the pituitary to GnRH varies during the menstrual cycle in
synchrony with changes in circulating oestradiol (E2) concentrations. In the early fol-
licular phase, when E2 levels are low, pituitary sensitivity and gonadotropin content
are at a minimum; as E2 levels rise, consequently upon follicular development, both
sensitivity and content increase – particularly the latter, as E2 has a stimulating effect
on pituitary synthesis and storage and promotes the self-priming effect of GnRH on
the pituitary. At the time of the mid-cycle surge, sensitivity to GnRH is maximal, with
the resultant release of large amounts of gonadotropins. E2 also potentiates GnRH
responsiveness, increasing the number of GnRH receptors by directly stimulating the
protein synthesis required for receptor formation.
The arcuate nucleus of the hypothalamus acts as a transducer for neuronal into
endocrine signals, although the cellular nature of the GnRH pulse generator is still
unknown. Here, the GnRH-secreting neurones act in a pulsatile manner, with vary-
ing frequencies throughout the normal ovulatory cycle, resulting in variable fre-
quencies and amplitudes of gonadotropin release. The control of the rhythmicity of
the GnRH pulse generator is not fully understood. Although there does not appear
to be feedback from within the pituitary itself, gonadal steroids and other factors
modulate GnRH action at the pituitary level, and possibly also at the level of the
hypothalamus.
Some of the factors that influence GnRH activity include β-endorphin and opiate
peptides, angiotensin II, serotonin, neuropeptide Y, neurotensin, somatostatin,

c orticotropin-releasing factor, dopamine, melatonin, norepinephrine (noradrenaline),

oxytocin and substance P. The interrelationship of these factors is unclear. Endogenous
opioid tone is important in the regulation of LH and prolactin secretion. Opioids, such
as β-endorphin, inhibit GnRH release from the human mediobasal h ypothalamus.
It has been postulated that withdrawal of endogenous opioid tone in the presence
of sufficient quantities of E2 may contribute to the initiation of the LH surge. When
opioid tone decreases, a chain of neurosecretory events is initiated, that, in the rat,
activates neuropeptide Y neurones that, in turn, either alone or together with adren-
ergic transmitters stimulate secretion of GnRH. The effects of opioids appear to be
dependent upon the steroid hormone environment, in particular oestrogen, whose
effect is augmented by progesterone.
Tonic hypersecretion of LH in women with the PCOS has been suggested
as being caused by, at least in part, a combination of diminished opioid and
dopaminergic tone [44]. There is also evidence that adrenergic activity is altered
in women who hypersecrete LH. Women with PCOS were found to be very sensi-
tive to exogenous dopamine, and it was proposed that these women had a defi-
ciency in endogenous dopaminergic inhibition of GnRH secretion. In normal
women, both dopamine receptor antagonists, such as metoclopramide, and opiate
receptor antagonists, such as naloxone, elicit a rise in serum LH concentrations
[44]. Conversely, a dministration of synthetic β-endorphin elicits a fall in serum
LH concentration. In women with PCOS, the administration of metoclopramide,
naloxone and β-endorphin did not alter LH secretory activity. It was therefore
proposed that an underlying hypothalamic defect might lead to hypersecretion of
LH, through a reduction in endogenous dopaminergic and opioid control of GnRH
secretion [44].
The interactions of factors at the level of the hypothalamus are therefore com-
plex, and the factors that predominate in influencing LH secretion are unknown.
Central disturbances in the PCOS (i.e. at the level of hypothalamus and pituitary)
are probably secondary to peripheral factors that may be ovarian in origin. Since the
isolation and characterisation of inhibin, it has become apparent that not only are
there several members of the inhibin family of glycoprotein hormones but also there
are other non-steroidal gonadal signals that influence gonadotropin secretion and
help to fine-tune reproductive function. It has been established that ovarian inhibin
exerts negative feedback on pituitary gonadotropin production, preferentially effect-
ing FSH. More recently, a feedback pathway that influences pituitary LH secretion
has been proposed, after in vivo and in vitro evidence that has suggested the presence
of a putative inhibitory peptide that has been named gonadotropin surge inhibiting
or attenuating factor (GnSIF/GnSAF). The proposed actions of GnSIF and GnSAF
are similar, although this conclusion will only be confirmed if and when they are
purified [50].
An area of controversy is whether there is an increase in GnRH pulse frequency
in women who hypersecrete LH. This frequency increase is important because if
steroids are the main ovarian product to influence LH secretion, they are able to cross
the blood–brain barrier and so might be expected to effect GnRH p ulsatility also. If
however the primary defect is through perturbed secretion of an ovarian peptide, it
would not be predicted to cross the blood–brain barrier to affect GnRH pulse fre-
quency. It has been found that some women with hypogonadotropic h ypogonadism

(HH) also have polycystic ovaries detected by pelvic ultrasound, and when these
women were treated with pulsatile GnRH to induce ovulation they had signifi-
cantly higher serum LH concentrations than women with HH and normal ovaries
[51]. Furthermore, the elevation in LH concentration was observed before serum E2
concentrations rose. Thus, hypersecretion of LH occurred in these women when the
hypothalamus was replaced by an artificial GnRH pulse generator (i.e. the GnRH
pump), with a fixed GnRH pulse interval of 90 min (equivalent to the pulse interval
in the early follicular phase). These results suggest that the cause of hypersecretion
of LH involves a perturbation of ovarian–pituitary feedback, rather than a primary
disturbance of hypothalamic pulse regulation. These findings are also consistent with
the notion that there may be a non-steroidal factor(s) that disturbs ovarian–pituitary
feedback control of LH secretion.
The data collected in women with PCOS undergoing laparoscopic ovarian dia-
thermy are also consistent with the hypothesis that it is altered ovarian–pituitary
feedback that causes hypersecretion of LH. In these patients, LH pulse amplitude
decreased but no change in the (normal) pulse frequency was detected after the pro-
cedure [52]. Rossmanith et al. [52] found an attenuation of GnRH-stimulated LH
secretion after laparoscopic ovarian diathermy, a result consistent with abnormali-
ties in the production of an ovarian factor(s) that regulates LH secretion, rather than
with the theory that the disorder starts at the level of either the hypothalamus or
pituitary.
We performed a small prospective study to compare unilateral with bilateral ovar-
ian diathermy to observe which ovary responded by ovulating [53]. Three of the four
patients who received unilateral diathermy ovulated, all from the contralateral ovary
in the first cycle and then alternately from each ovary. There were no significant
differences between the baseline hormone measurements of the responders and the
non-responders. When the pre- and post-treatment values were compared, there were
no differences in the serum FSH and T concentrations in either the responders or the
non-responders. In the responders, however, there was a significant fall of the serum
LH concentration after limit of detection (LOD) (p = .045, 95% CI 0.2–13.4), whereas
in the non-responders there was no difference in the LH concentrations before and
after treatment.
The mechanism of ovulation induction by LOD is uncertain. It appears however
that minimal damage to an unresponsive ovary either restores an ovulatory cycle or
increases the sensitivity of the ovary to exogenous stimulation. Furthermore, the find-
ing of an attenuated response of LH secretion to stimulation with GnRH suggests an
effect on ovarian–pituitary feedback and hence pituitary sensitivity to GnRH. Our
study goes one step further by demonstrating that unilateral diathermy leads to bilat-
eral ovarian activity, showing conclusively for the first time that ovarian diathermy
achieves its affect by correcting a perturbation of ovarian–pituitary feedback. Our
own hypothesis is that the response of the ovary to injury leads to a local cascade of
growth factors and those such as IGF-1, which interact with FSH, result in stimula-
tion of follicular growth and ovarian–pituitary feedback leads to a fall in serum LH
concentrations [53] (see Chapter 7).
Gonadotropin biosynthesis and secretion are influenced by hypothalamic, para-
crine and endocrine factors, and there is considerable overlap between all three. The
influence of non-steroidal factors on pituitary and hypothalamic function is still being

elucidated. Further work is required to examine both the pathophysiology of hyperse-

cretion of LH and its effects at the level of the oocyte.
Hyperinsulinaemia
The association between insulin resistance, compensatory hyperinsulinaemia and
hyperandrogenism has provided insight into the pathogenesis of the PCOS. The cel-
lular and molecular mechanisms of insulin resistance in PCOS have been extensively
investigated, and it is evident that the major defect is a decrease in insulin sensitivity
secondary to a post-binding abnormality in insulin receptor-mediated signal trans-
duction, with a less substantial, but significant, decrease in insulin responsiveness
[54]. It appears that decreased insulin sensitivity in PCOS is potentially an intrinsic
defect in genetically susceptible women, because it is independent of obesity, met-
abolic abnormalities, body fat topography and sex hormone levels. There may be
genetic abnormalities in the regulation of insulin receptor phosphorylation, result-
ing in increased insulin-independent serine phosphorylation and decreased insulin-
dependent tyrosine phosphorylation [54].
Although the insulin resistance may occur irrespective of BMI, the common
association of PCOS and obesity has a synergistic deleterious impact on glucose
homeostasis and can worsen both hyperandrogenism and anovulation. An assess-
ment of BMI alone is not thought to provide a reliable prediction of cardiovascular
risk. It has been reported that the association between BMI and coronary heart
disease almost disappeared after correction for dyslipidemia, hyperglycaemia and
hypertension. Some women have profound metabolic abnormalities in the presence
of a normal BMI and others few risk factors with an elevated BMI [53]. It has been
suggested that rather than BMI itself, it is the distribution of fat that is important,
with android obesity being more of a risk factor than gynaecoid obesity [55]; hence,
the value of measuring waist:hip ratio (WHR), or waist circumference, a measure-
ment that detects abdominal visceral fat rather than subcutaneous fat. It is the vis-
ceral fat that is metabolically active and when increased results in increased rates of
insulin resistance, type 2 diabetes, dyslipidemia, hypertension and left ventricular
enlargement [55]. Lord and Wilkin [55] have found a closer link between waist
circumference and visceral fat mass, as assessed by computed tomography scan,
than with wait:hip ratio or BMI. Waist circumference should ideally be less than
79 cm, whereas a measurement that is greater than 87 cm carries a significant risk.
Exercise has a significant effect on reducing visceral fat and reducing cardiovascu-
lar risk – indeed, a 10% reduction of body weight may equate with a 30% reduction
in visceral fat.
Insulin acts through multiple sites to increase endogenous androgen levels.
Increased peripheral insulin resistance results in a higher serum insulin concentra-
tion. Excess insulin binds to the IGF-1 receptors, thereby enhancing the androgen
production by theca cells in response to LH stimulation [56]. Hyperinsulinaemia
also decreases the synthesis of SHBG by the liver. Therefore, there is an increase in
serum free T concentration and consequent peripheral androgen action. In addition,
hyperinsulinaemia inhibits the hepatic secretion of insulin-like growth factor binding
protein-1 (IGFBP-1), leading to increased bioavailability of IGF-1 and -2, the impor-
tant regulators of ovarian follicular maturation and steroidogenesis [57]. Together

with more IGF-2 secretion from the theca cells, IGF-1 and -2 further augment ovarian
androgen production by acting on IGF-1 receptors.
Insulin also may increase endogenous androgen concentrations by increased
cytochrome P450c17a enzyme activity, which is important for ovarian and adrenal
steroid hormone biosynthesis. Insulin-induced overactivity of P450c17a and exag-
gerated serum 17-hydroxyprogesterone (17-OHP) response to stimulation by GnRHa
also have been demonstrated [58]. Intraovarian androgen excess is responsible for
anovulation by acting directly on the ovary promoting the process of follicular atresia.
This latter process is characterised by apoptosis of granulosa cells. As a consequence,
there is an increasingly larger stromal compartment that retains LH responsiveness
and continues to secrete androgens.
Insulin Resistance
Insulin resistance is defined as a reduced glucose response to a given amount of
insulin and may occur secondary to resistance at the insulin receptor, decreased
hepatic clearance of insulin and/or increased pancreatic sensitivity. Both obese and
non-obese women with PCOS are more insulin resistant and hyperinsulin aemic
than age- and weight-matched women with normal ovaries. Thus, there appear to be
factors in women with PCOS that promote insulin resistance and that are independent
of obesity [59]. Pancreatic beta cell dysfunction has been described in women with
PCOS, whereby there is increased basal secretion of insulin yet an inadequate post-
prandial response. This defect remains even after weight loss, despite an improvement
in glucose tolerance [60].
Insulin acts through its receptor to initiate a cascade of post-receptor events
within the target cell. Phosphorylation causes insulin receptor substrates (IRS1–4)
to promote glucose uptake via the transmembrane glucose transporter (GLUT4) and
also intracellular protein synthesis. Tyrosine phosphorylation increases the tyrosine
kinase activity of the insulin receptor, whereas serine phosphorylation inhibits it, and
it appears that at least 50% of women with PCOS have excessive serine phosphory-
lation and inhibition of normal signalling [59]. This serine phosphorylation affects
only glucose homeostasis and not the other pleiotropic actions of insulin, so that cell
growth and protein synthesis may continue. Serine phosphorylation also increases
activity of P450c17 in both the ovary and adrenal, thus promoting androgen synthe-
sis, so this may be a mechanism for both insulin resistance and hyperandrogenism in
some women with PCOS.
Health Consequences of PCOS

Cardiovascular Disease and Diabetes
Obesity and metabolic abnormalities are recognised risk factors for the development
of ischemic heart disease (IHD) in the general population, and these abnormalities
also are recognised features of PCOS [11]. IHD accounts for 18% of deaths in men
and 14% of deaths in women in Europe. In men, the incidence of IHD increases after
the age of 35 years, whereas in women an increased incidence is noted after the age

of 55 years. The questions are whether women with PCOS are at an increased risk
of IHD, and whether this increased risk will occur at an earlier age than women
with normal ovaries. The basis for the idea that women with PCOS are at greater
risk for cardiovascular disease is that these women are more insulin resistant than
weight-matched controls and that the metabolic disturbances associated with insulin
resistance are known to increase cardiovascular risk in other populations.
In the general population, cardiovascular risk factors include insulin resistance,
obesity, especially an increase in waist circumference; glucose intolerance; diabetes;
hypertension; and dyslipidemia, in particular raised serum triglycerides.
Insulin sensitivity varies depending upon menstrual pattern. Women with PCOS
who are oligomenorrhoeic are more likely to be insulin resistant than women with
regular cycles – irrespective of their BMI. Women with PCOS have a defect in insulin
signalling at the insulin receptor, which causes insulin resistance. The sex steroid–
induced increase of growth hormone that initiates the adolescent growth spurt also
leads to insulin resistance and explains the timing of onset of symptoms in those
prone to develop PCOS. The presence of obesity and/or type 2 diabetes worsens the
degree of insulin resistance.
Insulin resistance is restricted to the extrasplanchnic actions of insulin on glucose
dispersal. The liver is not affected, hence the fall in SHBG and high-density lipopro-
tein (HDL); neither is the ovary, hence the menstrual problems and hypersecretion of
androgens; nor the skin, hence the development of acanthosis nigricans. The insulin
resistance causes compensatory hypersecretion of insulin, particularly in response to
glucose, so euglycaemia is usually maintained at the expense of hyperinsulinaemia.
It is reported that up to 20% of slim women and 40% of obese women with PCOS
demonstrate IGT. A prospective population-based study of 1462 women aged between
38 and 60 years was undertaken in Gothenberg, to examine cardiovascular risk
factors in women [61]. Dahlgren et al. [61] noted the prevalence of type 2 diabetes
was 15% in women with PCOS compared with 2% in the controls. The prevalence of
treated hypertension also was found to be three times higher in women with PCOS
between the ages of 40 and 59 years compared with controls [61]. Most women with
type 2 d iabetes under the age of 45 years have PCOS. Insulin resistance combined
with abdominal obesity is thought to account for the higher prevalence of type 2
diabetes in PCOS. There is a concomitant increased risk of gestational diabetes. We
recommended a glucose tolerance test for white Caucasian women with PCOS and a
BMI > 30 kg/m2 and for Asian women with PCOS if they have a BMI > 25 kg/m2 (see
Chapter 5). Women with PCOS are also at increased risk of developing gestational
diabetes.
Dyslipidemia
Women with PCOS have high concentrations of serum triglycerides and suppressed
HDL levels, particularly a lower HDL2 subfraction. HDLs play an important role in lipid
metabolism and are the most important lipid parameter in predicting cardiovascular
risk in women. HDLs perform the task of reverse cholesterol transport. That is, they
remove excess lipids from the circulation and tissues to transport them to the liver
for excretion, or transfer them to other lipoprotein particles. Cholesterol is only one
component of HDL, a particle with constantly changing composition forming HDL3

then HDL2, as unesterified cholesterol is taken from tissue, esterified and exchanged
for triglyceride with other lipoprotein species. Consequently, measurement of a single
constituent in a particle involved in a dynamic process gives an incomplete picture.
In a detailed study of HDL composition, it was found that obesity was the most
important factor associated with elevated serum total triglyceride, cholesterol and
phospholipid concentrations in both PCOS subjects and controls [62]. In addition,
obese women with PCOS had lower HDL cholesterol and phospholipid concentrations
in all subfractions compared with obese controls. This finding was in the presence
of normal quantities of the protein component of HDL apolipoprotein-a1. These
findings imply that the number of HDL particles was the same in obese PCOS sub-
jects c ompared with obese controls but that the HDL particles were lipid depleted
and hence less effective in function. The only factor which appeared to have an inde-
pendent influence on the HDL composition was the presence of PCOS, rather than
obesity or raised serum androgen or insulin concentrations.
Plasminogen activator inhibitor-1 (PAI-1) is a potent inhibitor of fibrinolysis and
has been found to be elevated in both obese women and non-obese women with
PCOS. Plasma levels of PAI-1 correlate directly with serum insulin concentrations
and have been shown to be an important predictor of myocardial infarction. Thus,
when examining the surrogate risk factors for cardiovascular disease, there is evi-
dence that insulin resistance, central obesity and hyperinsulinaemia are features of
PCOS and have an adverse effect on lipid metabolism. Women with PCOS have
been shown to have dyslipidemia, with reduced HDL cholesterol and elevated serum
triglyceride concentrations, along with elevated serum PAI-1 concentrations. The
evidence is thus mounting that women with PCOS may have an increased risk of
developing cardiovascular disease and diabetes later in life, which has important
implications in their management.
PCOS in Younger Women

At what stage do the risk factors for cardiovascular disease become apparent in
women with PCOS? The majority of the studies that have identified the risk factors
of obesity and insulin resistance in women with PCOS have investigated adult popu-
lations, commonly including women who have presented to specialist endocrine or
reproductive medicine clinics. However, PCOS has been identified in much younger
populations [6] in which women with increasing symptoms of PCOS were found to
be more insulin resistant. These data emphasise the need for long-term prospective
studies of young women with PCOS to clarify the natural history and to determine
which women will be at risk of diabetes and cardiovascular disease later in life. A
study of women with PCOS and a mean age of 39 years, followed over a period of 6
years, found that 9% of those with normal glucose tolerance developed IGT and 8%
developed NIDDM [63], whereas 54% of women with IGT at the start of the study had
NIDDM at follow-up. The risks of disease progression, not surprisingly, were greatest
in those who were overweight.
In a large retrospective study, Pierpoint et al. [64] reported the mortality rate in 1028
women diagnosed as having PCOS between 1930 and 1979. All the women were older
than 45 years, and 770 women had been treated by wedge resection of the ovaries. In
total, 786 women were traced; the mean age at diagnosis was 26.4 years and average

duration of follow-up was 30 years. There were 59 deaths, of which 15 were from
circulatory disease. Of these 15 deaths, 13 were from IHD. There were six deaths
from diabetes as an underlying or contributory cause compared with the expected 1.7
deaths. The standard mortality rate both overall and for cardiovascular disease was
not higher in the women with PCOS compared with the national mortality rates in
women, although the observed proportion of women with diabetes as a contributory
or underlying factor leading to death was significantly higher than expected (OR 3.6,
95% CI 1.5–8.4). Thus, despite surrogate markers for cardiovascular disease, in this
study no increased rate of death from cardiovascular disease could be demonstrated.
A follow-up report from the same study, however, did then demonstrate an increased
although non-significant risk of death due to diabetes. After adjustment for BMI (OR
2.2, 95% CI 0.9–5.2) for diabetes [65], there was still no increased long-term coronary
heart disease mortality in the PCO group, although there was evidence of increased
stroke-related mortality even after adjustment for BMI [65].
Elevated Plasma Homocysteine

A moderately increased total plasma homocysteine (Hcy) concentration is a ssociated
with an increased risk of atherosclerosis. Hcy is an essential intermediate in the
transfer of activated methyl groups from tetrahydrofolate to S-adenylmethionine in
the synthesis of cysteine from methionine and in the production of homocysteine
thiolactone. An abnormal elevation of Hcy in plasma and urine is caused by an imbal-
ance between Hcy production and metabolism that can be of demographic, genetic,
nutritional or metabolic aetiology and is associated with premature vascular disease.
Mild hyperhomocysteinaemia has been demonstrated to induce sustained injury
to the arterial endothelial cell that accelerates the development of thrombosis and
atherosclerosis. Normal concentrations of total plasma Hcy are in the range 5–16
mmol/L, although 10 mmol/L is considered the desired upper limit; there is an age-
related rise and lower concentrations in women.
There have been reports of elevated plasma Hcy in Caucasian women with PCOS
[66,67]. One study showed a correlation between elevated Hcy and e chocardiographic
evidence of diastolic dysfunction (considered as an early marker of CAD), plasma
insulin and uric acid concentrations in young women with PCOS, thus linking
hyperhomocysteinaemia with the insulin resistance of PCOS [66]. A recent study
showed that migrant South Asians with PCOS present at a younger age, with more
severe symptoms and greater insulin resistance than white Europeans with PCOS,
suggesting that the degree of metabolic dysfunction in PCOS has an ethnic basis [68].
The even greater degree of insulin resistance among the indigenous South Asians
than British Asians excludes migration as being the sole explanation for the p reviously
observed ethnic variation in the metabolic syndrome of PCOS. A f urther report from
the same researchers has been the first to demonstrate an ethnic d ifference in the
elevation of Hcy in women with PCOS, which mirrors an ethnic variation in the
degree of insulin resistance of PCOS [69]. Moreover, the significantly higher concen-
trations of plasma Hcy and insulin among normal Sri Lankan women of reproductive
age compared with other control groups supports the hypothesis of an inherent ethnic
propensity to insulin resistance and hyperhomocysteinaemia among the indigenous
South Asians.

Randeva et al. [67] reported a significant decrease in plasma Hcy and WHR among
young overweight/obese PCOS women after 6 months of regular physical exercise.
Weight reduction and regular physical exercise are recognised interventions that help
towards reducing insulin resistance of the metabolic syndrome. It has been proposed
that hyperhomocysteinaemia and insulin resistance are directly linked by similar
pathogenic effects on vascular endothelial cells, as well as the establishment of a
vicious cycle of an elevated Hcy-induced insulin resistance, whereas hyperinsulinae-
mia in turn leads to further accumulation of plasma Hcy.
It is noteworthy that central obesity as determined by WHR, an important component
of the metabolic syndrome, showed a significant linear relationship with plasma Hcy
in PCOS. This relationship is particularly significant in the light of Sri Lankan women
with PCOS, who were found to have the highest mean concentration of Hcy as well as
the highest WHR for a given BMI [69]. A difference in central obesity also is attributed
to one’s ethnic origin, with Asians being identified to have a higher body fat percentage
at a lower BMI. These findings being of the greatest severity in the cohort of young Sri
Lankan PCOS subjects, who were recruited in an identical manner to the U.K.-based
subject recruitment, are supported by the highest prevalence of glucose intolerance
among Sri Lankan with PCOS compared with British Asians and white Europeans
with PCOS [69]. Nevertheless, the greater metabolic derangement observed in the
indigenous Asians is likely to be explained by differing environmental influences.
Endometrial Cancer
Endometrial adenocarcinoma is the second most common female genital malignancy,
but only 4% of cases occur in women less than 40 years of age. The risk of developing
endometrial cancer has been shown to be adversely influenced by several factors,
including obesity, long-term use of unopposed oestrogens, nulliparity and infertility.
The relative risk of endometrial cancer is 1.6 in women with a menarche before the
age of 12 years and 2.4 in women who have their menopause after the age of 52 years
[70]. Women with endometrial carcinoma have had fewer births compared with
controls, and it also has been demonstrated that infertility per se gives a relative risk
of 2. Hypertension and type 2 diabetes mellitus have long been linked to endometrial
cancer, with relative risks of 2.1 and 2.8, respectively [70] – conditions that are now
known also to be associated with PCOS.
A study by Coulam et al. [71] examined the risk of developing endometrial c arcinoma
in a group of 1270 patients who were diagnosed as having chronic anovulation
syndrome. The defining characteristics of this group included p athological or macro-
scopic evidence of the Stein–Leventhal syndrome, or a clinical diagnosis of chronic
anovulation. This study identified the excess risk of endometrial cancer to be 3.1
(95% CI 1.1–7.3) and proposed that this high risk might be due to abnormal levels of
unopposed oestrogen. The true risk of endometrial carcinoma in women with PCOS,
however, is difficult to ascertain.
Endometrial hyperplasia may be a precursor to adenocarcinoma, with cystic
glandular hyperplasia progressing in perhaps 0.4% of cases and adenomatous hyper-
plasia in up to 18% of cases over 2–10 years. Precise estimation of rate of progression
is impossible to determine. Some studies have reported conservative management of
endometrial adenocarcinoma in women with PCOS with a combination of curettage

and high-dose progestogens. The rationale is that cancer of the endometrium often
presents at an early stage, is well differentiated, of low risk of metastasis, and
therefore is not perceived as being life-threatening, whereas poorly differentiated
adenocarcinoma in a young woman has a worse prognosis and warrants hysterectomy.
In general, however, the literature on women with PCOS and endometrial hyper-
plasia or adenocarcinoma suggests that this group has a poor prognosis for fertility.
This prognosis may be because of the factors that predisposed to the endometrial
pathology – chronic anovulation combined often with severe obesity – or secondary
to the endometrial pathology disrupting potential embryonic implantation. Thus, a
more traditional and radical surgical approach (i.e. hysterectomy) is suggested as the
safest way to prevent progression of the cancer. Early stage disease may permit ovar-
ian conservation and the possibility of pregnancy by surrogacy [72].
Although the degree of risk has not been clearly defined [11], it is generally accepted
that for women with PCOS who experience amenorrhoea, or oligomenorrhoea, the
induction of artificial withdrawal bleeds to prevent endometrial hyperplasia is prudent
management.
Indeed, we consider it important that women with PCOS shed their endometrium at
least every 3 months. For those women with oligomenorrhoea/amenorrhoea who do not
wish to use cyclical hormone therapy, we recommend an ultrasound scan to measure
endometrial thickness and morphology every 6–12 months (depending upon menstrual
history). An endometrial thickness greater than 10 mm in an amenorrhoeic woman
warrants an artificially induced bleed, which should be followed by a repeat ultrasound
scan and endometrial biopsy if the endometrium has not been shed. Another option is
to consider a progestogen-secreting intrauterine system such as the Mirena®.
Breast Cancer
Obesity, hyperandrogenism and infertility occur frequently in PCOS, and they are
features known to be associated with the development of breast cancer. However,
studies examining the relationship between PCOS and breast carcinoma have not
always identified a significantly increased risk [11]. The study by Coulam et al. [71]
calculated a relative risk of 1.5 (95% CI 0.75–2.55) for breast cancer in their group
of women with chronic anovulation, which was not statistically significant. After
stratification by age, however, the relative risk was found to be 3.6 (95% CI 1.2–
8.3) in the post-menopausal age group. Pierpoint et al. [64] reported a series of 786
women with PCOS in the United Kingdom who were traced from hospital records
after histological diagnosis of polycystic ovaries between 1930 and 1979. Mortality
was assessed from the national registry of deaths and standardised mortality rates
(SMRs) calculated for patients with PCOS compared with the normal population. The
average follow-up period was 30 years. The SMR for all neoplasms was 0.91 (95% CI
0.60–1.32) and for breast cancer 1.48 (95% CI 0.79–2.54). In fact, breast cancer was
the leading cause of death in this cohort.
Ovarian Cancer
There has been much debate about the risk of ovarian cancer in women with infertility,
particularly in relation to the use of drugs to induce superovulation for assisted

conception procedures. Inherently, the risk of ovarian cancer appears to be increased

in women who have multiple ovulations – that is, in women who are nulliparous
(possibly because of infertility), with an early menarche and late menopause. Thus,
it may be that inducing multiple ovulations in women with infertility will increase
their risk (see Chapter 18), a notion that is by no means proven. Women with PCOS
who are oligo-ovulatory/anovulatory might therefore be expected to be at low risk
of developing ovarian cancer if it is lifetime number of ovulations rather than preg-
nancies that is critical. Ovulation induction to correct anovulatory infertility aims
to induce unifollicular ovulation, and so in theory, should raise the risk of a woman
with PCOS to that of a normal ovulating woman. The polycystic ovary, however, is
notoriously sensitive to stimulation, and it is only recently with the development of
high-resolution transvaginal ultrasonography that the rate of unifollicular ovulation
has attained acceptable levels. The use of clomifene citrate and gonadotropin therapy
for ovulation induction in the 1960s, 1970s and 1980s resulted in many more mul-
tiple ovulations (and indeed multiple pregnancies) than in recent times and might
therefore present with an increased rate of ovarian cancer when these women reach
their s ixties – the age of greatest incidence.
There are a few studies that have addressed the possibility of an association between
polycystic ovaries and ovarian cancer. The results are conflicting, and generalisability
is limited due to problems with the study designs. In the large U.K. study of Pierpoint
et al. [64], the SMR for ovarian cancer was 0.39 (95% CI 0.01–2.17).
Management of Non-Fertility Aspects of PCOS

For investigations, for women with PCOS, see Chapter 5. Ovulation induction for
anovulatory infertility is covered in Chapter 7. A detailed description of the manage-
ment of non-fertility aspects of PCOS is beyond the scope of this book, so a brief
overview only is given.
Psychological Support and Quality of Life

The symptoms typically associated with PCOS also have been shown to lead to a
significant reduction in health-related quality of life (HRQoL) [73]. HRQoL is a mul-
tidimensional, dynamic concept that encompasses physical, psychological and social
aspects that are associated with a particular disease or its treatment. Therefore, any
management of the woman with PCOS needs to consider and understand the negative
impact this condition may have upon these psychosocial parameters. For example,
although the management of hirsutism may be considered as a purely cosmetic issue,
excessive facial hair has been shown to be one of the major causes of marked psy-
chological stress in women with PCOS, often caused by the embarrassment about the
excessive hair growth. Infertility and weight issues also have been found to affect
other social and psychological parameters. Infertility can cause tensions within the
family, altered self-perception and problems at work. Although obesity worsens the
symptoms, the metabolic scenario conspires against weight loss and many women
experience frustration in attempts to lose weight and suffer from low self-esteem and
poor body image.

Obesity
The management of women with PCOS should be focussed on the patient’s particular
problems. Obesity worsens both symptomatology and the endocrine profile, so obese
women (BMI > 30 kg/m2) should be encouraged to lose weight, by a combination of
calorie restriction and exercise. Weight loss improves the endocrine profile, the likeli-
hood of ovulation and a healthy pregnancy.
Insulin-sensitising agents such as metformin became popular for the management
of PCOS as it was thought that they might act directly at the pathogenesis of the
syndrome and help correct both metabolic and endocrine problems. Early studies sug-
gested an improvement in reproductive function and menstrual cycle regulation and
the possibility of benefits to health of long-term use, including deferring the onset of
type 2 diabetes. However, the results of large, prospective, randomised studies have
failed to demonstrate benefit: weight loss is not achieved by the therapy and although
some biochemical parameters may improve, this improvement does not translate into
a significant benefit in outcome. Therefore, at present, the role of insulin-sensitising
and-lowering drugs such as metformin and the thiazolidinediones is uncertain in the
management of PCOS [11,74].
Much has been written about diet and PCOS. The right diet for an individual is one
that is practical, sustainable and compatible with her lifestyle. There does not appear
to be a particular diet that is most appropriate for women with PCOS. It is sensible to
reduce glycaemic load by lowering sugar content in favour of more complex carbohy-
drates and to avoid fatty foods. Meal replacement therapy or low-calorie diets may be
appropriate: it is often helpful to refer to a dietitian, if available. An increase in physi-
cal activity is essential, preferably as part of the daily routine. Thirty minutes per
day of brisk exercise is encouraged to maintain health, but to lose weight, or sustain
weight loss, 60–90 min/day is advised. Concurrent behavioural therapy improves the
chances of success of any method of weight loss.
Anti-obesity drugs may help with weight loss. Orlistat is a pancreatic lipase inhibi-
tor that prevents absorption of approximately 30% of dietary fat but that is not effec-
tive in a low-fat diet! Bariatric surgery is used increasingly because of the global
epidemic of obesity (see Chapter 4) and certainly has a role in the management of
obese women with PCOS. It is recommended by some that anyone with a BMI > 40
kg/m2 should be referred for consideration of bariatric surgery. If there are comorbidi-
ties, such as diabetes, then the BMI cut-off for surgery is lower at 30–35 kg/m2.
Menstrual Irregularity
The simplest way to control the menstrual cycle is the use of a low-dose combined oral
contraceptive preparation (COCP). This approach will result in an artificial cycle and
regular shedding of the endometrium. It is also important once again to encourage
weight loss. As women with PCOS are thought to be at increased risk of cardiovas-
cular disease, a lipid-friendly combined contraceptive pill should be used. The third-
generation oral contraceptives are lipid friendly but present the potential disadvantage
of venous thromboembolism, particularly in overweight women. Dianette® is a COCP
that has anti-androgenic properties and will have additional b enefits for women with
hyperandrogenism. Yasmin® contains a newer anti-androgen, drospirenone, that is

a derivative of spironolactone. Alternatives to the COCP include a progestogen, for

example, medroxyprogesterone acetate (Provera®) or dydrogesterone (Duphaston®),
for 12 days every 1–3 months to induce a withdrawal bleed, or simply the insertion of
a Mirena intrauterine system.
In women with anovulatory cycles, the action of oestradiol on the endometrium is
unopposed because of the lack of cyclical progesterone secretion. This action may
result in episodes of irregular uterine bleeding, and in the long-term endometrial
hyperplasia and even endometrial cancer (see above). An ultrasound assessment of
endometrial thickness provides a bioassay for oestradiol production by the ovaries
and conversion of androgens in the peripheral fat. If the endometrium is thicker than
10 mm, a withdrawal bleed should be induced; if the endometrium fails to shed,
endometrial sampling is required to exclude endometrial hyperplasia or malignancy.
Hyperandrogenism and Hirsutism

The bioavailability of T is affected by the serum concentration of SHBG. High lev-
els of insulin lower the production of SHBG and thus increase the free fraction of
androgen. Elevated serum androgen concentrations stimulate peripheral androgen
receptors, resulting in an increase in 5-α reductase activity and directly increasing
the conversion of T to the more potent metabolite dihydrotestosterone. Symptoms of
hyperandrogenism include hirsutism and acne, which are both distressing conditions.
Hirsutism is characterised by terminal hair growth in a male pattern of distribution,
including chin, upper lip, chest, upper and lower back, upper and lower abdomen,
upper arm, thigh and buttocks. A standardised scoring system, such as the modi-
fied Ferriman and Gallwey Score, should be used to evaluate the degree of hirsutism
before and during treatments.
Treatment options include cosmetic and medical therapies. As drug therapies may
take 6–9 months or longer before any improvement of hirsutism is perceived, physical
treatments such as electrolysis, waxing and bleaching may be helpful while waiting
for medical treatments to work. For many years, the most permanent physical treat-
ment for unwanted hair has been electrolysis. Electrolysis is time-consuming, painful
and expensive and should be performed by an expert practitioner. Regrowth is not
uncommon and there is no really permanent cosmetic treatment, but the last few years
have seen much development in the use of laser and photothermolysis techniques.
There are many different types of lasers in production, and each requires evaluation
of dose intensity, effectiveness and safety. The technique is promising, being faster
and more effective than shaving, waxing or chemical depilation. Repeated treatments
are required for a near-permanent effect because only hair follicles in the growing
phase are obliterated at each treatment. Hair growth occurs in three cycles, so 6–9
months of regular treatments is typical. Patients should be appropriately selected
(dark hair on fair skin is best) and warned that complete hair removal cannot be guar-
anteed and some scarring may occur. At present, it is not widely available and is still
an expensive option.
Eflornithine (Vaniqua®) has been recently developed as a topical treatment for hir-
sutism. It works by inhibiting the enzyme ornithine decarboxylase in hair follicles
and may be a useful therapy for those who wish to avoid hormonal treatments, but it
also may be used in conjunction with hormonal therapy.

Medical regimens should stop further progression of hirsutism and decrease the
rate of hair growth. Therapy for acne should aim to lower sebum excretion, alter
follicular cell desquamation, reduce propionibacteria and reduce inflammation.
If using anti-androgen therapy, adequate contraception is important in women of
reproductive age as transplacental passage of anti-androgens may disturb the genital
development of a male fetus.
The best pharmacological treatment of proven effectiveness is a combina-
tion of the synthetic progestogen cyproterone acetate, a antigonadotropic and
a nti-androgenic, with ethinyloestradiol. Dianette contains ethinyloestradiol (35 μg)
in combination with cyproterone, although at a lower dose (2 mg) (75). Dianette is
licenced for moderate to severe hirsutism and severe acne. The anti-androgen effect
reduces sebum excretion in 2–3 months and results in clinical improvement in acne
in 4–6 months.
Oestrogens lower circulating androgens by a combination of a slight inhibition
of gonadotropin secretion and gonadotropin-sensitive ovarian steroid produc-
tion and by an increase in hepatic production of SHBG, resulting in lower free
T. Cyproterone acetate can rarely cause liver damage, and liver function should
be checked regularly (after 6 months and then annually). There is also thought
to be an increased risk of thromboembolism, so once symptom control has been
achieved and sustained over 3–4 months, it is recommended to switch to a lower
dose COCP. There are, however, many women who take Dianette long term with-
out any ill effect.
Spironolactone is a weak diuretic with anti-androgenic properties and may be used
in women with either hirsutism and/or acne in whom the COCP is contraindicated at
a daily dose of 25–100 mg. Drospirenone is a derivative of spironolactone and con-
tained in the new COCP Yasmin, which also appears affective for women with PCOS.
Other anti-androgens such as ketoconazole, finasteride and flutamide have been tried,
but they are not widely used in the United Kingdom for the treatment of hirsutism in
women due to their adverse and potentially serious side effects. Furthermore, they are
no more effective than cyproterone acetate.
Topical anti-acne agents can be safely and successfully combined with systemic
anti-androgen therapy in an attempt to target as many aetiological factors as possible.
However, these topical treatments alone have little effect on sebum production, so
they are not generally successful when used alone in acne associated with PCOS.
Topical retinoids impact on the microcomedo, a precursor to non-inflammatory and
inflammatory acne lesions. They also have direct comedolytic and anti-inflammatory
activity. These agents are useful adjuvant therapies in combination with anti-
androgen treatments and can be used as maintenance treatment after discontinuation
of s ystemic therapy. Topical antimicrobials (benzoyl peroxide/antibiotics) have good
anti-inflammatory activity and should help to reduce inflammatory lesions when used
alongside anti-androgen treatment.
Oral isotretinoin, a hospital-only prescribed medication, is the single systemic
therapy that targets the four main aetiological factors implicated in acne. However,
it is currently only licenced for severe acne not responding to alternative therapies.
A recent European Directive concerning isotretinoin has enforced a strict Pregnancy
Prevention Program due to the high risk of teratogenicity with this drug. COCPs can
be used safely alongside oral isotretinoin and are recommended by the European

Directive. Although clinical clearance of acne lesions with oral isotretinoin is very
likely, relapse rates post-therapy are higher than average when acne is associated
with PCOS.
Conclusions
PCOS is one of the most common endocrine disorders. It may present, at one end of
the spectrum, with the single finding of polycystic ovarian morphology as detected
by pelvic ultrasound. At the other end of the spectrum, symptoms such as obesity,
hyperandrogenism, menstrual cycle disturbance and infertility may occur, either
singly or in combination. Women with PCOS are characterised by the presence of
insulin resistance, central obesity and dyslipidemia that appears to place them at a
higher risk of developing diabetes as well as cardiovascular disease. There are several
environmental factors that may influence the expression of the syndrome, in particu-
lar, a tendency to insulin-resistant states induced by overeating and underexercising.
A plausible hypothesis for the survival of PCOS in the population is that of the thrifty
phenotype/genotype, whereby in times of famine, individuals who have a tendency
to obesity preserve the population by maintaining fertility, whereas individuals of
normal body weight fall below the threshold body weight for fertility. This relation-
ship might explain the greater prevalence of PCOS among South Asians in the United
Kingdom, where there is relatively greater nutrition and thus the right environment
to express PCOS. In addition, the thrifty phenotype hypothesis suggests that in utero
insulin resistance results as an adaptation to impaired nutrition and then persists
through to adult life and is then amplified by overnutrition (obesity).
PCOS is probably the same worldwide, although without an agreed definition one
cannot say for sure that this is the case. There may be factors that affect expression
and presentation – whether because of racial differences in the colour and d istribution
of hair (e.g. Japanese vs. Mediterranean women) or variations in hormone produc-
tion and receptor activity. Fundamentally, the underlying condition is likely to be
the same. Management should be directed towards an individual’s needs whether
cosmetic, reproductive or metabolic, and attention should be given to potential long-
term sequelae. To compare treatments and define the genotype, we must be clear on
the phenotype.
Women with PCOS are characterised by the presence of insulin resistance, c entral
obesity and dyslipidemia, conditions that appear to place them at a higher risk of
developing diabetes as well as cardiovascular disease. The retrospective long-term
follow-up studies have confirmed the higher incidence of diabetes, although they
have not shown a higher risk of mortality from IHD. Cross-sectional studies have
demonstrated a significant association between PCOS and IHD. Prospective longi-
tudinal studies confirming this risk are still awaited. There does seem to be enough
biochemical evidence regarding the potential for long-term risks of cardiovascular
disease and diabetes, which need to be addressed when counselling women with
PCOS. Encouraging weight loss remains the most effective first-line therapeutic
intervention in these women, albeit hard to achieve. Further longitudinal studies need
to be performed to investigate the natural history of PCOS and its sequelae for the
health of women [11].

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(metformin, rosiglitazone, pioglitazone, d-chiro-inositol) for women with polycystic
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FURTHER READING
Assessment and management of polycystic ovary syndrome: summary of an evidence-
based guideline (2011). Available from: http://www.managingpcos.org.au/
pcos-evidence-based-guidelines
Balen A, Franks S, Homburg R, Kehoe S, eds. Current management of polycystic ovary syn-
drome. Proceedings of 59th RCOG Study Group, London: RCOG Press, 2010: 228.

9
Premature Ovarian Insufficiency
(Failure) and Oocyte Donation
Introduction
Premature ovarian insufficiency (POI), formerly known as premature ovarian failure
(POF), occurs in approximately 1% of women and is defined as the cessation of ovar-
ian function under the age of 40 years. The function of the ovary depends upon the
total number of oocytes contained within primordial follicles. Primordial follicles
and oocytes are derived during fetal life, and the oogonial stem cell line is lost before
birth.
Control of Ovarian Aging

The control of ovarian aging is still one of the biggest enigmas in reproductive b iology.
The function of the ovary depends upon the total number of oocytes contained within
primordial follicles. Primordial follicles and oocytes are derived during fetal life, and the
oogonial stem cell line is lost before birth. In humans at approximately 4 weeks’ gesta-
tion, the germ cells arise from the yolk sac and migrate along the hindgut to the genital
ridge. The oogonia are able to move by pseudopodial amoeboid movements. Once the
oogonia reach the genital ridge, they become associated with cortical cords and lose their
motility. From week 5 through week 28, the oogonia undergo mitotic divisions. At the
same time, many oogonia are lost by atresia, some in their passage from the yolk sac and
others once they have reached the gonad itself. Meiosis starts in approximately week 9,
and the life cycle of the oocyte is such that it undergoes only part of the first meiotic
division, entering meiotic arrest at the dictyate stage of prophase 1. The final number of
oocytes is therefore determined by three factors: first, the maximum number achieved by
mitotic divisions; second, the time at which they enter meiosis, thus preventing further
increase in number; and third, the rate of atresia. The factors that affect the number of
mitotic divisions and the transition from mitosis to meiosis are largely unknown.
From approximately 16 weeks’ gestation, the somatic pre-granulosa cells form
in the genital ridge and differentiate into the granulosa cells lying on a basement
membrane opposite theca cells. From approximately 16 weeks’ gestation to 6 months
post-partum, the oocytes secrete their zona pellucida. Thus, the primordial follicles
begin to appear. The numbers of oogonia are maintained by cytokines and growth
factors, in particular stem cell growth factor that has its own receptor (C-kit).

More germs cells die during fetal life than survive in primordial follicles. The maxi-
mum number of germs cells is approximately 7 million, and this number is achieved at
20 weeks’ gestation [1]. By birth, this number is reduced to between 1 and 2 million. It is
thought that the eliminated germ cells might have a higher rate of chromosomal abnormal-
ities than those that remain, although this hypothesis has never been conclusively proven.
The number of primordial follicles at puberty has been mathematically related to
the final adult weight of a particular species. This relationship has been expressed
by the equation N = 27700M0.47, with M being the adult weight in kilograms [2]. This
equation remains true for different species [2], and the life span of a species also is
related to the number of primordial follicles at puberty and has been expressed as
N = 820L1.58. In all species, the primordial follicle number declines with age. In mice,
for example, this rate is faster before than after puberty, whereas in humans the rate
of disappearance of primordial follicles appears to be accelerated in later life. The
size of the follicle store is not directly related to the rate of ovulation but instead to the
daily fraction recruited, which changes with age. Recruitment of primordial follicles
occurs throughout life and is initially independent of follicle-stimulating hormone
(FSH), and the FSH receptor is expressed only at the primary follicle stage. The
growing fraction of primordial follicles appears to be up-regulated when the total
numbers are reduced, thereby explaining the increased rate of loss in humans with
age [3]. The accelerated rate of depletion in older ovaries is due more to the initiation
of growth than to atresia, although the control mechanisms are still to be elucidated.
From birth to puberty, approximately 75% of the follicle store is lost. At puberty,
approximately 250,000 follicles remain, and between puberty and menopause there is
the potential for up to 500 ovulations (Figure 9.1) [4].
Menopause occurs when there are approximately 1000 follicles left in the ovary.
Post-menopausally, therefore, some follicles do remain, but they do not grow to matu-
rity, perhaps because high circulating levels of FSH cause receptor down-regulation.
Several mathematical models have been developed to express the rate of decline of
primordial follicle number [4–6]. When 10,000 follicles remain, menopause will
occur in approximately 5–10 years and when there are 100,000 remaining, it will
occur between 21.5 and 26.5 years. At the age of 25, approximately 37 follicles leave
the human ovary by either growth or atresia daily (thus, approximately 1000 per
month), whereas at the age of 45 this number has been reduced to approximately two
per day. The rate of ovarian aging appears to be intrinsically determined, and the half-
life of the follicle population is approximately 7 years, increasing exponentially with a
doubling of the exponential rate after the age of approximately 37.5 years.
If the rate of follicle loss did not increase, menopause would be expected to occur
at approximately 71 years of age. The reason for humans having menopause is
unclear and may actually represent an extension of life due to increased nutrition
and well-being of the human population rather than as a physiological feature itself.
With respect to the recruitment of the primordial follicles, this recruitment is due to
unknown processes in cellular metabolism/signalling, and no physiological interven-
tions are able to halt recruitment. Thus, recruitment occurs while an individual is
pregnant and also while taking the contraceptive pill.
A study from many years ago assessed the number of follicles around the time of
menopause by looking at 17 women between the ages of 45 and 55 years who had
undergone a hysterectomy with bilateral salpingo-oophorectomy [7]. Patients were

Premature Ovarian Insufficiency (Failure) and Oocyte Donation 241
107
106
Number of follicles
105
104
103
102
0 10 20 30 40 50 60
Age (years)
FIGURE 9.1 Decline in oocytes with age. (From Faddy MJ, Gosden RG, Hum Reprod 11, 148,
4–6, 1996.)
divided into three groups depending upon their menstrual pattern. The mean age
was similar in all groups, and it was found that women who had regular menstrual
cycles had a mean number of 1694 (SEM 460) follicles, whereas women who were
perimenopausal with an erratic cycle had 181 (SEM 88) follicles and women who
were menopausal had no follicles remaining. The frequency distribution of the age at
menopause has been described in 763 American women [8]. The age of menopause
appears to be similar in all Western communities, although women in developing
countries appear to have a menopause 5 or 6 years earlier; this difference may be a
reflection of under-nutrition during fetal life as nutritional status during infant or adult
life does not appear to have a direct bearing on ovarian aging.
Using mathematical models for the aging of the ovary, devised from data of follicle
counts at different ages together with projected mean ages at menopause, Faddy and
Gosden [4] have developed certain algorithms. For example, it has been suggested
that the surgical loss of one ovary is not likely to hasten menopause by more than
7 years (thus, to the age of 44 years, by which time 5% of the population are meno-
pausal). If 50% of the follicle store is lost by the age of 30 years, the expected age of
menopause is 44 years, and for each further year that a 50% reduction has occurred,
menopause will be delayed by 0.6 years. Thus, if 50% have been lost by the age of
37.5 years, menopause can be expected to occur at the age of 48. In contrast, if 90%
of the follicle store is lost by the age of 14 years, another 13 years of ovarian activ-
ity can be expected, with menopause occurring at the age of 27 years, and for each
further year that a 90% reduction has occurred, menopause will be delayed by 0.6 of

a year, so that if 90% have been lost at the age of 37.5 years, menopause will be at the
age of 41 years.
Atresia and apoptosis (i.e. programmed/physiological cell death), which are initiated
by genes that code for effector proteins that lead to cell death in response to external
stimuli, occur once the follicle has passed its primary stage. Follicles that are not selected
for ovulation undergo atresia at the later pre-antral or early antral stage (1–5 mm in diam-
eter) when continued growth would be FSH dependent. Follicles destined for atresia can
be rescued by FSH administration and the oocyte remains healthy until late stages of
atresia, at which point it will resume meiosis due to loss of the cumulus complex.
The exact incidence of POI is unknown as many cases go unrecognised, but estimates
vary between 1% and 5% of women [9]. In a study of 1858 women, the incidence of
POI was 1:1000 by age 30 and 1:100 by age 40 [9]. Studies of a menorrhoeic women
report the incidence of POI to be between 10% and 36% [10,11].
Resistant Ovary Syndrome

Before the absolute cessation of periods of true POI, some women experience an
intermittent return of menses, interspersed with variable periods of amenorrhoea [12].
Gonadotropin levels usually remain moderately elevated during these natural cycles,
with plasma FSH concentrations of 15–20 IU/L. This occult/incipient ovarian failure,
or resistant ovary syndrome, is associated with the presence of primordial follicles
on ovarian biopsy. Ovarian biopsy is no longer recommended in the assessment of
these cases because a single sample is not reliably representative and will not help
with management. Occasionally, pregnancies occur naturally in patients with resistant
ovary syndrome. Ovulation induction therapy is of no benefit because the ovaries are
usually as resistant to exogenous gonadotropins as they are to endogenous hormones.
In one series [13], suppression of gonadotropin secretion with oestradiol before
human menopausal gonadotropin (hMG) stimulation was associated with ovula-
tion in 68 of 361 cycles (19%), although there were only eight ongoing pregnancies.
A similar approach has been reported by using the combined oral contraceptive pill
to suppress FSH levels in poor responders undergoing in vitro fertilisation (IVF),
with some limited success [14]. In our experience, this approach has not been suc-
cessful. In a few patients, immunosuppressive therapy has achieved limited success,
but this is therapy not a form of treatment that we can recommend, in the absence
of a randomised controlled trial. It is probable that reports of pregnancy in women
with POI or resistant ovary syndrome represent cases of fluctuating ovarian function
rather than successes of treatment. There have been occasional reports of resumption
of ovulation and conception, and it has been suggested that these cases may represent
the fluctuating ovarian function of a premature perimenopause or transient ovarian
failure caused by viral oophoritis. It has been found that most remissions occur in
patients in whom the ovaries can be visualised by ultrasound.
If a patient with resistant ovary syndrome and symptoms of oestrogen deficiency
wishes to conceive, she should be advised to take a hormone replacement therapy
(HRT) preparation that will not inhibit ovulation (or adversely affect a pregnancy).
Alternatively, if a pregnancy would be unwanted, it is important to advise the use of
either an oral contraceptive preparation or contraception together with HRT.

Diagnosis of POI
As women age, variability of intermenstrual interval increases, but the mean interval
falls (from 28 to 23 days). The mean age of menopause in the United Kingdom is 50.6
years; we define a premature menopause as cessation of periods by 45 years and POI
as cessation of periods by 40 years, although some practitioners use the two terms pre-
mature menopause and premature ovarian failure/insufficiency interchangeably and
define the cut-off as 40 years for both [15]. The first endocrine change is an isolated
elevation of FSH, followed by elevation of FSH and luteinising hormone (LH), with a
fall in serum oestradiol concentrations with the development of amenorrhoea. Over the
next year, there is a further fall of oestradiol. The ultrasound shows normal and then
small ovaries with few follicles, followed by ovaries of less than 2 mL with no follicles.
Serum anti-Müllerian hormone (AMH) concentrations also fall to negligible levels.
If a woman has amenorrhoea and an elevated serum FSH concentration (>20 IU/L)
on more than two occasions, it is likely that she has POI. The longer the period of
amenorrhoea, the higher the FSH level and the lower the AMH and the greater the
likelihood that the ovarian failure is permanent. A single elevated FSH level, even
if greater than 40 IU/L, should be treated with caution as spontaneous ovulation
and pregnancy have still been observed. Once the diagnosis of POI has been made,
further specific endocrinological tests are unnecessary. Additional investigations
include karyotype, screening for autoantibodies and associated autoimmune disease
if relevant and a baseline assessment of bone mineral densitometry. A cardiovascular
assessment is also important, including blood pressure and lipid profile. As always,
a detailed history is important with particular attention to a family history of POI or
autoimmune disease.
Causes of Premature Ovarian Failure

In approximately two-thirds of cases, the cause of ovarian failure cannot be identified
(Box 9.1) [15]. It is unknown whether these cases are truly idiopathic or instead due
to as yet undiscovered genetic, immunological or environmental factors. A series of
323 women with POI identified 23% with Turner’s syndrome; 6% after chemotherapy;
BOX 9.1 CAUSES OF POI

Idiopathic
Genetic: commonly Turner’s syndrome, familial
Autoimmune
Pelvic surgery
Pelvic irradiation
Chemotherapy
Viral/bacterial infection
Galactosaemia

and 4% with familial POI and 2% each who had pelvic surgery, pelvic irradiation,
galactosaemia and 46 XY gonadal dysgenesis [16]. Viral and bacterial infection also
may lead to ovarian failure; thus, infections such as mumps, cytomegalovirus or human
immunodeficiency virus (HIV) in adult life can adversely affect long-term ovarian
function, as can severe pelvic inflammatory disease. Ovarian failure occurring before
puberty is usually due to a chromosomal abnormality, or a childhood malignancy that
required chemotherapy or radiotherapy. The likelihood of developing ovarian failure
after therapy for cancer is difficult to predict, but the age of the patient is a significant
factor – the younger the patient, the greater the follicle pool and the better her chances
of retaining ovarian function. The dose and type of chemotherapy are also important
(see Chapter 19). Environmental toxins might be a factor in causing POI. The best
known toxin is smoking, which has been shown to lower the age of menopause [17].
Genetic Causes of POI

Adolescents who lose ovarian function soon after menarche are often found to have a
Turner’s mosaic (46,XX/45,X) or an X-chromosome trisomy (47,XXX). There are many
genes on the X chromosome that are essential for normal ovarian function. Two active
X chromosomes are required during fetal life to lay down a normal follicle store. One
X chromosome is then inactivated in female cells for dosage compensation of X-linked
genes between males and females. Genetic defects resulting in POI usually involve the
X chromosome, although several rare autosomal abnormalities also have been identi-
fied [15]. In fetuses with Turner’s syndrome, normal numbers of oocytes appear on the
genital ridge, but accelerated atresia takes place during late fetal life [18]. Thus, streak
gonads occur, and it is only the mosaic form of Turner’s syndrome that permits any
possibility of ovarian function. X chromosomal mosaicisms such as 45,X/46,XX and
45,X/47,XXX are the commonest chromosomal abnormality in reported series of POI,
ranging from 5% to 40% [11]. X chromosomal deletions and translocations involving
the POF1 and POF2 loci may lead to either primary amenorrhoea or more commonly
to secondary amenorrhoea, with POI occurring either early (16–21 years for POF2
translocations) or later (24–39 years for POF1 translocations) [15].
Turner’s Syndrome
Turner’s syndrome is the commonest cause of gonadal dysgenesis. In its most severe
form, the 45 X genotype is associated with the classical Turner’s features, including
short stature, webbing of the neck, cubitus valgus, widely spaced nipples, cardiac and
renal abnormalities, and often autoimmune hypothyroidism. It is very important to
detect coarctation of the aorta, as it is not safe to get pregnant by egg donation unless
treated. Spontaneous menstruation may occur, particularly when there is mosaicism,
but POF usually ensues. Management includes low-dose oestrogen therapy to pro-
mote breast and uterine development without further disturbing linear growth; cycli-
cal oestrogen plus progestogen may be used as maintenance therapy.
Fragile X Syndrome
The fragile X syndrome is the commonest inherited cause of learning disability, with a
prevalence of 1:4000 males and 1:8000 females. It is characterised by a heterogeneous

mixture of physical, behavioural and cognitive features. Most published information

refers to fragile X syndrome in males, of whom approximately 80% are moderately
to severely mentally retarded, whereas females usually display a milder phenotype
with a borderline IQ of 70–85. Fragile X syndrome is an X-linked dominant disor-
der with reduced penetrance. Unaffected carriers in a family have an increased risk
of transmitting the disorder with successive generations. The disorder is due to a
mutation in a gene on the long arm of the X chromosome, known as fragile X men-
tal retardation-1 (FMR-1, Xq27.3); this protein transcribes a cytoplasmic protein that
is found in all cells but in higher concentration in ovary, brain and testis. It is the
absence of this protein that results in the fragile X syndrome phenotype. Affected
families have mutations in the FMR-1 gene leading to hereditary instability. These
mutations can be of variable sizes, the largest resulting in a full mutation, whereas
smaller mutations are known as pre-mutations. As somatic cells in females have a
randomly inactivated X chromosome, only one-half of females with the full mutation
have a fragile X phenotype. Women with a pre-mutation are phenotypically normal but
appear to have a significantly increased risk of POI. A large series of 395 pre-mutation
carriers found 16% with POI compared with 0.4% of a control population [19].
Familial POI
There is evidence for strong genetic factors determining the age of menopause.
Interest has recently turned to specific familial forms of POI/POF in which abnor-
malities are present in the critical region of the long arm of the X chromosome from
Xq13 to Xq26. At least two genetic variants have been identified: the POF1 gene
(Xq21.3-q27) [20] and the POF2 gene (Xq13.3-q21.1) [21]. There are also several rare
syndromes that are associated with POF, such as galactosaemia.
Autoimmune Causes of POF

Ovarian autoantibodies have been found in up to 69% of cases of POI. However, the
assays are expensive and not readily available in most units. It is therefore impor-
tant to consider other autoimmune disorders and to screen for autoantibodies to the
thyroid gland, gastric mucosa parietal cells and adrenal gland if there is any clinical
indication. Studies have reported that between 20% and 40% of women with POI
have a history of other autoimmune disorders, most commonly thyroid disease [15].
There are many potential ovarian antigens, and the potential for autoantibody forma-
tion has long been recognised. The clinical significance of anti-ovarian antibodies is
uncertain, particularly as their concentrations fluctuate and do not always relate to
the severity of disease. It is therefore uncertain whether anti-ovarian antibodies are
pathogenic or secondary to antigen release after ovarian damage [11].
Iatrogenic Causes of POI

There are many iatrogenic causes of amenorrhoea that may be either temporary or
permanent. These causes include malignant conditions that require either radia-
tion to the abdomen/pelvis or chemotherapy. Both of these treatments may result in
permanent gonadal damage, with the amount of damage being directly related to

the age of the patient, the cumulative dose and the patient’s prior menstrual status.
The likelihood of developing ovarian failure after therapy for cancer is difficult to
predict, but the younger the patient, the greater the follicle pool and the better her
chances of retaining ovarian function. It is estimated that 1 in every 1000 adults
are now survivors of childhood malignancy, and for these women – and men – the
cryopreservation of gonadal tissue before treatment might soon offer a real chance of
restoring fertility and possibly natural hormone replacement.
Gynaecological procedures such as oophorectomy and hysterectomy inevitably
result in amenorrhoea. Hormone replacement should be prescribed for these patients
where appropriate. Hormone therapy itself can be used to disrupt the menstrual cycle
deliberately. However, iatrogenic causes of ovarian quiescence have the same conse-
quences of oestrogen deficiency due to any other aetiology.
Management of POI
The diagnosis and consequences of POI require careful counselling of the patient. It
may be particularly difficult for a young women to accept the need to take oestrogen
preparations that are clearly labelled as being intended for older post-menopausal
women, while at the same time having to come to terms with the inability to conceive
naturally. The short- and long-term consequences of ovarian failure and oestrogen
deficiency are similar to those occurring in the fifth and sixth decade. However, the
duration of the problem is much longer; therefore, HRT is advisable to reduce the
consequences of oestrogen deficiency in the long term.
Young women with premature loss of ovarian function have an increased risk of
osteoporosis. A study of 200 amenorrhoeic women between the ages of 16 and 40
years demonstrated a mean reduction in bone mineral density of 15% compared
with a control group, after correction for body weight, smoking and exercise [22].
The degree of bone loss was correlated with the duration of the amenorrhoea and
the severity of the oestrogen deficiency rather than with the underlying diagnosis,
and it was worse in patients with primary amenorrhoea compared with patients with
secondary amenorrhoea. A return to normal oestrogen status may improve bone mass
density, but bone mineral density is unlikely to improve more than 5%–10%, and it
probably does not return to its normal value. However, it is not certain if the radiologi-
cal improvement seen will actually reduce the risk of fracture, as re-mineralisation is
not equivalent to the re-strengthening of bone. Early diagnosis and early correction of
oestrogen status are therefore important.
Women with POI also may have an increased risk of cardiovascular disease.
Oestrogens have been shown to have beneficial effects on cardiovascular status in
women. They not only increase the levels of cardioprotective high-density lipoprotein
but also increase the levels of total triglyceride, while decreasing total cholesterol and
low-density lipoprotein levels. The overall effect should be of cardiovascular protec-
tion, although this effect has never been convincingly demonstrated.
Women with hypoestrogenic amenorrhoea require hormone replacement. A cycli-
cal oestrogen/progestogen preparation is required for patients with a uterus to pre-
vent endometrial hyperplasia. The HRT preparations prescribed for menopausal
women are also preferred for young women as even modern low-dose combined

oral contraceptive preparations contain at least twice the amount of oestrogen that
is recommended for HRT. HRT also contains natural oestrogens rather than the
synthetic ethinylestradiol that is found in most oral contraceptives. A direct, long-
term comparison however has not been performed. Furthermore, the preferences
of the individual should be discussed as some young women may prefer to have a
packet of the combined oral contraceptive pill rather than HRT preparations that are
usually associated with older post-menopausal women.
The beneficial effects of hormone replacement in reducing osteoporosis and car-
diovascular mortality are thought to outweigh the risk of breast cancer, particularly in
women with POI. It is now thought necessary to perform annual breast examination
only in women considered to be at high risk, for example, those women with a fam-
ily history of breast cancer. Mammography in normal women, with active glandular
breasts, is difficult to interpret, so the use of mammography as a screening procedure
in young women taking HRT is not recommended. It is the lifetime exposure to oes-
trogen that is important, so young women with POI should be reassured that the use
of HRT should not put them at increased risk of breast cancer at least until they reach
the average age of menopause (i.e. 51 years) – and then only if they continue to take
HRT for a further 5 years or more. Follow-up of patients with POI should be at least
on an annual basis to monitor HRT, detect the development of associated diseases and
provide appropriate support and counselling.
Oocyte Donation
Oocyte donation can be used to treat women with POI, of whatever cause, and for
women who do not wish to use their oocytes for genetic reasons. Oocyte donation also
may have a place for women who do not respond to ovarian stimulation during IVF or
for women whose oocytes repeatedly fail to fertilise in the presence of apparently nor-
mal sperm. More controversial is the use of donated eggs for post-menopausal women
in their 50s and 60s – a practice that is not approved in the United Kingdom or by the
European Society of Human Reproduction and Embryology (ESHRE). However, the
outcomes to date have not demonstrated a detrimental effect on the recipients, at least
until they get into their mid- 50s, and it is a matter of ethical debate as to who should
determine an individual couple’s right to parenthood.
Implantation rates for the recipient are those appropriate for the age of the oocyte
donor and usually approximately 30%–40% per treatment cycle. Favourable results
are thus widely achievable, although a downward trend in the birth rates, particu-
larly above 40 years, suggests a small uterine effect on the outcome. An endometrial
effect on implantation rates in patients having oocyte donation is apparent when one
examines the aetiology of the ovarian failure because the highest pregnancy rates are
achieved in women with POI who have an anatomically normal uterus. Women with
Turner’s syndrome who have not had a spontaneous puberty and women who have
received radiotherapy to the pelvis have reduced uterine blood flow and suboptimal
endometrial development in response to exogenous oestrogen therapy (sometimes
radiotherapy destroys any subsequent endometrial function). These patients therefore
do less well when undergoing oocyte donation. Furthermore, it would seem inadvis-
able to use the oocytes donated by a sister of a woman with POI as they also appear
to do less well than those of anonymous fertile donors [23].

Donor’s oocyte collection

Menses
GnRH agonist starts day 2 until Drop dose, continue to day of

“down-regulation”, usually either embryo thawing or the
14 days donor’s oocyte retrieval
Oestradiol valerate 6 mg
daily (oral)
Donor’s hCG Progesterone

p.v./i.m.
Embryo transfer
FIGURE 9.2 HRT regimen for frozen embryo replacement cycles or for oocyte donation. Women
with a menstrual cycle should first undergo pituitary desensitisation, whereas women with POF
commence oral oestradiol instead of their usual HRT regimen. It used to be thought that the
oestradiol valerate should be gradually increased in a stepwise manner, but it is now clear that a fixed
dose of 6 mg from the start is satisfactory and can be continued for up to 100 days with no ill effect.
The usual duration of oestradiol therapy is 12–14 days before the commencement of progesterone.
Progesterone should commence when endometrial thickness is at least 8 mm, and the embryo t ransfer
is performed on the fourth day of progesterone therapy (either vaginal Cyclogest (800 mg at night),
Uterogestan (300 mg of micronised progesterone daily) or intramuscular injections of Gestone
(100 mg daily)). Both progesterone and oestradiol are continued beyond the positive p regnancy test
and until the serum progesterone is greater than 127 nmol/L, usually at 7–8 weeks’ gestation. The
hormone support is then gradually withdrawn over the following 2 weeks. In reality, the oestradiol
could be stopped on the day of embryo transfer, and the progesterone could probably also be stopped
once the pregnancy test is positive.
It is necessary to provide the recipient with an artificial hormone replacement

r egimen, usually with increasing doses of oral oestrogens [24], with the addition of
progesterone 3 days before embryo transfer (Figure 9.2). Recipients who have a natu-
ral menstrual cycle require pituitary desensitisation before commencing the hormone
regimen, whereas amenorrhoeic women with ovarian failure do not. Interestingly,
it is the latter group who appear to have better results, possibly because the HRT
regimen has not been imposed on a pre-existing cycle. Close synchrony is required
between the recipient’s cycle and the donor’s IVF cycle if fresh embryos, which
provide better pregnancy rates than cryopreserved embryos, are to be transferred.
As with sperm donation (see Chapter 12), careful counselling is required for both
partners, and for the donor, who might be undergoing assisted conception herself or
have an altruistic desire to donate eggs and thereby undergo an IVF cycle. Donor ano-
nymity is usually preferred, although known donation is not uncommon. The donor
should be under the age of 36 years to reduce the chance of age-related chromosomal
problems.
Egg sharing is an approach to egg donation that is gaining popularity. In egg
sharing, a woman requiring IVF who has insufficient funds for her own treat-
ment donates some of her oocytes in return for free treatment. With appropriate
counselling, egg sharing appears to work well, without adverse psychological con-
sequences if the donor fails to conceive. A strict protocol is required to prevent

unnecessary overstimulation of the donor’s ovaries and to ensure that surplus oocytes
are donated only if a prerequisite number (usually 6–10) have been collected for the
donor’s own use.
Cryopreservation of Ovarian Tissue and Oocytes

Experimental work in animals has succeeded in transplanting primordial follicles into
irradiated ovaries, with subsequent ovulation and normal pregnancy (see Chapter 19)
[25]. An extension of this work has resulted in successful cryopreservation of human
ovarian tissue [26] and re-implantation of the thawed tissue with resultant follicular
growth, after stimulation with exogenous FSH. The methods used were devised for
the preservation of fertility and ovarian function in young women before sterilising
chemotherapy or radiotherapy. The potential exists for the cryopreservation of ovarian
tissue or oocytes for women destined to undergo ovarian failure – an event that might
be predictable from genetic or family studies. Whether the cryopreserved ovarian
tissue is genetically competent would, of course, be uncertain, but it is easy to foresee
the day when women with fragile X pre-mutations or Turner’s mosaicism might be
asking for ovarian cryopreservation during their adolescent years. We also have cryo-
preserved oocytes from a woman with mosaic Turner’s syndrome and assessed them
to confirm that they were genetically normal [27].
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10
Endometriosis
Introduction
Endometriosis can cause pelvic pain and infertility. In the context of the manage-
ment of subfertility, we have to ask what degree of endometriosis requires treatment.
Treatment when it is advisable is best achieved with surgery without delaying the
chance of conception by hormonal therapies that are contraceptive.
Diagnosis
Careful laparoscopic assessment of the pelvis reveals signs of endometriosis in up
to 18% of women with proven fertility [1]. It is recognised that not all endometriotic
lesions have the classic blue–black pigmented appearance. Atypical lesions consist of
flame-like blisters, clear nodules, white plaques and peritoneal defects [2]. Endometrial
glands also have been found after microscopic inspection of biopsies from macro-
scopically normal-looking peritoneum. Whether these changes represent pathology
or simply one end of the normal spectrum is still a matter for debate (Figure 10.1) [2].
It has been suggested that the non-pigmented lesions are more common in
younger women and that the darker lesions represent older or burnt-out disease [3].
Furthermore, endometriotic lesions change in position and with time. It has been
suggested that endometriosis is analogous to a field of mushrooms, with lesions
appearing and disappearing at different times and in different places.
Although several theories have been proposed for the pathogenesis of endometrio-
sis, that of retrograde menstruation is the most popular and plausible. Retrograde men-
struation is common, being seen in 75%–90% of women who have had laparoscopies
performed at the time of menstruation [4]. Menstrual blood does not always contain
endometrial cells, and the factors that influence implantation of ectopic endometrium
are uncertain, as the prevalence of endometriosis has been estimated to be 1%–20%,
not 75%–90%. Women with endometriosis appear to have altered immune function
that may permit implantation of regurgitated endometrium. Abnormalities of cellular
adhesion molecules, including the integrins and extracellular matrix proteins, are also
thought to play a role in pathogenesis. The detection of endometriosis in women being
investigated for subfertility is thought to reflect their lack of conception and expo-
sure to frequent menstruation rather than necessarily being a cause of the infertility.
Indeed, the likelihood of finding evidence of endometriosis in women who attend for
sterilisation is increased in proportion to the interval since the birth of their last child.

Surface membrane of peritoneum

Microscopic
Intramesothelial
Submesothelial
Early endometriosis
Vascularised papule
Red vesicle
Classical
Puckered, black/blue
Healed/scarred
Fibrotic, white
FIGURE 10.1 Development of peritoneal endometriosis. (After Brosens I et al., Baillières Clin
Obstet Gynaecol 7, 741–57, 1993.)

Endometriosis 253
Umbilicus
Bowel
Fallopian tube Ovary
Rectus muscle Myometrium (adenomyosis)

(and surface of uterus)
Round ligament Uterosacral ligament
Bladder Pouch of Douglas

and vagina
FIGURE 10.2 Sites of endometriosis.
Women with symptomatic endometriosis may have a genetic disposition to endometrial

implantation on the peritoneum and a further disposition to an inflammatory response to
the cyclical changes that occur in the ectopic endometrium. As is well known, the degree
of endometriosis does not correlate with symptomatology: pelvic pain, dyspareunia and
dysmenorrhoea. It is not possible, moreover, to predict which patients will develop pro-
gressive disease with resultant pelvic adhesions and ovarian cysts.
It is easy to envisage how severe endometriosis can affect fertility by distorting
pelvic anatomy, with adhesions that smother the ovaries and tubes and with endo-
metriotic ovarian cysts (Figure 10.2). Furthermore, the prevalence of endometriosis
in infertile women is as high as 20%–68% [5]. Although endometriosis is found on
the surface of the fallopian tubes, it does not tend to affect the tubal lumen and typi-
cally the tubes are patent. Fertility also can be impaired by the dyspareunia that often
accompanies the condition. There is still debate about the extent to which endometri-
osis affects fertility in the absence of pelvic deformity. It has been suggested that the
peritoneal environment is altered, with an increased concentration of macrophages
that impede sperm motility, phagocytose spermatozoa and interfere both with oocyte
pick-up by the fallopian tube and with fertilisation. Although the relevance of these
hypotheses was previously tempered by the failure of medical or surgical treatment to
improve the pregnancy rates of women with minimal or mild endometriosis [6], evi-
dence from two randomised trials has suggested a benefit from surgical ablation [7,8].
Descriptive Classification of Endometriosis

Most investigative tests in reproductive medicine indicate reproductive function at the
time of the test and give little information about the dynamics of the underlying problem.

This discrepancy is particularly the case with mild endometriosis, when diagnostic
laparoscopy gives no indication about the possible progression of the disease.
Markers
Many markers for endometriosis have been investigated, although more as non-
invasive diagnostic tests rather than to monitor progression of the disease. Probably,
the most commonly used marker is the glycoprotein CA-125, an oncofetal coelomic
epithelium differentiation antigen. CA-125 levels in aspirates of peritoneal fluid and
cysts of patients with endometriosis are much higher than in serum. Serum CA-125
concentrations also are elevated in patients with acute pelvic inflammatory disease
and ovarian carcinoma; although the levels tend to be higher than in patients with
endometriosis, there is considerable overlap. It has been suggested that 35 U/mL
be used as a cut-off serum concentration for CA-125, below which endometriosis is
unlikely to be present. Unfortunately, CA-125 measurements do not correlate well
with either the progression of the disease or the response of endometriosis to treat-
ment. However, the assessment of the CA-125 concentration may help distinguish
cystic ovarian endometriosis from corpus luteum cysts that may be difficult to dis-
criminate by either ultrasonography or laparoscopy.
Anti-Endometrial Antibodies
Anti-endometrial antibodies have been found to be significantly elevated in patients
with endometriosis, although again this elevation provides poor sensitivity or predict-
ability of either severity or progression of the disease. This incongruity is particularly
so as early lesions might elicit a stronger antibody response than older lesions and
the techniques used to assay endometrial antibodies are not quantitative. The study
of these markers and at least 100 other markers for endometriosis has been evaluated
without any one candidate or panel of biomarkers having been shown to be clinically
useful [9]. Furthermore, we are not convinced that widespread screening for endo-
metriosis will have a place in clinical practice, although there might be a place for
screening in patients in whom there is a family history of endometriosis to help deter-
mine when more invasive investigations are indicated.
Laparoscopy
Laparoscopy is the mainstay of the classification of endometriosis and the best
known system of classification is that of the American Fertility Society (AFS), now
the American Society of Reproductive Medicine (ASRM), in which the appearance
of the disease, the degree of adhesions and obliteration of the pouch of Douglas pro-
vide a score (Table 10.1). We feel that there is no substitute for a careful descriptive
record of the laparoscopic findings, together with photographs or a video if avail-
able (Figure 10.3 and Box 10.1) [10]. It has been suggested that the AFS classifica-
tion is limited by its inability to provide an indication of the activity of the disease
and has no predictive value with respect to either pain or subfertility. A more recent
and clinically validated scoring system is the endometriosis fertility index (EFI;
Tables 10.2 and 10.3) [11]. The EFI takes into consideration age, years of infertility

Endometriosis 255
TABLE 10.1
Modified American Fertility Society Scoring System for Endometriosis
Endometriosis <1 cm 1–3 cm >3 cm
Peritoneum Superficial 1 2 4
Deep 2 4 6
Ovary: R Superficial 1 2 4
Ovary: L Deep 4 16 20
Superficial 1 2 4
Deep 4 16 20
Posterior cul-de-sac Partial Complete

Obliteration 4 40
Adhesions <1/3 enclosure 1/3–2/3 enclosure >2/3 enclosure

Ovary: R Filmy 1 2 4
Dense 4 8 16
Ovary: L Filmy 1 2 4
Dense 4 8 16
Tube: R Filmy 1 2 4
Dense 4a 16 20
Tube: L Filmy 1 2 4
Dense 4a 8a 16
a If the fimbrial end of the tube is completely enclosed, score 16.
(a)
FIGURE 10.3 (See colour insert.) Endometriosis at laparoscopy. (a) Active spots of endometriosis
are seen between the uterosacral ligaments (u), and in the pouch of Douglas (open arrow), there is
adjacent neovascularisation, and new peritoneal formation (closed arrow).

(b)
(c)
FIGURE 10.3 (See colour insert.) (Continued) Endometriosis at laparoscopy. (b) The left ovary
is supported behind the uterus (U) and is distended by a large endometriotic cyst. (c) Another view
of the left ovary (O) indicates recent ovulation by virtue of a corpus luteum (C). The fimbrial end of
the tube (F) appears reasonably healthy, although there is an endometriotic deposit on its posterior
margin (arrow).

Endometriosis 257
BOX 10.1 CLASSIFICATION OF ENDOMETRIOSIS BY SEVERITY

Mild: Scattered fresh lesions on peritoneal surfaces; minimal lesions on ovarian
surfaces; no peritubal adhesions
Moderate: Several surface lesions on one or both ovaries, with scarring, retrac-
tion or small endometriomata; minimal periovarian or peritubal adhesions;
superficial implants in pouch of Douglas with scarring and retraction
Severe: Involvement of one or both ovaries with endometriomata (>2 cm3); one
or both tubes bound down or obstructed by adhesions; obliteration of pouch of
Douglas; thickening of uterosacral ligaments, bowel or ureteric involvement
Source: Acosta et al., Obstet Gynecol 42, 19–25, 1993.
TABLE 10.2
Endometriosis Fertility Index (EFI) Surgery Form: Least Function (LF) Score at
Conclusion of Surgery
Score Description Left Right
Fallopian tube +
4 = Normal
3 = Mild dysfunction
2 = Moderate dysfunction Fimbria +
1 = Severe dysfunction
0 = Absent or non-functional Ovary +
Lowest score + =
To calculate the LF score, add together
the lowest score of the left side and the Left Right LF score
lowest score of the right side. If an ovary
is absent on one side, the LF score is
obtained by doubling the lowest score
on the side with the ovary.
Source: From Kovacs G, The Subfertility Handbook: A Clinician’s Guide, 2nd ed., Cambridge
University Press, Cambridge, 2010. With kind permission from Cambridge University Press.
and whether there have been previous pregnancies together with the surgical findings.
The higher the EFI score, the greater the cumulative chance of pregnancy over time,
being approximately 80% after 3 years in those with a score of 8–10 compared with
5% if it is 0–3 (Figure 10.4) [12].
Biopsy
If there is doubt about the diagnosis at laparoscopy, the lesions can be biopsied to
provide a histological diagnosis, although in up to one-third of clinically typical cases
histological examination does not provide endometrial tissue. Furthermore, biopsy of

TABLE 10.3
Endometriosis Fertility Index
Historical Factors Surgical Factors
Factor Description Points Factor Description Points
Age LE score
If age is ≤ 35 years 2 If LF score = 7 to 8 (high score) 3
If age is 36 to 39 years 1 If LF score = 4 to 6 (imoderate score) 2
If age is ≥ 40 years 0 If LF score = 1 to 3 (low score) 0
Years infertile AFS endometriosis score

If years infertile is ≤ 3 2 If AFS endometriosis lesion 1
If years infertile is > 3 0 score is < 16
If AFS endometriosis lesion 0
score is ≥ 16
Prior pregnancy AFS total score
If there is a history of a 1 If AFS total score is < 71 1
prior pregnancy If AFS total score is ≥ 71 0
If there is no history of 0
prior pregnancy
Total historical factors Total surgical factors

EFl = Total historical factors + =
+
Total surgical factors Historical Surgical EFI score
Note: AFS, American Fertility Society; EFI, Endometriosis Fertility Index; LF, least function.
Source: From Kovacs G, The Subfertility Handbook: A Clinician’s Guide, 2nd ed., Cambridge
University Press, Cambridge, 2010. With kind permission of Cambridge University Press.
EFI
score
100
9–10
80
7–8
60 6
5
%
40
4
20
0–3
0
0 6 12 18 24 30 36
Months
FIGURE 10.4 (See colour insert.) Estimated percent pregnant by Endometriosis Fertility Index
(EFI) score. (From Kovacs G, The Subfertility Handbook: A Clinician’s Guide, 2nd ed., Cambridge
University Press, Cambridge, 2010. With kind permission of Cambridge University Press.)

Endometriosis 259
the peritoneum can lead to bleeding and damage to other structures, so it is not part of
routine practice. Peritoneal lesions change with age, with clear papules usually being
seen under the age of 25 years, followed by red (highly active), black (fibrotic, with old
haemorrhage and intermediate activity) and white (scarred, inactive tissue) lesions,
with a considerable degree of overlap between all types (Figure 10.3).
Cysts
Some consider that ovarian endometriomata occur as a result of deposits on the surface
of the ovary that cause invagination of the cortex, with adhesions over the surface
that then result in an encapsulated cyst. The ovary may be adherent to the peritoneal
surface of the ovarian fossa, with vessels and ureter beneath. Careful dissection to
mobilise the ovary may be required to expose the appropriate surface of the ovary to
incise the endometrioma rather than cut through healthy ovarian tissue.
Management of Endometriosis
The management of endometriosis depends upon the wishes of the patient, specifi-
cally whether her predominant complaint is pain or infertility. If fertility is required
but pain is also a problem, then management is usually with analgesics, either alone or
combined with surgical treatment. Appropriate analgesics include the non-steroidal
anti-inflammatory drugs (NSAIDs); naproxen (250 mg three times a day (t.i.d.) or
four times a day (q.d.s.)) and mefenamic acid (500 mg t.i.d.) are particularly effec-
tive. There is some evidence that NSAIDs inhibit the process of ovulation through
their antiprostaglandin action, but endometriotic pain usually occurs at the time of
menstruation rather than mid-cycle, so these drugs should be safe in women wishing
to conceive.
When evaluating the outcome of therapy for endometriosis, it is essential to distinguish
between visible regression of the disease, as assessed by second-look laparoscopy, and
the desired outcome, that is, pregnancy and/or pain relief. Parenthetically, it is important
to remember that post-treatment laparoscopic evaluation of the pelvis should be per-
formed once the menstrual cycle has resumed rather than immediately the therapy has
been discontinued, to obtain a representative assessment [13]. Second-look laparoscopies
are usually reserved for patients within clinical trials rather than being part of routine
clinical practice, which tends to be more orientated towards management of infertility.
Medical Therapy for Fertility

Controlled studies, with an untreated control group, have failed to demonstrate
improvement in fertility with either medical or surgical therapy of mild endometrio-
sis (in the absence of mechanical distortion). There is little to choose between the
medical therapies with respect to subsequent fertility and a body of evidence that
indicates no benefit compared with expectant management [7,14,15]. These therapies
have been collected together in a systematic review [16] in which 23 trials involv-
ing 3043 women were included. The odds ratio (OR) for pregnancy following ovula-
tion suppression versus placebo or no treatment for all women randomised was 0.79
(95% CI 0.54–1.14, p = .21) and 0.80 (95% CI 0.51–1.24, p = .32), respectively, for

subfertile couples despite the use of a variety of suppression agents [16]. This result
indicates that treatment does not increase pregnancy rates and, if anything, it may
actually reduce them. This absence of demonstrable efficacy, together with the fact
that the treatments are contraceptive, means that we do not advocate the use of medi-
cal therapies for women who wish to conceive. Furthermore, medical therapy simply
suppresses endometriosis for the duration of the therapy and does not prevent longer
term progression of the disease.
Endometriosis undergoes changes during the menstrual cycle, with age and during
hormonal therapy. Superficial endometriotic lesions, including lesions that underlie
ovarian endometriomata, tend to undergo secretory changes during the luteal phase
of the cycle, whereas enclosed nodular lesions are proliferative and do not undergo
necrosis or shedding during menstruation. Endometriosis responds to the cyclical
changes in ovarian hormones and regresses during pregnancy, when oestrogen and
progesterone serum concentrations are high. Pseudopregnancy treatment involves
continuous administration of a combined oral contraceptive (COC) preparation, and
endometriotic implants eventually atrophy, although they tend to hypertrophy and
undergo decidualisation first. There are fewer oestrogen and progesterone receptors
in endometriotic tissue than in the endometrium, so therapy should be continued for
several months for the disease to become quiescent.
The initial studies involved higher doses of synthetic oestrogens/progestogens
than contained in low-dose COCs, and they were often discontinued because of side
effects. The use of continuous low-dose COCs has not been adequately studied for
the treatment of endometriosis-related infertility. The COC does result in reduced
menstrual bleeding, and the rates of endometriosis in women who are either tak-
ing the COC or who have stopped recently are low compared with those who have
stopped the COC for more than 12 months. Whether the COC should be prescribed
prophylactically to women with a strong family history of endometriosis is uncertain.
Medroxyprogesterone Acetate
Progestogens alone cause decidualisation followed by atrophy. Oral medroxyproges-
terone acetate (MPA) will induce amenorrhoea and should be commenced at a dose
of 30 mg/day [17,18]. If breakthrough bleeding occurs, the dose can be increased to
50 mg/day and rarely even higher to achieve amenorrhoea. The main side effects are
weight gain, breast tenderness, mood changes and fluid retention.
Gonadotropin-Releasing Hormone Agonists

Gonadotropin-releasing hormone (GnRH) agonists cause pituitary desensitisation
and thereby induce amenorrhoea. Depot preparations can be administered monthly
or trimonthly, and this administration aids adherence to treatment. Side effects
are those of oestrogen deficiency: hot flushes, reduced libido, acne and oily skin.
Various regimens have been proposed in which add-back progestogens [18] or oes-
trogen have been used to prevent bone loss and other long-term effects of hypoes-
trogenism. We favour the combined steroid preparation tibolone because it provides
effective add-back with minimal side effects. Such therapies are more relevant to the
chronic treatment of endometriosis in women who experience pain rather than for

Endometriosis 261
the treatment of infertility. Furthermore, we do not favour the prolonged use of GnRH

agonists before in vitro fertilisation (IVF) therapy, other than in the short period
between surgery and subsequent IVF (see below).
Danazol
Danazol is a synthetic anabolic steroid preparation that is also antiprogestogenic and
anti-oestrogenic. It inhibits gonadotropin secretion and also has androgenic effects. Both
danazol and GnRH agonists suppress disease activity and levels of anti-endometrial
autoantibodies [21]. Efficacy correlates with achieving amenorrhoea, which is usually
induced within 8 weeks of administration, although the starting dose (200 mg/day)
sometimes has to be increased to 600–800 mg/day. Side effects can be troublesome
and are secondary to the anabolic and androgenic properties of the drug. Side effects
include hot flushes, acne, oily skin, hirsutism, deepening of the voice, reduced libido,
weight gain, nausea, headache and muscle cramps. Because of the side effects, it is my
practice not to use danazol as a first-line therapy in the management of endometriosis.
Efficacy
GnRH agonists, MPA and danazol have been compared in many prospective ran-
domised studies, and they appear to be equally effective in reducing the endometriosis
score by approximately 50% and achieving remission in approximately 25% of cases
[22–28]. An issue of ongoing debate is the possible effects of severe endometriosis on
the success of IVF therapy, as it has been suggested that rates of fertilisation and
implantation are impaired. It has been shown that outcome of IVF is improved by sup-
pression of active endometriosis with a GnRH agonist for 2–3 months before treatment
[29,30]. Care should be taken, however, in those women who have had previous surgery
to the ovaries or who have reduced ovarian reserve as prolonged suppression with a
GnRH agonist might impede subsequent response to stimulation with gonadotropins.
New Treatments: Selective Progesterone Receptor

Modulators and Aromatase Inhibitors
The antiprogestogen RU486 (mifepristone) inhibits ovulation, disrupts endometrial
integrity and antagonises the mitogenic effect of oestrogen on the endometrium,
without producing a fall in mean serum oestrogen concentrations[20]. Other selec-
tive progesterone receptor modulators (SPRMs), such as ulipristal acetate, also may
achieve amenorrhoea and suppress endometriosis while maintaining adequate circu-
lating oestrogen levels, and these SPRMs are being studied for their potential. Also
of interest are the aromatase inhibitors that inhibit the ability of aromatase P450 to
convert androgens (androstenedione and testosterone) to oestrone and oestradiol.
Interestingly, aromatase activity is undetectable in normal endometrium but very high
in endometriotic tissue and is therefore of great potential interest.
Surgical Therapy
Surgical therapy for the treatment of endometriosis can be performed at the time of
the diagnostic laparoscopy, although only if the diagnosis has been suspected and

the patient has been given appropriate information and consent. It is our practice to con-
sent women undergoing diagnostic laparoscopy for the possibility of ablation of minor
endometriosis or adhesiolysis, which adds no more than 10–15 minutes to the proce-
dure. Severe disease is sometimes apparent without pre-existing signs or symptoms,
and in these cases a detailed discussion with the patient is required before proceed-
ing to more major surgery. Pre- or post-surgery medical suppression of endometriosis
serves only to delay conception, with only anecdotal evidence to suggest therapeutic
benefit. Preoperative medical suppression of severe endometriosis reduces vascular-
ity and might make surgery easier, but oestrogen-deficient tissues may become more
friable and heal less well [31]. A systematic review has looked at the effectiveness of
systemic medical therapies used for hormonal suppression before or after surgery for
endometriosis [31]. One study comparing pre-surgical medical therapy with surgery
alone showed a significant improvement in AFS scores in the medical therapy group
(weighted mean difference (WMD) 9.60, 95% CI 11.42 to −7.78), but this improvement
may or may not be associated with better outcomes for the patients. Post-surgical hor-
monal suppression of endometriosis compared with surgery alone showed no benefit
for the outcomes of pain or pregnancy rates but did show a significant improvement
in disease recurrence (AFS scores (WMD −2.30, 95% CI 4.02 to −0.58)) [31]. There
was no significant difference between pre-surgery hormonal suppression and post-
surgery hormonal suppression for the outcome of pain in the one trial identified [risk
ratio (RR) 1.01, 95% CI 0.49–2.07). Information concerning AFS scores and ease of
surgery was reported only as a descriptive summary, so any difference between the
groups cannot be quantified [31]. We suggest that if the surgery has been aimed at
removing active disease before IVF, it is advisable to continue GnRH-agonist therapy
after surgery, to reduce the risk of postoperative adhesion formation, and plan to com-
mence superovulation therapy after 6–8 weeks (add-back therapy is not used at this
time). Furthermore, there is evidence from a Cochrane review that clinical pregnancy
rates are significantly higher in women receiving the GnRH agonist compared with
controls (three studies: OR 4.28, 95% CI 2.00–9.15) [30].
In considering surgery for endometriosis, a distinction should be made between
ovarian endometriomata and deeply infiltrating endometriosis, that is, endometriosis
that penetrates more than 5 mm below the peritoneal surface. Cystic ovarian endome-
triosis tends to be associated with adhesions, whereas deep infiltrating endometriosis
is not and is often found in the pouch of Douglas, on the uterosacral ligaments and in
the uterovesical fold. Sometimes, the lesions can be very deep, yet they have only a
small visible surface area. Magnetic resonance imaging can be helpful in localising
the lesions and guiding the surgery. It is sometimes necessary to perform rectoscopy
and an intravenous urogram before surgery. Where there is deeply infiltrating disease,
it is wise to prepare the bowel preoperatively. CO2-laser excision appears to achieve
better results than electrosurgery, as it has a minimal depth of penetration and pro-
vides greater control and precision.
There is some evidence that excisional surgery for endometriomata of greater
than 3 cm provides for a more favourable outcome than simple drainage and abla-
tion [32]. A systematic review reported that laparoscopic excision of the cyst wall of
the endometrioma was associated with a reduced rate of recurrence of the endome-
trioma (OR 0.41, CI 0.18–0.93), reduced requirement for further surgery (OR 0.21,
CI 0.05–0.79), reduced recurrence rate of the symptoms of dysmenorrhoea (OR 0.15,

Endometriosis 263
CI 0.06–0.38), dyspareunia (OR 0.08, CI 0.01–0.51) and non-menstrual pelvic pain

(OR 0.10, CI 0.02–0.56). It also was associated with a subsequent increased rate of
spontaneous pregnancy in women who had documented prior subfertility (OR 5.21,
CI 2.04–13.29) [32].
Laparoscopic surgery should only be performed by appropriately trained and
skilled surgeons as endometriosis taxes the skill of the surgeon more than any
other disease in the pelvis. It may be necessary to resect affected bowel or bladder,
and the help of a colorectal surgeon or a urologist may be required. Great care is
required when operating near the ureter, and ureteric stenting may be helpful. Large
lesions often require laparotomy, although such major surgery is usually reserved
for patients with severe pain who have completed their family rather than for those
with infertility, in whom GnRH-agonist therapy combined with IVF is usually more
appropriate.
Aggressive treatment of deeply infiltrating endometriosis and cystic ovarian endo-
metriosis is associated with cumulative pregnancy rates of up to 60% over 12 months,
after which IVF will probably provide a greater chance of conception than a second-
look procedure.
Endometriomata can cause significant problems during IVF. Indeed, it is our expe-
rience that the only severe pelvic infections that have occurred after transvaginal
ultrasound-guided oocyte collection have been when an endometriotic cyst has been
entered accidentally. It has been suggested that pre-treatment drainage of endome-
triomata increases the number of oocytes collected and enhances pregnancy rates.
Medical therapy tends to have little effect on endometriotic cysts. We prefer to drain
endometriotic cysts under direct visualisation at the time of laparoscopic surgery
rather than transvaginally, although others have reported good results with transvagi-
nal aspiration of cysts. Laparoscopic drainage also enables definitive treatment to
minimise recurrence. One should always remember that cysts can be malignant in
women of any age and appropriate follow-up surveillance is required. Because of the
risks of either laparoscopic surgery or transvaginal aspiration of endometriotic cysts,
our preferred strategy is not to interfere with a small cyst (<2 cm) in a woman with
two functional ovaries and to avoid aspiration during the oocyte retrieval procedure.
If there is an impaired ovarian response to stimulation, we advise treatment of the cyst
before further IVF therapy. If there is a large cyst or bilateral endometriomata, we
recommend surgery before IVF is commenced. If a cyst is entered accidentally during
oocyte retrieval, we attempt to drain it completely and provide prophylactic antibiotic
therapy (co-amoxiclav or a cephalosporin + metronidazole) for 7 days.
Surgery for Mild Endometriosis

In an attempt to answer whether mild/minimal endometriosis should be treated, the
Endocan study, a multicentre, randomised controlled trial, was conducted in Canada
[8]. It aimed to establish whether the ablation or resection of endometriosis in mini-
mal or mild (stage I or II) endometriosis improved the cumulative probability of preg-
nancy. The primary outcome was pregnancy with follow-up for 36 weeks. The study
was well designed, with the exclusion of all other factors that might affect fertility and
randomisation at the time of laparoscopy. Patients were not, however, blinded to ran-
domisation. Inclusion in the study depended on the visualisation of typical blue–black

endometriotic lesions and an AFS score of less than 16. This protocol unfortunately
meant that patients with adhesions were included in the study, so the intervention was
not solely ablation of implants. At the end of the study, results in 341 patients were
eligible for analysis: 172 patients underwent therapeutic laparoscopy and 169 had only
a diagnostic laparoscopy. Those patients undergoing treatment had not only ablation
of endometriotic deposits, usually with electrocautery, but also a division of adhe-
sions. Thus, although the aim of the study was to investigate the effect of ablation or
resection, in 9% of patients a significant co-intervention took place.
Patients treated at the time of laparoscopy had a significantly higher pregnancy
rate (OR 2.03, 95% CI 1.28–3.24) and ongoing pregnancy rate after 20 weeks (OR
1.95, 95% CI 1.18–3.22). Excluding those with adhesions, the OR was still higher,
but in both groups the confidence intervals were quite wide and the lower value
approached 1. When patients who had adhesions were excluded, only 284 patients
remained; thus, the study to consider the effect of ablation alone was underpowered
(estimated requirement 330 patients). It is interesting to note that despite a longer
follow-up period than the 24 weeks seen in randomised controlled trials of medical
therapy, the cumulative probability of pregnancy in the treated group was less than
that observed in the expectant management group in the Cochrane review [14], where
pregnancy rates ranged from 23.5% to 47.2%. This difference may reflect the impact
of the inclusion of patients with adhesions, but again questions the generalisability
of the results of this trial and begs the question of whether the original aim has been
adequately addressed.
A smaller study by the Italian Group for the Study of Endometriosis [9] randomly
assigned 54 patients to treatment of mild endometriosis and 47 to laparoscopy alone.
After 1 year, the pregnancy rates were no different, at 24% and 29%, respectively.
Thus, although treatment is unlikely to do harm and should not unduly lengthen the
laparoscopic procedure, there is conflicting evidence of benefit.
The two studies were combined in a Cochrane review [33] with the conclusion
that the use of laparoscopic surgery in the treatment of minimal and mild endome-
triosis may improve success rates. By combining ongoing pregnancy and live birth
rates, there was a statistically significant increase with surgery (OR 1.64, 95% CI
1.05–2.57). But, the relevant trials have some methodological problems, and further
research in this area is needed [33].
Proposed Strategy for Management of Endometriosis

Women with endometriosis-associated infertility have reduced fecundity of 1%–3%
per cycle; yet, in the absence of mechanical distortion of pelvic organs, the mecha-
nism is unclear. Medical therapy should be reserved for those women with moderate
to severe endometriosis who are proceeding to assisted conception therapies within
the following 2 months to render the endometriosis quiescent before commencing
ovarian stimulation. Laparoscopic surgery should be performed at the time of the
diagnostic procedure in mild cases and after careful preparation for moderate to
severe cases, with the aim of removing endometriomata and alleviating periovarian
and peritubal adhesions. If conception does not occur within 6–12 months, assisted
conception in the form of IVF should be offered (Box 10.2).

Endometriosis 265
BOX 10.2 KEY POINT OF ENDOMETRIOSIS

• Retrograde menstruation is the probable cause of most cases of
endometriosis.
• The pathophysiology and time course of endometriosis are not fully
understood.
• Minimal and mild endometriosis affect fertility and should be treated
during the assessment laparoscopy.
• Moderate to severe endometriosis can result in infertility and may
require more extensive surgery.
• The medical treatment of endometriosis is contraceptive, so it is
appropriate for patients with pain but not infertility.
• Surgical treatment of endometriosis can improve the fertility of
appropriately selected patients.
• Assisted reproduction technology is often required for those with
severe endometriosis.
• Endometriomata may lead to severe pelvic infection if aspirated trans-
vaginally, for example, accidentally during oocyte collection for IVF.
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11
Tubal Infertility and Fibroids
Introduction
In vitro fertilisation (IVF) has revolutionised many forms of fertility therapy, yet the
question of IVF versus tubal surgery for mild to moderate tubal disease is sometimes
still debated. IVF is a stressful and time-consuming treatment, and each attempt
offers only a single chance for pregnancy, unless embryos can be frozen for future
use. Successful tubal surgery, in contrast, can provide a permanent cure, with the
possibility of more than one pregnancy. Furthermore, tubal surgery can be performed
laparoscopically, although there is still debate about the respective indications for
open tubal microsurgery and laparoscopic tubal surgery. It has been suggested that
the only indication for open tubal surgery is reversal of sterilisation. In the United
Kingdom, tubal surgery is often funded by the National Health Service, whereas IVF
is to a much lesser extent. In our initial discussion, however, we propose to set aside
the matter of cost and select the appropriate treatment for the individual patient.
Techniques
The techniques used in tubal surgery are of paramount importance and require a dequate
training, whether performed at laparotomy or laparoscopy. Open tubal s urgery is opti-
mally performed using an operating microscope. Magnification of the tube, usually
by 20–40 times, allows inspection of the mucosa and the correct a lignment of the
canal during tubal reconstruction. Adequate access to the pelvic organs is required,
although this access does not always necessitate a large incision. The tissues should
be handled carefully, and continuous irrigation with a physiological solution (Ringer’s
lactate or Hartmann’s solution, sometimes heparinised) should be used [1]. Synthetic
non-absorbable sutures (8–0 nylon) are usually used to m inimise tissue reaction dur-
ing healing, although some surgeons prefer synthetic absorbable sutures (e.g. Vicryl).
Although some surgeons advocate the continued use of open microsurgery, the
laparoscopic approach has gained favour. Even after a four-portal procedure,

the patient recovers more rapidly than after a laparotomy and can usually return
home the day after surgery, or sometimes the same day. One study compared the
outcome of microsurgical and laparoscopic adhesiolysis and found no statistically
significant difference in cumulative conception rates, which were a little more than
40% after 12 months [2]. The single most significant variable that affected the chance
of a p regnancy was the duration of infertility, and it was found that for each a dditional

year of infertility the probability of a pregnancy was reduced by approximately 20%.

The implications for delay through slowly moving waiting lists are therefore profound.
The technique of laparoscopic surgery has to be meticulously executed and the
limitations of the tools and risks of injury to adjacent structures appreciated, espe-
cially during use of laser or electrocoagulation. Follow-up studies have revealed no
differences in the amount of tissue damage and adhesion reformation between CO2
laser and electromicrosurgery (as assessed by measurement of residual particulate
carbon, foreign body reaction or tissue necrosis).
Endoscopic Tools
Electrosurgery is most commonly used endoscopic tool and can be used with a
coagulating (intermittent) current, resulting in cell dehydration, or a cutting (continu-
ous) current that vaporises the tissue; alternatively, the two modes can be blended.
Unipolar diathermy produces a flow of electrons through tissue to the earth plate,
whereas bipolar diathermy causes less adjacent tissue damage as the current flows
between the two prongs of the forceps. Endocoagulation coagulates by heating tissue
to 120°C without electrical energy escaping into the patient.
Laser therapy requires expensive equipment. Short-wavelength lasers (KTP,
Nd:YAG) coagulate well but cause poor vaporisation. CO2 lasers cut precisely as they
vaporise well but coagulate less well, thereby causing wider areas of tissue damage
when used to coagulate.
The ultrasonic vibrating scalpel vibrates at more than 50 kHz, denatures proteins
and cuts tissue with minimal adjacent tissue injury compared with electrosurgery or
lasers. As the protein cools, it forms a haemostatic coagulum.
Pre-Surgical Considerations
The couple will have been investigated thoroughly before the decision is made to
perform tubal surgery. If there are coexisting fertility problems, for example, sperm
dysfunction, IVF should be recommended. The patient’s age is another important
consideration, as the success rates of IVF decline with age, and in women over the age
of 38 years, it is prudent to move on to IVF quickly rather than wait for tubal surgery
to have a chance to work.
Pre-surgical investigations should include assessment of both the uterine cavity,
by hysterosalpingography (HSG) or hysteroscopy, and the fallopian tubes, usually
by laparoscopy (see Chapter 5). It was once suggested that further assessment of the
tube from within may be helpful by either salpingoscopy (via the laparoscope) or fal-
loposcopy (via the hysteroscope) (Figure 11.9). However, these techniques are costly,
time-consuming and have not been shown to improve outcome; hence, after initial
interest they have largely been abandoned. Selective salpingography and fallopian
tube cannulation can help distinguish the location of a proximal occlusion of the tube,
and they are sometimes used to achieve recannulation without resort to surgery. This
procedure is performed dynamically by a radiologist at the time of an HSG either

Tubal Infertility and Fibroids 271
in the outpatient setting or sometimes under general anaesthesia. Surgery is least

likely to be of benefit when there is gross tubal damage with only a short length of
normal tube or when there are extensive pelvic adhesions or an active disease such as
endometriosis (Figure 11.8 and see Chapter 10).
Adhesiolysis
Peritubal adhesions interfere with ovum pick-up and tubal transport, whereas peri-
ovarian adhesions may inhibit ovulation. When the tubes are patent and the ovaries
freely mobile, adhesiolysis (Figures 11.1 through 11.3) will result in good cumulative
conception rates (60% in 24 months), although at second-look laparoscopy there is
often a recurrence of the adhesions to some degree [3]. Dense adhesions carry a worse
prognosis than fine, filmy adhesions. It is important to avoid producing raw areas
of denuded peritoneum that will increase post-operative adhesion formation. Some
advocate an early second-look laparoscopy, between 5 days and 2 months after the
initial procedure, to allow further treatment of filmy adhesions before they become
too dense (usually by 4–6 months after surgery).
The degree of magnification achieved during laparoscopy permits equivalent ease
of surgery as with open microsurgery and the initial access to adherent pelvic organs is
more easily achieved, without the need for macrodissection. The Canadian Infertility
Evaluation Study Group performed a multicentre, randomised study of laparoscopic
salpingo-ovariolysis versus no treatment and found pregnancy rates at 12 months of
(a)
FIGURE 11.1 (a) Laparoscopic peritubal and periovarian adhesiolysis.

FIGURE 11.1 (Continued) (b, c) Laparoscopic fimbriolysis. (d) Salpingolysis.

(a)
(b)
FIGURE 11.2 (See colour insert.) (a) Laparoscopy and dye. Perifimbrial adhesions lead to locu-
lation of the injected dye, yet there is some spill into the peritoneal cavity. In such cases, an HSG
examination can give the impression of normal tubal patency. (b) An adhesiolysis has been per-
formed, and the fimbrial end of the tube are displayed to allow free flow of dye.

(a)
(b)
FIGURE 11.3 (See colour insert.) (a) Laparoscopy and dye. The left ovary (O) is tethered to the
posterior leaf of the broad ligament, and the tube (T) is adherent in the pouch of Douglas. Scissors
are used to release the adhesions. (b) An adhesiolysis has been performed, but the tube (T) is retort
shaped, distended and considerably damaged. The uterus (U) is seen to the right.

45% and 16%, respectively [4]. The ectopic pregnancy rate after salpingo-ovariolysis
is approximately 5% compared with a population rate of 0.5%–1% [5] (Figure 11.2).
Salpingostomy
The mainstay of salpingostomy is the fashioning of a small ostium at the tip of the tube,
with eversion of the tubal mucosa so that the reconstructed fimbriae are positioned
to allow the ostium free movement over the ovary. Raw areas and linear incisions
in the tube will heal over and should be avoided. The best cases to treat are those
in which the tubes have thin walls, normal mucosa and no periovarian a dhesions,
although when the distal end of the tube is blocked there are usually periovarian and
peritubular adhesions.
Large hydrosalpinges, greater than 1.5 cm in diameter, carry a worse prognosis and
are often excised (see below).
Some advocate the insertion of a salpingoscope before deciding upon formal
laparoscopic fimbrial reconstruction as the presence of intratubal adhesions or grossly
damaged tubal mucosa will lead to abandonment of the procedure. Although this
approach has scientific logic, the tube has to be opened at its distal end to insert the
salpingoscope, so there is little to be lost by proceeding with a fimbrioplasty. Pregnancy
rates after salpingostomy range between 20% and 40%, with ectopic p regnancy rates
of 5%–20% (Figures 11.4 through 11.6). It is essential to advise patients with tubal
damage to always seek an early ultrasound assessment of the site of a pregnancy so
that an ectopic pregnancy can be identified and managed early (see Chapter 22).
Cornual Occlusion
Tubocornual anastomosis is best achieved using open microsurgery. Advocates of lapa-
roscopic surgery are, however, exploring the use of tubotubal anastomoses, but with
variable results to date. Where there was damage to the intramural portion of the tube,
re-implantation of the tube used to be practiced. The results of tubal re-implantation are
often poor, and there is a risk of uterine rupture during pregnancy, so these cases are
now best treated by IVF. Cornual occlusion due to infection (e.g. salpingitis isthmica
nodosa, pelvic inflammatory disease, tuberculosis) is often associated with microscopic
damage along the length of the tube, so there is a worse prognosis and greater risk
of ectopic pregnancy than after reversal of sterilisation. The repair of the tube should
be in two layers – muscularis with submucosa and serosa – using 8–0 non-absorbable
synthetic sutures. Splinting of the tube may result in endothelial damage and is not
recommended. It is important to remove an adequate section of the tube so that none
of the diseased tube remains after surgery, as tubal patency, which results in 85% of
cases, does not equate with tubal function or pregnancy, which occurs in approximately
50%–60% of cases. Post-surgery ectopic pregnancy rates are reported to be between
5% and 10%.
Reversal of sterilisation leads to the best results not only because the patient is
of proven fertility (although it is essential to check ovarian function and her new

Glass rod
Cutting
diathermy
(a)
(b)
Glass rod
(c)
FIGURE 11.4 Open tubal microsurgery: salpingostomy. (a) A cruciate incision is made into the
tube by using cutting diathermy and (b) carefully extended. (c) The mucosal edges of the tube are
then everted and sutured using a non-absorbable 6–0 suture.
partner’s semen analysis before embarking on surgery) but also because damage is
to a very small portion of the tube. It is however essential to ascertain the method of
sterilisation as the older methods of Pomeroy ligation and tubal diathermy leave much
less in the way of functional tube than the use of the fallope ring, which, in turn, is
more damaging than a clip. The best results are obtained if the reconstructed tube is
longer than 4 cm, with at least 1 cm of distal ampulla. Pregnancy rates are between
60% and 80%, with ectopic pregnancy rates usually less than 5% (Figure 11.7).
Although open laparotomy and microsurgical tubal reconstruction are still standard
practice, some are achieving good results using laparoscopic techniques, sometimes
robotically assisted.
The cumulative chance of delivery over 72 months after reversal of sterilisa-
tion has been reported as 72% for women under the age of 37 years, compared
with 52% with IVF (p = .012), whereas in women over the age of 37, the deliv-
ery rates were 51% and 36% (not significant) [6]. When taking cost effectiveness
into consideration, it is recommended that older women may be better proceeding
straight to IVF [6].

(a )
(b)
(c)
(d)
FIGURE 11.5 Laparoscopic salpingostomy with sutures using (a) laser or cutting diathermy, (b)
sharp dissection and (c, d) laparoscopic sutures.
Reconstruction of Contralateral Tubes and Ovaries

In rare cases, when a tube has been lost from one side and the ovary lost from the
other, it is necessary to mobilise the ovarian pedicle and bring it to the contralateral
side to be close to the tube. In other cases, a single tube has been fashioned from the
remnants of two damaged tubes.
Transcervical Recannulation of the Tube

A false impression of tubal occlusion can be obtained during salpingography or lapa-
roscopy because of either tubal spasm or the presence of viscous mucus plugs, which
can be dislodged by either falloposcopy or selective salpingography. Transcervical
cannulation of the tube using balloon tuboplasty, under fluoroscopic guidance, has
been evaluated in recent years, with reports of tubal patency being achieved in
approximately 80% of cases and pregnancy rates of 35% [7,8]. There are, to date,
no controlled studies of these methods, but the best cases are likely to conceive and
might even undergo spontaneous resolution of a functional blockage (Figure 11.8) [9].

(a)
(b)
(c)
FIGURE 11.6 Laparoscopic salpingostomy with laser or diathermy to (a) incise the tube and
(b) scar the serosa to cause (c) eversion of the mucosa.
Falloposcopy
The flexible falloposcope is inserted under hysteroscopic vision and provides both
an image of the tubular lumen and the potential for recannulation by either flushing
or tuboplasty [10]. Falloposcopic recannulation of the tube is likely to be successful
only when there are minor intratubular adhesions or for the removal of mucus plugs
and fibrinous deposits. The visualisation of mucosal abnormalities might lead one
to guide the patient to IVF sooner than if the architecture of the recannulated tube
appeared normal (Figure 11.9). Falloposcopy is limited by the optical systems avail-
able and, after early interest, it has not become widely used. Furthermore, the product
has now been withdrawn from the market.
Salpingoscopy
It has been suggested that the salpingoscope, inserted laparoscopically through the
fimbrial end of the tube, provides clear visualisation of the ampullary segment of the
tube and is used more to guide decision making on the selection of patients for tubal

(a)
(b)
(c)
FIGURE 11.7 Open tubal microsurgery: tubocornual anastomosis. (a) After excising the stenosed
segment of tube with a combination of cutting diathermy and sharp dissection, the clean edges are
opposed using 8–0 nylon. (b) The first suture is placed at 6 o’clock ‘a’ through the muscularis (not
mucosa). Between four and eight sutures are required. (c) The serosa and mesosalpinx are then
repaired with 6–0 nylon.
surgery or IVF than for therapeutic procedures (Figure 11.9). Despite early promise,
this technique has not gained popularity and it is seldom performed.
In Vitro Fertilisation
Most women with tubal infertility are optimally treated with IVF (see Chapter 14). If
they have a history of repeated ectopic pregnancy, there is a case for performing a ster-
ilisation before IVF, as there is nothing more traumatic than developing a further ecto-
pic pregnancy after the stresses of an IVF treatment cycle. The overall rate of ectopic
pregnancy after IVF is 5% (i.e. higher than normal) because uterine transfer of the
pre-embryo(s) does not ensure that it will remain in the uterine cavity. It is a big step to
sterilise a woman who wishes to conceive although those who have experienced ecto-
pic pregnancies and have severe tubal damage will usually accept this. If an ectopic

100
Normal
50
Severity grade I
II
III
0 IV
0 12 24 36
(a) Months
100
Normal
Severity grade I
50
II
III
0
0 12 24 36
(b) Months
FIGURE 11.8 Cumulative conception rates (CCRs) (a) before and (b) after tubal surgery related
to severity of tubal disease (grade IV disease was not operated on). (From Wu CH, Gocial B, Int
J Fertil 33, 341–6, 1998.)
occurs after IVF in a patient with pre-existing tubal damage, the option of sterilisation
or salpingectomy should be discussed before surgery for the ectopic pregnancy.
There is good evidence to suggest that the presence of hydrosalpinges affects the
outcome of IVF by having an effect on the endometrial environment, possibly through
the passage of toxic fluid into the uterine cavity, which disrupts implantation [11–13].
If the tubes are completely blocked and there are large hydrosalpinges, there is a case
for their removal before IVF. In the largest prospective randomised controlled trial
(RCT) to date, 204 patients were entered and 192 commenced IVF [14]. Although there
was no significant difference in the pregnancy rate between the s alpingectomy group
(36.6%) and the non-intervention group (23.9%), the live birth rates were increased
(28.6% vs. 16.3%, p = .045). The differences were more significant in the presence
of bilateral hydrosalpinges and particularly so with ultrasound visible hydrosalpinges
(Figure 11.10) (clinical pregnancy rate 45.7% vs. 22.5%, p = .029 and live birth rate

Salpingoscope
Falloposcope
FIGURE 11.9 Falloposcopy and salpingoscopy. The flexible falloposcope is inserted via a channel
in an operating hysteroscope, whereas salpingoscopy (usually rigid) is performed transabdominally
during laparoscopic evaluation of the pelvis.
FIGURE 11.10 Transvaginal ultrasound scan of a hydrosalpinx. (Courtesy of Mrs J. Smith,

Assisted Conception Unit, Leeds Centre for Reproductive Medicine.)

40% vs. 17.5%, p = .038). A systematic review of the five RCTs performed to date
looking at either salpingectomy, laparoscopic tubal occlusion or ultrasound aspiration
of hydrosalpinges has confirmed the benefit of treatment before IVF (15). In the four
trials that involved salpingectomy, the odds ratio (OR) for pregnancy was 2.49 (95%
CI 1.60–3.86), with no increase in complication rate during treatment or effect on
miscarriage or ectopic pregnancy rates (15). The average pregnancy rate was 21.7%
higher after surgery (95% CI 15.1–28.3); hence, for every five surgical procedures,
there was one additional IVF pregnancy. Salpingectomy can usually be performed
laparoscopically and care should be taken not to compromise ovarian blood supply.
Although an early study suggested no impairment of ovarian response in subsequent
IVF [16], a more recent study demonstrated impaired response, without effecting
pregnancy rates [17].
Adhesion Barriers
Pelvic surgery is associated with high rates of both adhesion formation and adhesion
reformation, both of which may affect subsequent fertility. There has therefore been
much interest in the prevention of adhesions by several substances, including steroids,
antihistamines, heparin, 4% icodextrin, hyaluronic acid agents and SprayGel, all of
which were reviewed for the Cochrane database [18]. There is no evidence of benefit
from the use of steroids, dextran or other pharmacological agents in fertility out-
comes. The use of hyaluronic acid agents may decrease adhesion formation (OR 0.31,
95% CI 0.19–0.51) and prevent the deterioration of pre-existing adhesions (OR 0.28,
95% CI 0.12–0.66), but there was insufficient evidence for the use of 4% icodextrin
or SprayGel as adhesion-preventing agents [18]. One study, however, has suggested
a significant benefit from the use of 4% icodextrin in the prevention of adhesion for-
mation compared with lactated Ringer’s solution in a prospective, randomised dou-
ble-blind study in which second-look laparoscopy was performed [19]. Nevertheless,
none of the studied agents has been shown to improve the pregnancy rate when used
as an adjunct during pelvic surgery.
Uterine Surgery
Myomectomy
Fibroids are common and increase in incidence with age. Prevalence has been
reported as low as 3% in Swedish Caucasian women aged 25–32 years and 8%
in those aged 33–40 years [20], whereas rates have been reported as high as 70% in
white Americans and 80% in African Americans 50 years of age [21]. Imaging and
initial assessment of fibroids is by ultrasonography, but magnetic resonance imaging
(MRI) can be extremely helpful in further delineating the position of multiple fibroids
and distinguishing fibroids from adenomyomata [22]. Classification of fibroids is by
their position: with serosal fibroids being of least significance to fertility, there is then
increasing significance of the presence of subserosal fibroids in which greater than
50% projects out of the serosal surface; intramural fibroids that do not deform the
cavity of the uterus and have less than 50% projecting from the wall of the uterus;

and submucus fibroids that, in turn, may be pedunculated into the cavity of the uterus
(type 0), sessile with intramural extension of either 50% (type I) or equal to or greater
than 50% (type II). It is thought that fibroids are most likely to affect fertility if they
either distort the endometrial cavity or have an intramural component of greater than
4 cm. As with many aspects of the epidemiology of infertility, studies that have looked
at the effect of fibroids on infertility are very heterogeneous and usually retrospective.
Fibroids are often removed indiscriminately, and myomectomy can result in
extensive pelvic adhesion formation and damage to the integrity of the uterine cavity.
Until recently, it was thought that fibroids should only be removed if they are causing
a significant distortion of the uterine cavity or if they are blocking the cornual region
of the tube. Thus, a study by Farhi et al. [23] demonstrated that implantation rates
after IVF were not affected by the presence of fibroids unless the shape of the uterine
cavity was altered. It is probably not the presence of fibroids that affects implanta-
tion rates but rather the distortion of the uterine cavity that they cause – perhaps by
affecting endometrial proliferation and altering vascularisation. Fibroids may have
adverse effects on pregnancy, with growth in the first trimester causing pain, miscar-
riage, preterm delivery, fetal malpresentation and an increased need for caesarean
delivery.
Myomectomy is a major procedure with potential risks to the integrity and via-
bility of the uterus. Preoperative treatment with a gonadotropin-releasing hormone
agonist for 6–8 weeks will cause significant shrinkage of the fibroids and reduce
vascularity and blood loss during surgery. Small submucosal fibroids can be removed
hysteroscopically (Figure 11.11). There has yet to be a randomised controlled study of
myomectomy before assisted conception or for that matter looking at natural fertility.
A systematic review that examined the effects of intramural fibroids on both natural
and assisted conception found a reduction in clinical pregnancy rate (risk ratio (RR)
0.81, 95% CI 0.70–0.94), implantation rate (RR 0.68, 95% CI 0.59–0.80) and live
birth rate (RR 0.70, 95% CI 0.58–0.85) in women with intramural fibroids (Table 11.1)
[23]. Miscarriage rates also were increased (RR 1.75, 95% CI 1.23–2.49). The effect
on pregnancy and live birth and miscarriage rates was lost when only studies with
assessment of the uterine cavity were included. Nonetheless, it is generally felt that
intramural fibroids do have an adverse effect on fertility; yet, their removal does not
appear to have a significant effect on clinical pregnancy or live birth rates [24].
Submucosal fibroids also have an adverse effect on clinical pregnancy rate (RR
0.36, 95% CI 0.18–0.74), implantation rate (RR 0.28, 95% CI 0.12–0.65) and live birth
rate (RR 0.32, 95% CI 0.12–0.85) and an increase in miscarriage rate (RR 1.68, 95%
CI 1.3–2.05) [24]. This systematic review did demonstrate an improvement in clini-
cal pregnancy rate after surgery (RR 3.77, 95% CI 0.47–30.14) but not in miscarriage
or live birth rate [24]. Furthermore, it is difficult to demonstrate any correlation with
fibroid size and outcomes.
It is our practice to pretreat women before myomectomy with a long-acting GnRH
agonist for 6–8 weeks before surgery to reduce the blood flow through the uterus and
to minimise the degree of haemorrhage. It also has been suggested that the selec-
tive progesterone receptor modulator ulipristal acetate (5 mg daily) may be beneficial
for the preoperative treatment of moderate to severe symptoms of uterine fibroids in
adult women of reproductive age. The duration of treatment is limited to 3 months
and is comparable to monthly GnRH agonist (leuporelin) injections in controlling

(a)
(b)
FIGURE 11.11 (a) Fibroids distorting the uterine cavity and causing tubocornual occlusion. (b) A pro-
ton density MRI scan showing two sagittal sections through the uterus, cervical canal (C) and bladder
(B). Multiple intramural fibroids (F) can be seen. A large pedunculated submucosal fibroid (S) is outlined
by the hyperintense (white) endometrium (arrow). This is the same patient as in Figure 5.30 (p. 104).
uterine bleeding in women with symptomatic uterine fibroids before planned surgery
and has a better side-effect profile. Two large RCTs have been recently performed.
In the first trail, ulipristal at two doses was compared with placebo over 13 weeks
in women with symptomatic fibroids, excessive uterine bleeding and anaemia [25].
All women received iron supplementation. After 13 weeks, bleeding was controlled

TABLE 11.1
Meta-Analysis on the Influence of Fibroids on IVF Outcome according to Their
Localisation
Number of Breslow–Day
Localisation Studies Included Test (p Value) Common OR (95% CI)
Clinical pregnancy rate
Submucosal 2 .92 0.3 (0.1–0.7)
Intramural 7 .38 0.8 (0.6–0.9)
Subserosal 3 .92 1.2 (0.8–1.7)
Intramural and/or submucosal 11 .30 1.0 (0.8–1.2)
All types 16 .24 0.8 (0.7–1.0)
Delivery rate
Submucosal 2 .79 0.3 (0.1–0.8)
Intramural 7 .09 0.7 (0.5–0.8)
Subserosal 3 .94 1.0 (0.7–1.5)
Intramural and/or submucosal 11 .68 0.9 (0.7–1.1)
All types 16 .43 0.8 (0.6–0.9)
in 91% of women receiving ulipristal at 5 mg, 92% of women receiving 10 mg and

19% of women receiving placebo. Rates of amenorrhoea were 73%, 82% and 6%,
respectively, with amenorrhoea occurring within 10 days in the majority of patients
receiving ulipristal. Median changes in uterine fibroid volume were –21%, –12% and
+3%, respectively, and shrinkage of the fibroids is maintained for much longer in
those treated with ulipristal. The second study was a straight comparison between uli-
pristal and leuprolide acetate in 307 women with symptomatic fibroids and excessive
uterine bleeding [26]. Uterine bleeding was controlled in 90% of patients receiving
5 mg of ulipristal, 98% of patients receiving 10 mg and in 89% of patients receiving
leuprolide acetate. Median times to amenorrhoea were 7 days for 5 mg ulipristal,
5 days for 10 mg and 21 days for leuprolide. Hot flushes were reported in 11%, 10%
and 40% of patients, respectively, and serum oestrogen levels were maintained in the
pre-menopausal range in the women treated with ulipristal [25,26]. Ulipristal acetate
also may cause a benign endometrial thickening in 10%–15% of patients and reverses
when treatment is stopped and menstrual periods resume. It is unclear at the time of
writing how long after such treatment it is then safe to conceive.
Less invasive procedures than operative myomectomy are being evaluated for
the management of fibroids, including uterine artery embolisation and MRI-guided
laser coagulative necrosis or high-intensity focused ultrasound for the destruction of
fibroids. The place of these techniques in the management of infertility is debated.
Furthermore, although uterine artery embolisation has become popular in the
management of fibroids, it is not recommended for women who wish to preserve
fertility because of the potential adverse effect on both uterine and ovarian blood
supply [27]. There is also an increase in adverse events during pregnancy, including
miscarriage, placenta accreta, the need for caesarean delivery and post-partum
haemorrhage [28,29]; so, we do not recommend embolisation in women wishing
to conceive.

Intrauterine Polyps
Polyps are often found at the time of sonographic investigation of the uterine cavity,
during an HSG or at the time of hysteroscopy. If the polyp appears to be blocking the
cornual opening of the tube or if it is associated with an abnormal bleeding pattern, it
should be removed. If a hysteroscopy is being performed, the polyps can be removed
easily. If however the polyp is an incidental finding during imaging of the pelvis, in the
absence of symptoms, there is still debate as to whether surgery is indicated as there is
no clear evidence for an association between the presence of a polyp and infertility [30].
There is 1 RCT in 215 women that found a higher pregnancy rate in women undergo-
ing intrauterine insemination treatment after a polypectomy had been performed (63%
vs. 28%; RR 2.3, 95% CI 1.6–3.2) [31]. It is our practice to remove polyps greater than
1 cm in diameter, and if the patient is experiencing irregular bleeding or discharge, the
polyp should be removed to exclude malignant change. It is generally felt to be benefi-
cial to perform a hysteroscopic assessment of the uterine cavity before embarking upon
fertility treatment, to remove polyps and identify any other anomalies, and some would
advocate a repeat hysteroscopy after two failed cycles of IVF, with evidence of an
almost twofold increase in pregnancy rate (RR 1.7, 95% CI 1.5–2.0) [32].
Intrauterine Synechiae
Hysteroscopic division of synechiae should be performed. If the patient is
amenorrhoeic with Asherman’s syndrome, the integrity of the cavity should be
maintained using an indwelling intrauterine contraceptive device for 2 months, to
allow the resumption of regular menstrual shedding, before it is removed and the
patient allowed to conceive (Figure 11.12). An intrauterine adhesion barrier also
may be applied. Cyclical hormone therapy (containing oestrogen and progestogen
combinations) also may be beneficial to encourage endometrial regeneration.
Reconstruction of Uterine Anomalies

Some congenital uterine anomalies may be associated with infertility and an
increased risk for miscarriage, although many women conceive and might only
be found to have a uterine anomaly during incidental ultrasonography of the preg-
nancy or caesarean delivery [33]. Approximately 5.5% of women have a congeni-
tal uterine anomaly, with the commonest being an arcuate uterus. In women with
infertility and miscarriage, the septate uterus is the most common anomaly, but
less common anomalies such as bicornuate, unicornuate and didelphic uterus also
are associated with reduced reproductive performance, although there is little sur-
gical help that can be done in these cases. Large intrauterine septa may result in
an increased risk of miscarriage, and if a septate uterus is found during routine
investigations for infertility, then one should question the need for surgery on the
basis of whether the abnormality is having an effect on fertility. Is it reasonable,
however, then to allow a patient who has been having difficulty in conceiving to
continue with a high risk of miscarriage once she finally gets pregnant? As a mis-
carriage is by no means a certainty, we would counsel caution before performing
major surgery on the uterus, which might in any case further disrupt the integrity of

FIGURE 11.12 Hysteroscopic resection of intrauterine synechiae.
the uterus or lead to damaging adhesion formation. There have been no prospective
RCTs that have addressed this issue; nonetheless, a large septum probably warrants
hysteroscopic resection.
The only chance of pregnancy for women with major uterine anomalies or con-
genital absence of the uterus (Mayer–Rokitansky–Küster–Hauser syndrome) is IVF
surrogacy, in which the patient’s oocytes are collected, usually by the transvaginal
route (as these patients usually have a fully functional vagina), fertilised with her
partner’s sperm and then the embryos transferred to a surrogate host. Sometimes, the
ovaries are situated high out of the pelvis and an ultrasound-guided transabdominal
oocyte retrieval is required, a procedure that can be quite challenging for the o perator.
Uterine transplantation has been performed now in both non-human primates and
women, with the first pregnancies being reported in the former [34,35].
Management Strategy for Tubal Infertility

The practical management of tubal infertility is a choice between tubal surgery or
IVF. If there are other factors in a couple’s subfertility, such as sperm d ysfunction or
if the woman is more than 37 years of age, it is logical to consider IVF rather than

surgery. IVF also is indicated if there is moderate to severe tubal disease, that is, distal
tubal occlusion with hydrosalpinges, particularly if the latter are greater than 1.5 cm
in diameter, thick walled and associated with extensive adnexal adhesions. Distortion
of the intraluminal architecture or endotubal adhesions, detected u sually by HSG
and infrequently these days by falloposcopy or salpingoscopy, further worsens the
prognosis for tubal surgery. Adhesiolysis is more likely to work in the presence of
patent tubes and filmy adhesions, with dense adhesions being a poor prognosticator.
Table 11.2 presents the British Fertility Society c lassification of pelvic disease related
to the prognosis for natural conception after surgery.
Laparoscopic surgery is preferable to open microsurgery for all but tubal
re-anastomoses, and there is little to choose between the use of sharp dissection,
laser or electrosurgery. Constant irrigation of the tissues and good haemostasis
are essential to minimise post-operative adhesion formation. Cumulative conception
rates decline rapidly 12 months after tubal surgery, so IVF should then be advised
(Box 11.1).
TABLE 11.2
British Fertility Society Classification of Tubal/Pelvic Infective Damage
Minor (favourable surgical prognosis: >50% over 2 years)
Proximal occlusion without tubal fibrosis
Distal occlusion without tubal distension
Healthy mucosal appearance at HSG, salpingography
Flimsy peritubal/ovarian adhesions
Intermediate (questionable surgical prognosis)

Unilateral severe tubal damage
Limited dense adhesions of tubes and ovaries, with otherwise normal tubes
Severe (poor prognosis: <10% over 2 years)

Bilateral severe tubal damage
Extensive tubal fibrosis
Tubal distension > 1.5 cm
Abnormal mucosal appearance
Bipolar occlusion
Extensive dense adhesions
BOX 11.1 KEY POINTS OF TUBAL DISEASE

• Laparoscopic surgery has largely taken the place of open tubal micro-
surgery other than for reversal of sterilisation.
• IVF is indicated if a pregnancy has not occurred within 6–9 months
of tubal surgery.
• Bilateral salpingectomy or tubal sterilisation should then be consid-
ered for women with tubal damage and a history of ectopic pregnancy
and women with hydrosalpinges.

Bilateral salpingectomy or tubal sterilisation should be considered for women under-

going IVF who have tubal damage and a history of ectopic pregnancy, especially if
the ectopic pregnancy has occurred as a result of IVF, because of the increased risk of
a further ectopic pregnancy. The same applies for patients with hydrosalpinges, which
adversely affect implantation rates during IVF, presumably because of a ntegrade flow
of noxious fluid.
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Drife JO, eds. Infertility. London: RCOG, 1992: 185–98.
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laparoscopic adhesiolysis for infertility. Hum Reprod 1995; 10: 2887–94.
3. Graebe RA. The role of endoscopy in the management of the infertile patient. Curr
Opin Obstet Gynecol 1995; 7: 265–72.
4. Tulandi T, Collins JA, Burrows E, et al. Treatment-dependent and treatment
independent pregnancy among women with periadnexal adhesions. Am J Obstet
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5. Maier DB, Nulsen JC, Klock A, Luciano AA. Laser laparoscopy versus laparotomy
in lysis of pelvic adhesions. J Reprod Med 1992; 37: 965–8.
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ilization: surgical reversal or IVF? Hum Reprod 2007; 22: 2660–4.
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plasty study: conclusions and comparisons to alternative technologies. Hum Reprod
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8. Lederer KJ. Transcervical tubal cannulation and salpingoscopy in the treatment of
tubal infertility. Curr Opin Obstet Gynecol 1993; 5: 240–4.
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33: 341–6.
10. Kerin JF, Williams DR, San Romano GA, Pearlstone AC, Grundfest WS, Surrey ES.
Falloposcopic classification and treatment of fallopian tube lumenal disease. Fertil
Steril 1992; 57: 731–41.
11. Andersen AN, Yue Z, Meng FJ, Petersen K. Low implantation rate after in vitro
fertilisation in patients with hydrosalpinges diagnosed by ultrasonography. Hum
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12. Fleming C, Hull MG. Impaired implantation after in vitro fertilisation treatment
associated with hydrosalpinx. Br J Obstet Gynaecol 1996; 103: 268–72.
13. Strandell A. The influence of hydrosalpinx on IVF and embryo transfer: a review.
14. Strandell A, Lindhard A, Waldenstrom U. Hydrosalpinx and IVF outcome: a pro-
spective, randomized multicentre trial in Scandinavia on salpingectomy prior to IVF.
Hum Reprod 1999; 14: 2762–9.
15. Johnson NP, van Voorst S, Sowter MC, Strandell A. Surgical treatment for tubal disease
in women due to undergo IVF. Cochrane Database Syst Rev 2010; (1): CD002125.
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17. Gelbaya TA, Nardo LG, Fitzgerald CT, Horne G, Brison DR, Lieberman BA.
Ovarian response to gonadotropins after laparoscopic salpingectomy or division of
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18. Metwally M, Watson A, Lilford R, Vandekerckhove P. Fluid and pharmacological

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the endometrium: low prevalence of leiomyoma in a random sample of women age
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The Indianapolis consensus. Hum Reprod 2013; 28: 288–91.

12
Male Factor Infertility
Introduction
A clear diagnosis of the cause of male factor infertility can be made in only a small
proportion of men who present with infertility. Many of these men labelled as having
idiopathic male factor infertility for which there are no specific therapies. Indeed, a
survey a few years ago of more than 7000 men with male factor infertility revealed
that there was no identifiable cause in 48.5%, idiopathic abnormal semen in 26%
(12% oligozoospermia, 7% teratozoospermia, 4% asthenozoospermia), varicocele in
12% (and this diagnosis is disputed), infection in 7%, immunological factors in 3%,
congenital and sexual factors each 2% and endocrine factors 0.6% [1].
There is no single test that will predict the fertility potential of an individual. The
semen analysis has little or no relation to the underlying aetiology (see Chapter 5), and
most treatments are based on enhancing sperm quality in vitro rather than treating
the underlying dysfunction. Couples with severe male factor infertility may benefit
from in vitro fertilisation (IVF)/intracytoplasmic sperm injection (ICSI), although
mild to moderate infertility is poorly defined and treatment strategies are highly vari-
able. Concern has been expressed that the evolution of microassisted techniques for
IVF has led to a move away from trying to understand the causes of male infertility.
We consider that our goal should be to give couples the possibility to conceive by
natural intercourse rather than feed them into assisted conception programmes that
are stressful, costly and not without risks that are largely borne by the female partner.
In addition to a thorough investigation of the man, it is essential to ensure that
his partner has normal reproductive function, as at least one-third of couples with
infertility have problems with both partners.
Cryptorchidism
The management of undescended testes is discussed in Chapter 2.
Hypogonadism
Clinical Presentations
Endocrinological dysfunction as a cause of male infertility is uncommon but read-
ily amenable to treatment. The causes of female hypogonadotropic hypogonadism

were described in Chapter 7 and apply equally to men. In addition to Kallmann’s

syndrome, other congenital disturbances of gonadotropin-releasing hormone (GnRH)
secretion include the Prader–Willi syndrome, the Laurence–Moon–Biedl syndrome
and familial cerebellar ataxia; all present with delayed puberty, as does constitutional
delay of puberty.
Pituitary insufficiency is usually secondary to craniopharyngioma, pituitary ade-
nomas, trauma, metastases or haemochromatosis. Occasionally, congenital isolated
deficiency of one of the gonadotropins occurs.
Treatment
The most physiological treatment for hypogonadotropic hypogonadism is replace-
ment of pulsatile GnRH. The hormone is administered subcutaneously via a mini
infusion pump at dose of 5–20 μg every 120 min. It can take several months for the
testes to grow and produce sperm, so it may take 1 year or more before a pregnancy
occurs. More practical than pulsatile GnRH is the use of parenteral (intramuscular or
subcutaneous) gonadotropins, given two or three times a week.
Some men with hypogonadotropic hypogonadism can be resistant to treat-
ment, particularly if they have a history of undescended testes. The associa-
tion of hypogonadotropic hypogonadism with cryptorchidism is caused by the
failure of neonatal hypersecretion of gonadotropins, which normally occurs as
the p ituitary of the newborn becomes free of negative feedback suppression by
maternal/placental steroids – it is this mechanism that normally aids testicular
descent.
Both follicle-stimulating hormone (FSH) and testosterone are required for sper-
matogenesis. Testosterone administration at doses sufficient to achieve normal extra-
testicular functions does not, however, produce intratesticular levels that stimulate
spermatogenesis. Thus, if there is pituitary failure, it is necessary to administer
gonadotropin preparations that contain FSH and luteinising hormone (LH) activity,
for example, human chorionic gonadotropin (hCG) 1500–2500 IU twice weekly or
human menopausal gonadotropin (hMG) 150 IU two to three times a week (some
regimens add hMG after 8–12 weeks’ treatment with hCG). Recombinantly derived
FSH also has been used with some success. Some men with hypogonadotropic hypo-
gonadism are also growth hormone deficient and may benefit from adjuvant growth
hormone therapy.
If fertility is not required or after a pregnancy has been achieved, it is important that
hypogonadal men are given maintenance testosterone, which is available in several
forms but is usually administered a depot injection every 1–3 months. Testosterone
administration does not reduce the subsequent chance of stimulating spermatogenesis
by either GnRH or gonadotropins, although spermatogenesis occurs more rapidly if it
has already been achieved in the past. Thus, it has been suggested that young men with
newly diagnosed hypothalamic or pituitary hypogonadism should be given a course
of GnRH/gonadotropin therapy to initiate spermatogenesis before c ommencing tes-
tosterone maintenance therapy. It would then be possible to cryopreserve sperm as a
backup, for use in future years.

Male Factor Infertility 293
General Health Factors

Alcohol can impair spermatogenesis, and even moderate intake (10 units/week) may
further compromise the fertility of a man with pre-existing sperm dysfunction. Men
with oligospermia should be counselled to reduce the amount they drink or stop alto-
gether, but they should not expect to see an improvement for at least 3 months and
even then the change may be gradual. Cigarette smoking also impairs fertility, and
both partners should be encouraged to stop smoking, particularly while trying to con-
ceive. Exposure of the testes to heat can have a detrimental effect, which is also likely
to be more pronounced if there is already an underlying problem. Thus, sitting in hot
baths and wearing tight-fitting underpants and trousers should be avoided. We do not,
however, recommend cold showers, as suggested in the past by some studies.
We have seen a man with severely oligozoospermic semen demonstrate a complete
recovery when the cycling season ended. His sperm count fell dramatically again a
few weeks into the next season, when he resumed vigorous training wearing Lycra®
shorts. Athletes also may develop hypothalamic hypogonadism similarly to the
hypothalamic amenorrhoea seen in sportswomen. There are well-described s easonal
variations in semen quality, with a decline during summer, that may be enough to
render some men subfertile.
Obesity appears to have an adverse effect on spermatogenesis [2] (see Chapter 4),
and any chronic debilitating illness may lead to infertility in men. There are also
a few notable conditions that particularly affect male fertility, namely, diabetes [3],
chronic renal failure and thyrotoxicosis. As simple an acute illness as a s treptococcal
sore throat requiring penicillin also can result in a temporary azoospermia. It is there-
fore important to note any such illness in the past 3 months when reviewing the results
of semen analyses.
Several drugs and industrial toxins impair male fertility:
• Drugs: sulfasalazine (but not mesalazine), cimetidine, calcium antagonists,

nitrofurantoin, spironolactone
• Radiotherapy and cytotoxic agents
• Occupational toxins: lead, arsenic, carbon disulphide, biphenyls, herbicides,
insecticides, dichlorodiphenyltrichloroethane (DDT), radiation
• Recreational drugs: alcohol, anabolic steroids, marijuana, opiates
Oligoasthenozoospermia
The majority of men with subfertility have oligoasthenozoospermia of unknown
cause. There is some evidence to suggest a familial tendency to subfertility in men,
with an autosomal recessive mode of inheritance accounting for up to 60% of cases
of male subfertility [4]. At present, little can be done in the way of direct treatment,
although assisted conception procedures such as superovulation with intrauterine
insemination (IUI) or IVF ± ICSI may be of benefit.

There are some chromosomal causes of azoospermia, such as Klinefelter’s syn-

drome (47,XXY karyotype, 1:500 males) in which there is fibrosis of the seminif-
erous tubules and Leydig cell abnormalities. Men with Klinefelter’s syndrome are
infertile, although occasionally pregnancies have been reported by using testicular
sperm and ICSI, and also in Klinefelter variants, in which there is chromosomal
mosaicism. The 47,XYY karyotype is associated with spermatogenic arrest and
the Sertoli-cell-only syndrome, although some of these men do have normal
spermatogenesis. Autosomal translocations may result in either azoospermia or

severe impairment of fertility.
Genes responsible for spermatogenesis have recently been traced to an area on the
long arm of the Y chromosome, azoospermia factor (AZF or deleted in azoospermia
(DAZ) locus). The relative frequency and significance of Y-chromosome microdele-
tions in men with unexplained spermatogenic disorders is currently subject to intense
scrutiny and is likely to have a major impact on both diagnosis and therapy in the
near future [5]. More subtle problems, such as the effect of oxidative stress on sperm
integrity and deoxyribonucleic acid (DNA), are harder to identify (see Chapter 5) and
treat effectively [6].
It is important to appreciate that many men with apparent azoospermia do have
small foci of normal spermatogenesis within the testes. As many as 50% of men
with supposed untreatable infertility (e.g. Sertoli-cell-only syndrome, maturation
arrest) may produce sperm. Sperm may either be recovered from the ejaculate by
using special sperm preparation techniques such as multiple ejaculation, resuspension
and centrifugation (MERC) or from the testes themselves, by using multiple biopsy
techniques that increase the likelihood of finding the normal foci. Although numbers
of sperm found may be low, if mature sperm are present, that will be usually sufficient
for ICSI. There is, however, a high rate of chromosomal abnormalities in the sperm
when serum FSH concentrations are elevated or if testicular tissue is used for the
extraction of sperm – and these abnormalities may possibly be transmitted to children
conceived by ICSI (see Chapter 17) [7].
Frequency of Intercourse
The concentration of motile sperm in sequential ejaculates decreases in normosper-
mic men, but men with oligozoospermia or asthenozoospermia apparently benefit
from sequential ejaculations, with intervals of either 1–4 h or 24 h producing either
similar or more motile sperm in the second ejaculate compared with the first ejaculate
(hence, MERC preparation for assisted conception) [8,9]. These observations sug-
gest that impaired sperm transport through the male genital tract may have a role
in causing reduced sperm motility [10]. Men with subfertility should therefore be
advised to have intercourse at least daily, if not twice daily, around the time of ovu-
lation rather than follow the usual advice given to normospermic men of alternate-
day intercourse (see Chapter 5) [11]. If assisted conception is required, it may be
beneficial to use pooled fresh ejaculates collected on the same day (see Chapter 14).
Furthermore, if there is uncertainty about what might be available on the day of
oocyte retrieval, it is sensible to have sperm cryopreserved as a backup before the
treatment cycle commences.

Leukospermia
The finding of significant numbers of leukocytes (>10 6/mL) in the semen analysis
in a man without overt symptoms of genital tract infection may indicate subclini-
cal infection, contamination by urethral commensal organisms or misdiagnosis
(immature germ cells can be mistaken for leukocytes by inexperienced laboratory
scientists). Chlamydial epididymitis can result in either permanent damage or a
prolonged inflammatory response in the absence of persistent organisms. There
is evidence that the presence of leukocytes is associated with reduced fertilisation
capacity of sperm, mediated through the release of cytokines and reactive oxygen
species (ROS). Although the empirical use of antibiotics has been associated with
a reduction in the concentration of leukocytes and improved sperm penetration
assay scores (see Chapter 5), this does not always equate with improved fertilisa-
tion in vitro. Methods of improving sperm dysfunction caused by ROS include the
addition of superoxide dismutase during sperm processing for IVF and the use
of pentoxifylline – again in vitro. The reason for the relative lack of success of
antibiotics is that leukospermia is probably associated with viral rather than bacte-
rial infection (e.g. cytomegalovirus), so some have suggested that antiviral agents
such as azidothymidine (AZT) be tried. Prospective randomised studies that have
tested the use of antibiotics also have found a high spontaneous remission rate in
the control groups.
Management
There is uncertainty about the optimum way to manage men with significant leuko-
spermia: whether to give antibiotics and if so, which antibiotic(s) to prescribe and for
how long. Early studies were promising, but there is a high spontaneous remission
rate in untreated patients. Furthermore, seminal plasma contains natural antioxidants,
so the effects of mild leukospermia on fertilisation in vivo may not be as relevant as
that seen in vitro.
In the presence of leukospermia, it is our practice to prescribe either doxy-
cycline (100 mg/day) or ciprofloxacin (500 mg/day) for 4–6 weeks and then to
repeat the semen analysis. If there is an improvement, we would repeat the semen
analysis after 3 months without therapy and if the leukocytes have recurred, we
would advise long-term antibiotic therapy until a pregnancy has been achieved.
If there has been no improvement with antibiotic therapy, we discontinue the
treatment in the absence of proven clinical infection. If the couple is undergo-
ing assisted conception, we advise antibiotic prophylaxis, commencing the day
the female partner starts GnRH agonist therapy through to the day of oocyte
retrieval. If significant leukospermia persists during an IVF cycle, leukocytes can
be removed in vitro using Dynabeads® or their effects can be neutralised with
antioxidants.
In our practice, it is rare to see men with overt genital infections; but historically,
and in some parts of the world, sexually transmitted diseases such as gonorrhoea are
a major cause of occlusion of the spermatic tract.

Oxidative Stress and ROS

We have already referred to the possibility of damage to the integrity of the
sperm by ROS, which may affect the membrane and thereby motility of the sperm
and their ability to fuse with an oocyte. Furthermore, ROS may directly dam-
age sperm DNA, thereby compromising the paternal genomic contribution to the
embryo [6]. ROS comprise oxygen ions, free radicals and peroxides. They are
products of normal c ellular m etabolism, arising in semen from both sperm and
leukocytes. Leukocytes produce higher concentrations of ROS than the sperm them-
selves, although there is still debate about the link between leukocytes and sperm
DNA damage, as it is thought that intrinsic ROS production by the spermatozoa
t hemselves is more relevant. Furthermore, antioxidants within seminal plasma and
sperm play a vital role in ensuring sperm integrity and reduction of their func-
tion appears critical. Protective antioxidants include the enzymes superoxide dis-
mutase, catalase and glutathione peroxidase together with ascorbic acid (vitamin
C), α-tocopherol (vitamin E), glutathione, albumin, carnitine, carotenoids, flavo-
noids, urate, proteosomes and the amino acids taurine and hypotaurine [6].
Oxidative stress may be due to lifestyle factors (e.g. smoking, alcohol, diet, obesity,
extreme exercise), ageing, environmental pollutants, infection, chronic disease, auto-
immunity and possibly also the presence of a varicocele.
Management
Many supplements have been used to combat the effects of ROS, for example,
folate; vitamins B6, B12, C and E; zinc; selenium; and various other preparations [6].
Unfortunately, there is conflicting evidence on the effect of vitamins and antioxidants
on semen parameters, and there are no conclusive studies that demonstrate benefit for
fertility. As ever, larger studies are still required.
Varicocele
Ligation of varicoceles has been one of the most controversial areas in male infertility
practice. Approximately 10%–20% of the male population have a varicocele compared
with 30%–40% of men attending infertility clinics. Having detected a varicocele, it
can be graded (see Chapter 5) and further investigated by ultrasonography (± Doppler
flow studies), nuclear scintigraphy, thermography or venography. Varicoceles may be
associated with impaired seminal and hormonal parameters, which worsen with time,
although the size of varicocele correlates poorly with the degree of spermatogenic
dysfunction [12]. The presence of a varicocele is often associated with a reduction in
the size of the ipsilateral testis, and although the other testis can sometimes compen-
sate, with time there can be a decline in spermatogenesis and testosterone production
and an elevation in serum FSH concentration. In some cases, both testes may be
adversely affected by a unilateral varicocele. It appears that varicoceles may act as
a cofactor in the pathophysiology of male infertility along with disruption of normal

spermatogenesis and sperm head formation, increased levels of ROS and abnormal
acrosome function [13].
The development of varicoceles has been monitored in adolescent boys, and a
corresponding decline in the rate of testicular development was observed. Varicocele
ligation has been shown to reverse this trend, but the widespread use of surgery in
teenage boys is not standard practice, particularly as there are no long-term follow-up
data of either semen analyses or fertility [14]. There is also a school of thought that
the varicocele is a progressive lesion in adult men, that left untreated might, in some
cases, lead to increasing and irreversible infertility [15].
Varicocele ligation is usually performed via an inguinal incision, with ligation of
the spermatic vein(s). As with virtually every surgical procedure nowadays, the lapa-
roscopic approach also has been tried. Alternatively, embolisation can be p erformed
by an experienced radiologist, and it is with this minimally invasive therapy that the
future of varicocele treatment probably lies (Figure 12.1).
The most recent meta-analysis does now suggest a benefit [16]: five studies were
included of a total of 396 subjects and 174 controls; only one study showed clear
significant benefit and this study had small numbers and large confidence intervals.
The overall odds of natural conception after surgery was 2.87 (95% CI 1.33–6.20) and
the number needed to treat 5.7 (95% CI 4.4–9.5). This is certainly a contentious issue
for which there is no clear consensus at present. In the United Kingdom, treatment
tends only be offered to those who are symptomatic.
Antisperm Antibodies
Antisperm antibodies (ASABs) on the surface of sperm and in the cervical mucus
have been implicated as the cause of infertility in some couples, but there is lack of
standardisation of the assays, and therapy is largely of unproven value. ASABs that
interfere with fertility are heterogeneous and react with many epitopes on the sperm
plasma membrane and acrosome. Assays for ASABs are discussed in Chapter 5.
Spermatozoa are protected from the circulation by tight inter-Sertoli junctions
that develop behind the developing gametes and prevent the entry into the seminif-
erous tubules of blood components, such as immunoglobulins (Igs), macrophages
and leukocytes. The prevention of autoimmunity is further aided by the presence of
T-suppressor lymphocytes in the epididymis and vas deferens. ASABs are thought
to develop in men either when the blood–testis barrier breaks down or if there is a
decrease in T-suppressor cell activity. Subfertility is thought to be caused more by IgA
than IgG antibodies. Breaches in the blood–testis barrier occur with obstruction or
injury to the reproductive ducts in the following situations.
• After vasectomy, at least 50% of men develop serum ASABs. The risk is
increased in men with HLA-A28 and HLA-Bw22. Seminal plasma ASAB
levels are low.
• Congenital obstruction of the vas deferens is associated with high serum-,
but low sperm-associated ASABs. Any cause of obstruction (e.g. after
herniorrhaphy) can result in antibody formation, and if there is unilateral
obstruction, removal of the obstructed testis can lead to an improvement.

(a)
FIGURE 12.1 Embolisation of varicocele. (a) Digital subtraction venogram of the left testicular
vein showing a varicocele around the left testis.

(b)
FIGURE 12.1 (Continued) Embolisation of varicocele. (b) After embolisation, there are multiple
stainless-steel coils that have been placed via the angiographic catheter along the length of the left
testicular vein up to the level of the left renal vein.
• Infection: chlamydial or gonococcal.

• Testicular trauma such as biopsies and injury increases the likelihood of
ASAB formation. Thus, biopsies should only be performed after careful
consideration in infertile men in units with the facility to perform ICSI
(see Chapter 14). Pre-pubertal testicular torsion does not lead to antibody
formation, because of the absence of sperm antigens.
• Idiopathic.

The development of ASABs in women could be due either to a deficient epithelial

barrier in the genital tract, peritoneal cavity or gastrointestinal tract or to inadequate
immunosuppressive substances in the seminal plasma. Reassuringly, although per-
haps surprisingly, there does not appear to be an increased rate of ASAB formation in
women who have undergone IUI.
The rate of detection of ASABs in the serum, semen and cervical mucus of infer-
tile couples ranges from 5% to 25%, compared with less than 2% in fertile couples.
A wide range of tests is used (see Chapter 5), and the cut-off levels of a significant
concentration of antibodies are poorly defined. Furthermore, the detection of ASABs
in the serum does not necessarily equate with a significant problem in the genital
tract, so the value of performing serum assays is uncertain.
ASABs may impair sperm motility. Sperm-associated IgG activates complement
and results in binding to polymorphonuclear leukocytes that then inactivate the sperm.
IgA is secreted from the endocervix and fallopian tubes and further affects sperm
motility and, possibly, fertilisation. There is a good correlation between the presence
of cervical mucus ASABs and both sperm motility in cervical mucus and pregnancy
rates. Fertilisation rates also are reduced if more than 80% of sperm are bound with
IgA ASABs, possibly by interfering with capacitation and the a crosome reaction.
There are numerous publications that deal with the effects of ASABs, but opinions
still differ as to whether IgA or IgG antibodies are the more significant. Furthermore,
although some studies suggest that antibodies directed against the sperm head disrupt
fertilisation directly, others consider that antibodies directed to the tail are of greater
significance because they interfere with sperm movement.
Management
The management of patients with ASABs is problematic. Corticosteroids are used
widely in men and do suppress serum ASAB concentrations, but they appear to have
less of an effect on sperm-bound ASABs. Corticosteroid therapy has several side effects
(e.g. mood changes, which can be severe; gastritis; weight gain) and complications (e.g.
duodenal ulceration, hypertension, glucose intolerance, aseptic necrosis of the femoral
neck). A suggested regimen is prednisolone 40 mg daily from day 1 to day 10 of the
partner’s menstrual cycle, reducing to 20 mg on day 11 or 12 and then stopping (some
use 5 or 10 mg/day for day 11 or 12) [17]. It has been suggested that therapy should
continue for at least 9 months to have a beneficial effect on pregnancy rates, although
some studies have found that steroids provide no benefit [18]. It has been suggested that
the men who gained most benefit from oral corticosteroids were those men who started
with significantly higher concentrations of IgG (tail) antibodies and grade I motility [19].
Since the advent of ICSI, the use of corticosteroid therapy has largely been abandoned.
At present, it is not possible to wash antibodies off sperm in vitro without damag-
ing the sperm. Pregnancy rates tend to be low with IUI when there are associated
ASABs. IVF offers a better chance of a pregnancy, although it is important not to
use the female partner’s serum for incubation (as was often done in the past) if she
has a significant concentration of ASABs. There is conflicting evidence as to whether
steroid therapy improves the outcome of IUI or IVF for men with ASABs. If these
therapies are required, in our opinion it is probably the assisted conception rather than
the steroids that enhances fecundity.

Obstructive Azoospermia
No underlying cause can be found in more than one-half of patients with obstruc-
tion of the epididymis. The cause is often infective in origin, particularly in devel-
oping countries, although less so in the West; infective causes include gonorrhoea,
Chlamydia, filariasis, tuberculosis and bilharzia.
Congenital Bilateral Absence of the Vasa Deferentia

In two-thirds of European men with congenital bilateral absence of the vasa deferentia
(CBAVD), there are associated mutations of the genes that cause cystic fibrosis (CF).
Pregnancies have been achieved using epididymal sperm, but the fertilisation rates
are reduced. Furthermore, the CF gene complex mutations will be present in one-half
of the children born by these techniques, and we do not yet know how many of the
male offspring will have the same problems as their fathers. Both partners should
therefore undergo genetic screening before treatment, although at least two-thirds
of men with isolated bilateral absence of the vas and point mutations of the CF gene
complex do not have symptoms of CF. Sperm autoantibodies are often present when
the vasa deferentia are absent.
Young’s Syndrome
Young’s syndrome involves a combination of chronic respiratory problems and
obstructive azoospermia, secondary to inspissated epididymal secretions. The epi-
didymes are often large and cystic, the vasa deferentia are normal and there are no
ASABs. There was an association between the development of this condition and
the use of tooth powders containing mercury, which are no longer available. Young’s
syndrome overlaps both CF and Kartagener’s syndrome.
Kartagener’s Syndrome
Kartagener’s syndrome, or immotile cilia syndrome, is an autosomal recessive condi-
tion in which male infertility caused by reduced sperm motility is associated with
sinusitis, bronchiectasis and transposition of viscera (e.g. dextrocardia). There is an
ultrastructural defect in the dynein arms that creates ciliary movements by causing
movement between adjacent microtubules.
Surgical Trauma and Vasectomy

Surgical obstruction of the vas deferens may occur accidentally during childhood
surgery for an inguinal hernia, during the repair of a hydrocele or deliberately during
vasectomy. The breach of the blood–testis barrier results in ASAB production only
after puberty. Surgical reconstruction of the vasa in a man who requests reversal of
vasectomy is associated with a significant rate of ASABs, and the success of surgery
declines with increasing time over 5 years post-vasectomy [20].

Microsurgical Reconstruction of the Vasa

A vasovasostomy should only be undertaken by a skilled urologist using an operating
microscope and 9–0/10–0 nylon sutures. The anastomosis is traditionally performed
in two layers, although this has been modified in some cases. In a review of nearly
1500 vasectomy reversals, the patency rate was 97% and the pregnancy rate 76% in
men within 3 years of the vasectomy. The figures were 76% and 30%, respectively, if
the vasectomy had been performed more than 15 years previously [20]. Even without
the use of an operating microscope, patency has been achieved in up to 80% with
pregnancy rates of 50% after 2–3 years.
Vasoepididymostomy is required if there is blockage in the epididymis, and it is
most successful if the anastomosis, which can be end to end or end to side of a single
epididymal tubule, is performed in the distal epididymis (Figures 12.2 through 12.4).
Whenever any of these surgical procedures are performed, it is essential to have the
facilities available to collect a sample of sperm for cryopreservation, either from the
epididymis or directly from the testis. Sperm stored in this way can be kept in reserve
for future IVF/ICSI if the primary operation is unsuccessful.
Vas deferens
Patent epididymal
tubule Tail of epididymis
Transected
epididymis
FIGURE 12.2 Microsurgical anastomosis: vasoepididymostomy. End-to-end anastomosis of a

single epididymal tubule. The distal epididymis is transected, and the obstructed area excised if
necessary. After identifying a patent epididymal tubule, an anastomosis is performed to the vas.

FIGURE 12.3 End-to-side anastomosis.
FIGURE 12.4 Side-to-side anastomosis of epididymis and vas deferens.

If reconstructive surgery fails, it may be possible to retrieve sperm surgically from

either the epididymis or the testis. In simple cases, for example, after vasectomy,
a percutaneous epididymal sperm aspiration (PESA) can be performed under local
anaesthetic. If this aspiration fails, a direct transcutaneous approach called testicular
sperm extraction (TESE) can be attempted. Alternatively, microsurgical epididymal
sperm aspiration (MESA) may be performed (Figure 12.5) under general anaesthetic.
Spermatozoa thus obtained are cryopreserved. They are usually of insufficient quan-
tity or quality for either insemination or conventional IVF, but they may do well when
ICSI is performed (see Chapter 14).
Idiopathic Male Factor Infertility

If there is no obvious reason for sperm dysfunction, as is the case in perhaps 50%
of patients, the choice lies between assisted conception (e.g. superovulation/IUI
or IVF ± micromanipulation techniques) or empirical treatments. A huge number of
empirical treatments have been tried, but none with any objectively demonstrated suc-
cess. For completeness, we list these therapies, before dismissing them:
• hCG, hMG or anti-oestrogen (clomifene citrate, tamoxifen) therapies are of

no value in normogonadotropic idiopathic male infertility; in some cases,
sperm numbers may be increased but most are abnormal.
• Testosterone administration is similarly ineffective and might be
contraceptive.
• Testolactone increases serum FSH concentrations by inhibiting the conver-
sion of testosterone to oestradiol, but this process is of unproven value in
male infertility.
• Bromocriptine has been used unsuccessfully; if serum prolactin levels are
elevated, the consequence is usually impotence rather than infertility.
• The results of individual trials with kallikrein show no real benefit, although
when pooled there might be a slight beneficial effect. Kallikrein does not
play a part in our clinical practice.
• The caffeine-derivative pentoxifylline enhances sperm function in vitro but
neither oral pentoxifylline nor caffeine aids natural conception.
• Artificial vaginal insemination of an unprepared sample of the husband’s
sperm (AIH) is pointless.
Paternal Ageing
There is an increased risk of congenital genetic defects with older fathers, just as
there is with older mothers (see Chapter 2). Such conditions include dominant dis-
orders such as achondroplasia, myositis ossificans, Alpert’s syndrome, Marfan’s
syndrome, Duchenne muscular dystrophy, haemophilia and the sex-linked recessive
bilateral retinoblastoma. It has been suggested that there is a link between male factor

(a)
(b)
(c)
FIGURE 12.5 Microsurgical epididymal sperm aspiration (MESA) from (a) the proximal
epididymis, (b) vasa efferentia and (c) rete testis.

infertility and accelerated testicular ageing, so that patients with infertility may have
an increased risk of producing offspring with the above-mentioned conditions.
Coital Dysfunction and Psychosexual Problems

Psychosexual Problems
It is self-evident that if there are problems with sexual function, fertility will be
impaired. Furthermore, the desire for a child, which might be stronger in one part-
ner, exacerbates psychosexual difficulties. These problems require a sympathetic
approach, with counselling by trained personnel.
Erectile Dysfunction
Penile erection is under parasympathetic control (S2,3,4), and the rigidity of the cor-
pora cavernosa requires testosterone, an intact arterial supply and venous closure.
The sympathetic nervous system initiates ejaculation (T10–L2), and closure of the
internal sphincter of the bladder prevents retrograde ejaculation. The varied causes of
impotence and failure to ejaculate are listed below. Approximately 80% of cases of
erectile dysfunction have a cause, usually associated with reduced blood supply, and
only 20% are psychogenic.
• Impotence: psychogenic, anxiety, depression, peripheral arterial disease,

diabetes mellitus, hyperprolactinaemia, hypogonadism and antihyperten-
sive and psychotropic drugs.
• Ejaculatory failure: psychogenic, hypogonadism, phenothiazines, α-blockers,
aortic or abdominal surgery (e.g. abdominal perineal (AP) resection), radial
prostatectomy spinal cord injury, sympathetic nervous system injury, diabe-
tes mellitus and multiple sclerosis.
Impotence/erectile dysfunction may be managed in primary care. Men and their part-
ners will benefit from counselling and the role of negative and positive psychological,
behavioural and relationship influences on their sexual behaviour. Treatment is initially
with a phosphodiesterase type-5 inhibitor (e.g. oral sildenafil, tadalafil or vardenafil).
If oral medication has failed, the next step is either an intracavernosal injection or an
intraurethral pellet of prostaglandin El (alprostadil) or papaverine. This procedure must
be performed with care and initially under medical supervision. Vascular microsurgery
is indicated if there is vascular disease and localised arterial lesions. Inflatable penile
prostheses also have been used with varying degrees of success.
It is important not to give testosterone to men with impotence caused by neuro-
pathic lesions (e.g. men with diabetes mellitus) as it increases libido, which cannot be
satisfied, and worsens an already most distressing condition.
Many causes of ejaculatory failure can be treated using external vibratory massage,
which can be performed by the patient or his partner placing a vibrator at the base of
the penis and collecting semen for self-insemination. If this approach fails, electroe-
jaculation can be achieved using a rectal probe. This probing has to be performed by

properly trained personnel because of the risk of autonomic dysreflexia and profound
hypertension. Electroejaculation has been used for many spinal cord–injured men.
Semen quality tends to decline with time after the injury, so the collected sperm often
has to be used for IVF/ICSI rather than intravaginal insemination or IUI. Sperm res-
ervoirs have been used in some cases, and these reservoirs are surgically attached to
the epididymis and sperm is withdrawn transcutaneously when the reservoir is full,
but they frequently block and they have not gained popularity. Recently, aspiration
of sperm from the vas has achieved success. Drug therapies include α-agonists, such
as ephedrine hydrochloride (25 mg twice daily), although retrograde ejaculation is a
common sequela.
Retrograde Ejaculation
Retrograde ejaculation can occur after prostatectomy, bladder neck injury, sympathec-
tomy or with diabetes or multiple sclerosis. If the ejaculate is absent or of small volume
(<1 mL) with few or no sperm, then the diagnosis is suspect. The diagnosis is con-
firmed by finding sperm in a urine specimen collected after ejaculation. An α-agonistic
drug can be tried initially, such as ephedrine hydrochloride (25 mg twice daily). If
this treatment fails, the sperm can be collected by catheterisation after ejaculation and
washed immediately in IVF culture medium before insemination. It is important to
alkalinise the urine; to achieve this alkanisation, oral sodium bicarbonate should be
taken (1.3 g four times daily). An alternative approach is to fill the bladder to obstruct
the retrograde passage of sperm and for the patient then to try to ejaculate.
Hypergonadotropic Testicular Failure

Hypergonadotropic testicular failure may be congenital (germ cell aplasia, Sertoli-
cell-only syndrome, germ cell arrest or hypospermatogenesis) or acquired, for
example, as the result of viral orchitis (e.g. mumps), trauma or toxins (Box 12.1).
Some men with Klinefelter’s mosaicism produce a few sperm intermittently, although
most are sterile.
Evidence exists for the presence of an area on the long arm of the Y chromosome
that is involved in azoospermia and has been termed the AZF (or DAZ) locus. Point
mutations or deletions in this area may lead to azoospermia (see Chapter 5).
In some cases, the serum FSH concentration alone is elevated, with normal concen-
trations of LH and testosterone; in other cases, both elevated gonadotropins and low
serum testosterone concentrations are present. Administration of testosterone will not
achieve intratesticular levels sufficient to stimulate spermatogenesis, and intratesticu-
lar injection of testosterone, which has been successful in animal experiments, is of
no benefit in humans.
Recently, there has been a change of policy towards men with azoospermia and
elevated serum FSH concentrations, who previously would have been offered donor
insemination. If the testes are not atrophic bilaterally and at least one testis is of a
normal size, it is worthwhile considering testicular exploration and biopsy as sper-
matozoa are sometimes found and can be cryopreserved and later used for IVF +
ICSI (see Chapter 14). The elevated FSH level in these cases may be due to an overall

BOX 12.1 CAUSES OF HYPERGONADOTROPIC

TESTICULAR FAILURE
Anorchism – fetal loss of testes, trauma, torsion, tumour
Infections – mumps, orchitis
Gonadal dysgenesis – defective Y chromosome
Persistent oviduct syndrome – lack of Müllerian inhibitory factor
Germ cell or Leydig cell aplasia
Klinefelter’s syndrome
Cryptorchidism
Sickle cell disease
Noonan’s syndrome
Myotonic muscular dystrophy
reduction in functional testicular mass and the azoospermia due to obstruction some-
where along the spermatic duct. Nowadays, it is even worthwhile considering biopsy
of bilaterally small testes as a few sperm can sometimes, albeit rarely, be obtained.
IUI, IVF and ICSI (see Chapter 14)

IUI of a prepared sample of sperm became a popular treatment for mild male infertil-
ity when the total motile count after preparation is greater than 1 × 106/mL. IUI may
be performed in a natural cycle or with mild stimulation with either clomifene citrate
or low-dose gonadotropins, both of which should be monitored by serial ultrasonogra-
phy to minimise the risk of multiple pregnancy. Unfortunately, meta-analysis of stud-
ies of both stimulated and unstimulated IUI for male infertility have failed to show any
benefit [21,22]. The management of male factor infertility was revolutionised by the
advent of ICSI, by which a single spermatozoon is injected into an oocyte to achieve
a viable embryo and pregnancy. Several techniques for the collection of sperm have
evolved around ICSI so that fertility can be offered for men with obstructive azoosper-
mia for whom surgery is either inappropriate or has already failed. Thus, sperm can be
aspirated from the epididymis, vas deferens or the testis itself (Box 12.2).
Androgen Insensitivity Syndrome

Individuals with androgen insensitivity (formerly known as testicular feminisation
syndrome), which may be complete or partial, have a male genotype and abdominal
testes but varying degrees of androgen target organ insensitivity. They have female
external genitalia and are reared as girls, the diagnosis usually being made at puberty
when there is primary amenorrhoea, associated with lack of pubic hair. Sometimes
inguinal herniae require surgery in infancy, when the diagnosis becomes apparent by
the presence of testes in the hernia. The intra-abdominal testes should be removed
because of the risk of malignancy, although there has been debate about the opti-
mal timing of the operation. Although fertility has not been possible, there has been
discussion about retrieving genetic material from the gonads for possible use in vitro.

BOX 12.2 KEY POINTS OF MALE INFERTILITY

• Optimise health, limit alcohol and smoking.
• Hypogonadotropic hypogonadism responds to endocrine treatment.
• Idiopathic male factor infertility does not respond to hormones or
other drugs.
• Infection should be treated with prolonged courses of antibiotics –
doxycycline or ciprofloxacin – for at least 4–6 weeks.
• Varicocele ligation or embolisation should not be recommended
routinely.
• ASABs are a difficult problem. Some men respond to prolonged
courses of high-dose steroids, but side effects may be very severe and
dangerous. We advise assisted reproduction technology (IVF ± ICSI).
• An elevated serum concentration of FSH no longer indicates the
impossibility of conception as testicular exploration may yield small
numbers of spermatozoa that can be used for ICSI.
• Donor insemination is still required for those men with complete azo-
ospermia or genetically transmissible conditions.
Donor Insemination
Despite the advent of microsurgical techniques for assisted conception, which has
opened the possibilities for treatment for many men with either obstructive azoosper-
mia or severe oligoasthenoteratozoospermia, there will always be a proportion of men
who have complete azoospermia or genetic disease and therefore require donated
gametes.
Selecting Donors
The selection and screening of sperm donors has to be scrupulous, not only to ensure
that the frozen sperm has a good chance of achieving a pregnancy but also to prevent
the transmission of disease to the recipient. Although it is preferable to use donors
with proven fertility, in reality the majority of donors have been students whose incen-
tive is often the receipt of a small payment for their college or living expenses. In
the United Kingdom, the Human Fertilisation and Embryology Authority (HFEA)
requires that donated sperm be cryopreserved for at least 6 months so that the donor
can be tested for HIV and hepatitis B and C after this period. Often, part of the reim-
bursement is held back as an incentive for the follow-up HIV test. Fresh sperm is no
longer used for donor insemination treatment.
Spermatozoa are frozen in 7.5% glycerol at –196°C in liquid nitrogen. The pre-
freezing sperm density should ideally be at least 50 × 106/mL, with normal morphol-
ogy and greater than 50% progressive motility. After thawing, there should be at
least 10 million/mL motile sperm and 2 million/mL in the final insemination prepa-
ration, or a 50% survival with 30% motility. If, however, sperm are being stored

from a patient who requires cryopreservation before chemotherapy, these criteria can
be relaxed, although when the sperm are required, they might have to be used for
assisted conception (possibly ICSI) rather than conventional insemination therapy.
Screening of donors should include a thorough medical history, encompassing fam-
ily history of genetic disease; clinical examination for herpes, human papillomavirus
and urethral swab for Chlamydia; semen culture; and blood screening for hepati-
tis B and C, HIV, syphilis and cytomegalovirus. The donor’s blood group (rhesus
status) and chromosomal analysis also are assessed. Additional screening for CF is
performed.
Matching the Donor with the Recipient

Matching of the donor with the infertile male partner of the recipient is usually based
on phenotypic characteristics (e.g. race, hair and eye colour, height and build) and
sometimes on ABO and rhesus blood groups (although the latter more for family than
medical reasons).
The fertility status of the female partner should be assessed. Investigations can be
kept to a minimum if she is young and healthy, with a regular menstrual cycle and no
history of gynaecological disease; at the very least, she should be immune to rubella
and have an ovulatory luteal-phase progesterone concentration. Unless there is a sug-
gestion of tubal damage from the history, a test of tubal patency can be deferred until
after six cycles of donor insemination. A pre-treatment ultrasound scan of the pelvis
is prudent to inspect ovarian morphology.
Timing
Monitoring for ovulation can be performed with kits that test for LH in the urine
(morning and evening) at the time of the mid-cycle surge. As soon as LH is detected,
the patient should contact the clinic and attend for donor insemination. We prefer to
commence treatment by monitoring with serial ultrasonography. Once we have con-
firmed that ovulation is occurring, we can then minimise the number of clinic atten-
dances by using urinary LH kits. Ultrasonography not only provides an assessment of
the developing follicle but also allows the administration of hCG to trigger ovulation
and time insemination accurately. Ultrasound is particularly helpful if the woman has
an erratic cycle; sometimes ovulation induction therapies (clomifene citrate in the first
instance) also are required.
Procedure
The nurse who performs the insemination procedure should assess the cervical
mucus to ensure it has a well-oestrogenised consistency. The sperm is loaded into a
1-mL syringe and insemination catheter and under direct vision it is deposited into
the cervical canal or uterus. There is evidence from several prospective randomised
studies, however, that IUI of donor sperm is more effective than intracervical insemi-
nation [23]. Clinics vary as to whether one or two inseminations are performed (on
consecutive days), although there is no evidence that double insemination improves
outcome.

Conception Rates
Monthly conception rates (Figures 12.6 and 12.7) [24] using cryopreserved sperm
are in the region of 10%, with an expected cumulative conception rate of 40%–50%
after 6 months and 70%–80% after 1 year in women under the age of 35 years [24].
Conception rates tend to be higher in couples where the problem is azoospermia
rather than oligozoospermia, as in the latter there are more likely to be adverse female
factors as well. If a pregnancy has not occurred after 10–12 cycles of treatment, it
is appropriate to consider assisted conception techniques. Superovulation with IUI
requires a preparation of washed sperm and thus a higher initial number of motile
70
Cumulative conception rate (%)
60 Less than 30 years

50
40
30 years or more
30
20
10
0
0 1 2 3 4 5 6 7 8 9 10 11 12
Cycle number (first course of treatment only)
FIGURE 12.6 Cumulative conception rates for women aged under 30 years (square) and over the
age of 30 years (circle) undergoing donor insemination at the Middlesex Hospital, London. (From
Shenfield F et al., Hum Reprod 8, 60–4, 1993. With permission.)
100
Cumulative conception rate (%)
80 Further courses
60
40
First course
20
0
0 1 2 3 4 5 6 7 8 9 10 11 12
Cycle number
FIGURE 12.7 Cumulative conception rates for women undergoing donor insemination in their first
course of treatment (circle) and in subsequent courses, after previous successful treatment (square).
Thus, if treatment is successful patients are more likely to return for more treatment and have a good
chance of further success. (From Shenfield F et al., Hum Reprod 8, 60–4, 1993. With permission.)

sperm than simple donor insemination. IVF, in contrast, requires fewer sperm but is,
of course, more invasive than IUI.
Genetic Origins
The HFEA currently prohibits the use of donated sperm once 10 pregnancies have
been achieved, because of the putative risk of paternal siblings meeting in years to
come and wishing to have children without knowing their own origins. The HFEA
keeps a central record of all donors and resultant pregnancies, but the genetic origins
of the child are not recorded on the birth certificate. Identifying information about the
donor is now available to the offspring of donor insemination when they reach the age
of 18 years. However, fewer than 20% of couples who use donated sperm actually tell
their children how they were conceived. There was a groundswell of opinion in the
United Kingdom that identifying information is important, particularly expressed by
people who know the method by which they were conceived but wish to know their
genetic origin. However, since the law changed in the United Kingdom to permit the
release of identifying details, the number of men coming forwards to donate sperm has
declined significantly, such that couples in need of treatment are having to wait longer,
pay more and sometimes give up. The matter is discussed further in Chapter 17.
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13
Unexplained Infertility
Introduction
One can consider two approaches to the diagnosis and management of unexplained
infertility. The first approach is strictly scientific, with a quest for and exclusion of
each known cause of infertility before the label unexplained infertility can be given.
The second approach is a pragmatic approach based upon a management-oriented
policy, whereby treatment is commenced after the common obstacles to fertility have
been excluded [1]. The treatment of unexplained infertility essentially aims to boost
fertility, usually by a combination of superovulation and close apposition of sperm
and egg(s). Sometimes, the use of assisted conception techniques provides clues to
the underlying diagnosis, for example, if there are problems with fertilisation that can
only be detected during in vitro fertilisation (IVF) therapy.
Assessing the Cause of Infertility

Many centres have their own highly specialised areas of interest and research that
they then promote as the missing cause of unexplained infertility (Box 13.1). Thus, it
is possible to draw long lists of putative and subtle causes of infertility, many of which
cannot be proven with certainty and few of which are actually amenable to a correc-
tive remedy that has been shown to enhance fertility. One also should remember that
couples with normal fertility can have abnormal test results. Once the well-known
and obvious causes of infertility have been excluded (see Chapter 5), the treatment
of couples with unexplained infertility should follow clear protocols. The important
tests are the assessment of ovulation (by serum progesterone), sperm function (basic
semen analysis) and tubal patency (hysterosalpingogram). Supplementary investiga-
tions, such as follicular scanning, endometrial biopsy, laparoscopy/hysteroscopy and
complex sperm function tests, are useful in helping to predict the chance of concep-
tion, but they may not influence the outcome of treatment.
Studies of populations of patients with infertility indicate that approximately
10%–25% have unexplained infertility, 20%–30% ovulatory dysfunction, 20%–35%
tubal damage, 10%–50% sperm dysfunction, 5%–10% endometriosis, 5% cervical
mucus problems and 5% coital dysfunction [2]. A degree of subfertility is found in
both partners in 30%–50% of couples, as usually a couple’s subfertility is a relative
rather than an absolute barrier to conception. It should be remembered that the greater

BOX 13.1 POSSIBLE SUBTLE CAUSES

PROPOSED FOR SUBFERTILITY
Subtle causes of subfertility that have been proposed as underlying unexplained
infertility, many of which have been found in couples of normal fertility (cor-
rection of the abnormality has not always been shown to improve fertility).
Ovarian and endocrine factors
• Abnormal follicle growth

• Luteinised unruptured follicles and functional ovarian cysts
• Hypersecretion of luteinising hormone (LH)
• Hypersecretion of prolactin in the presence of ovulation
• Reduced growth hormone secretion/sensitivity
• Cytological abnormalities in oocytes
• Genetic abnormalities in oocytes
• Antibodies to zona pellucida
Peritoneal factors
• Altered macrophage and immune activity

• Mild endometriosis
• Antichlamydial antibodies
Tubal factors
• Abnormal peristaltic or cilial activity
• Altered macrophage and immune activity
Endometrial factors
• Abnormal secretion of endometrial proteins
• Abnormal integrin/adhesion molecules
• Abnormal T-cell and natural killer cell activity
• Secretion of embryotoxic factors
• Abnormalities in uterine perfusion and contractility
Cervical factors
• Altered cervical mucus
• Increased immunogenicity
General immune factors
• Altered cell-mediated immunity
Male factors
• Reduction in motility, acrosome reaction, oocyte binding and zona
penetration
• Ultrastructural abnormalities of head morphology

Unexplained Infertility 317
Embryological factors
• Poor quality embryos

• Reduced progression to blastocyst in vitro
• Abnormal chromosomal complement – increased miscarriage rate
100
90
80 1–2 years
70
2–3 years
60
Couples (%)
50
40
3–5 years
30
≥5 years
20
SE
10
0
0 6 12 18 24
Months (cycles)
FIGURE 13.1 Cumulative conception rates in patients with unexplained infertility without any
treatment related to the duration of infertility at the time of initial investigations. (From Hull MG
et al., BMJ 291, 1693–7, 1985. With permission.)
the prevalence of a condition, the greater the predictive value of its screening test, so
everyday tests are of most value in detecting the commonest causes of subfertility. The
limitations of the various tests, however, also should be appreciated: tubal patency
does not necessarily equate with normal function, and an elevated luteal-phase pro-
gesterone concentration does not confirm that an oocyte has been released from the
follicle.
Unexplained infertility has been defined as the inability to conceive after 1 year in
the absence of any abnormalities. The natural pregnancy rate in couples with unex-
plained infertility has been reported as between 2% and 4% per menstrual cycle [3].
One study reported conception rates of 15% of couples with unexplained infertility
within 1 year and 35% within 2 years [4]. And the cumulative chance of pregnancy
over 3 years has even been reported as being 80% [2,5]. Therefore, it has been sug-
gested that treatment should be deferred until the couple has been trying to conceive
for 2–3 years, as before this time therapy may not confer any benefit over the natural
chance of conception (Figure 13.1) [2].

It appears that the most important prognostic factors are the duration of infertil-
ity and the age of the female partner. Of course, the rate of progression to treatment
through the various therapies that are used to boost fertility will depend upon the
age of the couple and their levels of anxiety together with the available (and afford-
able) resources. The management of unexplained infertility is usually empirical, but
couples undergoing treatment should always be treated as individuals.
Management of Unexplained Infertility

Several approaches have been used in the management of unexplained infertility.
Some of the therapies that have been used are discussed here, and we propose a strati-
fied protocol used in practice. Therapy should aim to boost the monthly pregnancy
rate above the natural rate of 1.5%–3% that is expected for couples who have been
trying to conceive for over a year.
Clomifene Citrate
It used to be thought that clomifene enhanced fertility by correcting a subtle defect in
ovarian function – either of follicular development or of luteal-phase defect. It appears
more likely, however, that stimulation of ovulation achieves its effect by increasing
the number of follicles that develop and consequently the oocytes that are released.
When using clomifene citrate, one should always remember the side effects of mul-
tiple pregnancy and the possible association between its prolonged use (>12 cycles)
and the putative risk of ovarian cancer (see Chapter 18).
Over the years, many studies have been published and systematic reviews have
fluctuated in and out of favour for the use of clomifene for the management of u nexplained
infertility. The latest Cochrane review of data relating to 1159 participants from seven
randomised trials reports no evidence that clomifene was more e ffective than no treat-
ment or than placebo for live birth (odds ratio (OR) 0.79, 95% CI 0.45–1.38; p = .41)
or for clinical pregnancy both with intrauterine insemination (IUI) (OR 2.40, 95% CI
0.70–8.19; p = .16), without IUI (OR 1.03, 95% CI 0.64–1.66; p = .91) and without IUI but
using human chorionic gonadotropin (hCG) (OR 1.66, 95% CI 0.56–4.80; p = .35) [6].
Superovulation with IUI

There are few prospective randomised studies involving the use of gonadotropins
alone in the treatment of unexplained infertility, and most of the studies that have
evaluated gonadotropins with IUI are retrospective analyses. Gonadotropin therapy
requires careful monitoring with serial ultrasound scans to minimise the risks of
ovarian hyperstimulation syndrome and multiple pregnancy (see Chapter 18).
It is reasonable to expect that the combination of gonadotropins to induce super-
ovulation, with the release of two or three oocytes, with insemination of a prepared
sample sperm into the uterine cavity should boost fertility. There are, however,
contrasting studies in the literature. Melis et al. [7] have reported a large, prospec-
tive, randomised study comparing gonadotropin therapy and timed intercourse with
gonadotropin therapy and IUI. Two hundred couples with at least 3 years’ unex-
plained infertility received superovulation with follicle-stimulating hormone (FSH)

to produce at least two follicles. There was no significant difference in the outcome
of the two groups, with a cumulative conception rate of approximately 43% after
three cycles and a multiple pregnancy rate of 10%. A similar study from Glasgow [8]
randomised 100 patients to receive ovulation induction, using pituitary desensitisa-
tion with a gonadotropin-releasing hormone (GnRH) agonist followed by FSH, with
timed intercourse or IUI. There was a significant increase in the ongoing pregnancy
rate after three cycles of 42% in the IUI group compared with 18% in the timed inter-
course group.
A meta-analysis in the Cochrane database has recently published the evidence
[9]. There was no evidence of a benefit of IUI alone with expectant management, but
when ovarian stimulation was used, IUI increased the chance of pregnancy com-
pared with timed intercourse (6 randomised controlled trials (RCTs), 517 women:
OR 1.68, 95% CI 1.13–2.50) [9]. A significant increase in live birth rate was found
for women where IUI with ovarian stimulation was compared with IUI in a natural
cycle (four RCTs, 396 women: OR 2.07, 95% CI 1.22–3.50). However, the trials
provided insufficient data to investigate the impact of IUI with or without ovar-
ian hyperstimulation (OH) on several important outcomes, including live births,
multiple pregnancies, miscarriage and risk of ovarian hyperstimulation. There
was no evidence of a difference in pregnancy rate for IUI with ovarian stimula-
tion compared with timed intercourse in a natural cycle, and interestingly, IUI in
natural cycle was better than timed intercourse with ovarian stimulation (1 RCT,
342 women: OR 1.95, 95% CI 1.10–3.44) [9]. In summary, there is evidence that
IUI with ovarian stimulation increases the live birth rate compared with IUI alone.
The likelihood of pregnancy also was increased for treatment with IUI compared
with timed intercourse in stimulated cycles. Overall, IUI with ovarian stimulation
appears to have a potential, albeit relatively limited role in the management of unex-
plained infertility.
Superovulation with IUI Protocols

The rationale behind superovulation with IUI [10] encompasses the deposition of a
prepared or enhanced preparation of sperm as close as possible to at least one oocyte
(Figure 13.2). Sperm can be prepared in many ways, the most common of which includes
simple sperm washing, swim-up techniques and gradient separation techniques. Sperm
washing is achieved by diluting a sample of liquefied sperm in culture medium, fol-
lowed by centrifugation and resuspension in the medium, thereby removing seminal
plasma but leaving bacteria and immotile spermatozoa in the preparation [10]. The sam-
ple is enhanced further if the wash is repeated and the sperm then left to swim up to the
surface of the media for 30–60 min, whence it is recovered, leaving debris, bacteria and
immotile spermatozoa at the bottom of the tube. The supernatant should now contain
80%–100% motile sperm and a significantly higher percentage with normal morphol-
ogy. Alternatively, sperm can be layered on an isotonic Percoll column, which provides
a density gradient for the separation of morphologically normal, motile spermatozoa.
Ovarian stimulation is optimally achieved using gonadotropin injections without
prior pituitary desensitisation. We have found a step-down protocol to be of ben-
efit, with the aim of recruiting two or three dominant follicles, using a starting dose
of 150 units (75–100 units if under 30 years or polycystic ovarian morphology on

FIGURE 13.2 Intrauterine insemination.
baseline ultrasound scan) and dropping to 75 units (50–37.5 units) after three doses.
Treatment is started on day 2 of the cycle, and ultrasound monitoring is commenced
on day 8. Stimulation is continued and the dose adjusted, as necessary until there are
two follicles of 16-mm diameter or more, with the largest follicle having a diameter
of at least 18 mm and no more than three follicles in total greater than 14 mm. With
this approach, the monthly rate of conception is approximately 15%–20% and the
4-month cumulative conception rate is 40%. The risk of twins is in the region of 20%
and the rate of triplet pregnancies is less than 1%.
The main concern is that ovarian stimulation increases multiple pregnancies.
Nonetheless, we believe that with careful ultrasound monitoring and strict criteria for
cancellation if there are more than two mature pre-ovulatory follicles, the multiple
pregnancy rates should be able to be kept to less than 5%.
Gamete Intrafallopian Transfer

Gamete intrafallopian transfer (GIFT goes one step further than superovulation/IUI
as it involves the collection of oocytes and the direct transfer of oocytes and sperm
into a fallopian tube (Figure 13.3 and see Chapter 14). GIFT was evolved for the treat-
ment of unexplained infertility because it was thought that the fallopian tube provided
a more physiological environment for fertilisation than a dish in an incubator. The
main disadvantages compared with IUI are the need for a laparoscopy and a more
complicated ovarian stimulation regimen (see Chapter 14). Compared with IVF, GIFT
fails to provide the couple with fertilised oocytes, although surplus oocytes can be
fertilised in vitro and cryopreserved for future use. GIFT is seldom used these days.
IVF is a less invasive therapy than GIFT and confers the advantages of being able to
study fertilisation and the selection of good quality pre-embryos for transfer into the

FIGURE 13.3 Gamete intrafallopian transfer (GIFT). Laparoscopic aspiration of oocytes before

cannulation of the fallopian tube and transfer of oocytes and sperm.
uterus. The Cochrane database included six studies and showed that the live birth rate
(LBR) per woman was significantly higher with IVF (45.8%) than expectant man-
agement (3.7%) (OR 22.00, 95% CI 2.56–189.37, 1 RCT, 51 women) [11]. There was
no difference in LBR between IVF and IUI alone (40.7% vs. 25.9%, OR 1.96, 95%
CI 0.88–4.36, one RCT, 113 women). In studies comparing IVF with IUI + ovarian
stimulation, LBR per woman did not differ significantly between the groups among
women who had yet to receive any treatment (OR 1.09, 95% CI 0.74–1.59, two RCTs,
234 women) but was significantly higher in a large RCT of women pretreated with
IUI + clomifene citrate who then had IVF compared with IUI (OR 2.66, 95% CI
1.94–3.63, 1 RCT, 341 women). There was no evidence of a significant difference
in multiple pregnancy rate or ovarian hyperstimulation syndrome between the two
treatments [11].
We believe that it seems sensible to progress to IVF in couples with unexplained
infertility after initial treatment with superovulation/IUI. In women more than 35
years of age, we believe that IVF should be offered as first-line therapy.
Strategy for Management of Unexplained Infertility

In developing a strategy for the management of unexplained infertility, one has to
balance the efficacy of treatment, including cost-effectiveness, against the relative
invasiveness of the various therapeutic options. The available evidence suggests that
there is little to be gained by commencing therapy before a couple have been trying
for at least 2–3 years. However, it is difficult to enforce this guideline in practice
when confronted in the clinic by a distressed couple with unexplained infertility.
Furthermore, some of these couples will have as yet unidentified sperm, oocyte or
fertilisation defects that will only be discovered during the process of IVF. There is

a certain logic, therefore, in proceeding straight to IVF and if fertilisation is normal,

reverting to either no treatment until 3 years have elapsed or a less invasive treatment
such as IUI with superovulation. The age of the female partner also should be con-
sidered, and there is a case for treating women more than the age of 35 years more
aggressively. IVF is the most effective way to enhance the chance of conception and
live birth and has been increasingly used for the management of unexplained infer-
tility. The pace and intensity of treatment often are governed by the couple’s desires
and anxiety, some wishing to proceed swiftly to assisted reproduction technology and
others wishing to avoid high-tech treatments for as long as possible. It is essential to
present the couples with a realistic appraisal of their chance of pregnancy with and
without treatment and also to counsel them fully about the risks and side effects of
the various therapies.
REFERENCES
1. Siristatidis C, Bhattacharya S. Unexplained infertility: does it really exist? Does it
matter? Hum Reprod 2007; 22: 2084–7.
2. Hull MG, Glazener CM, Kelly NJ, et al. Population study of causes, treatment and
outcome of infertility. BMJ 1985; 291: 1693–7.
3. Polyzos NP, Tzioras S, Mauri D, et al. Treatment of unexplained infertility with
aromatase inhibitors or clomiphene citrate: a systematic review and meta-analysis.
Obstet Gynecol Surv 2008; 63: 472–9.
4. Isaksson R, Tiitinen A. Obstetric outcome in patients with unexplained infertility:
comparison of treatment-related and spontaneous pregnancies. Acta Obstet Gynecol
Scand 1998; 77: 849–53.
5. Guzick DS, Sullivan MW, Adamson GD, et al. Efficacy of treatment for unexplained
infertility. Fertil Steril 1998; 70: 207–13.
6. Hughes E, Brown J, Collins JJ, Vanderkerchove P. Clomiphene citrate for unex-
plained subfertility in women. Cochrane Database Syst Rev 2010; (1): CD000057.
7. Melis GB, Paoletti AM, Ajossa S, Guerriero S, Depau GF, Mais V. Ovulation induc-
tion with gonadotropins as sole treatment in infertile couples with open tubes: a
randomized prospective comparison between intrauterine insemination and timed
vaginal intercourse. Fertil Steril 1995; 64: 1088–93.
8. Chung CC, Fleming R, Jamieson ME, Yates RW, Coutts JR. Randomized comparison
of ovulation induction with and without intrauterine insemination in the treatment of
unexplained infertility. Hum Reprod 1995; 10: 3139–41.
9. Veltman-Verhulst SM, Cohlen BJ, Hughes E, Heineman MJ. Intra-uterine insemina-
tion for unexplained subfertility. Cochrane Database Syst Rev 2012; (9): CD001838.
10. The ESHRE Capri Workshop Group. Intrauterine insemination. Hum Reprod Update
2009; 15: 265–77.
11. Pandian Z, Gibreel A, Bhattacharya S. In vitro fertilisation for unexplained subfer-
tility. Cochrane Database Syst Rev 2012; (4): CD003357.

14
Assisted Conception
Introduction
Assisted conception techniques involve the laboratory preparation of gametes, artifi-
cially bringing them closer together and hence enhancing fertility by either by-passing
an absolute obstruction to fertilisation or boosting fecundity above that expected
without treatment.
Indications for Assisted Conception

Assisted conception is used in treatment of the following conditions or indications.
Tubal Damage
Assisted conception is indicated if the prognosis for tubal surgery is considered too
poor or if conception has failed to occur within 6–12 months of tubal surgery (see
Chapter 11). Consideration should be given to discussion of pre-treatment tubal ster-
ilisation, to minimise the risk of ectopic pregnancy after treatment, although in prac-
tice this discussion is seldom performed. The presence of hydrosalpinges, if visible
on a pelvic ultrasound scan, is associated with a reduced implantation rate, which has
been shown to improve after salpingectomy (see Chapter 11).
Endometriosis
In vitro fertilisation (IVF) is indicated for moderate to severe disease if conception
has failed to occur within 12 months of ablative laparoscopic surgery, depending, of
course, on age and other fertility factors (see Chapter 10). Consideration also should
be given to pre-treatment management of endometriotic cysts (see Chapter 10).
Male Factor Infertility

When there is severe sperm dysfunction and sperm preparation provides an inad-
equate specimen for superovulation with intrauterine insemination (IUI; see
Chapters 12 and 13) or if conception has failed to occur after three or four cycles of
superovulation/IUI, IVF should be offered. Micromanipulation techniques such as
intracytoplasmic sperm injection (ICSI) may be required to achieve fertilisation if
there is severe male factor infertility.

IVF is also indicated in couples in whom there is azoospermia and conception has
not occurred with donor insemination (DI). The number of cycles of DI treatment
should be governed by the female partner’s age and other fertility problems: in women
under 35 years of age, it is reasonable to attempt 12 cycles, although conception
should occur in 50%–60% of couples by six cycles of treatment; women over the age
of 35 may take longer to conceive, but results of assisted conception treatments also
are reduced, so the more successful therapies should not be delayed.
Unexplained Infertility
An argument can be made for a cycle of IVF to test the ability of the sperm to achieve
fertilisation, albeit in an artificial environment. If fertilisation occurs and yet there
is no pregnancy, then a less high-tech treatment, such as superovulation/IUI (see
Chapter 13), could be used for a few cycles before reverting to IVF, although this
sequence is not a sequence that we have used. Most couples and clinicians prefer a
stepwise progression through therapies, culminating in IVF as the last resort. It is
obviously appropriate to discuss the options with the couple and to map out a man-
agement plan. Most couples feel more secure in the knowledge that they are to have
a certain number of cycles of a particular treatment before moving on to another
therapy. Sometimes, the hardest part of fertility therapy, for both patients and clini-
cian, is knowing when to move on, because there is a tantalising uncertainty about the
outcome if another cycle of a particular treatment is undertaken.
Cervical Infertility
Cervical infertility accounts for fewer than 5% of cases of infertility, and in the past
this condition was overdiagnosed. Whether the real cause is unexplained or cervical
infertility, the treatment of choice is superovulation/IUI (see Chapter 13), followed by
IVF, if IUI fails. So, the diagnosis of cervical infertility and studies of cervical mucus
have become redundant.
Coital Dysfunction
Psychosexual counselling should be offered in the first instance (see Chapter 6),
unless there is an organic cause for the sexual dysfunction (see Chapter 12). If assisted
conception is required, then the treatment of choice is IUI (plus or minus superovula-
tion; see Chapter 13), followed by IVF if IUI fails. It may be advisable to cryopreserve
sperm as a backup for the day of treatment in case there is difficulty in producing on
the day.
Pre-Implantation Genetic Diagnosis

IVF can be used to generate embryos from which single cells can be obtained for
genetic studies or simple sexing in cases where there are life-threatening congenital
diseases. Each cell in the pre-embryo is pluripotent, so a single cell can be removed
up to the blastocyst stage without damaging the development of the fetus. Using this
technique, it is possible to transfer only healthy pre-embryos and avoid the risks of

Assisted Conception 325
antenatal testing (e.g. chorion villus biopsy, amniocentesis) and the possibility of
a termination should such tests prove positive. The number of conditions that can
be detected is increasing the whole time, although only a handful of centres in the
United Kingdom are currently performing pre-implantation genetic diagnosis. In the
future, it may be possible to perform aneuploidy screening on all pre-implantation
embryos, although the validity of this approach is debated.
Assisted Conception Therapies

This book is not intended to provide a detailed account of all the various assisted
conception techniques, and we refer the reader who requires more information to
the References section. We outline current management strategies so that the inter-
ested gynaecologist or general practitioner is well informed about assisted conception
therapies. IVF is the most commonly performed assisted conception therapy and is
dealt with in greater detail at the end of this section.
Before assisted conception treatment, in addition to baseline infertility investiga-
tions, it is usual for most clinics to test couples for human immunodeficiency virus
(HIV) and hepatitis B and C, to avoid iatrogenic transmission from one partner to the
other and also to protect laboratory staff who are handling bodily fluids. Furthermore,
cryopreserved gametes and embryos have the potential – albeit unproven – of cross-
contamination through liquid nitrogen.
Superovulation/IUI
IUI with or without superovulation may be indicated for couples with unexplained,
mild-to-moderate male factor and cervical infertility. For a detailed account of IUI,
see Chapter 13.
Gamete Intrafallopian Transfer

Gamete intrafallopian transfer (GIFT) [1] requires the presence of at least one func-
tional fallopian tube as 50,000–200,000 prepared sperm plus up to three oocytes
are transferred into the tube, usually under direct laparoscopic visualisation (see
Figure 13.3). Superovulation is achieved in an identical fashion to IVF, and the oocyte
retrieval procedure immediately precedes the GIFT. Some collect the oocytes lapa-
roscopically, although it is our preference to perform an ultrasound-guided oocyte
retrieval, as for IVF, because this type of retrieval permits a more reliable aspiration
of all of the stimulated follicles.
The indications for GIFT are essentially the same as those for superovulation/IUI
(see Chapter 13), although GIFT should not be performed as a first-line treatment
when there is male infertility. The aim of the therapy is different, however, in that
the gametes are placed directly into the fallopian tube, the normal site of fertilisa-
tion. Furthermore, there is a fail-safe if more than three mature follicles develop,
as they are all aspirated, whereas if this were to occur during superovulation/IUI, the

treatment would have to be cancelled (or converted to an oocyte retrieval-associated

treatment at the last minute). Surplus oocytes can be fertilised with a view to cryo-
preservation of suitable pre-embryos.
GIFT evolved as a therapy that required little laboratory input, although if IVF
is performed on the surplus oocytes, this so-called advantage is lost. The disadvan-
tages of GIFT compared with IVF are that a general anaesthetic and laparoscopic
procedure are required and the fate of the transferred gametes is unknown, with
respect to fertilisation. Although GIFT has been attempted without laparoscopy, by
way of transcervical cannulation of the fallopian tube under ultrasound guidance,
the results are not as good as with conventional GIFT. Success rates with GIFT are
certainly no better than with IVF and, in some cases, inferior. Thus, because of the
more invasive nature of the procedure, GIFT is seldom performed these days in the
United Kingdom. Our current practice would be to perform a laparoscopic transfer
only when there is significant cervical stenosis (e.g. after cone biopsy), and in these
rare cases, we would prefer to perform zygote intrafallopian transfer (ZIFT), after
fertilisation has occurred (see below). GIFT may also be performed if a couple has
ethical or religious reasons against in vitro creation of embryos.
Zygote Intrafallopian Transfer, Pronuclear Stage

Transfer and Tubal Embryo Transfer
The ZIFT procedure goes one step further than GIFT by transferring fertilised
oocytes at the pronuclear stage, usually 18–24 h after insemination. Tubal embryo
transfer (TET) is performed after 48 h when the pre-embryo has cleaved. These tech-
niques [2,3] can be performed by either laparoscopy or retrograde transcervical can-
nulation of the tube (Figure 14.1) [4].
FIGURE 14.1 Transcervical or transfallopian transfer of pre-embryos or zygotes.

The rates of ongoing intrauterine pregnancy and ectopic pregnancy are similar
whether the gametes/pre-embryos are transferred into the uterine cavity or directly
into the fallopian tubes. Our experience is in favour of IVF rather than ZIFT
(or related techniques) because of the avoidance of laparoscopy, which carries
significant morbidity and mortality. We would suggest that laparoscopic intrafal-
lopian transfer be reserved for those very rare cases in which cannulation of the
cervix is not possible, for example, after surgery for cervical intraepithelial neopla-
sia (CIN), although even in these cases an alternative option is a transmyometrial
embryo transfer [5]. These treatments are therefore mentioned only for historical
completeness as they are very seldom performed in developed countries.
The indications for assisted conception have been listed above. For a couple to
undergo IVF, the female partner should have at least one functioning ovary and a
normal uterus and the male partner at least one sperm per ejaculate. However, the lack
of ovarian function can be bypassed with oocyte donation, the absence of sperm can
be bypassed with sperm donation (or of both by embryo donation) and the absence of
a uterus by IVF surrogacy. Sometimes, both sperm and oocytes, or surplus embryos
from another couple, are donated so that the resultant child has inherited no genetic
material from either parent. Such parents have in reality adopted the embryos but do,
of course, gain from the experience of pregnancy and childbirth.
It is my opinion that IVF is sometimes embarked upon before all other treatment
modalities have been exhausted, and although we do not advocate unnecessary delay,
particularly in older patients, the notion that IVF is the high-tech modern answer to
every couple’s subfertility is erroneous [6]. The stresses placed upon a couple by IVF
(and other assisted conception procedures) are immense, and the treatment has risks
and complications (e.g. ovarian hyperstimulation syndrome (OHSS) and multiple
pregnancy; see Chapter 18).
Regimens for IVF

IVF therapy has become increasingly simplified in recent years [7,8]. The use of
gonadotropin-releasing hormone (GnRH) agonists and antagonists combined with
gonadotropins has resulted in greater ease of planning the superovulation stimulation
than was possible with the earlier use of clomifene citrate (CC) with gonadotropins,
which needed to be monitored carefully to predict the occurrence of an endogenous
pre-ovulatory luteinising hormone (LH) surge. In the absence of GnRH analogue–
controlled cycles, there was a cancellation rate of 15%–20% because oocyte retrieval
had to be performed 26–28 h after the detection of the endogenous surge, and this
time frame often meant that oocyte collections were performed at night and through-
out weekends.
When GnRH agonists or antagonists are used (Table 14.1 and Figure 14.2), the
oocyte retrieval can be timed precisely to occur 34–38 h after the administration
of human chorionic gonadotropin (hCG). The latter acts as a surrogate for the nor-
mal mid-cycle LH surge and causes resumption of meiosis within the oocytes and

TABLE 14.1
GnRH Agonists (with Modifications to the Structure Indicated in Bold Type)
Trade Name Structure Relative Potency Dose
Native – GnRH Glu.His.Trp.Ser.Tyr. 1
Gly.Leu.Arg.Pro.
Gly. NH
Buserelin Suprecur Glu.His.Trp.Ser.Tyr. 100 150 μg (1 dose)
D-Ser9.(tBut). nasal spray
Leu.Arg.Pro.EA 4 times/day
Suprefact 100 500 μg s.c. drop
to 200 μg
Nafarelin Synarel Glu.His.Trp.Ser. 100 200 μg nasal
Tyr.D.Nal(2). Leu. spray
Arg.Pro. Gly.NH (2 doses) b.d.
Triptorelin Decapeptyl Glu.His.Trp.Ser. 100 3 mg i.m. every
Tyr.D.Trp. Leu. 4 weeks
Arg. Pro.Gly.NH
Goserelin Zoladex Glu.His.Trp.Ser. 50 3.6 mg s.c.
Tyr.D.Ser.(+But). every 4 weeks
Leu.Arg.Pro. Aza.
Gly.NH
Leuprorelin Prostap Glu.His.Trp.Ser.Tyr. 50 3.75 mg s.c. or
D.Leu.Leu.Arg. i.m. every
Pro.EA 4 weeks
Note: The dose of the shorter acting preparations can be reduced once pituitary desensitisation has
been achieved.
thus prepares them for fertilisation. Furthermore, there is good evidence that the
oocytes do not become over mature within follicles that are considered to be ready
for collection, so the administration of hCG can be delayed to avoid oocyte col-
lection at weekends [8]. Indeed, by avoiding oocyte collections on Thursdays also,
embryo transfer can be avoided at weekends and the clinic can be run virtually on
a weekday-only basis. Most large clinics, however, provide flexibility and a 7-day
service, which also provides flexibility for both day 3 and/or day 5 (blastocyst)
transfers.
A disadvantage of the use of GnRH agonists is the 10–14 days’ lead-in to the therapy
during which pituitary desensitisation (‘down-regulation’) is achieved before stimula-
tion with gonadotropins can be commenced. Pituitary desensitisation is assessed by a
combination of endometrial shedding and low serum concentrations of oestradiol and
LH (although ultrasound confirmation of a thin endometrium and quiescent ovaries is
adequate without recourse to biochemistry). Some clinics prefer to commence agonist
therapy on day 21 of the menstrual cycle and suggest that desensitisation occurs more
rapidly than if it is commenced during menstruation – usually day 2. A day 21 start,
however, carries the risk of rescuing a corpus luteum with resultant functional cyst
formation. A day 2 start virtually guarantees that the patient is not pregnant (although
GnRH agonists are not detrimental to a developing pregnancy if inadvertently taken).
We sometimes control and plan the start of treatment by administering the combined

1. Clomifene citrate plus gonadotropins (hMG or FSH)

Oocyte collection
Menses (day 1)
Clomifene 100 mg per day
day 2 for 5 days
Gonadotropin stimulation from day 4 to day of hCG
hCG
2. Long GnRH agonist protocols
a. Luteal-phase start (i.e. 7 days after presumed day of ovulation)
Oocyte collection
Ovulation Menses
GnRH agonist day 21 Drop dose, continue to
day of hCG
Gonadotropins to day of hCG
hCG
b. Follicular-phase start
Oocyte collection
Menses
GnRH agonist starts day 2 until Drop dose, continue to
‘down-regulation,’ day of hCG
usually 14 days
Gonadotropins to day of hCG
hCG
3. Short GnRH agonist protocal
Oocyte collection
Menses (day 1)
GnRH agonist starts day 2 to day of hCG
hCG
4. Ultra short GnRH agonist protocol
Oocyte collection
Menses (day 1)
GnRH agonist from
day 2 for 3 days
hCG
5. GnRH antagonist protocol (a GnRH agonist can be given instead of
hCG)
Oocyte collection
Menses (day 1)
Daily injection of antagonist when leading follicle of 14 mm
hCG
FIGURE 14.2 Most stimulation regimens commence the day after menses has started (i.e. day 2)
for practical reasons. A day 1 start is acceptable but often not practical as most clinics like to com-
municate with their patients when they are about to start treatment. Alternatively, the combined oral
contraceptive pill can be used to programme the cycle (see text). Pituitary desensitisation (down-reg-
ulation) has occurred when the serum concentration of LH is less than 5 IU/L and that of oestradiol
less than 150 pmol/L (progesterone, if measured, should be greater than 3 nmol/L). Gonadotropin
preparations consist of hMG or follicle-stimulating hormone (FSH) (see text). hCG or recombinant
LH is given to trigger oocyte maturation when the largest follicle reaches at least 18 mm in diameter,
and there are at least two others greater than 17 mm. Oocyte collection is performed 35–36 h later.
Embryo transfer occurs approximately 48 h after oocyte collection. Luteal support commences on
the day of embryo transfer and is usually given as progesterone pessaries or suppositories (Cyclogest
200–800 mg nocte) or intramuscular injections (Gestone or Prontogest 50–100 mg/day) and con-
tinued until the day of the pregnancy test. Some continue luteal support up to 12 weeks’ gestation,
although this continued support is unnecessary if progesterone pessaries have been used.

oral contraceptive pill (COCP) for between 2 and 3 weeks, commencing on day 1 of
the menstrual cycle. The pill is discontinued after 2–3 weeks, and treatment with the
agonist is commenced. This regimen allows scheduling of cycles in a busy clinic and
also the use of the COCP minimises the occurrence of ovarian cysts resulting from
the GnRH agonist flare. The disadvantage, of course, is further prolongation of the
treatment cycle.
The GnRH agonists can be administered intranasally, subcutaneously or intra-
muscularly (by depot in some instances). The shorter acting preparations also can
be used to induce a flare response, being commenced on day 1 of the cycle, with
gonadotropin stimulation starting the following day. The agonist is then either con-
tinued through to the day of hCG administration (the short protocol) or given for 3
days only (the ultrashort protocol). The flare response can be used in those patients
who have had a poor response in the past to try to maximise the response to stimula-
tion – this maximisation it does to varying degrees. It is, in fact, difficult to predict
an individual’s response to stimulation: young women and women with polycys-
tic ovaries (PCOs) tend to respond well, whereas older patients and patients with
reduced ovarian reserve respond less well (see below). CC and GnRH stimulation
tests (see Chapter 5) have been used to improve the predictability of response, but
they do not tend to be highly sensitive and are not popular in the United Kingdom.
An assessment of ovarian antral follicle count and anti-Müllerian hormone (AMH)
concentration have become popular in assessing ovarian reserve (see Chapter 5,
Ovarian Reserve Tests). A more detailed account of GnRH agonist regimens may be
found in Balen [9].
As with many aspects of the current clinical practice, the evidence on which our
therapy is based relies upon data from relatively small trials. Furthermore, different
preparations, criteria for treatment and protocols have been used, making compari-
son of studies difficult. This has led to the use of meta-analyses of studies to provide
firmer conclusions. A recent review in the Cochrane database has compared studies
using different GnRH agonist regimens [10]. Of 29 included studies, 17 compared long
with short protocols; two compared long with ultrashort protocols; four compared a
follicular start with a luteal-phase start of the GnRHa; three compared continuation
versus stopping the GnRHa at the start of stimulation; three compared continuation of
the same dose versus reduced dose of GnRHa and one compared a short versus short
stop protocol. There was no evidence of a difference in the live birth rate (LBR), but
this outcome was only reported by three studies. There was evidence of a significant
increase in clinical pregnancy rate (odds ratio (OR) 1.50, 95% CI 1.16–1.93) in a long
protocol compared with a short protocol. This difference did not persist when the meta-
analysis was done only on the studies with adequate randomisation (OR 1.38, 95% CI
0.93–2.05). There was evidence of a 60% increase in the number of oocytes when a
long protocol was used compared with a short protocol, although approximately 13
more ampoules of gonadotropins (at 75 IU/ampoule) were required. There was no evi-
dence of a difference in any of the outcome measures for luteal versus follicular start
of GnRHa and stopping versus continuation of GnRHa at the start of stimulation [10].
The advent of the third-generation GnRH antagonists enables us to dispense with
pituitary desensitisation and commence ovarian stimulation on day 2, with the daily
administration of an antagonist on day 5 or 6 of stimulation or once the leading
follicle(s) has reached a diameter of 14 mm (usually day 6 or 7), although it appears

that success rates are better when commenced on day 6 rather than using a flexible
protocol [11]. The GnRH antagonist acts immediately to inhibit pituitary secretion
of follicle-stimulating hormone (FSH) and LH, without the flare effect of agonists or
the need for 10–14 days of desensitisation. An endogenous LH surge is still prevented,
thereby allowing oocyte retrieval at the desired time. GnRH antagonist cycles are cer-
tainly much shorter and more convenient for patients than the long protocol, and many
clinics are now increasingly using them. Scheduling can be achieved with a COCP or
oestradiol valerate, which is then discontinued 3 days before commencing the gonad-
otropin stimulation. There are conflicting data on the benefit of this approach, which
may help clinic scheduling more than patient outcome as the clinical pregnancy rate
appears to be slightly reduced (risk ratio (RR) 0.80, 95% CI 0.66–0.97) as judged by
a recent meta-analysis [12].
In GnRH antagonist cycles, the maturation of oocytes before collection may be
initiated with a single shot of a GnRH agonist rather than hCG – a strategy that
was proposed to reduce the risk of OHSS because of the shorter half-life of the
agonist compared with hCG; however, pregnancy rates appear to be lower, so the
conventional use of hCG is recommended [13]. Furthermore, the antagonist proto-
cols g enerally are associated with a reduced risk for OHSS than the long agonist
protocols. The use of GnRH antagonists also may reduce the total requirements
for gonadotropins. It also appears that GnRH antagonist cycles are preferred by
patients because of their short duration and minimal side effects (e.g. avoidance
of symptoms of oestrogen deficiency during pituitary desensitisation). There is no
evidence that the type or dose of gonadotropin needs to be modified when using
antagonists compared with agonist regimens. Initial studies found that pregnancy
rates were approximately 5% lower than with GnRH agonist cycles, although it
was suggested that there might be a learning curve in appreciating the optimal
time to plan oocyte retrieval. We are certainly encouraged by a meta-analysis,
which concludes that there is a similar probability of a live birth when either GnRH
agonists or antagonists are used [14]. Overall, the antagonist protocol appears to
provide a sensible strategy for the majority of IVF cycles, although most clinics
still appear to use the long agonist protocol because of ease of planning and tim-
ing for clinic organisation – a potential problem in antagonist cycles that can be
overcome by using a COCP until 5 days before the cycle is due to start. If a GnRH
agonist is used to trigger final oocyte maturation, rather than the conventional use
of hCG, it is possible significantly to reduce the risk of OHSS [15]. However, early
studies suggested that this compromised the chance of an ongoing pregnancy due
to the duration of effect of hCG stimulating ovarian progesterone secretion into
the luteal phase, so it has become necessary to further modify luteal support in
a GnRH antagonist protocol with either the combined use of progesterone and
oestrogen supplementation or additional boluses of hCG in luteal phase (at a low
dose to minimise the risk of OHSS) [15]. Some clinicians even advocate the elec-
tive cryopreservation of all embryos in GnRH antagonist cycles, irrespective of
perceived risk of OHSS, and later transfer of frozen embryos in a hormone replace-
ment therapy (HRT) cycle where the endocrine milieu is thought by some to be
more conducive to implantation and normal placentation. This approach has yet to
gain widespread popularity and, of course, relies upon a good quality cryopreser-
vation programme.

Gonadotropin therapy for the stimulation of superovulation was initially with hMG,
which contained urinary-derived FSH and LH in differing proportions depending
on the preparation and then with urinary-derived FSH alone. The preparations were
initially for intramuscular use, but with purification and extraction of extraneous pro-
teins they became available for administration subcutaneously (see Table 7.8). The
advent of the recombinantly derived gonadotropins broadened the scope of therapeutic
agents and resulted in a potentially unlimited supply. There was initial evidence that
recombinant FSH (rFSH) may result in the production of more oocytes and embryos
than the urinary-derived preparations and hence the potential for a greater overall
pregnancy rate when pregnancies from subsequent frozen embryo replacement cycles
(FERCs) are taken into consideration. Current evidence however suggests that the use
of hMG is more cost-effective (see below). Of course, more than the absolute numbers
of oocytes is their quality and prospect of achieving an ongoing pregnancy and live
birth. The use of recombinant LH has been formulated as a more physiological sur-
rogate for the LH surge and, with a shorter half-life than hCG, should theoretically
reduce the risk of OHSS.
In discussing the benefits of a gonadotropin preparation, one has to consider clini-
cal efficacy, side effects and cost-effectiveness. Clinical efficacy includes the abil-
ity to stimulate folliculogenesis; the production of mature oocytes; appropriate
steroidogenesis for endometrial development; and, in the context of IVF, sufficient
quality pre-embryos and ultimately good rates of pregnancy. The original sources of
gonadotropins for therapeutic use were post-mortem pituitary extracts and the urine
of post-menopausal women. The former source was withdrawn because of cases of
Creutzfeldt–Jakob disease (CJD), which occurred predominantly in Australia but
cases also were reported in Europe.
The extraction and purification of post-menopausal urine were pioneered in
Italy in the late 1940s to result in the production of hMG. Twenty to 30 litres of
post-menopausal urine was required to provide sufficient gonadotropin to treat one
patient with one cycle of hMG. Through the 1960s, the extraction process to remove
non-specific co-purified proteins became more sophisticated, such that activity was
increased 10-fold over the early preparations to 100–150 IU FSH/mg protein. Greater
purity produced fewer hypersensitivity reactions and less discomfort from the smaller
volume of the injection. Despite the increased purity of hMG (menotropin) and uFSH
(urofollitropin) compared with the original preparations, their active ingredients only
constituted 1%–2% of the final product. The preparations still contain large amounts
of urinary protein (including cytokines, growth factors, transferrins and other pro-
teins that might modulate ovarian activity), which makes uniform standardisation
very difficult and may lead to local reactions at the injection sites and very rarely
systemic illness.
The use of monoclonal antibodies in the 1980s enabled further purification to be
achieved by specifically selecting FSH out from the bulk hMG [16]. The extract was
95% pure, with a several hundredfold enhancement of specific gonadotropin bioactiv-
ity and was known as highly purified urinary FSH (u-hFSH HP). Extended clinical
trials comparing uFSH (urofollitropin) and highly purified FSH demonstrated equiva-
lent ovulation and pregnancy rates. Reduced hypersensitivity was reported, such that

the subcutaneous route could be adopted for administration. However, the problems
of supply, collection, transport, storage and processing of an ever-increasing require-
ment of urine remained, and the pharmaceutical companies led to the use of the tech-
nology of genetic engineering to produce biosynthetic preparations. The genes for
the α and β subunits of FSH were incorporated into vectors that were then intro-
duced into cells from a Chinese hamster ovary cell line. This process has resulted
in an unlimited supply of highly stable therapeutic preparations with a high specific
activity (for review, see Hayden et al. [17]).
The biological activity of FSH is largely determined by the degree of glycosylation,
which can only be measured by bioassay and is not measurable by immunoassay [18].
Pharmacopoeial monographs, taking account of the inherent precision of the meth-
ods in bioassays, allow 95% confidence limits of 80%–125% of the stated dose on
estimates of activity, thus between 60 and 94 units of activity in a 75-unit ampoule
(a potential variation of up to 57% between ampoules from different batches). The
same pharmacopoeial requirements have been applied to the recombinantly derived
FSH preparations, although in reality the variation is very much lower (±2%–3%).
There is evidence that there is heterogeneity between the different recombinantly
derived preparations, hence the nomenclature follitropin α and β. Data from in vivo
bioassays suggest that one of the major factors that controls FSH action is the relative
degree of clearance of different isoforms. It is interesting to note that those forms of
FSH that are most potent in vitro tend to be least potent in vivo.
Many intrinsic and extrinsic factors affect the performance of a drug in vivo. For
rFSH, the pattern of glycosylation, specifically terminal sialylation of the protein
backbone, has excited much interest as it is crucial to the bioactivity of the hormone.
Overall, the isohormone composition of rFSH has proved to be very similar to pitu-
itary extract, but great effort has been spent establishing which forms have greatest
bioactivity to design the most specific and predictable drug. Sialylation determines
acidity and isoelectric charge. Basic forms have higher receptor binding activity and
therefore in vitro bioactivity, but they are cleared more rapidly from the circulation
than acidic forms. The more acidic isoforms have a 20-fold higher in vivo bioac-
tivity, mainly due to their higher absorption, lower clearance rate and longer elimi-
nation half-life. Modifications have been made to the molecular structure that lead
to an extension of the half-life and in vivo bioactivity, for example, by adding the
C-terminal peptide from hCG (FSH-CTP, corifollitropin α) and achieving a 7-day
duration of effect [19].
NOTE: Until about 10 years ago, all gonadotropin preparations were produced with
75 international units of activity per ampoule. Now, there is great variation in the
way that the different products are packaged. It has become important, therefore,
to refer to dosages in terms of units and not ampoules. For a list of currently avail-
able gonadotropin preparations, see Table 14.2. The optimal starting dose in women
under the age of 40 years with normal ovarian reserve is 150 units daily. Although
an increase in dose may result in an increased yield of slightly more oocytes, there
is no evidence of an improvement in pregnancy and embryo cryopreservation rates
[20]. In women thought to be at risk of overresponse, that is, women with PCOs, we
would usually commence with dose of 100 units daily and in women with reduced
ovarian reserve or a history of poor response, we commence with 300 units or at

TABLE 14.2
Currently Available Gonadotropin Preparations
Gonadotropin Source Constituents Trade Names
Menotropin Urinary FSH:LH 1:1 Merional, Menopur
Urofollitropin Urinary FSH Bravelle, Fostimon
Chorionic gonadotropin Urinary hCG Choragon, Pregnyl
Follitropin α Recombinant FSH Gonal-F
Follitropin β Recombinant FSH Puregon
Lutropin α Recombinant LH Luveris
Follitropin α and Lutropin α Recombinant FSH:LH Pergoveris
Corifollitropin α Recombinant FSH-CTP Elonva
Chorionic gonadotropin α Recombinant hCG Ovitrelle
most 450 units daily. There has been much publicity about mild stimulation, and mild
stimulation has become very much a buzz word in some circles. We would agree that
it is important to use the lowest effective dose, tailor the treatment to the individual’s
needs, be sensitive to predictors and be prepared to modify the dose if there is an
unexpected response.
Advantages and Disadvantages of rFSH

There are several potential advantages of rFSH over its urinary predecessors. Aside
from the improved logistics of the pharmaceutical process, controlled manufacture
has led to a more homogeneous product with less interbatch variability compared
with the purification of enormous quantities of heterogeneous urine. The supply is
potentially unlimited, and shortages should no longer be a threat to clinical practice.
There is no risk of infection or contamination with drugs or their metabolites as there
may potentially be with products from a human source. The manufacturers also have
confirmed that there have been no reported cases of seroconversion to antigonadotro-
pin antibodies. The purity of the products has facilitated their administration, which
is effective, safe and less traumatic when the subcutaneous route is used. The most
obvious advantages of rFSH are greater purity and specificity. It was initially sug-
gested that smaller doses and a more predictable response would result, although this
has not been confirmed.
Studies comparing the different gonadotropin preparations are varied and include
a heterogeneous mix of protocols and various comparisons of hMG, purified urinary
FSH and rFSH. The two rFSH preparations (α and β) are similar to each other, but
studies comparing them are relatively small. Several of meta-analyses comparing the
various types of gonadotropin have been performed over the years, with varying con-
clusions. The current consensus is that the LBR is slightly less with rFSH compared
with hMG (OR 0.84, 95% CI 0.72–0.99), although rFSH is not statistically differ-
ent to the other urinary gonadotropins [21]. Furthermore, hMG appears more cost-
effective, especially when the FERCs are factored into the analysis [22]. There were
no significant differences between hMG and rFSH with respect to gonadotropin use,
spontaneous abortion, multiple pregnancy, cancellation or OHSS rates. These studies

were performed in long agonist protocols and the evidence to date suggests similar
outcomes in antagonist protocols.
An interesting series of publications have demonstrated improved fertilisation
and ongoing pregnancy rates in women who had serum LH concentrations greater
than 0.5 IU/L on the day of hCG compared with women whose LH concentrations
were less than 0.5 IU/L [23]. It appears that a low but critical level of LH is required
throughout and towards the end of the follicular phase of the cycle and during super-
ovulation regimens. The required LH need not necessarily be contained within the
gonadotropin preparation that is administered provided that the level of pituitary
desensitisation is not too profound.
Most of the randomised controlled trials (RCTs), and also the meta-analyses,
included both IVF and ICSI cycles. However, these two types of fertilisation may
reflect two somewhat distinct populations, because of different reasons for infertil-
ity and certainly different oocyte/embryo handling. Pooling of IVF and ICSI data
may therefore not constitute an optimal approach from either a methodological or a
clinical point of view. In one of the large RCTs comparing HP-hMG and rFSH, ran-
domisation was stratified by fertilisation method and the results have been analysed
separately for IVF and ICSI cycles [24]. Among women who had undergone IVF,
a significantly higher ongoing pregnancy rate was observed in the HP-hMG group
(31%) compared with the rFSH group (20%) (p = .037) [24]. For the ICSI patients,
no significant difference in ongoing pregnancy rate was found between treatment
groups (21% for the HP-hMG group and 23% for the rFSH group). The largest RCT
comparing gonadotropins in women undergoing IVF has contributed with additional
data on the influence of LH activity on treatment outcome [25]. Most of the LH
activity in the HP-hMG preparation used in this trial is provided by the hCG com-
ponent [26]. Increasing concentrations of serum hCG on day 6 of stimulation were
associated with a significantly higher frequency of top quality embryos and ongoing
pregnancy rate [27].
These data indicate that pregnancy rates in relation to LH activity supplementa-
tion might be different between IVF and ICSI patient subsets. The mechanisms for
the improved outcome in IVF cycles after exposure to exogenous LH activity are not
fully understood. However, a hypothesis on better oocyte/embryo quality because of
cumulus cell’s characteristics after exposure to LH activity during ovarian stimula-
tion has been supported by recent gene expression data that provided some molecular
evidence for a mediation of the cumulus cells in embryo development [28].
Human transmissible spongiform encephalopathies (TSEs) encompass a group of
rare neurodegenerative diseases, including sporadic CTD, which is ubiquitous but
with a frequency of approximately 1 in 2 million. As mentioned, iatrogenic trans-
mission of CJD from pituitary-derived gonadotropins occurred and recently, since
the outbreak of cases variant CJD, predominantly in the United Kingdom, questions
have been asked about the potential risk of transmission of the prion protein infec-
tivity in human urine. To date, no infectivity in urine has been demonstrated, and
no definite cases of transmission via urine have been reported [29]. However, it is
currently not possible to monitor donor urine or finished product for the presence of
prions. Therefore, the assessment of risk has to be based on the likelihood of infec-
tion in urine, the source of the urine and the capacity of the manufacturing process
to remove any adventitious infection. Urine for the production of medicinal products

should be obtained from sources that minimise the possible presence of materials
derived from subjects suffering from human TSEs. As no strong evidence for TSE
infectivity in urine exists, it can be concluded that the risk of disease-generating
prions and TSE infectivity being present in donor urine is low. Evidence indicates
that, with respect to the risk of TSE infection, urinary-derived gonadotropins appear
to be safe [29].
Cautionary notes: In assessing the debate about gonadotropins, it is essential to be
aware of the interests of the pharmaceutical companies that manufacture gonadotro-
pin preparations and to examine both authorship and sponsorship of the published
studies.
Ovarian Reserve and Prediction of Response to Stimulation

Ovarian reserve, or the number of releasable oocytes, declines with ovarian age,
which does not always equate with the age of the woman. As ovarian reserve declines,
so too does the chromosomal integrity of the ovulated oocytes, so that there is a rise
in the rates of miscarriage and fetal chromosomal abnormalities. There are several
tests of ovarian reserve, but all have limitations. A baseline measurement of serum
FSH concentration, usually on day 3 of the cycle, is a fairly good predictor of ovarian
reserve. As the ovary fails, the FSH begins to rise in the follicular phase of the cycle.
When FSH is elevated, there is a greater likelihood of monthly fluctuations in FSH
concentration than when the FSH is normal. A fluctuating baseline FSH level is indic-
ative of already compromised ovarian function. There is little to be gained by waiting
to start treatment in a cycle in which the FSH level is closer to the normal range.
Measurement of ovarian hormones, in particular AMH, may provide a better reflec-
tion of ovarian age (for details, see Chapter 5). An ultrasound scan of the ovaries also
may be helpful. Ovarian response has been positively correlated with ovarian volume
and the number of antral follicles (see Chapter 5). The response of the ovary to stimu-
lation by gonadotropins is the essential test of ovarian function but provides only a
retrospective analysis rather than a prospective indication of the likely response to
treatment that can be used to determine the starting dose or stimulation regimen.
The appearance of PCOs, whether or not there is overt polycystic ovary syndrome
(PCOS), indicates that the ovaries are likely to respond sensitively to stimulation,
with the likely production of many follicles, although not necessarily with an equiva-
lent number of oocytes of good quality. Patients with PCOs are at the greatest risk of
OHSS (see Chapter 18).
Stimulation tests have been evaluated with the aim of enhancing the predictability
of ovarian response to superovulation. CC (100 mg) can be administered from day 5 to
day 9, and the serum FSH concentration can be measured on day 3 and day 10. It is
thought that in response to clomifene the day 10 FSH rises before there is a rise in the
basal day 3 FSH concentration. The clomifene challenge test appears to be more useful
in predicting reduced ovarian reserve when abnormal than in predicting normal ovar-
ian function when the test is normal. Ovarian reserve also can be assessed by stimula-
tion with a GnRH agonist. If these tests are used, normal ranges need to be developed
for patients of different ages. In practice, such tests are seldom used, and most would
still assess a baseline endocrine profile on day 3 of the cycle (FSH, LH, oestradiol) and
a measurement of AMH combined with an ultrasound scan of ovarian morphology (to

include antral follicle count). These tests should then be repeated annually in women
attending the fertility clinic, or more frequently if there is a change in the patient’s
menstrual cycle or an unexpectedly poor response to ovarian stimulation.
Our recommended starting dose for stimulation in superovulation regimens for IVF
is 150 units of FSH or hMG in women under the age of 38 years with normal ovar-
ian reserve. Women over the age of 38 years may be given 200–250 units, depending
upon their baseline ovarian reserve tests. In women with poor ovarian reserve or in
women who have responded poorly in a previous cycle (i.e. fewer than five oocytes
collected), we increase the dose to a maximum of 450 units. There appears to be no
benefit in using higher doses (indeed, some clinics use a maximum dose of 300 units);
neither does there appear to be significant benefit in increasing the dose of stimula-
tion mid-treatment after follicles have been recruited. If a baseline ultrasound scan
indicates the presence of PCOs (whether or not there are signs of the PCOS), we
reduce the starting dose to 50–100 units, depending upon age and previous response
to stimulation (see below for further discussion on different regimens). If an exuberant
response to stimulation is anticipated, we commence ultrasound monitoring earlier
(day 6 or 7 of stimulation) and may reduce the dose of FSH as soon as follicles greater
than 10 mm in diameter have been recruited. The patient’s response is reviewed
after each cycle of treatment, and the dose of stimulation is adjusted according to the
response obtained. We prefer to use the lowest dose that achieves the desired response
and reduce the risk of ovarian hyperstimulation.
Poor Responders
In poor responders, it has been suggested that the addition of recombinant LH (rLH)
may be of benefit, although more research in this area is required. A meta-analysis to
compare the effectiveness and safety of a combination of recombinant LH and rFSH
with rFSH alone in controlled ovarian hyperstimulation (COH) protocols in IVF or
ICSI found no evidence of a statistical difference in clinical pregnancy or LBRs [30].
Other adjunctive therapies have been used in poor responders, including dehydroepian-
drosterone (DHEA) about which there has been much commercial publicity and con-
sequent patient demand. Similarly, the addition of growth hormone has been proposed.
Several small studies using this approach have been performed, none of which has
confirmed statistical benefit, although when combined in a meta-analysis there is a
suggestion of benefit, with a 22% increased chance of achieving an embryo transfer
and 16% increased likelihood of a clinical pregnancy (95% CI +4 to +28) [31]. There
is, however, no good evidence from appropriately sized RCTs that any adjuvants or
particular protocols benefit women with reduced ovarian reserve [32,33].
Response of PCO to Stimulation for IVF

The response of the PCO to ovulation induction aimed at the development of unifol-
licular ovulation is well documented and differs significantly from that of normal
ovaries (see Chapters 7 and 8). The response tends to be slow during low-dose ovula-
tion induction protocols, with a risk of ovarian hyperstimulation and/or cyst forma-
tion (see Chapter 7). It is thus to be expected that the response of the PCO within the
context of an IVF programme also should differ from the normal; indeed, several

studies have shown that significantly more oocytes are recovered per cycle in women
with PCOs compared with normal ovaries. The overall number of mature eggs and
fertilisation rates may be reduced in percentage terms, yet patients with and without
PCO undergoing IVF appear to have similar pregnancy and LBRs as each tend to
have similar numbers of good quality embryos for transfer [34]. Despite the fact that
they often require a lower total dose of gonadotropin during stimulation compared
with women with normal ovaries, women with PCOS are at a greater risk of develop-
ing moderate to severe OHSS, quoted at 10%–18% versus 0.3–5% [34].
Although most data suggest that the pregnancy rates per transfer are compa-
rable with controls, the miscarriage rates after IVF treatment may be increased in
women with PCOS, which may relate to their high body mass index (BMI), the
increased waist: hip ratio and insulin resistance [35]. Fedorcsak et al. [36] reported
a relative risk of 1.77 (95% CI 1.05–2.97) of miscarriage for women with a BMI >
25 kg/m2 before 6 weeks’ gestation.
A consequence of obesity among women with PCOS is an increased requirement
for FSH stimulation. Therefore, they may not respond to a low-dose stimulation regi-
men. However, once the dose of FSH is increased and the threshold reached, the
subsequent response can be explosive, with an increasing risk of OHSS. The mecha-
nism of poor response to gonadotropins is uncertain, but it is likely to be related to
hyperinsulinaemia and insulin resistance [37].
There are several possible explanations for the excessive response of the PCO to
ovarian stimulation. Women with PCOS have an increased number of antral folli-
cles. Contrary to earlier theories, these follicles are not atretic, but rather there is an
increased cohort of selectable antral follicles that are sensitive to exogenous gonado-
tropins. An increased number of antral follicles also is reflected by elevation of AMH
levels in women with PCOS compared with women with normal ovaries. An increased
stockpile of antral follicles is contributed by an increase in recruitment of primordial
follicles from the resting pool. There is a spectrum of response, with some responding
easily to treatment and others with more difficulty, often being those with higher AMH
levels, who may exhibit more symptoms such as amenorrhoea and insulin resistance.
Superovulation Strategies for Women with PCO, PCOS or Both

There are few studies that specifically compare different treatment regimens for
women with and without PCOS, and women that do vary in their definition and diag-
nosis of the syndrome. The two particular aims of treatment in this group of women
are the correction of the abnormal hormone milieu, by suppressing elevated LH and
androgens, and the avoidance of ovarian hyperstimulation. Prolonged pituitary desen-
sitisation avoids the initial surge of gonadotropins with the resultant ovarian steroid
release that occurs in the short GnRH agonist protocol. Although the long protocol
theoretically provides controlled stimulation, the PCO is still more likely than the
normal ovary to become hyperstimulated. The use of short GnRH antagonist pro-
tocols has been shown to reduce the risk of OHSS and is now favoured for women
with PCOS, combined with a lower initial starting dose than average (75–100 units).
GnRH antagonists do not activate the GnRH receptors and produce a rapid suppres-
sion of gonadotropin secretion within hours, thereby offering the potential for shorter
treatments compared with the long protocol using a GnRH agonist. A Cochrane

review showed no evidence of a statistically significant difference in rates of live

birth (9 RCTs; OR 0.86, 95% CI 0.69–1.08), and there was a statistically significant
lower incidence of OHSS in the GnRH antagonist group (29 RCTs; OR 0.43, 95% CI
0.33–0.57) [38].
Native GnRH or a GnRH agonist can displace the antagonist from the pituitary
GnRH receptors. This displacement realises the potential to use a GnRH agonist as
the final trigger for the LH surge and consequent oocyte maturation. Itskovitz-Eldor
et al. [39] demonstrated a rapid rise in LH after administration of a GnRH agonist,
with a peak in levels 4 h after injection. This trigger is potentially more physiologi-
cal, with a lower risk of OHSS, due to the shorter half-life of LH (60 min compared
with 32–34 h). It was shown that the number of oocytes retrieved, quality of embryos,
implantation and pregnancy rates were shown to be comparable when either an ago-
nist trigger or hCG were administered [40]. A Cochrane review, however, found an
inferior LBR (OR 0.44, 95% CI 0.29–0.68) but the reduction in OHSS is certainly an
advantage [41]. A multicentre, double-blind study revealed that recombinant human
LH can be as effective as hCG in inducing the final follicular maturation in IVF treat-
ment with a lower incidence of OHSS [42]. Its clinical application within assisted
reproductive technology (ART) has yet to be fully elucidated.
Insulin resistance and compensatory hyperinsulinaemia contribute to the patho-
genesis of PCOS (see Chapter 8). Many studies have investigated the effects of using
the insulin-sensitising agents, mainly metformin, on women with PCOS, and recent
large RCTs were unable to demonstrate any benefit, especially among those who
are overweight (see Chapters 4 and 7). Hyperinsulinaemia is often associated with
hyperandrogenism, and high androgen levels may contribute to a lower fertilisation
rate among the oocytes retrieved from women with PCOS compared with controls.
Therefore, co-treatment with metformin in IVF treatment was proposed as an adjunct
to improve the response to exogenous gonadotropins. Five RCTs exist to answer this
question, four of which used a GnRH agonist for down-regulation. The total dose
and duration of metformin use was not standardised, ranging from 500 mg twice a
day to 850 mg three times a day taken for up to 16 weeks, usually up to hCG trigger.
Fleming et al. [43] demonstrated that a protracted treatment of metformin over 4
months may decrease the antral follicle count and AMH levels; however, this treat-
ment was not shown to improve the number of oocytes retrieved or fertilisation rates.
Tang et al. [44] reported a significant improvement in LBRs for those taking metfor-
min over a much shorter time (from the commencement of GnRH agonist to the day
of hCG in a long protocol), with rates of 32.7% versus 12.2% in the placebo arm. The
lower-than-expected birth rate in the placebo group is difficult to explain and may be
secondary to subtle effects on oocyte/embryo quality or endometrial development.
Kjotrod et al. [45] corroborated the findings of Tang by suggesting that the LBR may
be improved in the lean women with PCOS. The consistent advantage of using met-
formin appears to be a reduction in OHSS, with an OR of 0.27 (95% CI 0.16–0.47,
p = .000044) in a recent Cochrane review [46]. The use of GnRH antagonists in IVF
protocols also reduces the risk of OHSS from 15% with placebo to 5% with metfor-
min [47]. Although promising, this study was inadequately powered to show a sig-
nificant improvement, and we are currently performing a prospective RCT to attempt
to answer this question. Metformin may reduce serum testosterone concentration and
free androgen index (FAI), and it is interesting to note that a negative correlation

exists between day 12 post-embryo transfer β-hCG levels and FAI. Alleviation of
hyperandrogenism and insulin resistance at the ovarian level may improve follicu-
logenesis and therefore the developmental potential of the embryo. Serum vascular
endothelial growth factor (VEGF) and oestradiol concentrations on the day of hCG
administration also are greatly reduced in women on metformin [44]. By ameliorat-
ing the expression of VEGF, the risk of OHSS can be reduced. Thus, although there
are variable data on the ability of metformin to not improve the take-home baby
rate after IVF, it does reduce the risk of moderate to severe OHSS in these high-risk
patients with PCOS.
Ovarian Cysts and IVF

The presence of simple cysts at the pre-treatment scan should be noted, and careful
surveillance instituted to ensure that they resolve spontaneously. Simple cysts do not
require drainage before treatment, provided they are not producing oestrogen and
preventing endometrial shedding. It is not unknown for ovarian malignancy to occur
in young women, and if there are any suspicious features (e.g. solid areas, multiple
septa), a measurement of CA125 should be made and the cysts should be treated
before IVF is commenced. Transvaginal aspiration of complicated cysts should not
be performed.
A few years ago, study was performed in which ovarian cysts that were encoun-
tered during IVF were divided into two categories: ovarian cysts present before and
after GnRH agonist therapy was commenced [48]. The outcome of IVF was studied
in both groups of patients who were randomly allocated either to having the cyst
aspirated or having it left alone. In the patients who had a baseline cyst, unrelated
to hormonal stimulation, the ovaries in which the cysts were aspirated developed a
greater number of follicles and hence eggs than the ovaries that were not aspirated.
There was however no difference in the total number of follicles or eggs between the
two patient groups. In contrast, the patients who developed cysts as a result of GnRH
agonist therapy had a comparable response to treatment in both ovaries, irrespective
of whether cyst aspiration was performed before ovarian stimulation. Aspiration of a
unilateral cyst does not therefore appear to improve either folliculogenesis or oocyte
recovery rates. We only advise aspiration if the cyst is hormonally active as evidenced
by failure of endometrial shedding.
Monitoring Therapy
Monitoring ovarian response to superovulation can be achieved by ultrasonography
alone. The dimensions of the growing follicles are plotted either daily or every other
day, from approximately day 8 of stimulation, together with a measurement of endo-
metrial thickness. The daily measurement of serum oestradiol concentrations is of little
help in the prediction of either success or the development of OHSS (see Chapter 18).
Furthermore, serum oestradiol concentrations appear to be proportional to the amount
of LH in the gonadotropin preparation used in the stimulation regimen. When FSH
alone is used to stimulate the ovaries, the serum oestradiol concentration is approxi-
mately one-half the level found when hMG is used in the long GnRH agonist protocol.

FIGURE 14.3 Transvaginal ultrasound scan of a stimulated ovary with three mature follicles seen
in this plane.
The pre-ovulatory hCG trigger is usually administered when the leading follicle is at
least 17–18 mm in diameter, and there are at least three follicles greater than 17 mm
(Figure 14.3).
Oocyte Retrieval
Ultrasound-guided oocyte retrieval is usually performed under light sedation plus
analgaesia; combinations of benzodiazepines, midazolam, opiates and sometimes pro-
pofol are given intravenously, with appropriate monitoring during and after the proce-
dure. Administration of a local anaesthetic (1% lidocaine (lignocaine)) into the vaginal
fornices is of additional benefit. The procedure should be pain free. The patient is
awake or lightly sedated and may be shown the oocytes on a closed circuit video moni-
tor attached to the embryologist’s microscope. Although it is possible for the patient’s
partner to be present, this presence is not my current practice because of variable stress
at seeing one’s partner sedated. It is appropriate however that both partners are present
at the embryo transfer. It is important that the patient is counselled carefully prior to
oocyte retrieval as the procedure can occasionally be painful. Anxious patients may
require heavy sedation or even general anaesthesia with the attention of an anaesthetist
(Figures 14.4 and 14.5).
Oocyte retrieval should take approximately 20 min. We use a double lumen
needle attached to an electronic pump, which enables rapid aspiration of each fol-
licle with minimal flushing. Indeed, we have found that repeated follicular flushing
produces oocytes that fertilise less well and produce poorer quality embryos than

(a)
(b)
(c)
FIGURE 14.4 Oocyte retrieval. (a) During the oocyte collection procedure, the ovary is magnified
further, and the needle guide (dotted line) indicates the track that the needle will take as it passes into
the ovary. (b) The needle enters a follicle. Its tip is seen as a small echodense area (arrow). (c) As the
follicular fluid is aspirated, the needle tip (solid arrow) can still be visualised within the collapsed
follicle. It is also possible to see the dotted line of the needle if the needle guide is removed from the
screen (open arrows).

Follicle aspiration
Channel for
flushing medium
Ultrasound
probe
Aspiration
channel
Follicular fluid
containing oocyte
Needle guide
Handle of ultrasound
probe
Needle
Ultrasound probe
(covered with protective
condom )
FIGURE 14.5 Oocyte collection.
oocytes that appear in the initial follicular aspirate and first flush, so we have aban-
doned flushing unless there are very few follicles and we are anticipating fewer than
five oocytes [49].
Patients considered to be at risk of developing the OHSS (see Chapter 18) must
be given an information sheet warning them of the symptoms that can occur,
because oral information will not suffice after sedative drugs have been given.
It is also essential that arrangements be made for a follow-up assessment after 3
and 5 days, particularly if the plan is to freeze all pre-embryos and defer embryo
transfer.
After oocyte retrieval, the semen is washed and prepared. Insemination is usu-
ally performed 1–6 h after oocyte retrieval with 50–200,000 motile spermatozoa
being placed with each oocyte; 16–18 h later the oocytes are examined to ensure
that correct fertilisation has occurred, as defined by the presence of two pronuclei
(Figures 14.6 through 14.10). Multiple pronuclei indicate polyspermic fertilisation or
digyny (i.e. failure to extrude the second polar body) and are not suitable for transfer.
Embryo Transfer
Embryo transfer (Figures 14.11 through 14.19) is usually performed 2–5 days after
oocyte collection (at anything from the four-cell stage to the blastocyst stage;

First division Second division

Prophase I Metaphase II
Leptotene Diakinesis First

polar
body
Zygotene Ovulation
Anaphase II
Metaphase I
In fetus
Pachytene
Diplotene Telophase II
Anaphase I
Dictyate stage
(meiotic arrest)
Two pronucleate
Telophase I pre-embryo
Second
polar
Germinal body
vesicle
FIGURE 14.6 Meiotic division of the oocyte. Prophase commences in fetal life. During zygotene
and pachytene, the homologous chromosomes pair and then cleave longitudinally, with potential
interchange of genetic material. During diplotene the chromosomes separate, except at the chias-
mata, and enter first meiotic arrest. Meiosis is resumed at the time of the LH surge just before ovula-
tion. The second meiotic division is then completed after fertilisation.
Figures 14.12 and 14.13). It has been suggested that delaying transfer from day 2 to
day 3 or even to the blastocyst stage (days 5–6) would allow for further development
of the embryo and might have a positive effect on pregnancy outcomes. Blastocyst
transfer is thought to reduce cellular stress on the embryo, enables synchronisation
of the embryo development with the endometrium and achieves transfer when uter-
ine contractions are reduced. Furthermore, embryo selection may be better at the
blastocyst stage, so when there are three or more good quality embryos on day 3 (the
eight-cell stage), it is beneficial to leave them in culture to day 5 and aim to transfer a
single embryo (as twin rates with double blastocyst transfer are approximately 50%).
Gardner and colleagues [50] have proposed sequential culture media to permit good
rates of blastocyst development. Other groups, in particular that of Leese (51) in York,
in conjunction with ourselves, also have been looking at embryo culture conditions to
improve embryo quality. By analysing the turnover of amino acids by single embryos
in culture using high-performance liquid chromatography, it is possible to distinguish
between embryos that are destined to progress to blastocysts from embryos whose
development will arrest, thereby enabling selection on day 2 or 3 for transfer. This
interesting finding is not only of clinical significance but also suggests that oocyte

a b c
Petri dish Droplet of culture medium

containing oocyte
and spermatozoa
FIGURE 14.7 In vitro fertilisation. (a) The washed oocyte is exposed to sperm. (b) Fertilisation is
observed. (c) The pre-embryo is drawn into the embryo transfer catheter. In vitro fertilisation is per-
formed either in a test tube or in a Petri dish in droplets of culture medium under a surface layer of oil.
FIGURE 14.8 (See colour insert.) Oocyte (arrow) immediately after follicular aspiration, covered
in cumulus cells.

FIGURE 14.9 (See colour insert.) Phase contrast microscopy of normal spermatozoa.
FIGURE 14.10 (See colour insert.) After fertilisation, two pronuclei can be seen clearly, and
spermatozoa can be seen attached to the outside of the zona pellucida.

FIGURE 14.11 (See colour insert.) Oocyte immediately after intracytoplasmic sperm injection
has been performed. The site of the passage of the needle can be seen clearly (open arrow), as can the
head of the spermatozoon (closed arrow).
FIGURE 14.12 (See colour insert.) Two-cell pre-embryo.

FIGURE 14.13 (See colour insert.) Four-cell pre-embryo.
FIGURE 14.14 (See colour insert.) Morula stage.

FIGURE 14.15 (See colour insert.) Blastocyst.
FIGURE 14.16 (See colour insert.) Blastocyst hatching.

FIGURE 14.17 (See colour insert.) Hatched blastocyst (on right).
FIGURE 14.18 Embryo transfer.
quality must play a major role in determining embryo viability as the activation of the
zygotic genome does not occur until the four- to eight-cell stage.
The Cochrane database has assessed the potential benefits of blastocyst transfer,
and 12 RCTs reported LBRs, with a significant improvement (1510 women, Peto OR
1.40, 95% CI 1.13–1.74) (day 2–3, 31%; day 5–6, 38.8%, I2 = 40%) [52]. This means
that for a typical rate of 31% in clinics that use early cleavage stage cycles, the rate

FIGURE 14.19 Embryo transfer catheter and syringe.
of live births would increase to 42% if clinics used blastocyst transfer. There are
however fewer embryos to freeze, so the studies that looked at cumulative pregnancy
rates (266 women, Peto OR 1.58, 95% CI 1.11–2.25) (day 2–3, 56.8%; day 5–6, 46.3%)
significantly favoured early cleavage [52].
Number of Embryos for Transfer

One major problem that has arisen from the growth of assisted conception treatment
in a competitive environment is the dramatic rise in multiple births. Triplets and
greater have been prevented by legislation introduced by the Human Fertilisation and
Embryology Authority (HFEA) in 2002 limiting the number of embryos transferred
to two for women under 40 year of age, as there is no evidence that the transfer of
three significantly increases the chance of pregnancy and recommends the transfer of
no more than three in women over the age of 40 (Table 14.3). However, the number
of twin pregnancies did not initially decline, which is why the HFEA in the United
Kingdom has presented targets for clinics to achieve a progressive reduction in the
multiple pregnancy rate. Many countries nowadays have a policy of elective single-
embryo transfer (eSET) for all good candidates (young patients under 35 years of
age in their first cycle). Evidence suggests that by adopting an eSET policy and cryo-
preserving the spare embryos for subsequent replacement if the initial cycle fails,
the LBR is not significantly different to that after a double-embryo transfer (DET),
and multiple pregnancy rates can be reduced to 5% [53,54]. Furthermore, there is a
significant cost benefit with respect to maternity and paediatric care [55,56]. The evi-
dence indicates that although the LBR in a single fresh treatment is higher after DET
than single-embryo transfer (SET) (OR 2.10, 95% CI 1.65–2.66; p < .00001), there is

TABLE 14.3
HFEA Data 2010
Age (Years) Pregnancy Rates (%) Live Birth Rates (%)
18–34 40.2 32.3
35–37 35.2 27.2
38–39 28.6 19.2
40–42 20.8 12.7
43–44 9.9 5.1
>45 3.9 1.5
All ages 33.4 25.2
Source: Fertility Treatment in 2010. Available from: http//www.HFEA.gov.uk.
Note: Treatment cycles started (IVF and ICSI) 45,264 women had a total of 57,652 cycles of IVF or
ICSI, resulting in 13,015 pregnancies.
no difference in cumulative live birth rates (CLBRs) after DET compared with SET
followed by transfer of a single frozen thawed embryo (OR 0.81, 95% CI 0.59–1.11;
p = .18) or two fresh cycles of SET (OR 1.23, 95% CI 0.56–2.69, p = .60) [57]. And,
not surprisingly, the multiple pregnancy rate is much lower after SET (OR 0.04, 95%
CI 0.01–0.11; p < .00001) [57].
Luteal Phase after IVF

The embryo transfer procedure usually takes 5–10 min. The procedure should be
performed under ultrasound guidance rather than using the clinical touch method, as
ultrasound guidance results in significant increase in ongoing pregnancy (OR 1.51,
95% CI 1.31–1.74) and LBRs (OR 1.78, 95% CI 1.19–2.67) [58]. After embryo transfer,
the patient can go about her normal daily activities. Indeed, inactivity is best avoided
as the 2 weeks up to the pregnancy test are hard for couples to cope with as they are
no longer attending the clinic for regular scans and monitoring. There is now good
evidence that luteal support improves outcome [59]. It is usual to provide luteal sup-
port until the results of the pregnancy test are known, and this itself can delay the
onset of menstruation and give the couple false hope. Luteal support can be provided
by either hCG or parenteral or vaginal progesterone (see Figure 14.2 for regimens).
The administration of hCG should be avoided if there is any risk of OHSS as it will
continue to stimulate the ovaries, whereas exogenous progesterone will, of course,
replace the secretion of the corpora lutea. Many clinics, including our own, have now
stopped giving hCG because OHSS is not always easy to predict.
There are a large number of protocols for luteal support, with hCG being given
every 2–5 days at doses of 1000–5000 units subcutaneously and/or progesterone
either 50–100 mg intramuscular daily or 200–800 mg vaginally daily. No one regi-
men or route of administration has been shown to be superior to another. Patients
appear to prefer vaginal progesterone to injections. We usually administer vaginal
progesterone 400 mg daily in all patients and stop on day 14 after embryo transfer
whether the pregnancy test is positive or negative. If parenteral progesterone is used,
the corpus luteum is more profoundly suppressed, so it should be continued until the
end of the first trimester of pregnancy.

There has been a vogue to consider the use of low-dose aspirin as a potential means to
improve implantation rates; however, a recent systematic reviews has failed to demon-
strate any benefit [60]. Furthermore, there is no evidence for a range of other adjunctive
therapies that have been proposed, often at significant financial cost to the patient.
Pregnancy Rates after IVF

Modifications to the treatment process, from superovulation strategies to create
a larger cohort of mature oocytes to the advances in culture technology to allow
embryos to thrive in the laboratory, have led to a steady increase in LBRs over the past
20 years, with the overall LBR per cycle in the United Kingdom greater than 25% per
cycle (Figures 14.20 and 14.21) [61]. Approximately 60,000 assisted conception treat-
ments are performed annually in the United Kingdom [61], resulting in approximately
35
30
Live birth rate (%)
25
20
15
10
5
0
22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45
Age (years)
1992 1996 2000 2004
FIGURE 14.20 Live birth rate per cycle started, for IVF cycles, 1991–2009 (From Fertility
Treatment in 2010. Available from: http//www.HFEA.gov.uk.).
30
25
20
15
10
0
Under 27–28 29–30 31–32 33–34 35–36 37–38 39–40 41–42 43–44 45 and
27 over
Age
IVF using own eggs
Micromanipulation (including ICSI) using own eggs
FIGURE 14.21 Live birth rate per cycle started related to the patient’s age, for IVF and ICSI cycles,
1991–2009 (From Fertility treatment in 2010. Available from: http//www.HFEA.gov.uk.).

2% of all births. There are huge variations in both provision and outcomes of assisted
conception treatments around Europe (and the globe).
A clinical pregnancy is defined as a rising level of hCG combined with ultrasound
visualisation of a gestational sac. Biochemical pregnancies are so named if hCG is
present in the serum (in the absence of exogenously administered hCG for luteal sup-
port), yet bleeding occurs before a gestational sac is seen on ultrasound. It is a sensible
convention not to include biochemical pregnancies in treatment results and care must
be taken when comparing the results of different clinics or studies to ensure that the
same definitions of pregnancy have been used.
The chance of a pregnancy after a single cycle of IVF is now approximately 30%–
40% in the larger units. The overall chance of twins or triplets is 22%, with most
now being twins. After the transfer of two pre-embryos, the triplet rate is virtually
abolished, and the twin rate remains at 15%–20%. The miscarriage rate is approxi-
mately 20%, and the chance of an ectopic pregnancy is approximately 5%.
The pregnancy rates achieved by IVF equate favourably with rates expected for a cou-
ple without infertility when adjusted for the age of the female partner. Cumulative con-
ception and LBRs, calculated by life-table analysis, provide the best form of comparison
between treatments, although they do not take into consideration couples who drop out
of treatment because they are perceived as having a poor chance or because they can-
not cope with the stresses of the therapy. The major factors that determine the chance
of an ongoing pregnancy are the age of the woman, with rates declining over the age of
35 years, increasing duration of infertility, low parity and number of oocytes collected
[62]. Basal FSH measurement is still considered to be a predictor, although may soon be
replaced by a measurement of AMH or an accurate assessment of antral follicle count
[63]. Not surprisingly, couples who have achieved a pregnancy are more likely to do so if
they try again. Indeed, many couples have now achieved their desired family size either
through repeated attempts at IVF or by the transfer of cryopreserved embryos obtained
in a previously successful or unsuccessful cycle of treatment (Box 14.1).
BOX 14.1 ASSISTED REPRODUCTION

TECHNOLOGY – KEY POINTS
• IVF is the endpoint treatment for many causes of infertility but should
not be abused or embarked upon too early.
• Assisted reproduction technology is stressful, expensive and carries
certain risks, which should not be underestimated.
• IVF is a test of fertilisation.
• Common regimens include pituitary desensitisation by using a long pro-
tocol with a GnRH agonist or short cycles with a GnRH antagonists.
• Age and baseline FSH are still the most commonly used predictors
of ovarian reserve, although AMH and antral follicle count provide
superior information.
• Micromanipulation techniques such as ICSI have revolutionised the
treatment of severe male factor infertility and couples with a history
of poor fertilisation in previous cycles.

Micromanipulation of Gametes for Severe Male Factor Infertility

Standard IVF requires the presence of more than 500,000 motile sperm in the total
ejaculate. In cases where the sperm count is lower, fertilisation can be assisted
by a variety of micromanipulation techniques. Initial attempts involved either
drilling through the zona with Tyrode solution (zona drilling) or by using a glass
m icroneedle (partial zona dissection (PZD); see Figure 14.23a). Alternatively,
several spermatozoa were injected into the perivitelline space beneath the zona
pellucida (subzonal insemination (SUZI); see Figures 14.22a and 14.23b). These
techniques have been superseded by ICSI, the injection of a single spermato-
zoon directly into the cytoplasm (ooplasm) of the oocyte (Figures 14.11, 14.22
and 14.23c). ICSI, pioneered by Van Steirteghem and his team in Brussels, has
revolutionised the management of male infertility and has provided the possibil-
ity of a pregnancy for men who previously would have required their partners to
undergo DI [64].
ICSI can be used not only for men with profound oligozoospermia or asthenotera-
tozoospermia but also for men with obstructive azoospermia, after microsurgical
or direct aspiration of sperm from either the epididymis or the testis. The sper-
matozoon is immobilised before ICSI, usually by breaking the tail, as flagellation
within the ooplasm is undesirable and only the genetic contents of the sperm head
are required.
Fertilisation rates with ICSI are 60%–70%, irrespective of the origin of the sperm,
providing 90% of couples with an embryo transfer and chance of a pregnancy.
Pregnancy rates after ICSI are the same as after IVF. ICSI can be offered to couples
in whom fertilisation has failed during IVF in the absence of an apparent sperm prob-
lem, as assessed by standard sperm function tests. Transcription in the human embryo
starts at the four- to eight-cell stage [65], so the signal for the first cleavage has to
be provided by an extranuclear signal, which arises from the surface of the sperm
(termed the cleavage signal (CS-1) protein). Thus, if fertilisation occurs but cleavage
fails, it also might be due to sperm dysfunction.
Micromanipulation of the embryo also can be performed in the form of assisted
hatching (Figure 14.23d), which is thought by some to improve implantation rates
for patients with previous IVF failures. There is no strong evidence however for
its use.
First
polar
body
Ooplasm
Nucleus of
Perivitilline
oocyte
space
a b
FIGURE 14.22 Microinjection of spermatozoa. (a) Subzonal insemination (SUZI), now no longer

performed and superseded by (b) intracytoplasmic sperm injection (ICSI).

(a)
(b)
FIGURE 14.23 Micromanipulation techniques. (a) Partial zona dissection (PZD): the oocyte
is held by a suction pipette while a glass needle is used to make a breach in the zona pellucida.
Spermatozoa can then find their way in through the opening. (b) Subzonal insemination (SUZI)
of sperm (SUZI).

(c)
(d)
FIGURE 14.23 (Continued) Micromanipulation techniques. (c) Intracytoplasmic sperm injection

(ICSI), which is nowadays the preferred technique. (d) Assisted hatching of a pre-embryo, a tech-
nique in which partial zona dissection (PZD) is used to aid the later hatching of the blastocysts from
embryos that have been generated in vitro.

Important Considerations on New Techniques

Recently, immature spermatids have been used for ICSI, thus opening up greater
possibilities for men with testicular dysfunction. When round spermatid nuclei are
injected into oocytes (ROSNI), spermatogenesis has not been completed and caution
has been expressed about the genetic integrity of immature sperm. These techniques
are not permitted in the United Kingdom. Various authorities have expressed concerns
about the use of micromanipulation techniques because we have limited knowledge
about the natural maturation process of spermatozoa and the ways in which sperm are
naturally selected for fertilisation. Most fertility therapies retain an element of natural
selection, whether it be ovulation induction or IVF; that is, only good eggs are likely
to become fertilised or result in good quality pre-embryos that are suitable for trans-
fer. We are not able to distinguish between good and poor quality sperm other than by
a crude assessment of morphology and nuclear condensation. There is some evidence
for an increased rate of strand breakages in the DNA of sperm from men with subfer-
tility, some of whom have cystic fibrosis or are carriers of cystic fibrosis mutations or
other recessive gene anomalies. Furthermore, the stage at which genomic imprinting
takes place is not known, and there is a suggestion that genes may be modified in the
epididymis – thus, distal to the site of aspirated testicular sperm. The data on children
born to date as a result of micromanipulation techniques are reassuring with respect
to major congenital abnormalities, but there is an increased rate of sex chromosome
anomalies and a suggestion that male children may have increased rates of infertility
themselves (for overview, see Chapter 17).
Cryopreservation of Gametes and Embryos

Cryopreservation of sperm is discussed in Chapter 12. Cryopreservation of oocytes has
become much more successful in the past 5 years, particularly with the development
of vitrification techniques as an alternative to slow freezing. Many pregnancies have
now been achieved, albeit with a lower overall return rate for the number of oocytes
frozen compared with outcomes after embryo cryopreservation. The main indication
for oocyte cryopreservation is for women who require chemotherapy or radiotherapy
that is likely to put them into an early menopause or oophorectomy. The concept of
fertility preservation for social reasons also has gained popularity and is somewhat
controversial, as this technique requires a healthy young woman to undergo cycle(s)
of ovarian stimulation to build up a store of oocytes for use at an older age, once, for
example, her career has become established. It is difficult to predict how many oocytes
may be required and how many cycles would give a realistic future chance of suc-
cess – women requiring urgent freezing before cancer therapy have only one chance
and so little choice about building up a large oocyte store in the freezer. Embryos are
more robust than oocytes during the freezing process, but, naturally, for embryos to
be created, the woman requires a male partner. Other options for fertility preservation
include the cryopreservation of ovarian tissue, removed at laparoscopy, followed by
re-implantation at a later stage or possibly in vitro culture of follicles (see Chapter 19).
Embryos are stored in liquid nitrogen at −196°C, at either the early cleavage stages
(days 2–3) or blastocyst stage (day 5). We prefer to store only good quality embryos.

FIGURE 14.24 (See colour insert.) Colour Doppler studies of the endometrium. Transvaginal
ultrasound (5 MHz) with superimposed pulsed Doppler demonstrating flow through subendometrial
vessels. Absent subendometrial or intraendometrial vascularisation on the day of hCG administra-
tion during IVF appears to be a useful predictor of failure of implantation in IVF cycles, irrespective
of the morphological appearance of the endometrium. (With thanks to Dr. J. Zaidi.)
Some clinics freeze a proportion of embryos on day 3 and leave the remainder for
continuous culture and day 5 transfer and further freezing if there are sufficient good
quality blastocysts. Embryo survival is approximately 70%, and if individual blas-
tomeres are damaged, as each is pluripotent, there appears to be no harmful effect
on the developing fetus. Thawed embryos are transferred 2–3 days after ovulation
in carefully monitored natural cycles or 3–5 days (depending upon the embryo
stage) after the commencement of progesterone therapy in artificial cycles in which
pre-treatment has been performed, first with a GnRH agonist and then with oral or
transdermal oestradiol that is administered until the endometrium has developed ade-
quately (Figure 14.24). Progesterone is then combined with oestradiol from 4 days to
6 days before transfer (depending upon the embryo stage). Both are continued until
the pregnancy test 2 weeks later and then to 12 weeks’ gestation if the treatment is
successful. Doppler flow studies of the uterine vasculature have been used to optimise
the timing of embryo transfer, although these techniques have not become common-
place in routine practice.
There has been an interesting recent proposal to electively cryopreserve embryos
rather than transfer them fresh, not only for women who are at risk of OHSS but also
potentially in all cycles as outcomes may be improved [66]. This is quite a departure
from the natural expectation of a fresh embryo transfer but may improve the prospects
not only of women at risk of OHSS but also of women having treatment in a GnRH
antagonist protocol.

Important Considerations
Embryo storage used to be limited by the HFEA to 5 years in the first instance, with
a possible extension for a further 5 years, although there is no evidence that dete-
rioration occurs beyond this time. In fact, it has been estimated that it would take
2000 years for background cosmic radiation levels to have a detrimental effect on
the genetic integrity of the cryopreserved cells. Children conceived from cryopre-
served embryos have similar rates of minor and major congenital abnormalities as
children conceived normally (see Chapter 17). Furthermore, the rates of pregnancy,
m iscarriage and congenital anomalies do not appear to be related to the duration
of embryo storage. The current statutory storage period is 10 years in the United
Kingdom, but the HFEA permits extension of storage with consent to the gamete
provider’s 55th birthday.
Oocyte Donation
See Chapter 9 for a description of oocyte donation.
Surrogacy
IVF surrogacy is an option for women with ovaries but without a uterus, either because
of a congenital absence (e.g. Rokitansky syndrome) or after hysterectomy (e.g. after
severe obstetric haemorrhage or cervical carcinoma), or for women for whom a preg-
nancy would be a medical risk (e.g. severe heart or lung disease). Sperm must be
frozen and quarantined for 6 months to reduce the risk of infection with Hepatitis (B
and C) or HIV. A standard IVF regimen is used and the surrogate host prepared as for
an FERC. Egg collection can sometimes be difficult if the ovaries are situated high in
the abdomen, in which case a transabdominal approach may be required.
Straight surrogacy is another option, less commonly performed, in which the sur-
rogate host donates her own oocytes either to be inseminated in vitro, in a standard
IVF protocol, or in vivo, in an IUI protocol.
There are strict regulations concerning surrogacy arrangements, and few clinics
offer this treatment because of ethical concerns and the complexities of the arrange-
ments. It is our experience that surrogacy can work extremely well and achieve higher
success rates than standard IVF. Key components of a successful programme are an
experienced counsellor and the selection of properly motivated surrogates who are
fully informed of all of the IVF processes, their risks and complications.
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35. Wang JX, Davies MJ, Norman RJ. Polycystic ovarian syndrome and the risk of spon-
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36. Fedorcsak P, Storeng R, Dale PO, Tanbo T, Abyholm T. Obesity is a risk factor for
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Fertil Steril 2013; 13: 168–73.

15
The Human Fertilisation and
Embryology Authority and Regulation
Introduction
The Human Fertilisation and Embryology Authority (HFEA) of the United Kingdom
was created in 1990 by the passage into law of the Human Fertilisation and Embryology
(HFE) Act. Its principal tasks are to licence and monitor clinics that carry out in vitro
fertilisation (IVF), donor insemination and research on human embryos. The HFEA
also regulates the storage of gametes (sperm and eggs) and embryos. By law, therefore,
these procedures may only take place in clinics licenced by the HFEA.
The HFEA has other statutory functions. It must produce a Code of Practice that
gives guidelines to clinics about the proper conduct of licenced activities; keep a
formal register of information about donors, treatments and children born from those
treatments; publicise its own role; and provide relevant advice and information to
patients, donors and clinics. The HFEA must keep under review information about
human embryos and their subsequent development and also the provision of treatment
services and activities governed by the HFE Act.
The HFEA is a quasi-autonomous non-governmental organisation (a quango) whose
members are appointed by the government of the day through the U.K. health ministers,
according to Nolan guidelines. Its members are neither elected nor appointed as
representatives of particular groups. By law, the chairman, deputy c hairman and at least
one-half of the authority’s members may not be involved in medical or scientific practice.
The members determine the authority’s policy and licence applications. The authority
has an executive responsible for implementing its policy and licencing decisions and
conducting its day-to-day activities. Seventy percent of the HFEA’s annual budget is
raised from licence fees. In 2013, a review of the functions of the HFEA has been initi-
ated after an initial proposal to subsume its activities into the Care Quality Commission.
The outcome of this review and the future restructuring that is likely to occur are awaited
with interest.
All licenced clinics require a person responsible who has specific responsibilities
to ensure the conditions of its licence are carried out. The centres must comply with
several statutory requirements and with the HFEA’s Code of Practice (see below). In
evaluating a clinic, the HFEA is enjoined to consider all relevant interests – including
those of patients, children, potential children, licenced clinics and the wider public –
and to take into account issues of safety, efficacy and ethics. Licences were originally
renewed annually. However, the HFEA has now determined that established clinics

can be issued with 3-year licences, recognising that a large proportion of clinics have
been licenced for many years and that, in general, compliance with the law and the
Code of Practice has been very good. A new clinic normally qualifies for a 3-year
licence only after it has achieved good compliance during its first 2 years.
Under the HFEA’s 3-year inspection cycle, each centre receives a broad-based
general inspection by a full team once in every 3 years, preceding renewal of its
licence. For interim or focused inspections, smaller teams are identified on a sys-
tematic basis, according to the nature and licencing history of the clinic. The team
examines the clinic’s compliance with the law, Code of Practice and any directions
previously made by the authority. It then submits a report to the licence committee
of the HFEA which determines whether or not a licence is to be granted and whether
any specific conditions are to be included. The authority also may undertake unan-
nounced visits and visits arranged at short notice. In addition, there are visits for
detailed audits of notes and data collection. There is not, however, a clearly defined
structure for an inspection; neither do clinics have to adhere to nationally agreed clini-
cal or laboratory-operating protocols. Nonetheless, it is recommended that each clinic
have a quality manager and quality systems in place which should be International
Organization for Standardization (ISO) accredited.
At the time of writing, 109 clinics are licenced by the HFEA for treatment and/
or storage of gametes and embryos. Satellite IVF (where clinical assessment, drug
therapy and monitoring take place at a secondary (satellite) centre, but egg retrieval,
embryology and embryo replacement are performed at a licenced primary centre)
and transport IVF (assessment, drug therapy, monitoring and egg retrieval take place
at the satellite centre, but embryology and embryo replacement at the primary centre)
do not in themselves require licencing. Nonetheless, centres offering these proce-
dures need written agreements with each of the satellites defining which of them is
responsible for assessment of welfare of the child, counselling, producing and provid-
ing patient information as well as completion of the HFEA and other consent forms.
Practitioners should be aware of the implication of breaching the HFE Act, the
directions of the HFEA, or the Code of Practice. Having made a preliminary inquiry
about whether there is prima facie evidence of a breach, the HFEA may take special-
ist, including legal advice. Its licence committee then decides on further action – and
may refer matters to the Director of Public Prosecutions. At the time of writing, two
cases have been referred to the police and, one licence has been revoked, although
several applications for new licences and variations to existing licences have been
refused. There is an appeal procedure that takes the form of a re-hearing and both the
clinic appealing and the licence committee can be represented. Ultimately, there is
right of appeal on points of law to the High Court.
The HFEA Register was started in 1991. It contains details of licenced treatments and
patient characteristics for the whole of the United Kingdom and is now the largest data-
base of its kind in the world. Since 1999, there has been a requirement to record addi-
tional information, especially regarding the storage of eggs and their subsequent use in
treatment. Modification of its software has been introduced for secure electronic transfer
of treatment data from clinics, which has phased out paper-based input. The register
provides clinical data for the Annual Report, which, inter alia, provides an overview
of national statistics of the outcome of licenced treatment. The Annual Report, Code
of Practice and the HFEA’s response to various issues are available free on its website

The Human Fertilisation and Embryology Authority and Regulation 367
(http://www.hfea.gov.uk). Publication of detailed, non-identifying data sets of treatments

and their outcomes is planned for the near future. The HFEA has published a Patients’
Guide to donor insemination (DI) and IVF clinics since 1995. In response to requests
from patients and others, the guide has been redesigned and separated into three book-
lets: The Patients’ Guide to Infertility and IVF, The Patients’ Guide to IVF Clinics, and
The Patients’ Guide to DI. The clinic data in these booklets are updated each year.
The HFEA maintains a manual for clinics, which provides guidance on comple-
tion of licence applications, details of the licencing process, representations and
appeals procedures, the licence structures, Code of Practice, the information clinics
are required to send to the HFEA, directions issued by the HFEA and relevant regula-
tions issued by Parliament. The Code of Practice is published, by law, by the HFEA, to
guide clinics on how they should carry out their licenced activities – currently, it is in
its eighth edition. The Code includes guidance on organisation, quality m anagement,
the assisted conception process, providing proper information, legal requirements for
consent, confidentiality, selection and screening of sperm donors, payment of expenses
to donors, handling and use of gametes and embryos; witnessing, centre staff and facil-
ities; welfare of the child; and what information and counselling should be offered.
The eighth revision of the Code of Practice was published in 2009 and last updated
in 2012. Each chapter of this comprehensive document is divided into a general s ection
applicable to all individuals and specific sections for people seeking treatment, people
providing gametes and embryos for donation, people seeking long-term storage of
gametes and people involved in egg-sharing arrangements (Box 15.1).
BOX 15.1 CONTENTS OF THE 8TH CODE OF PRACTICE

• Staff
1. Person Responsible
2. Staff
• Counselling
3. Counselling
• Information and consent
4. Information to be provided before consent
5. Consent to treatment, storage, donation, training and disclosure
of information
6. Legal parenthood
• Multiple births
7. Multiple births
• Welfare of the child
8. Welfare of the child
• Embryo testing
9. Pre-implantation genetic screening (PGS)
10. Embryo testing and sex selection
• Donation and surrogacy
11. Donor recruitment, assessment and screening
12. Egg-sharing arrangements
(continued)

BOX 15.1 (Continued) CONTENTS OF THE 8TH CODE OF PRACTICE

13. Payments for donors
14. Surrogacy
• Use of gametes and embryos
15. Procuring, processing and transporting gametes and embryos
16. Imports and exports
17. Storage of gametes and embryos
18. Witnessing and assuring patient and donor identification
19. Traceability
20. Donor assisted conception
21. Intra-cytoplasmic sperm injection (ICSI)
• Research and training
22. Research and training
• Facilities and administration
23. The quality management system
24. Third-party agreements
25. Premises and facilities
26. Equipment and materials
27. Adverse incidents
28. Complaints
• Treating people fairly
29. Treating people fairly
• Record keeping and other obligations
30. Confidentiality and privacy
31. Record keeping and document control
32. Obligations and reporting requirements of centres
Embryo Research
All research on human embryos must be licenced by the HFEA. An application must
be made for each project and applicants will need to convince the HFEA that human
embryos are necessary to fulfil the purposes of the investigation. Licences are only
granted if the research is designed to promote advances in the treatment of infertil-
ity, increase knowledge about the causes of congenital disease, increase knowledge
about the cause of miscarriage, develop more effective techniques for contraception
or develop methods for detecting the presence of gene or chromosome abnormali-
ties in embryos before implantation, increase k nowledge about the development of
embryos, increase knowledge about serious disease or enable such knowledge to be
applied in developing treatments for s erious disease.
The following activities are prohibited by law: keeping or using an embryo after
the appearance of the primitive streak or after 14 days, whichever is earlier; placing
a human embryo in a non-human animal; replacing a nucleus of a cell of an embryo
with a nucleus taken from the cell of another person or embryo; and altering the
genetic structure of any cell while it forms part of a human embryo.

Social and Ethical Issues

After public consultation, the HFEA concluded that, for infertility treatment, it is
acceptable to use only tissue from live donors. It does not approve the use of oocytes
obtained from adult cadavers nor the use of fetal ovarian tissue, although both sources
are acceptable for embryo research. The ban on using fetal eggs and embryos in infer-
tility treatment has been incorporated into the Criminal Justice and Public Order Bill,
so contravention of that ban would constitute a criminal offence.
The HFE Act states that no money or other benefit shall be given or received for
the supply of gametes or embryos, unless authorised by directions. In 2012, it became
permitted to compensate sperm donors with a fixed sum of up to £35 per clinic visit
and egg donors with a fixed sum of up to £750 per cycle of donation. And loss of earn-
ings or expenses for travel at a daily rate of £61.28 but with an overall limit of £250
for each course or cycle of donation. A maximum of 10 offspring may be derived from
a single sperm donor.
The statutory storage period for gametes and embryos is 10 and 5 years, respectively,
although embryo storage may be extended by a maximum of a further 5 years with
renewed consents. Regulations also allow the storage period for sperm and embryos
to be extended in certain circumstances.
Welfare of the Child

‘The welfare of any child who may be born as a result of the treatment (including
the need of that child for a father) and of any other child who may be affected by the
birth’ must be considered carefully before any treatment is offered. Although this
injunction relates to the particular rules of licencing under the HFE Act, it is such
an important position that in our opinion it should inform all types of infertility
treatment. In the HFE Act, the HFEA does not consider it precludes any particular
category of patient from receiving treatment, so single or lesbian women, unmarried
couples and post-menopausal women may all be treated. Factors that the HFEA,
through its Code of Practice, recommends for consideration include the following:
1. Commitment of the woman and her partner to having and bringing up

children
2. Ages and medical history of the partners
3. Risks, including inherited disorders, to the child to be born
4. Effect of a new baby on any existing child of the family.
Information
Licenced centres are obliged to provide details of treatment and its full cost,
the likelihood of success, risks and side effects, legal aspects (such as who
will be the legal parents (Box 15.2)). availability of counselling and the need

BOX 15.2 HFEA POLICY REVIEWS SINCE 2004

• Hybrids and chimeras
• Witnessing the identification of samples and patients/donors
• Donating eggs for research: safeguarding donors
• Standards for Assisted Conception Centres
The HFEA, in collaboration with the professional bodies of the assisted con-
ception sector, have drafted a set of Standards for Assisted Conception Centres.
These Standards include the technical requirements of the European Tissues
and Cells Directive which came into force on 7 April 2006.
• Multiple births and embryo transfer review

• Public attitudes to regulation in the United Kingdom
• Choices and boundaries – should people be able to select embryos
free from an inherited susceptibility to cancer?
• Tomorrow’s Children – Review of the HFEA’s guidance on Welfare
of the Child
• Sperm, Egg and Embryo Donation Review
• European Union (EU) Tissues and Cells Directive (EUTCD)
• Pre-implantation tissue typing
• Pre-implantation genetic diagnosis
• Sex selection
• Medical frontiers: debating mitochondria replacement
• National Donation Strategy Group
to consider the welfare of the child. One point that needs to be discussed about
costs is who will pay for the drugs; many general practitioners now refuse to sup-
ply National Health Service prescriptions to patients undergoing IVF in private
clinics.
Written information is essential and should be complemented by verbal expla-
nation. The provision of understandable information is of course a prerequisite of
obtaining informed consent.
Counselling
Although there is an obligation on the clinics to provide counselling, there is none
on the patients to accept it. Counselling by trained professionals should be the aim.
The code recognises three distinct types of counselling: implications counselling (to
ensure the person understands the implications for themselves, their family and for
children born as a result of the proposed treatment), support counselling and thera-
peutic counselling. The last includes helping people to adjust their expectations and
to accept their situation. It may continue after the course of treatment has ended.

Therapeutic counselling requires professional trained workers (see Chapter 6).

The code also recognises the need for genetic counselling.
Consent
Written consent is required for centres to store gametes, to use them for IVF or the
treatment of other women. Informed consent implies that the individual has been
provided with relevant information and has had an opportunity to receive counselling.
The HFEA has issued standard forms for consent both to treatment and for the use of
gametes. In most cases, it is appropriate to obtain consent from both partners. Anyone
consenting to storage of gametes or embryos must specify the maximum period (nor-
mally 10 years) and what is to be done with the gametes or embryos if they themselves
die or become incapable of varying or revoking their consent. Insemination with the
late partner’s or husband’s sperm is permitted under the HFE Act, but for it to take
place the man must have given written consent for its post-humous use. It is important
to realise that the act states that such a man is not to be regarded in law as the father
of offspring so produced.
Confidentiality
The HFE Act imposes a statutory limit on the disclosure of information so that, with a
few exceptions, it is a criminal offence to disclose, without the consent of the individ-
ual, information about the treatment of any identifiable person by IVF or DI, storage
of gametes or embryos from any identifiable person or the identity of anyone born as
a result of treatment. Information may, however, be disclosed in connection with legal
proceedings, to the HFEA or to another licenced centre in connection with treatment
or to avert imminent danger to the health of the patient. The importance of the last
reason is that it is permissible to supply information to the local hospital concerning
the risks to a patient of developing, say, the ovarian hyperstimulation syndrome. Most
clinics find it helpful to provide the couple with all the relevant information in the
form of a letter which can then be used as they wish.
All personnel working in an assisted conception unit must be aware of the HFEA
Code of Practice and, ideally, should have read it. Similarly, all personnel who have
access to identifying information have to appear on the clinic’s licence, whether
healthcare professional, scientist, administrator, secretary, receptionist or cleaner.
Register of Information
The HFEA must by law keep a register of information about people undergoing
licenced treatments and about donors. To compile this register, licenced clinics must
provide the HFEA with specified information on all cycles of treatment by IVF or DI.
The original purpose of this register was to inform adults (for these purposes defined
as people over the age of 18 years, or 16 years if they wish to marry) who can check
whether they are related to someone they want to marry and to give people who are

born as a result of the use of donated gametes some limited information about the
donor.
Names of children born as a result of treatment are not collected, although their
National Health Service (NHS) number should be recorded, which serves as a unique
identifier. It is now possible too for donor-conceived children to find out the identity
of the donor(s) – whether sperm, egg, or embryo – when they have reached the age of
18 years. This possibility has certainly led to the reduction in donors coming forward
to help infertile couples.

Pre-implantation genetic diagnosis (PGD) is used to detect whether an embryo cre-
ated in vitro is carrying a genetic defect that will give rise to a serious inherited
genetic disorder. It also can be used to determine the sex of an embryo where a family
is at risk of passing on a serious sex-linked disorder, such as Duchenne’s muscular
dystrophy.
The HFEA and the Advisory Committee on Genetic Testing (ACGT), a body that
was absorbed by the Human Genetics Commission (HGC), issued a consultation
paper on the issues surrounding the use of PGD at the end of 1999. In February
2002, the HFEA gave permission for an IVF clinic to use PGD and tissue typing
to select an embryo free from a particular disease that would genetically match an
existing relative. The particular circumstances of the case concerned the hopes of
the parents of a 3-year-old boy with β-thalassemia major, their wish being to cre-
ate a child who could be a cell donor for his sick brother. The plan was to use PGD
to select disease-free embryos followed by tissue typing to ensure a genetic match
to the existing child. The parents’ hope was that stem cells taken from the umbili-
cal cord of the resulting baby could be transplanted into his brother to avoid his
need for blood transfusion and marrow transplantation. The HFEA held a wider
consultation and published its findings in 2006 [1]. To quote from their summary
statement, ‘The HFEA has considered the use of pre-implantation genetic diagnosis
(PGD) for inherited, lower penetrance, conditions (conditions that only manifest in
a subset of the people that inherit a faulty copy of a particular gene). The condi-
tions in question are primarily caused by a fault in one specific gene (single-gene
disorder) and although other factors may contribute, the presence of the faulty gene
significantly increases the chance of an individual developing a serious disease
such as cancer. The Authority recognises that inherited forms of these diseases
are rare (less than 10 per cent of cases of breast and bowel cancer are thought to be
inherited). Carrying the faulty gene can cause significant anxiety which is not less-
ened by the fact that the condition is not fully penetrant. The Authority considers
conditions of this type to be serious genetic conditions. It also recognises that the
impact of carrying a gene that increases risk of developing a given condition dif-
fers between individuals. The impact can differ both in terms of how an individual
might perceive the risk as well as, more practically, the way that the condition will
manifest in any particular family. Therefore the Authority considers it essential
that the views of the individuals seeking treatment be taken into account in the
decision-making process. The HFEA believes that, in principle, it is appropriate

that PGD be available for serious, lower penetrance, later-onset genetic conditions
such as inherited breast, bowel and ovarian cancer. This decision does not fetter
the discretion of a License Committee which will consider the individual merits
of each application. The Authority decided that applications for lower penetrance
conditions should initially be considered on a case-by-case basis because of the dif-
ference in the way that families are affected by these conditions and also because
this is a new class of PGD conditions. This will be reviewed in two years when the
Authority has more knowledge and experience of dealing with such applications.
The HFEA plans to consider applications in which PGD is used for the sole benefit
of a relative on a case-by-case basis’ [1].
Egg Freezing
The HFEA supports licencing of this procedure and allows frozen eggs to be used
in IVF treatment. The HFEA has insisted that clinics offering this treatment must
inform patients of any risks involved and also give clear information about the s uccess
rate.
Cloning
In 1998, the HFEA held a joint consultation with the Human Genetics Advisory
Commission on human cloning (see Chapter 19). The ensuing report distinguished
between reproductive cloning and in vitro work using cell nucleus replacement tech-
nology with a therapeutic aim. The report recommended that, while reproductive
cloning should not take place, therapeutic cloning may hold promise for the treatment
of serious illnesses. Specifically, the report recommended to the Secretary of State
that consideration should be given to specifying in regulations two further categories
for which HFEA-licenced embryo research may take place:
• Developing methods of therapy for mitochondrial diseases

• Developing methods of therapy for diseased or damaged tissues or organs
In June 1999, the government announced the creation of an advisory group under
the Chief Medical Officer to examine further the potential benefits, risks and alter-
natives to therapeutic cloning. That group’s recommendations were endorsed by the
government in August 2000, and the following year, Parliament agreed that its rec-
ommendations should be implemented. In 2006–2007, there was a consultation on
the creation of hybrids and chimeras [2]. To quote from the conclusions of the report,
‘The general view was that currently there is no reason why scientists would want to
create human transgenic embryos, true hybrids or human chimera embryos. There
is evidence for success of these techniques in animal studies, so in theory it could
be technically possible to create such entities using animal material and researchers
will at some stage have good reasons to conduct research involving the creation of
human–human transgenic embryos. These techniques could facilitate the investiga-
tion of gene function in early embryo development or, for example, a gene could be

introduced in a human embryo to increase the efficiency of the derivation of stem

cells [2].
The use of adult cord blood stem cells has been suggested as a viable alternative to
the derivation of embryonic stem (ES) cells from human–animal embryos, and was
cited throughout the course of the consultation. Although the use of adult and cord
blood stem cells is already established in a number of treatments, including bone mar-
row, skin and corneal transplants, unlike ES cells they are limited in the types of cell
or tissue they can give rise to. Research into expanding the types of cells that adult and
cord blood stem cells can give rise to is at a preliminary stage and the mechanisms
involved are poorly understood. The technique of directly reprogramming somatic
cells to produce embryonic-like stem cells was also identified as an alternative option
to creating human–animal embryos. Recent success has been achieved with this tech-
nique in mice; however, research is still at a very early stage and there has been no
success in humans. The conclusion by the HFEA were that individual research teams
should be able to undertake research projects involving the creation of cytoplasmic
hybrid embryos if they can demonstrate, to the satisfaction of an HFEA licence com-
mittee, that their planned research project is both necessary and desirable. They must
also meet the overall standards required by the HFEA for any embryo research’ [2].
Egg Sharing
Egg sharing is an arrangement whereby a woman receives free or subsidised IVF
treatment in return for donating her surplus eggs (see Chapter 9). The HFEA per-
mits egg sharing and has issued guidance on how it should be regulated. Its guid-
ance is based on two general principles. The first principle requires that two separate
agreements are prepared, one agreement between the egg provider and the centre and
the other agreement between the recipient and the centre. The second principle con-
cerns the treatment of the egg provider when only a few eggs are available. The guid-
ance provides that, where there are fewer eggs collected than the minimum needed
for sharing, the provider should be given the option of using all of her eggs at no
additional cost to herself and with no further commitment. This principle must be
reflected in the agreements between the centre and the provider and recipient. The
issues are discussed in detail in Chapter 16.
REFERENCES
1. HFEA. The Use of PGD for Lower Penetrance, Later Onset Inherited Conditions.
2006. Available from: http://www.hfea.gov.uk.
2. HFEA. Hybrids and Chimeras. A Report on the Findings of the Consultation. 2007.
Available from: http://www.hfea.gov.uk.

16
Ethical Issues
Introduction
In this book, we do not offer a treatise on all aspects of the ethics of reproduction,
nor do we offer a prescription for each individual problem, but rather we attempt to
indicate broad areas that are helpful to consider when responding to the ethical issues
that often arise in infertility practice. Some of our discussion is general and reflects
familiar issues of medical ethics. Some is particular to reproductive medicine and
therefore requires knowledge of biology and reproductive technology.
The overall principles that inform any discussion of medical ethics include respect
for the autonomy of the patient, together with the concepts of beneficence and j ustice.
Respect for our patients’ autonomy obliges us to ensure that those giving consent
to treatment are fully informed and that confidentiality of their consultations is
guaranteed. Beneficence involves considering the welfare of others and doing no
harm. The problem, of course, is whose welfare are we talking about. For example,
can zygotes and pre-embryos enjoy benefit or suffer harm? It is commonplace in
infertility practice to place the physical harm risked by a potential mother against the
psychological benefit that a successful outcome of treatment will bring to the couple,
so we also have to think about the relative weight we apply to such benefit and harm.
When we turn to the issue of justice, we have to consider the fairness of the distri-
bution of benefits and harm. We also must consider social and financial implications
of fairness. Is a society behaving fairly when it makes the solution of a biological
problem such as infertility only available to those who can afford it? There is no doubt
that in the United Kingdom some health authorities regard in vitro fertilisation (IVF)
as a luxury form of treatment, on a parallel with the removal of tattoos and other
cosmetic procedures.
Philosophically and politically, beneficence is always uppermost for utilitarians. So
far as the libertarian is concerned, the patient’s autonomy dominates. For egalitarians,
justice is the driving force. Most people adopt a position that attempts to accom-
modate these principles in a kind of creative tension. Naturally, the extent to which
any one of them is emphasised differs between individuals, groups and, indeed,
countries. For example, in the United States, with its strong tradition of libertarian-
ism, issues of autonomy often dominate over egalitarianism. The overall feel of the
American approach to infertility treatment is facilitative rather than regulatory and
even now, so many years after the invention of IVF and with so many fertility-related
ethical issues identified and medicolegal disputes exposed, the United States does
not have a national agency for the regulation of assisted reproduction. In contrast,

policy in the United Kingdom has taken quite a proscriptive pathway and, as can be
seen in Chapter 15, departures from the Code of Practice of the Human Fertilisation
and Embryology Authority (HFEA) may breach the Criminal Justice Act and so be
punishable under criminal law. It is worth reflecting on what has determined the dif-
ference between the increasingly regulated position developing in Europe compared
with the situation in the United States and on whether the difference will have an
impact on such vital subjects as the regulation of cloning and stem cell research.
Does Everyone Have a Right to Treatment?

Two issues that will always be central to any consideration of the ethics of r eproduction
are who has the right to reproduce and to what extent this right has to be balanced
against the welfare of a child born as a result of the treatment. Generally, in most
societies a married heterosexual couple in a stable relationship is considered to
provide the most appropriate environment for rearing children. Alternatively, most
people recognise that legal marriage offers no guarantee of a suitable environment
and that couples and, some would argue, even individuals who are not married
may not only assert a moral right to be parents but, in fact, provide a satisfactory
environment in which to bring up children. Although many people feel that some
of the advanced technologies now used in fertility therapy challenge the meaning of
family, the challenge does not really come from technology but rather from social
changes which, in parts of the Western world, have resulted in divorce rates as high
as 50%. There are increasing numbers of single parents who have conceived their
children per via naturalis. The experience, therefore, of an increasing proportion of
our population is of a family life that has not included all the traditional components.
Increasingly fertility specialists are being asked to treat unmarried heterosexual
couples, homosexual couples and single women.
Although few would wish to limit the rights of married couples to have children,
concerns about duties to extracorporeal embryos and for the welfare of the offspring,
the family and the donors and surrogates have added strength when they also involve
unmarried, single or homosexual people requesting infertility treatment [1–4]. In the
United Kingdom, the view of the HFEA has been that, providing the medical team
considers that the usual criteria in relation to the welfare of the child can be met (see
Chapter 15), there need be no proscription of such treatments for unmarried couples
and single women. At the same time, it is also accepted that the moral discretion of
those providing treatment has to be respected, too, and there is no legal obligation to
treat.
Generally, lesbian women have been refused fertility treatment (usually, of course,
donor insemination) on the grounds that they would not provide an appropriate f amily
environment because the child would have two mothers (but no father), would be
genetically unrelated to one of the mothers and the donor would be unknown to both
of them. For single, heterosexual mothers, it has been argued that the lack of a father,
together with the use of an anonymous donor, might lead to psychological difficulties
for the child. People have questioned the suitability of a woman who is not involved
in an intimate relationship with a man to be a mother. In fact, there are empirical
data concerning these matters, and the continuing studies of Golombok and Tasker

Ethical Issues 377
[1] have not indicated that such children are at any particular risk for psychological
problems. It is, after all, most likely that it is the quality of parenting that is i mportant.
In general, quality of parenting seems very good in people undergoing fertility treat-
ment. In contrast, at present there are still few empirical data about the outcome of
being conceived using semen from an anonymous donor or, indeed, from a known
donor.
Biological Considerations
Much of the ethics of infertility therapy has been developed in response to advances in
IVF technology. The principles are, nonetheless, firmly rooted and they can often use-
fully be applied to other aspects of reproduction. It is necessary, however, to p recede
discussion with a brief reminder of the biology, so that the terminology clarifies rather
than confuses. Such definitions of terminology also may help in avoiding concepts
that relate to a fetus (often derived from our thinking about termination of pregnancy)
being applied to discussions about embryos and pre-embryos.
Fusion of gametes (sperm and egg) results in formation of the zygote, the fertilised
egg that has the potential to develop into a human being to whom ultimately the full
status and rights of a citizen are accorded. Only one-quarter to one-third of zygotes
are thought to develop into a newborn infant. The full developmental potential of a
zygote is therefore limited by the risks of prenatal development, childbirth, childhood
and early adult life. The statistics of these risks are, of course, influenced by many
factors. Some of them are quite unknown, but others are related to circumstances that
are entirely within our own gift. Examples would be the extent to which a person’s
potential is eroded by, for example, poverty, an inclement environment, malnutrition,
pollution, poor schooling and disease.
The zygote undergoes cleavage to produce the eight-cell blastomere, further
development of which produces an outer layer, which is extraembryonic and becomes
the placenta, and an inner layer, which becomes the embryo. It is the blastocyst whose
outer layer loses its pluripotentiality first and interacts with the mother. In the second
week after fertilisation, the inner cell mass is organised first into two and then into
three layers, with the development of the primitive streak. It is at this stage that the
pre-embryo is committed, in the sense that it loses its capacity to undergo twinning.
The zygote and early blastocyst are, therefore, pre-embryonic but it is the embryo
which is the rudiment of the whole unique human being. Uniqueness is firmly estab-
lished when the embryonic axis is formed approximately 2 weeks after fertilisation
and, after this time, twinning and mosaicism are thought not to occur.
Moral Status of the Pre-Embryo

When we consider the issue of the status to be accorded to the products of c onception,
it is clear that there are at least two opposed positions (by status, one means the
accepted manner in which an individual is treated within society). In most p luralistic
societies, status is progressive in the sense that a hierarchy is accepted in which pro-
gressive status is given to gametes, the zygote, the pre-embryo, the embryo, the fetus

and then finally to the newborn infant. In some traditions (notably the Roman
Catholic Church), full status is accorded to the zygote. When the latter p osition is
adopted, it becomes easy to understand why any kind of manipulation of pre-embryos
is unacceptable.
The moral status of human pre-embryos may be viewed in three ways. The first, as
mentioned immediately above, is that full human status is accorded from the moment
of fertilisation. The arguments in favour of this position are that a new genotype has
been established at the point of fertilisation and some of these zygotes will develop
into full-term babies and adult humans whose autonomy requires protection through-
out life. An alternative and equally polarised position is that the fertilised egg has
no moral status whatsoever and that, of course, means we have no obligations to
it at all. Arguments in favour of this point of view are that, at best, only 40% of
pre-embryos that have been produced naturally develop into live infants; that, as
described above, biological individuality is not established until the development of
the primitive streak; and, finally, that the pre-embryo is an undifferentiated entity,
made up of cells which are each totipotent. This collection of cells is without limbs,
organs or sentience.
Not surprisingly, there is a third position which accords some moral status to the
pre-embryo because of its unique genotype and its potential to develop into a sentient
human being. This attitude differentiates the pre-embryo from a collection of cells
that form a tissue, for example, a piece of skin (skin cells are not embryonic). It must
be accepted, however, that this intermediate position is not without its own problems.
Although it obliges one to strive to improve the medicine of infertility therapy, the
very notion of improvement implies a sense that we may value one pre-embryo over
another. Life is, therefore, not seen as a gift with its own intrinsic value but as a gift
of potential significance that can be modified or disposed of if it does not meet some
notion of quality. From this perspective, one can see how rapidly the very first ele-
ments of life may be developed into a commodity. That this is not merely a theoretical
notion is illustrated by events that took place in the United Kingdom in the summer
of 1996 when, as a result of fertility therapy (ovulation induction, not IVF), a woman
became pregnant with eight fetuses. A contract between the pregnant woman and a
national newspaper was made, such that in return for her story, she would receive
£125,000 per delivered fetus. It is this fear that a fertilised human egg will become a
means to another end, a commodity, rather than an end in itself (i.e. a child wanted
for its own sake) that underlies much public anxiety surrounding cloning and the use
of embryonic stem cells.
Is IVF Ethical?
So far as the major religions are concerned, IVF and embryo transfer are acceptable
within the framework of a marital relationship to Judaism, Islam, part of Christianity,
Hinduism and Buddhism. The Roman Catholic Church considers that, for the rea-
sons indicated above, IVF involves a disregard for the sanctity of human life (life
being defined here as starting at the moment of fertilisation). Moreover, the IVF
procedure separates procreation from sexual union, that is, it takes it away from an
act of love. Other objections that have been raised to the IVF procedure are that it

Ethical Issues 379
involves the possibility of harm to the progeny, that is, it involves exposing others
(the pre-embryo) to a risk of harm for which consent has not (cannot) been obtained.
Even if we apply the hierarchical view of the status of the products of conception
elaborated above, we have to accept that the resulting child has accepted a risk, in part
at least, for the benefit of its parents.
It has been argued that IVF is but one step down a slippery slope that will permit
strange variants of the procedure which themselves will not prove acceptable. Slippery
slope arguments are, of course, the very stuff of philosophy and, in our opinion, do
not constitute a very powerful argument against IVF. However, they do emphasise the
importance of thinking through its implications. It also has been argued that because
infertility is not life threatening, we should not permit medicalisation of what is not
seen as a medical problem. In our opinion, the view that medical therapy is only to
be used for life-threatening conditions is nonsense. Few medical interventions are life
saving, although it is to be hoped that all bring comfort. A general objection often
raised is that IVF involves the use of medical resources to provide more offspring to
an overpopulated world. In our view, this sets a perceived need of that vague entity,
the world, to have fewer people against the immediate and actual right of an indi-
vidual family to fulfil its reproductive potential.
In accord, then, with most of the major bodies that have offered opinions on the
subject – the Ethical Committee of International Federation of Gynaecology and
Obstetrics (FIGO), the American Society of Reproductive Medicine [5], the HFEA
and the majority of religions – we consider that IVF is ethically acceptable. However,
it has to be recognised that the major religions find third-party involvement in fertility
therapy objectionable.
Experiments on Human Pre-Embryos, Cloning and

Stem Cell Research
No one approves of experiments on people who have not given their consent, so one
of the fundamental questions about research on pre-embryos is concerned with our
notion of when the products of conception become human. For those who believe
that the sanctity of human life begins with fertilisation of an egg, experiments on
pre-embryos cannot be considered. For those who consider that development of the
primitive streak marks the stage at which the pre-embryo is committed, experimen-
tation up to this stage, that is, 14 days after fertilisation, is acceptable. Differences
between those who advocate and those who forbid experiments on the products of
conception are therefore not so much ethical, more to do with when human life is
perceived to have become established.
In contrast, the possibility of creating children as a result of experimental manipu-
lation of human gametes has alarmed most people, and almost every country that has
passed legislation on assisted human reproduction has banned human reproductive
cloning on pain of severe penalties. There are several reasons underlying this fear,
first and foremost of which is recognition that in the present state of knowledge it is
not safe to use such techniques to create a human being. Even if our worries about
safety could be resolved, there remain significant concerns about the impact of clon-
ing technology on individuals and society.

Clones are defined as a group of living organisms sharing the same nuclear gene
set. They are essentially monozygotic twins formed by biological manipulation [6].
In animals, two experimental methods have been used to produce cloned embryos:
nuclear splitting and nuclear transfer. It is the latter that has been the subject of most
of the published debate because it offers the possibility of creating a cloned embryo
with a nucleus from a chosen source. The possibility therefore exists of m anipulating
the nuclear genome before transferring it to the enucleated oocyte, so creating an
animal with a genome that can serve medical needs, for example, one that produces
large quantities of a protein needed for clinical purposes. The science of animal clon-
ing is still in its infancy, with many practical issues remaining unresolved at the time
of writing.
Most countries have banned human reproductive cloning, but the position with
regard to the creation of cloned embryos for therapeutic purposes (essentially to
obtain stem cells) is still evolving. Stem cells are tissue precursors that have two
contrasting abilities: they can self-renew and they can differentiate into more spe-
cialised cell types. In the embryo, stem cells are pluripotent, capable of giving rise
to any of the 200 or so human cell types. In the adult, stem cells are more committed
(termed multipotent) and their differentiation is more restricted. In general, their abil-
ity to self-renew is inversely related to the degree of differentiation. Stem cell therapy
is not new – it has been used in bone marrow transplantation and in the treatment of
Parkinson’s disease for some years – but it is the potential use of stem cells obtained
from human blastocysts created in vitro that has occasioned concern. The debate is
largely concerned with the extent to which we consider human embryos and fetuses to
have a right to protection, a debate that rehearses many of the issues raised earlier in
this chapter concerning the moral status we accord the human embryo [7,8]. There is
a further concern over the potential commercialisation of unborn humans – c reating
human embryos to save lives is one thing, creating them to make money quite another.
Although there are biological advantages of using fetal and embryonic stem cells
(e.g. they can be obtained relatively free of contamination from other cells, they have
the potential to multiply indefinitely in the laboratory so one cell line might be able to
treat many patients, theoretically they can be directed to differentiate into any of the
cell types the patient might need), ethical and logistical concerns mean that studies of
stem cells derived from adult tissues continue to be required. Stem cell research using
human embryos was approved in the United Kingdom by Parliament in 2001 by an
extension of the Human Fertility and Embryology Act.
Donors and Donation

Donor sperm, donor oocytes and donor embryos have become an integral part of the
modern management of infertility and nearly 25,000 babies have been born as a result
of donations since the HFEA register was set up in 1991. Indications for the various
donations go beyond the management of infertility and now include families with
genetic disorders. Oocyte donation is usually performed for women without gonadal
function (i.e. those with premature ovarian failure) or for women who do have intact
gonadal function but who have inherited diseases that can be avoided by oocyte
donation. Conditions requiring embryo donation include infertility, habitual abortion

Ethical Issues 381
and genetic diseases. The interests of the child, the recipients and the donors must
all be considered. In some countries, donation of genetic material to single women is
forbidden; where the practice is allowed, regulations cover the relationships between
biological and social parents, the banking and disposal of genetic material, the inter-
ests of the child and the maintenance of medical records (for the position in the
United Kingdom, see Chapter 15).
An important issue concerning third-party involvement in infertility treatment is
that of payment to donors or, indeed, to surrogates [4]. Several approaches can be
considered. In France and New Zealand, such donations are seen as genuine gifts,
a public service performed with no thought of compensation either in the form of a
reward or even for expenses. The position is similar to that for blood donation in the
United Kingdom. An alternative is payment for expenses but not for the donation itself.
Another possibility is that the donor receives a reasonable reward as recompense for
the time, pain (egg donors only) and inconvenience of the donation, processes that
clearly vary between men, women and surrogates. Suggestions have been made that a
reward be given for gametes, for pre-embryos or, indeed, for infants.
We think it unlikely that anyone would have difficulty in rejecting the idea of
payment for an infant. Payment for a pre-embryo implies no respect for its human-
ity and payment for gametes dehumanises them and turns them into a commodity.
The Ethics Committee of the American Society of Reproductive Medicine accepts
as ethical a reasonable reward for time and inconvenience. In the United Kingdom,
payment may be made for reasonable expenses together with a small sum for the
donation.
A recent development in the field of gamete provision is a procedure its originators
have termed egg sharing. Egg sharing is an arrangement whereby a woman
obtains free or subsidised IVF treatment in return for donating her surplus eggs.
The procedure, which has been fuelled by the universal scarcity of volunteer egg
donors, has c ertainly resulted in an increase in the number of women who require
egg donation being treated. Its proponents argue that because the donor is already
undergoing t reatment, egg sharing obviates the need for healthy volunteers to undergo
ovarian stimulation and oocyte retrieval and so avoids placing them at risk from
these procedures. Moreover, it is argued, the arrangement avoids wasting surplus but
precious human eggs.
As mentioned in Chapter 15, the egg-sharing procedure is accepted by the HFEA,
providing certain practical procedures are adhered to. However, we, do not find
the arguments in favour of egg sharing particularly persuasive. First, the donor is
required to provide her eggs in return for receiving a service she would otherwise
have to pay for, raising straightaway concern about the potential exploitation of those
who yearn for a treatment they cannot afford. We cannot but note wryly its propo-
nents’ use of the term sharing to describe a situation in which a commodity is given
as barter for a course of medical treatment. It does seem to us that at least some of the
eggs retrieved (i.e. those provided in return for payment for the course of treatment
the donor is undergoing) may be regarded as closer to means (in this case, subsidised
IVF) than to ends. The HFEA’s guidelines do specifically address management of the
case in which the donor’s ovaries do not produce sufficient eggs for sharing to proceed
(see Chapter 15). Alternatively, it is not difficult to imagine a scenario in which both
doctor and potential egg provider might be tempted, albeit for different reasons, to

elect for more powerful treatment than would have been required if simple IVF were
being performed.
Gamete donation is anonymous in the United Kingdom, except when it has
been intentionally undertaken between people who know each other. The Human
Fertilisation and Embryology Act 1990 makes unauthorised disclosure of donors’
names a criminal offense with a maximum penalty of 2 years’ imprisonment and
a fine. Moreover, the law does not allow children who apply for information from
the HFEA register to know the identity of current or past donors. The only people
allowed to know a donor’s name are members and employees of the HFEA and
staff covered by an HFEA licence at the clinic or storage centre. In recent years,
however, there has been considerable pressure from some of the people born as a
result of donated gametes to learn more about their genetic origins. They point to
the anomaly that adopted children gain the right of information about their birth
parents but that children born from donor gametes are denied it. There can be little
doubt that for some people their sense of personal identity is distressingly incom-
plete without this knowledge, a situation revealingly described by George Eliot in
the Victorian novel Daniel Deronda. In present times, one has only to consider the
promises held out by the Human Genome Project to understand the health implica-
tions of withholding from people information about their genetic provenance. We
find it difficult therefore to understand how the welfare of the child is best served by
denying that person such fundamental i nformation. Arguments about protecting the
donor seem to have had little purchase when applied to birth parents of adoptees,
and there seems no reason why donors could not be afforded the same legal protec-
tion that they have. For many clinicians, the most compelling reason for anonymity
has been the fear that if donors were to have their identity revealed, they would
cease to donate. This argument seems to us to prioritise the maintenance of a treat-
ment programme and the procreation of future children over the needs of existing
people, to place the needs of the adults involved in assisted conception programmes
over the interests and rights of the children born through their efforts. There are,
moreover, empirical data to show that, where access to donor information has been
made available, the service has not collapsed, rather there has been a shift in the
donor population away from students and towards older men who have completed
their families. Therefore, in 2005, the law was changed to bring the right to infor-
mation of children born as a result of donated gametes in line with that of adopted
children. As a result, donor-conceived individuals may find out the identity if the
donor when they reach 18 years of age.
Sex Selection
Approximately 300 genetic diseases have thus far been linked to the X chromosome.
Some are rare but others, like the fragile X syndrome, are among the most com-
mon genetic disorders causing mental retardation. Women carriers of an X-linked
recessive disease have a one in four chance of having an affected child and a one in
two chance if the child is a boy. If the child is a girl, she would not be affected but
would have a one in two chance of being a heterozygote and therefore a carrier of the
disease.

Ethical Issues 383
Prenatal sex selection may be undertaken by sorting sperm, by pre-implantation

identification of the sex of the embryo or by aborting a fetus of the sex that carries
the disorder. Although most people find sex selection for medical reasons acceptable,
there are issues to be considered, such as the severity of the condition to be prevented.
Prenatal sex selection for non-medical reasons is a very different matter. The major
religions oppose the procedure because, inter alia, it is seen to interfere with a divine
plan. Two sets of non-religious arguments also may be considered. The first argument
is who has the right to decide what sort of people there should be? The second argu-
ment considers the consequences of sex selection: would it, for example, unbalance
the sex ratio of the next generation? It would certainly have to be applied on a very
wide scale to do so. We consider that in Western society more pressing arguments
concern the commodification of life. Treating one sex as more desirable than another,
to the point of prenatal sex selection, is to value one sex (the commodity) above life
itself. It breaches the fundamental concept of equality of respect for men and women.
Fetal Reduction
The prognosis for a multiple pregnancy to be delivered successfully falls dramatically
as the number of fetuses increases. Selective reduction of multifetal pregnancy is the
procedure by which an attempt is made to save some of the fetuses by destruction of
the others. It is usually performed in the first trimester. The associated rate of preg-
nancy loss is 8%–15% in experienced centres. Controversy exists about the value of
the procedure in triplet pregnancies, but it clearly improves the perinatal outcome for
women carrying four or more fetuses.
The use of the euphemistic term selective reduction rather than selective abortion
indicates straight away how uncomfortable many people feel with this procedure [9].
Nonetheless, it is important to bear in mind that, in the United Kingdom at least,
some 400 abortions are performed every day. With fetal reduction, the principle is
to sacrifice one or more potentially normal lives so that the others will have a better
chance to survive and lead healthy lives. The analogy of the overfilled lifeboat has
been used – drowning people can legitimately be denied access to a dangerously filled
lifeboat if bringing them aboard would result in the loss of additional lives. In the
context of IVF, the number of multiple pregnancies and, therefore, the issue of selec-
tive abortion will be greatly reduced by adherence to the advice to transfer no more
than two or three embryos. It is likely, however, that as a result of ovulation induction,
cases where the procedure has to be considered will continue to occur.
Should Older Women Be Offered IVF?

The most important determinant of the outcome of infertility treatment is the
patient’s age, so IVF becomes, like all other forms of treatment for infertility, less
efficacious as the woman ages. The most important reason, therefore, for not offering
older women IVF has little to do with ethics and everything to do with the very poor
outcome of such treatment. The parallel is with not recommending coronary angio-
plasty to people who continue to smoke – there is no ethical objection to performing

the procedure, merely the knowledge that continuing to smoke heavily so changes
the ratio of risk to benefit that no advantage is gained from having the operation. In
IVF, a take-home baby rate of 1%–3% is achieved in women over the age of 40 years.
The major debate about infertility treatment for older women concerns the issue of
egg donation [10]. Here, the impact of aging on fertility is avoided because that impact
is predominantly exerted on the oocyte. The excellent results of oocyte donation in
general have encouraged clinicians, and indeed patients, to believe that there need be
no upper biological age limit to pregnancies achieved in this way.
There are empirical data describing the outcome of pregnancies achieved by oocyte
donation in women past the usual age of the menopause. Broadly speaking, the risks
to mother and baby are few and usually fully acceptable to the mother. So far as the
child is concerned, the point is sometimes made that the life expectancy of its parents
will be less than a child should normally expect. This argument should be seen in the
context of children born into families of a more usual age, in which one or other of
the parents dies.
Is it wrong for a woman to seek treatment if she knows that she will not be able
to cope well with being a mother? We could consider it wrong if her becoming a
mother is unjust, that is, if it infringes the child’s rights. But the child is not really
wronged because it cannot be born to other or better parents. The question that
should be asked then is are the interests of the potential child better served if he or
she is born to a mother over the age of 50 or are they better served if the child never
existed at all? As there is no possibility of the potential child being born to any other
parents, it becomes clear that there are very few situations indeed where it would be
better not to be born. The very same argument applies to a reduced life expectancy
resulting in the premature death of one’s mother; to deny fertility treatment for that
reason would be to suggest that it would be better never to have existed than for one’s
mother to have died when one was young. The conclusion then is that it is rarely right
to withhold fertility treatment on the grounds of the interests of the potential child
not being served.
Should People Who Are Human Immunodeficiency

Virus Positive Be Offered Infertility Therapy?
Most women who are human immunodeficiency virus (HIV) positive are of repro-
ductive age, and many of the risk factors that are linked to HIV infection (e.g. unsafe
sexual practices) may predispose them to infertility. In considering management of
infertility in these patients, issues to be considered include the risk of mother-to-child
transmission; the risk that the mother will die before the child reaches majority; and,
in couples who are discordant for the infection, the risk that the woman will become
infected by intercourse with her partner without barrier protection (and then transmit
the infection to her child).
In the early days of the acquired immunodeficiency syndrome (AIDS) epidemic,
approximately 25% of HIV-positive women who gave birth transmitted the virus
to their children. The prognosis for infected children was grim, and children that
were uninfected were likely to be orphaned very young. It seemed obvious then that
treatment of infertility was inappropriate, and guidelines issued by the American

Ethical Issues 385
Society of Reproductive Medicine in the early 1990s reflected that point of view.
Fortunately, modern treatment for HIV-infected women has changed the picture quite
dramatically. So what is the position now?
Recent studies indicate that when delivery by caesarean section is combined with
antiretroviral therapy and the avoidance of breastfeeding, the rate of mother-to-child
transmission falls to less than 2%. The prognosis for infected children and infected
mothers has improved substantially and will presumably continue to do so [11].
Seroconversion of women partners of HIV-positive men who have had insemination
with washed sperm has been reported only once and that many years ago. There are
now reports of several thousand inseminations with washed sperm with no serocon-
versions in mother or child [12]. It is clear therefore that progress in the management
of HIV infection in relation to infertility has been sufficiently reassuring to mean that
for many patients in this situation indications for infertility treatment need not depart
from those in uninfected couples. In contrast, particularities of management will still
have to take account of the severity of the HIV infection, comorbidities such as infec-
tion and addiction and risks that the infection will be transmitted.
Conclusions
Many other ethical issues frequently arise in infertility practice but we do not c onsider
their detailed discussion is feasible in a book primarily aimed at clinical management.
Rather, it is our hope that the discussions outlined here provide a framework for con-
sidering the numerous ethical judgements that face us in everyday practice. A few
examples are as follows: Who owns gametes and embryos and who should decide
their fate? What are the implications of the advances in pre-implantation diagnosis;
Are there limits to the extent that we should change nature? Are there indeed limits to
parental choice; What is our attitude, for example, to patients with say achondroplasia
or congenital deafness who wish to have a child with the same condition? Should
women be inseminated with their dead husband’s sperm? To what extent should
surrogacy be used to provide children for couples biologically unable to conceive,
for example, homosexual men? We may be sure that with the speed of developments
in medical technology, few of these problems will remain matters for armchair con-
templation for very long. The reader is encouraged to prepare before such problems
feature in the next consultation.
REFERENCES
1. Golombok S, Tasker F. Donor insemination for single heterosexual and lesbian
women: issues concerning the welfare of the child. Hum Reprod 1994; 9: 1972–6.
2. Englert Y. Artificial insemination of single women and lesbian women with donor
sperm. Artificial insemination with donor semen: particular requests. Hum Reprod
1994; 9: 1969–71.
3. Englert Y. Artificial insemination with donor semen: particular requests. Hum Reprod
1994; 9: 1969–71.
4. Shenfield F. Particular requests in donor insemination: comments on the medical
duty of care and the welfare of the child. Hum Reprod 1994; 9: 1976–7.

5. Ethics Committee of the American Fertility Society. Ethical considerations of

assisted reproductive technologies. Fertil Steril 1994; 62 (Suppl. 1): 1S–125.
6. Edwards RG, Beard HK. How identical would cloned children be? An understanding
essential to the ethical debate. Hum Reprod Update 1998; 4: 791–811.
7. Weissman IH. Stem cells – scientific, medical and political issues. N Engl J Med
2002; 346: 1576–9.
8. Evers K. European perspectives on therapeutic cloning. N Engl J Med 2002;
346: 1579–82.
9. Berkowitz RL. From twin to singleton. BMJ 1994; 313: 373–4.
10. Hope T, Lockwood G, Lockwood M, Bewley S, Jackson J, Craft I. Should older
women be offered in vitro fertilisation? Existing children are treated differently from
embryos. BMJ 1995; 310:1455–8.
11. Minkoff H, Santoro N. Ethical considerations in the treatment of infertility in women
with human immunodeficiency virus infection. N Engl J Med 2000; 342: 1748–50.
12. Gilling-Smith C. Assisted reproduction in HIV discordant couples. AIDS Reader
2000; 10: 581–7.
FURTHER READING
ESHRE. Task force on ethics and law. Ethical Considerations 2001–2005. In: Heineman
MJ, ed. A collection of papers published in a Supplement to Human Reproduction,
Oxford University Press, Oxford, 2007: 22 p.

17
Follow-Up of Children Born from
Assisted Reproduction Techniques
Introduction
With at least 1%–2% of children in the developed world being born as a result of
assisted reproduction techniques, it is essential that we evaluate their physical and
emotional/psychological development. In so doing, we must take into consideration
their origins:
• Manipulated gametes, for example, in vitro fertilisation (IVF) itself,

intracytoplasmic sperm injection (ICSI) or in vitro maturation (IVM)
• Cryopreserved gametes or embryos
• Donated gametes or embryos
• Surrogacy
• Non-heterosexual unions, for example, donor insemination of single or
lesbian women
When considering risks for the offspring of women treated by assisted r eproductive
technology (ART; Box 17.1), we should subdivide risks into three categories: first,
specific risks relating to the treatment itself, in other words, the drugs used; second,
risks relating to multiple pregnancy; and third, risks relating to the medical condi-
tion for which the treatment is required. The various drugs used in assisted concep-
tion treatments have not been associated with congenital anomalies or adverse fetal
outcome – the main concern in IVF and associated techniques appears to centre
around the artificial selection of gametes and embryos, the effects of micromanipula-
tion techniques and the possible effects of embryo culture conditions.
Manipulated Gametes
IVF and ICSI involve ovarian stimulation with collection of several oocytes, by
using drug regimens of variable complexity (see Chapter 14). The oocytes are then
either placed together with sperm (IVF) or injected with sperm (ICSI). The gam-
etes and consequent embryos are cultured, in specified culture media, usually for
2 days before embryo transfer; this media may be changed and refreshed if culture is

BOX 17.1 FOLLOW-UP OF CHILDREN

BORN FROM ART – KEY POINTS
• The major causes of neonatal and developmental problems after assisted
conception techniques are multiple pregnancy and prematurity.
• Minor and major congenital anomalies after IVF and ICSI may be
increased by 30%–40% compared with the normal population.
• ICSI is associated with an increased rate of chromosomal anomalies,
which may be due to both the procedure and the underlying paternal
abnormalities that necessitated ICSI.
continued through to the blastocyst stage before embryo transfer on day 5. The main
concern centres around the artificial selection of gametes and embryos, the effects of
m icromanipulation techniques and the possible effects of embryo culture conditions.
One of the difficulties when comparing the outcome of children born as a result of
assisted conception with those conceived naturally is the high rate of multiple preg-
nancy with fertility treatments, which inevitably results in an increase in p remature
delivery and handicap (see Chapter 18). Some studies have, however, reported that
even singleton IVF pregnancies have higher complication rates than natural singletons,
although this outcome may be secondary to maternal characteristics (e.g. increased
age and underlying medical problems that resulted in subfertility) rather than to the
IVF t echnology itself. Nonetheless, IVF singleton babies do appear to be at increased
risk of being born prematurely and of being small for gestational age [1,2]. This risk
may have something to do with a reduced overall reproductive capacity in women
with fertility problems. It has been shown, for example, that there is an increased risk
of neonatal mortality in women who take a long time to conceive naturally compared
with those who conceive quickly [3].
A study from Sweden evaluated every child born as a result of IVF between
1982 and 1995 [4]. There were approximately 6000 children, of whom 27% were
from multiple pregnancies. Of the singleton pregnancies, 2.6% were born before
32 weeks and 11.2% before 37 weeks, compared with 0.7% and 5.4%, respectively,
in the general population. There was also a significantly smaller birth weight in
the IVF babies when adjusted for duration of gestation. Interestingly, however, for
a given birth weight, IVF babies were more likely to survive the perinatal period
than naturally conceived babies. Twin IVF babies had similar outcomes to twin
non-IVF babies.
Several early studies indicated that IVF does not increase the rate of c ongenital
malformations or abnormal karyotype. Many studies comparing IVF and ICSI infants
with naturally conceived children, however, had serious methodological limitations,
and increased risk estimates were often dismissed because they were not statistically
significant [5]. There was a significantly increased risk of congenital malformations
in the Swedish study [4], with a risk ratio of 1.44 (95% CI 1.25–1.65) – with a risk

Follow-Up of Children Born from Assisted Reproduction Techniques 389
ratio in singletons of 1.25 (95% CI 1.07–1.46) and in multiples of 1.08 (95% CI 0.93–
1.25). There were more cases of neural tube defects (NTDs) and oesophageal atresia
than expected, although the rate of NTDs was also higher in an Australian study [6]
and oesophageal atresia may be more prevalent in children of women with infertility
for reasons that are unclear. These anomalies also appear more commonly in twins,
irrespective of mode of conception [7]. A further study from Finland has reported
a higher than expected rate of heart malformations – specifically septal defects –
in IVF babies, when corrected for multiplicity, with a fourfold increase compared
with a control group [8]. That study suggested that reproductive ability with differing
levels of maternal hormones may have an adverse effect on cardiac development. It
is difficult to know how to i nterpret these studies, as surveillance of IVF pregnancies
is often more intense than usual and couples who have conceived through assisted
reproduction may be less inclined to terminate a pregnancy when an anomaly is
detected antenatally. The overall conclusion is that it is probably maternal character-
istics (e.g. age, subfertility f actors and concurrent disease) that influence the outcome
of IVF rather than the IVF treatment itself.
A meta-analysis synthesised the data from 25 studies and described in detail the
methodological variations and potential flaws in the data [5]. Two-thirds of the studies
included suggested an increased risk of birth defects of at least 25%. Allowing for
an underlying population risk of birth defects of between 1% and 4%, it appears that
there is a 30%–40% increased risk in infants conceived using assisted reproduction
technologies [5]. It is essential that this topic continues to be kept under review.
There may also be problems when considering the prenatal screening of pregnan-
cies after IVF/ICSI as biomarkers appear to be elevated in singletons, leading to a
higher false-positive rate than in naturally conceived pregnancies [9]. And in twin
pregnancies, biomarkers are dependent upon chorionicity as well as gestational age;
and when there is a vanishing twin, the biomarkers may be further altered, such
that screening should be based only upon maternal age and the nuchal translucency
scan [9].
When assessing the later development of children, it is first important to note that
the rates of childhood cancer after IVF appear to be similar to the general population
[4,10]. Most studies have reported psychomotor development in children to be normal
[9]. Psychological development also appears to be normal and in some cases may
be better than average, perhaps because of a higher level of parental input and/or
expectation. Caution has been expressed, however, about overprotectiveness not

always resulting in better well-being of the child [11–13]. A detailed study of chil-
dren born from IVF at age 2–3 years, followed up to the age of 8–9 years, found no
significant difference in psychosocial development when compared with a control
group [14]. This and other studies dealt with singletons to make for easier comparison
with controls. Twins and triplets, of course bring, with them additional problems for
the family unit and can result in major stress, disharmony and the potential for poor
long-term outcome (see Chapter 18).
Intracytoplasmic Sperm Injection

As with standard IVF pregnancies, there is a high rate of multiple pregnancy
with ICSI, and this rate will have an adverse effect on perinatal outcome and

congenital anomalies. The current evidence indicates that ICSI itself leads to a
slight but statistically significant increase in de novo sex chromosome aneuploidy
(0.6% rather than 0.2%), structural autosomal abnormalities (0.4% rather than 0.07%)
and structural chromosomal aberrations inherited from the infertile father [15]. The
rate of major congenital malformations and developmental outcome of ICSI children
appears to be similar to IVF populations (see above).
The ICSI technique is, of course, usually used when there are significant male
fertility problems, which may in themselves have genetic origins. Thus, it is hardly
surprising that structural chromosomal anomalies are transmitted from father to
son. The ICSI process adds a further dimension, as single spermatozoa are selected
by the embryologist on morphological criteria, thereby bypassing the process of
natural selection, which occurs both with spontaneous conception and with stan-
dard IVF. The ICSI technique may result in damage to the oocyte and also the
injection of a small amount of culture medium along with the sperm. The unit in
Brussels that developed ICSI has itself kept a comprehensive follow-up of children
and coordinated a European database [15]. The incidence of major malformations
in the general population is 1%–4%. The Brussels survey has revealed an incidence
of major malformations of 3.4% (96/2840 live born children) – 3.1 in singleton and
3.7% in multiple pregnancies [16]. When pregnancies that were terminated were
included, the overall major malformation rate was 4.2%. There may be a slightly
increased rate of hypospadias in male infants, which might relate to the underlying
male factor problems.
With respect to longer term development of children born from ICSI, the data
are largely reassuring, with both the Belgian series [17] and a case control series of
singleton children from the United Kingdom [18], indicating no difference from the
normal or IVF-conceived populations. A report from Australia, however, showed
delayed development in memory, problem-solving and language skills, particularly
in boys [19] – although concerns were expressed about whether the control group
was matched appropriately. And more recent studies have failed to demonstrate any
significant concerns [20]. A large Australian study looked at 6163 births from ART
within a population of 308,974 births and found that a history of infertility was
associated with an increased risk of birth defects irrespective of the use of ART [21].
Overall, the odds ratio for birth defects with IVF and ICSI were 1.07 (95% CI 0.90–
1.26) and 1.77 (95% CI 1.47–2.12), respectively. In general, the data are reasonably
reassuring with respect to the actual effect of treatment but long-term surveillance
of outcome is obligatory.
Imprinting Disorders
Genomic imprinting is an epigenetic process in which allele-specific gene e xpression is
dependent on parental inheritance. Only a minority of genes are imprinted, and some
rare imprinting disorders have been described which are due to altered e xpression or
mutations in imprinted genes that are required for normal growth and development
(in particular, neurodevelopment). There have been reports of an increase of IVF or ICSI
conceptions in children with Beckwith–Wiedemann syndrome (BWS) and Angelman
syndrome (AS), with approximately 4% of BWS cases in one series having been con-
ceived by IVF/ICSI compared with 1.2% of the general p opulation [22]. A survey that

studied the issue by looking at children born after assisted reproduction treatment has
been more reassuring by indicating that the absolute risk of imprinting disorders in
children conceived by assisted reproduction technology is small (<1%) [23].
Cryopreserved Gametes or Embryos

There is no evidence that the cryopreservation of gametes or embryos has a detri-
mental effect on subsequent fetal or childhood development [24,25]. Furthermore, it
has been found that the risk for premature delivery is lower with cryopreserved than
fresh embryos [4].
Donated Gametes or Embryos

Physical development and the risk of congenital anomalies are the same as for the
general population. The main concerns centre around lack of disclosure of parental
origins, in which case there is only likely to be a problem if accidental disclosure
occurs at some time in the future. Alternatively, when there has been disclosure,
there may be extreme unhappiness at not being able to trace one’s genetic origins,
which used to be the situation in the United Kingdom before the law changed in
2004. This issue reaches to the core of current gamete donation practice, which is
very much altruistic in the case of oocyte donation (other than when there is egg
sharing; see Chapter 9) and perhaps more often financially motivated in the case of
sperm donation.
Surrogacy
As mentioned in Chapter 14, surrogacy works well provided thorough counselling is
undertaken before the selection of the surrogate host. It is certainly our experience
and that of others that outcomes are positive for both the surrogate’s own family and
that of the commissioning couple.
Non-Heterosexual Unions – Donor Insemination

of Single or Lesbian Women
In the United Kingdom, the Human Fertilisation and Embryology Authority (HFEA)
states that when considering the welfare of children born as a result of assisted
conception techniques, consideration should be given to the right for a child to
have a father. This is not to say that single women or lesbian couples should not be
treated with donor insemination, but careful counselling should be provided first.
The evidence to date indicates that children conceived in such circumstances are
psychologically well adjusted, well cared for and have the same rate of homosexuality
as the general population [26].

Congenital Anomaly Risk after Clomifene

Citrate and Aromatase Inhibitors
Over the years, several reports have suggested the possibility of an association
between clomifene citrate (CC) exposure and NTDs, although a pooled analysis
reported a prevalence ratio of 1.08 (95% CI 0.76–1.51) [27]. A more recent study
included spina bifida occulta and reported an odds ratio (OR) of 11.7 (95% CI
2.0–44.8) [28]. There also have been reports of an increased risk of hypospadias
[29]. The National Birth Defects Prevention Study of North America examined
19,059 women with babies affected by at least one birth defect compared with 6500
controls, of whom 94 (1.4%) had used CC [30]. The use of CC was not associated
with hypospadias, but there was a significant association with other anomalies
(Table 17.1).
A problem of this study, as with all others of this nature, is the inability to clearly
determine the reason for CC use; that is, it is likely that not all women had polycystic
ovary syndrome (PCOS), and furthermore, it is difficult to match cases with controls
and to adjust for the various components or characteristics of women with subfertility
and/or any influence their partners may have on congenital anomaly risk.
Aromatase inhibitors became off label for ovulation induction after an abstract
presentation at the 2005 American Society for Reproductive Medicine (ASRM)
meeting, which was never published and has been much criticised. In a subsequent
attempt to assess the safety of letrozole, a multicentre study was performed to assess
514 babies of mothers who conceived with letrozole treatment and 397 babies of
women who conceived with CC [31]. In the letrozole group, 252 babies were born
after the treatment with letrozole alone and 262 with a combination of letrozole and
follicle-stimulating hormone (FSH) treatment. In the CC group, 293 were born after
CC alone and 104 after CC and FSH treatment. Congenital malformations or chro-
mosomal abnormalities were found in 14 of 514 newborns in the letrozole group
(2.4%) and in 19 of 397 newborns in the CC group (4.8%). The major malformation
rate in the letrozole group was 1.2% (6/514) and in the CC group was 3.0% (12/397)
TABLE 17.1
Association of Clomifene Citrate with Anomalies
Defect Adjusted Odds Ratio 95% CI
Anencephaly a 2.3 1.1–4.7
Craniosynostosisa 1.9 1.2–3.0
Dandy Walker malformation 4.4 1.7–11.6
Septal heart defectsa 1.6 1.1–2.2
Muscular ventral septal heart defects 4.9 1.4–16.8
Coarctation aortaa 1.8 1.1–3.0
Oesophageal atresia 2.3 1.3–4.0
Cloacal extrophy 5.4 1.6–19.3
Omphalocelea 2.2 1.1–4.5
a Multiple births only.

(non-significant). One newborn in the letrozole group was found to have a v entricular
septal defect (VSD) (0.2%) compared with four in the CC group (1.0%). In addition,
the rate of all congenital cardiac anomalies was significantly higher (p = .02) in
the CC group (1.8%) compared with the letrozole group (0.2%). The rates of minor
congenital malformations were similar (letrozole, 1.6%; CC, 1.8%).
REFERENCES
1. Doyle P, Beral V, Maconochie N. Preterm delivery, low birth weight and small for
gestational weight in liveborn singleton babies resulting from in vitro fertilization.
Hum Reprod 1992; 7: 425–8.
2. Tanbo T, Dale P, Lunde O, Moe N, Abyholm T. Obstetric outcome in singleton
pregnancies after assisted reproduction. Obstet Gynecol 1995; 86: 188–92.
3. Basso O, Olsen J. Subfecundity and neonatal mortality: longitudinal study within the
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18
Complications of Ovarian Stimulation
Introduction
The adverse effects of ovarian stimulation may be divided into immediate problems,
such as drug-specific side effects; the consequences of overstimulation of the ovaries,
such as multiple pregnancy and the ovarian hyperstimulation syndrome (OHSS); and
long-term problems, such as the possible risk of ovarian cancer.
Drug-Specific Side Effects

Clomifene Citrate
Clomifene induces ovulation by stimulating endogenous gonadotropin secretion,
but the drug also is concentrated in the ovaries and can, for instance, be detected
in follicular fluid obtained at in vitro fertilisation (IVF). Clomifene can cause
overstimulation of the ovaries, and during treatment, many women notice breast
tenderness and a feeling of bloatedness. OHSS has been recorded with clomifene
therapy, but all but the very mildest cases are rare. Occasionally, solitary ovarian
cysts are formed. They usually resolve spontaneously, and aspiration is only rarely
required. The overall risk of multiple pregnancy rises from the background rate of
1 in 80 to 1 in 10, an increase which may be reduced by careful monitoring of each
cycle with ultrasound – a practice that we recommend, but that in reality is seldom
offered because of limited resources and practical considerations.
Given the extensive use of clomifene, in terms of reports of immediate side effects,
it does seem remarkably safe. As with all spontaneous reporting, one cannot know
how precisely the events are related to administration of the drug. It is worth noting,
however, that neurological complaints feature strongly so complaints of dizziness,
abnormalities of vision and depression should be carefully evaluated. More worrying
side effects that have been reported are grand mal epilepsy and hallucinations. The
risk of treatment with clomifene in relation to the development of ovarian cancer is
considered below.
Other side effects are caused by expression of the anti-oestrogenic activity of
clomifene, namely, flushing and sweating attacks. In doses above 100 mg/day for
5 days, the anti-oestrogen activity may adversely affect the endometrium and impair
formation of cervical mucus and so reduce the chance of conception. Some women
have reported transient loss of hair from the head.

Tamoxifen
The main side effects associated with tamoxifen have occurred with its long-term
use in women with cancer of the breast (endometrial hyperplasia, polyps and cancer).
When used for induction of ovulation, the immediate problems are similar to those
of clomifene, except that anti-oestrogenic effects in the genital tract do not seem to
occur and the neurological problems of clomifene have not been recorded.
Gonadotropin Preparations
Receptors for gonadotropins are found only in the gonads so that, other than
overstimulation of the ovaries, side effects caused by these preparations are essen-
tially attributable to their non-hormonal content. The preparations derived from urine
contain a substantial amount of urinary protein, itself containing various growth
factors and other potential immunogens. Yet, the remarkable fact is that, with the
exception of causing reactions at injection sites, these compounds seem to have been
free of immediate problems. The issue of long-term problems, for example, ovarian
cancer, is taken up below. The presence of the urinary proteins does mean, however,
that these preparations have to be injected by the intramuscular route. Preparations
purified by affinity chromatography from post-menopausal urine or synthesised
by recombinant technology can be injected subcutaneously and local reactions are
uncommon. However, it is important that practitioners remain alive to the possibility
of side effects and that adverse reactions reported.
Pituitary-derived gonadotropins were used for induction of ovulation in a small
number of women in the United Kingdom some 30 years ago. After the discovery
that a spongiform encephalopathy (Creutzfeldt–Jakob disease (CJD)) could occur
many years after treatment with pituitary-derived growth hormone, concern devel-
oped that a similar complication might occur after treatment with pituitary-derived
gonadotropins. In Australia, where pituitary-sourced gonadotropin was used in some
1500 women, four cases of CJD were identified. Despite a proactive campaign which
succeeded in contacting 320 of the known 360 recipients of pituitary gonadotropin
in the United Kingdom, no cases have so far been discovered. As the years pass, the
probability of cases occurring steadily declines.
Variant CJD (vCJD) can be transmitted to humans from cows affected by bovine
spongiform encephalopathy (BSE). There has been some debate about whether human
urine could be a potential source, but the evidence to date is reassuring (see Chapter 14).
There is no evidence to suggest that urinary-derived gonadotropin preparations are
any less safe than recombinant follicle-stimulating hormone (FSH) [1].
Gonadotropin-Releasing Hormone
The chief side effect of treatment with pulsatile gonadotropin-releasing hormone
(GnRH) is infection at the injection site. It has occurred in only two of more than 200
patients treated by us but is the main reason we have always favoured the subcutane-
ous route of administration. An allergic reaction at the infusion site may occur; it is
thought to be related to the intrinsic similarity of the tertiary structure of the GnRH
molecule to the H1 histamine receptor ligand.

Complications of Ovarian Stimulation 397
OHSS is almost unknown as a result of treatment with GnRH. Multiple pregnancy

(almost entirely twins) occurs in 5%–6% of women treated with pulsatile GnRH,
compared with 1.5% in the general population.
GnRH Analogues
The GnRH superactive agonists initially stimulate gonadotropin release (agonistic
phase). Pituitary desensitisation then occurs, with the development of variable degrees
of hypogonadotropic hypogonadism. Adverse effects are related to local problems at
the sites of administration, to the consequences of the agonistic phase (e.g. e xpansion
of solitary ovarian cysts) and to the consequences of overtreatment (e.g. oestrogen
deficiency; see Chapter 14).
With the present generation of superactive agonists, the fundamental biochemical
alterations to the GnRH molecule involve substitution of a D amino acid at the sixth
position and variable changes to the 10th amino acid, changes which inhibit peptidase
digestion of the molecule and therefore lead to its persistence at the pituitary GnRH
receptor. Several changes occur in the gonadotropin-secreting pituicyte, including
loss (down-regulation) of GnRH receptors. These cellular changes impair further
secretion of luteinising hormone (LH) and FSH.
Some of the analogues are administered by nasal insufflation (e.g. buserelin,
nafarelin). Only approximately 4% of the nasal dose is absorbed and the compounds
have to be sniffed between two and six times per day. They can produce local irrita-
tion and allergy, resulting in a stuffy and/or runny nose. Ordinary colds may impair
absorption and lead to loss of efficacy. The analogues can be given by subcutaneous
injection or as a long-acting depot preparation. Few problems at the site of injection
have been recorded.
During the initial (agonist) phase, there is a striking increase of endogenous gonad-
otropins, and not uncommonly ovarian cysts expand at this stage. We always precede
treatment with a GnRH agonist with an immediate pre-treatment ovarian ultrasound
scan, and if cysts of 10-mm diameter or more are seen, treatment is deferred. If cysts
are present, one can either await spontaneous resolution or give the patient a short
course of treatment (3 weeks) with the birth control pill and then start the GnRH
agonist when the repeat scan is clear. Indeed, we usually precede IVF treatment
cycles with the oral contraceptive pill to minimise the risk of cyst development (see
Chapter 14).
Many women using GnRH agonists for ovulation induction develop flushing and
sweating attacks from the acute oestrogen deficiency they provoke. Long-term com-
plications of estrogen deficiency are only seen when these compounds are used for a
long time as in the management of endometriosis. Using bone densitometry, numer-
ous studies have shown varying degrees of skeletal decalcification. In our experi-
ence, as much as a 10% fall in vertebral calcium may occur in 6 months. For this
reason, and to prevent the acute symptomatology of oestrogen deficiency, most clini-
cians offer add-back treatment with low-dose estrogens (25–50 mg oestrogen patch,
0.625 mg Premarin® or tibolone) to patients using these analogues for prolonged ovar-
ian suppression (e.g. in the medical treatment of endometriosis).
The GnRH antagonists are now being used increasingly. They achieve very rapid
suppression of FSH and LH by competitive inhibition at the pituitary gonadotropin

receptor. Because the antagonist is administered after ovarian stimulation with gonad-
otropins has commenced, there are no side effects of oestrogen deficiency, so the
drugs are very well tolerated. Irritation at the injection site, which was a major prob-
lem with first- and second-generation antagonists due to histamine release, does not
appear to be a problem with the third-generation preparations that are in current use.
The Ovarian Hyperstimulation Syndrome

OHSS is a consequence of superovulation therapy for assisted conception procedures.
This potentially fatal condition is avoidable by the judicious use of gonadotropins
and careful monitoring of stimulation regimens. Women who are at particular risk
of developing the syndrome include women who have polycystic ovaries (PCOs) and
women under 30 years of age.
The pathophysiological hallmark of OHSS is a sudden increase of vascular
permeability which results in the development of a massive extravascular exudate.
This exudate accumulates primarily in the peritoneal cavity, causing a protein-rich
ascites. Loss of fluid into the third space causes a profound fall in intravascular
volume, haemoconcentration and suppression of urine formation. Loss of protein into
the third space causes a fall in plasma oncotic pressure which results in further loss of
intravascular fluid. Secondary hyperaldosteronism occurs and causes salt retention.
Eventually peripheral oedema develops.
The syndrome is graded according to severity (Box 18.1). Mild ovarian
hyperstimulation is characterised by fluid accumulation, as evidenced by weight
gain, and abdominal distension and discomfort. Ultrasound examination shows
enlarged ovaries with a diameter greater than 5 cm (Figure 18.1). Grade 2 ovarian
hyperstimulation is associated with the development of nausea and vomiting. The
ovarian enlargement and abdominal distension are greater and cause more discomfort
and dyspnea. Ascites can be detected by ultrasound. Grade 3 (severe) OHSS is a
BOX 18.1 CLINICAL GRADING OF OHSS

Mild (Grade 1)
Weight gain, thirst, abdominal discomfort
Mild distension
Ovaries >5 cm in diameter
Moderate (Grade 2)
Nausea and vomiting, distension and pain
Dyspnea
Abdomen distended but not tense
Ascites detected by ultrasound
Severe (Grade 3)
Evidence of intravascular fluid loss
Third space fluid accumulation (tense ascites, hydrothorax)
Haemoconcentration, hypovolemia, oliguria, hepatorenal failure

FIGURE 18.1 Transabdominal scan of overstimulated ovaries, with some free fluid seen around
the uterus.
life-threatening condition in which there is clinical evidence of contraction of the

intravascular volume (subnormal central venous pressure with reduced cardiac output),
severe expansion of the third space (tense ascites, pleural and pericardial effusions,
all of which compromise the circulation and breathing), severe haemoconcentration
and the development of hepatorenal failure. In addition to the circulatory crisis,
these patients are at risk from intravascular thrombosis. Deaths have been recorded
in women with grade 3 OHSS, caused usually by cerebrovascular thrombosis, renal
failure or cardiac tamponade resulting from pericardial effusion.
OHSS generally only occurs after overstimulated ovaries have been exposed to
human chorionic gonadotropin (hCG). The condition therefore results most commonly
when sensitive (i.e. polycystic) ovaries are exposed to excessive quantities of FSH and
then to hCG; the finding that severe OHSS is often associated with pregnancy is prob-
ably related to the persistence of hCG in this situation. Even when the ovaries have
been severely overstimulated, OHSS can generally be prevented by avoiding exposure
of the ovaries to LH and/or hCG.
Prevalence
Most methods of ovarian stimulation can cause OHSS, and the mild form may even
result from the use of oral anti-oestrogens. In programmes of ovulation induction,
the risk is related, inter alia, to the dose of gonadotropins (see below) and is rare with
low-dose protocols (see Chapter 7). The overall risk is estimated to be approximately
4% and that of the severe form approximately 0.25%. In IVF, the prevalence varies in

published series from 1% to 10%, being highest in women combining gonadotropin

stimulation with treatment with a GnRH analogue. Severe cases occur in 0.25%–2%
of IVF cycles.
A distinction has been made between early and late OHSS [2], with women
presenting early (i.e. 3–7 days after hCG administration) having significantly higher
serum oestradiol concentrations than those presenting late (12–17 days after hCG),
whereas there is no difference in the number of oocytes collected. Women presenting
late are more likely to be pregnant and have a severe form of the syndrome, due to
persistent stimulation of the ovaries by hCG from the placenta.
Pathophysiology of OHSS
Although it has been known for many years that high circulating concentrations of
oestradiol are an immediate predictor of the syndrome, oestrogen itself is not the
cause of the sudden increase in vascular permeability. Such a change is not after all
a feature of treatment with estrogen itself, even when the levels rise very abruptly, as
after an implant. Although numerous compounds, such as prostaglandins and kal-
likreins, have been considered to mediate the process, the two prime movers in the
development of OHSS are activation of the ovarian renin–angiotensin system and
release of vascular endothelial growth factor (VEGF) from the ovary.
The follicle contains renin in an inactive form which is activated at mid-cycle
(and by exposure of the ovary to hCG) and which then causes conversion of angio-
tensinogen to angiotensin I. This ovarian renin–angiotensin system is thought to
be involved in the neovascularisation which is so central a feature of the conver-
sion of the avascular pre-ovulatory follicle into the richly vascularised corpus
luteum. Excessive levels of renin activity have been reported in the plasma of a
woman with severe grade 3 OHSS at a stage of her illness when, as a consequence of
treatment, the central venous pressure was several centimetres higher than normal
(i.e. when secretion of renal renin would have been suppressed). Subsequent stud-
ies have shown that ascitic fluid in this syndrome contains very large amounts of
angiotensin II c ompared with ascitic fluid obtained from women with liver failure.
In rabbits, angiotensin II increases peritoneal permeability and neovascularisation.
Moreover, in that species, treatment with an angiotensin-converting enzyme (ACE)
inhibitor blocks the increase in peritoneal permeability that occurs in response
to superovulation. Parallel studies have not, however, been performed in humans
because of concerns over the use of ACE inhibitors in pregnancy. There is no doubt
of the involvement of the renin–angiotensin system in the pathogenesis of OHSS,
with h aematocrit concentrations being directly related to plasma renin activity and
aldosterone concentrations [3].
Vascular Endothelial Growth Factor

VEGF, also known as vascular permeability factor or vasculotropin, is a dimeric
glycoprotein which promotes growth and cell division of vascular endothelial cells.
It increases capillary permeability. VEGF is expressed in steroidogenic and steroid-
responsive cells, such as those cells involved in repair of endometrial vessels and in
implantation [4]. In primates, production of VEGF increases after the LH surge and

is reduced by suppression of LH secretion during the luteal phase; VEGF production

by human luteinised granulosa cells is increased by incubation in vitro with hCG,
as detected by measuring messenger ribonucleic acid (mRNA), indicating synthesis
by the luteal cells, and VEGF itself, as detected by an immunofluorescent assay.
Using a bioassay which measured extravasation into the skin of an injected dye [5],
increased amounts of VEGF were found in ascitic fluid obtained from patients with
OHSS but not in ascitic fluid obtained from patients with liver failure. Most of the
activity could be neutralised by incubation with an antiserum to recombinant human
VEGF, indicating that VEGF is the major capillary permeability agent in OHSS. One
might speculate that the activity that was not neutralised by the antiserum to VEGF
was attributable to angiotensin II. Further studies have correlated follicular fluid
concentrations of VEGF with OHSS and also with ovarian blood flow, as assessed by
Doppler ultrasound flow studies [6]. Indeed, serum VEGF concentrations have been
proposed as a predictor for the development of the syndrome [7].
The angiogenic response to LH or hCG is normally confined to a single dominant
follicle. OHSS may be seen as an exaggeration of this response. Because of gonad-
otropin-stimulated overgrowth of follicles, VEGF, the major angiogenic mediator of
vascularisation of the corpus luteum, can no longer be confined to the ovary but spills
over, initially into the peritoneal cavity and then into the general circulation.
OHSS and Thromboembolism

The greatest cause of morbidity and potential mortality in OHSS is from thromboem-
bolism. When considering the pathophysiology of the OHSS, it is easy to appreciate
the potential risk of deep venous thrombosis (DVT) and thromboembolic events.
Indeed, there has been an expanding literature on this association in recent years [8].
Not only is there a hypercoagulable state but also the combination of enlarged ovaries
and ascites leads to reduced venous return from the lower limbs, which combined
with immobility places the patient at risk of DVT. Furthermore, the thrombotic event
need not only be in the lower limbs: a review of the world literature found that 75% of
cases reported were in venous sites, with 60% in the upper limb, head and neck veins,
with an associated risk of pulmonary embolism of 4%–12%. The remaining 25%
were arterial thromboses and were mostly intracerebral [8]. It is difficult to give an
explanation for these more unusual sites of thrombosis in young women, unless there
is relative overreporting because of their rarity.
The hypercoagulable state of OHSS may, in addition to the general vascular
changes described in the previous section, relate to a change in clotting factors, which
may be due to the recognised haematological changes of pregnancy:
• Increased concentrations of factors VII, VIII, IX, X, XII and fibrinogen

• Reduced concentrations of protein S, antithrombin III and fibrinolysis
Whether this thrombophilic state is secondary to high circulating oestrogen con-

centrations is less clear, as the thrombophilic state of pregnancy tends to occur closer
to term and post-partum. It is possible that women who develop OHSS have a tendency
to thrombophilias (e.g. deficiency of protein C, protein S or antithrombin III or factor
V Leiden expression), although the majority of women appear to screen negative after

the event. An alternative theory is a leakage of factors such as antithrombin III into
the ascitic fluid, thus resulting in a relative plasma deficiency [9]. Venous thrombosis
in the lower limb most often resolves without long-term sequelae, unless pulmonary
embolism occurs, which may be fatal. Upper limb venous thrombosis may lead to
disabling long-term disability, with persistent discomfort, cramp, weakness and cold
hands. Cerebral thrombosis may resolve completely, but it can lead to various forms
of long-term disability.
Risk Factors for the Development of OHSS

Two of the important risk factors can be identified before treatment starts, the others
as ovarian stimulation proceeds.
Presence of PCOs
Several studies have confirmed that patients most at risk are women with the charac-
teristic appearance on ultrasound of PCOs. The essential point is that we are referring
here to the presence of PCOs, as detected by ultrasound, not to the PCO syndrome.
The polycystic appearance occurs in 20% of normal women but in 40% of patients
undergoing IVF, irrespective of the indication for treatment. The significance of this
finding is shown in Figure 18.2 [10] which depicts the ovarian response to s timulation
by gonadotropins in three groups of women with anovulatory infertility. In women
with normal ovaries, a unifollicular response was easy to obtain; in those with PCO
syndrome, there was the familiar polyfollicular response. Women with PCOs on
ultrasound but without the clinical features of the syndrome had a polyfollicular
response that was indistinguishable from that seen in the patients with the clinical
features of the syndrome.
These observations indicate the sensitivity of the PCO to gonadotropic stimulation.
They emphasise the value of identifying PCOs before treatment starts so that the dose
of gonadotropins can be adjusted appropriately.
Age of Patient
Most cases of OHSS occur in younger women, consistent with the greater ovarian
responsiveness in this group compared with older women.
Use of Superactive GnRH Agonists

GnRH agonists protect the ovary from an endogenous LH surge, thereby facilitat-
ing more convenient scheduling of ovum pick-up. The protection so afforded renders
the ovary more amenable to stimulation of multifollicular development by high-dose
gonadotropin treatment. Not surprisingly, this very advantage makes OHSS more
common in treatment programmes using pituitary desensitisation. In some individu-
als, it is harder to reach the threshold for ovarian stimulation, so higher doses of
gonadotropins are administered to achieve an ovarian response, with an increased
likelihood of an explosion or uncontrollable multiple follicle development when the
ovaries e ventually do respond [11].

20
18
Number of follicles > 1 4 mm on day of the hCG
p < .0001 ns
16
14
12
10
0
Hypog-Hypog Hypog-Hypog Polycystic ovary
with normal with polycysti c syndrome
ovaries on ultrasound ovaries on ultrasound
FIGURE 18.2 Each circle represents the number of follicles greater than 14 mm on the day of hCG
in three groups of patients undergoing ovulation induction with human menopausal gonadotropin
(hMG) by using either conventional (closed circles) or low-dose (open circles) regimens. Patients
with PCOs, whether they had hypogonadotropic hypogonadism (hypog-hypog) or PCO syndrome,
exhibited the classic exuberant response to stimulation. (From Shoham Z et al., Fertil Steril 58, 37,
1992. With permission.)
Development of Multiple Immature and Intermediate-

Sized Follicles during Treatment
The development of large numbers of immature and intermediate follicles during
treatment (Figure 18.2) indicates an exuberant response to gonadotropic stimulation,
caused either by very sensitive, that is, polycystic, ovaries (the usual situation) or too
high a dose of gonadotropin in women with normal ovaries. This picture contrasts
with that seen in women at risk from multiple pregnancy in whom the development of
numerous large follicles (>16 mm in diameter) is the marker of risk. There is debate
as to how many follicles constitute an increased risk and several factors need to be
considered, including age, previous history and body mass, but certainly greater than
a total of 25–30 follicles is of concern.
Exposure to LH/hCG
The clinical observation that exposure of the ovaries to LH, and usually to hCG,
is a sine qua non of its development and that pregnancy is frequently associated
with OHSS is consistent with the role of LH and hCG in stimulating the processes
that mediate neovascularisation and vascular permeability. These observations add

plausibility to the clinical practice of attempting aspiration of all follicles in patients

considered at risk because it is luteinised granulosa cells that are the source of the per-
meability factors. Indeed, late presentation with severe OHSS has been suggested as
being diagnostic of a clinical IVF pregnancy [12]. Furthermore, multiple pregnancy
adds an additional risk to the development of OHSS [2].
Previous Episodes of OHSS

It is self-apparent that a woman who has already experienced OHSS is more at risk if
she undergoes further ovarian stimulation.
Prevention of OHSS
Most of the manoeuvers (Box 18.2) have been foreshadowed in the preceding
discussion. All patients undergoing ovarian stimulation, whether to correct anovula-
tion or for assisted fertility techniques, should have a pre-treatment ultrasound scan
and if PCOs are detected, the dose of gonadotropin should be lowered (for details of
the low-dose protocol, see Chapter 7). If pituitary desensitisation has been used, one
should be sensitive to the loss of the normal protection of the ovary caused by the
block to oestrogen-mediated positive feedback of LH release. If a long protocol of
GnRH analogue treatment is followed by treatment with one of the pure FSH prepa-
rations, one also must be aware that the lack of LH changes the usual relationship
of follicle maturation and number to circulating oestradiol levels. In this situation,
measurement of serum oestradiol concentrations underestimates follicle develop-
ment. It is therefore essential that endocrine monitoring is supported by high-quality
ultrasound, otherwise low circulating estradiol concentrations may encourage further
and inappropriate gonadotropic stimulation despite adequate follicular development.
Meta-analyses of the different gonadotropin preparations have indicated no significant
difference in risk of developing OHSS [13]. Women with PCOs should be treated in the
context of a short GnRH antagonist protocol rather than a long protocol as the former
BOX 18.2 PREVENTION OF OVARIAN

HYPERSTIMULATION SYNDROME
• Pre-treatment ultrasound assessment of ovaries: PCOs?
• Care with gonadotropin administration: use low doses in women with
PCOs
• Care with GnRH analogues: emphasise use of ultrasound rather than
oestradiol concentrations note whether an LH-depleted gonadotropin
preparation is being used
• Reduce use and dose of hCG: consider with holding ovulatory dose of
hCG substitute progesterone for hCG in luteal phase
• Meticulous aspiration of all follicles
• Consider cryopreservation with deferred embryo transfer
• Administer a dopamine agonist after oocyte retrieval

protocol has been shown to be associated with a significant reduction in OHSS risk
(see Chapter 14). Although the administration of metformin has been shown to reduce
risk in long p rotocols, the evidence for its benefit in antagonist protocols is less clear,
and we are currently studying this question in a randomised controlled trail (RCT).
For the patient with overstimulated ovaries who is approaching the time of hCG
administration, several strategies to make treatment safer may be considered. The
first strategy is to administer a low dose of hCG to initiate oocyte maturation and/or
ovulation (i.e. not more than a single injection of 5000 IU), and in patients receiving
GnRH analogue treatment and who therefore require luteal support, to give proges-
terone (either intravaginal or intramuscular) rather than hCG. It is the current practice
now to use progesterone routinely for luteal support. Recombinant LH has a shorter
half-life than hCG and so may reduce the risk of short-term OHSS, although it will not
influence OHSS resulting from hCG produced from the trophoblast of a developing
pregnancy. In protocols where GnRH antagonists are used, the pre-ovulatory trigger
can be with a single dose of a GnRH agonist, instead of hCG – again, a shorter acting
preparation which should reduce the short-term risk of OHSS, although attention is
required to provide adequate luteal support to not compromise the chance of preg-
nancy (see Chapter 14). Some advocate the elective cryopreservation of all embryos in
GnRH antagonist cycles irrespective of any perceived risk of OHSS (see Chapter 14).
In the treatment of anovulatory infertility, there are two considerations. The first is
the prevention of multiple pregnancy; if there are more than four follicles of 14-mm
diameter or more in a young woman with PCOs, the safest course is either to with-
hold the hCG and advise the patient to avoid intercourse or, preferably, to convert the
treatment to IVF-embryo transfer (ET) or gamete intrafallopian transfer (GIFT); see
Chapter 12. The second consideration is the prevention of OHSS. Here, the issue is
the development of multiple small follicles. Thus, if there are more than six follicles
with a diameter of 12 mm or more, we advise discontinuing treatment or converting
it to IVF. In the latter situation, having meticulously aspirated as many follicles as
possible, one may cryopreserve the embryos and defer their transfer to another cycle.
Alternatively, one may withhold hCG, continue treatment with the GnRH analogue
and restart gonadotropin stimulation at a lower dose.
In patients having IVF and using gonadotropin-containing LH activity (i.e. human
menopausal gonadotropin (hMG) preparations), the following are conservative cri-
teria for ovarian responses above which there is a significant risk of OHSS: a serum
oestradiol of greater than 10,000 pmol/L (3000 pg/mL) together with 20 or more
follicles of 12-mm diameter or more. In the interpretation of oestradiol concen-
trations, one needs to recognise the aforementioned effects of using LH-depleted
gonadotropin preparations in women receiving GnRH analogues in a long protocol
(less oestrogen than usual is made so oestradiol concentrations underestimate the
intensity of the ovarian response). For patients with a serum oestradiol greater than
17,000 pmol/L (5500 pg/mL) with more than 40 follicles, hCG should be withheld
and treatment abandoned. Treatment with the GnRH analogue is, however, contin-
ued and when the ovaries regain their normal size, ovarian stimulation is resumed
at a lower dose. This approach of coasting has recently been reviewed in a meta-
analysis in which there was no difference in the incidence of moderate and severe
OHSS (n = 30, odds ratio (OR) 0.76, 95% CI 0.18–3.24) and in the clinical pregnancy
rate (n = 30, OR 0.75, 95% CI 0.17–3.33) between the groups. There is also a lack of

RCTs comparing coasting with no coasting or other interventions such as embryo

freezing or intravenous albumin infusion for prevention of OHSS. There is insuf-
ficient evidence to determine whether coasting is an effective strategy for preventing
OHSS [14].
When serum oestradiol concentrations are 10,000–17,000 pmol/L with 20–40 fol-
licles, hCG may be given with care, but the embryos are cryopreserved and trans-
ferred at a later date.
Treatment with glucocorticoids does not prevent OHSS [15]. Prophylactic infusion
of albumin has been investigated [16] and may be of some benefit. The most signifi-
cant recent advance in reducing the incidence of OHSS is the use of the dopamine
agonist cabergoline, which has been shown in a meta-analysis to give an absolute
risk reduction of 12% (95% CI 6.1–18.2%) with an OR of 0.41 (95% CI 0.25–0.66),
although there was not a reduction in severe OHSS [17]. Reassuringly, there was no
evidence of an adverse effect on ongoing pregnancy. Various dose regimens have
been used. We advocate 0.5 mg daily for 3 weeks after oocyte retrieval.
Management of OHSS
Mild ovarian hyperstimulation is very common and is managed expectantly, its
importance being that it should alert both patient and doctor to the risk of a more
severe condition developing. The patient should be encouraged to weigh herself daily
and take abundant fluids. A marked increase in weight (>5 kg) with the development
of abdominal distension, nausea and vomiting indicates the onset of grade 2 hyper-
stimulation and the need for hospitalisation. Patients are often admitted to their near-
est hospital and not the specialist unit providing ovarian stimulation, so good liaison
is essential. We recommend patients are issued with an advice sheet concerning the
symptoms of OHSS and what to do if they suspect it may be happening to them. The
sheet should include the telephone number and contact name of the liaison person in
the treating clinic. In non-conception cycles, moderate ovarian hyperstimulation can
be expected to resolve with the development of menstruation, although the ovarian
cysts may persist for a month or so more.
Patients with grade 2 hyperstimulation need reassurance and explanation, together
with hospitalisation. Oral fluids are encouraged although vomiting may make an intra-
venous infusion necessary. If luteal support is required, progesterone should be used.
Full-length TED stockings and heparin 5000 IU (twice a day s.c.) or clexane 20 mg
daily are advised to reduce the risk of DVT and continued until 12 weeks’ gestation if
a pregnancy occurs. Adequate analgaesia is required. Preferred drugs are paracetamol,
with or without codeine, and pethidine for very severe pain. Non-steroidal anti-inflam-
matory drugs such as diclofenac should be avoided, although indomethacin has been
used experimentally with good results. Anti-emetics such as metoclopramide are given
as needed. Box 18.3 indicates the surveillance that should be undertaken.
The development of clinically detectable and usually painful ascites together with a
deterioration in respiration, circulation and renal function indicates the development
of severe grade 3 hyperstimulation, and in most cases, the need for admission to an
intensive care unit. The intravascular volume should be monitored by measurements
of central venous pressure, renal function by meticulous attention to input and urine
output and haemoconcentration by measurement of haematocrit, whose level reflects

BOX 18.3 SURVEILLANCE OF MODERATE AND

SEVERE OVARIAN HYPERSTIMULATION
Circulation
Intravascular contraction
(a) Monitor central venous pressure (consider administration of
colloids)
(b) Look for pleural and pericardial effusion
Haemoconcentration
(a) Measure haematocrit, white blood cell count, coagulation profile
Hepatic function
Measure ascites (girth, ultrasound) and consider paracentesis
Monitor liver function tests, in particular serum albumin
Renal function
Monitor urine output (consider administration of crystalloids)
Paracentesis, dialysis
intravascular volume depletion and blood viscosity. A haematocrit of greater than

45% is a serious warning sign and a measurement greater than 55% signals a life-
threatening situation. There may be a striking leukocytosis, with the white blood cell
count rising to 40,000/cm [3]. Measurement of body weight, serum urea, creatinine
and electrolytes, together with serum albumin and liver function tests and periodic
assessments of the coagulation profile, are mandatory.
Infusion of colloid is required to maintain intravascular volume, as indicated by
restoration of normal central venous pressure. The choice lies between human albu-
min (50–100 g repeated as required) or intravenous dextran or hydroxyethyl starch,
although the latter compounds carry the risk of anaphylactic reaction and dextran has
been implicated in severe adult respiratory distress syndrome (ARDS). Crystalloid
(normal saline usually) is administered with great care and only for rehydration – there
is a risk of pulmonary and pericardiac effusions and so the mainstay of fluid replace-
ment is colloid. If urine flow remains suppressed despite restoration of central venous
pressure and rehydration, abdominal paracentesis, under ultrasound guidance, should
be undertaken. The indications for this procedure are therefore the need for symp-
tomatic relief of a tense ascites, oliguria, rising serum creatinine, falling creatinine
clearance and haemoconcentration unresponsive to medical therapy. Severe oliguria
or renal failure persisting despite these measures usually necessitate dialysis.
Paracentesis of hydrothorax should be considered for relief of dyspnea. Cardiac
tamponade from pericardial effusion may prove fatal if not rapidly relieved. Careful
cardiological assessment together with cardiac ultrasound should therefore feature in
the management of these patients. One must be aware of the possibility of reaccumu-
lation of fluid in any of these cavities.
Surgery should be avoided in patients with OHSS unless there is evidence of ovarian
torsion or marked haemorrhage or rupture of one of the ovarian cysts. Diuretics are
contraindicated in these patients. Anticoagulation is indicated if there is evidence of
thromboembolism or a deteriorating coagulation profile.

Overall Incidence of OHSS in the United Kingdom

There are no good data on the overall incidence of severe OHSS, as the severity of
OHSS is often not standardised, although it is likely that severe cases will be those
most likely to be reported. There have been case reports of thromboembolism and
severe sequelae of ovarian hyperstimulation, but good data are not kept centrally.
In a World Health Organization (WHO) report from 2002, the overall incidence
of severe OHSS is estimated as 0.2%–1% of all assisted reproduction cycles, with
an estimated 1:45,000–1:50,000 mortality in women receiving gonadotropins [18].
This figure is widely reported, but the report itself is difficult to obtain. I have been
able to obtain a full copy of this report and have communicated with the first author,
Jean-Noel Hugues. Professor Hugues has informed me that he got the figure from
a review article by Brinsden et al. [19]. In that article, we estimate a mortality of
1:400,000–1:500,000 stimulated cycles – thus, there has been a transcription error
in Hugues’ WHO report. A detailed assessment of mortality in a cohort of 29,700
Australian patients who had in the past undergone IVF, failed to identify OHSS as a
contributing cause to any of the 72 deaths from any cause [20]. (In this study, the age-
standardised mortality ratio in IVF patients was actually lower than expected for the
general population at 0.58 (95% CI 0.48–0.69) [20].)
Thus, the mortality rate from OHSS would appear to be extremely low and difficult
to quantify. It goes without saying that there is no acceptable rate of mortality as a
result of fertility treatment. Furthermore, there is no doubt that OHSS is a condi-
tion that should be taken extremely seriously because of the physical and emotional
distress that it can cause and the thromboembolic risks.
In summary, one should attempt to identify the patient at risk, consider the impact
of the new gonadotropin preparations on the response to ovarian stimulation and
actively attempt to avoid trouble. Such an approach demands close contact with the
patient and good liaison with colleagues in other centres who may be providing
emergency care. Early referral to an intensive care unit will help to correct haemo-
dynamic disturbances but the reproductive specialist must continue to play an active
role in management, particularly concerning the issue of abdominal paracentesis and
the evaluation of abdominal pain.
1. OHSS is a recognised severe and potentially fatal complication of ovarian

stimulation for assisted conception – and also may occur after ovulation
induction for anovulatory infertility. The development of OHSS may be
unpredictable, but women at greatest risk are young women with sensitive,
usually polycystic, ovaries (without necessarily having the PCO syndrome).
Symptoms can be very distressing and are of variable duration, from a few
days in most cases to a few weeks, particularly if a pregnancy has resulted
from the treatment. Severe OHSS occurs in approximately 1% of ovarian
stimulation cycles for assisted reproduction treatments. Mortality from
OHSS in the United Kingdom is approximately 1:425,000 IVF cycles.
2. The risk of OHSS may be minimised by using low doses of gonadotropins
and reducing doses in women with PCOs. If an exuberant ovarian response
is observed, then the dose of gonadotropin should be reduced further and
the dose of hCG also reduced or hCG not administered, thus cancelling

the cycle. If greater than 30 oocytes are collected, any embryos generated
should be cryopreserved as if a pregnancy were to develop, placental hCG is
likely to worsen the development of the syndrome.
3. Treatment requires meticulous attention to fluid homeostasis and
prophylaxis against thromboembolism, as the latter may result in long-term
morbidity.
4. All units should have clear protocols for identifying patients at risk both
before and during ovarian stimulation. Furthermore, protocols should be in
place for the management of patients who develop symptoms.
5. Information should be provided to patients within the general pre-treatment
information leaflets and also after the egg collection, so that they are aware
of the risk and the symptoms.
6. Clinics should keep a record of cases of OHSS, with particular note of
patients who require hospitalisation. This record should be incorporated in
standard risk management protocols.
7. Clinics should ensure appropriate follow-up of patients after ET and be
cognisant of the possibility of admission to a local hospital if the IVF unit
is either in a large centre geographically distant from the patient’s home or
is a private unit without inpatient facilities. Protocols should be in place for
communication between the IVF unit and local hospital with clear guid-
ance provided to local gynaecologists who may not be used to dealing with
OHSS.
Multiple Pregnancy
The rate of multiple pregnancy has increased parallel to the introduction of assisted
conception technologies, although now with greater awareness, the trend should be
reversing. The avoidance of multiple pregnancy is now an issue of clinical governance,
and the duty of responsible practitioners. Strict guidelines should be in place during
ovulation induction protocols to ensure that the pre-ovulatory hCG trigger is only
administered if there are no more than two mature follicles (see Chapter 7). Poorly
monitored ovulation induction, whether by clomifene citrate or gonadotropin therapy,
is still the cause of the majority of multiple births. In IVF cycles, the transfer of more
than two pre-embryos is prohibited in the United Kingdom in women under the age
of 40 years, and there has been guidance advising the routine transfer of a single
embryo in women under the age of 37 years (see Chapter 14). With further refinement
of laboratory techniques (e.g. enhanced culture conditions, blastocyst transfer), it is
feasible to transfer a single pre-embryo without compromising success rates particu-
larly when the outcomes of the cryopreserved embryos are considered (Chapter 14).
In some countries, in particular North America, large numbers of embryos are still
transferred and fetal reduction offered at the end of the first trimester for high-order
multiples. Fetal reduction has a 15%–25% chance of miscarriage and is a procedure
that we prefer to avoid by reducing the multiple pregnancy rate in the first instance.
Multiple pregnancies carry increased risks. Approximately 30% of twin pregnan-
cies spontaneously reduce to singleton in the first trimester. Premature delivery is

three times as common with twins as with singleton pregnancies, and the risk of all
other obstetric complications is increased (e.g. pre-eclampsia, abnormal bleeding).
Triplet and quadruplet pregnancies further magnify the risks, with mean gestation at
delivery of 33 and 31 weeks, respectively, and neonatal morbidity increased at least
20-fold. Cerebral palsy rates have been reported as 2.3 per 1000 singletons, 12.6 per
1000 surviving twins and 44.8 per 1000 triplets [21]. In addition to the increase in
long-term morbidity in survivors of multiple gestation, there are significant effects on
family dynamics and the ability of parents to cope, as well as the potential detriment
to any existing children.
A few years ago, we performed what we believe to be the first attempt to study
the mode of conception of all babies born during a specified period related to
multiplicity [22]. A letter of invitation was sent to each of the 245 maternity units
in the United Kingdom with the aim to collect data on every baby born during
the week of 6–12 April 2003, including details of maternal age, parity, mode of
conception, delivery details and fetal outcome. Replies were received from 205
units – a response rate of 83.7%. Data were received on 6913 deliveries (7015
babies) of which 6812 (98.54%) were singleton, 100 (1.45%) twin and 1 (0.01%)
triplet. Of the pregnancies that resulted in deliveries, 6638 (96%) were conceived
naturally, 133 (1.9%) were conceived with assistance and information was not
provided for 142 (2.1%). The rate of multiple pregnancy was significantly greater
in assisted (18/133, 13.5%) compared with spontaneous (82/6638, 1.2%) concep-
tions (difference = 0.123, p ≤ 0.001, 95% CI = 0.102–0.144). The only triplet preg-
nancy was conceived naturally. Of all the multiple (i.e. twin) pregnancies that
resulted from fertility treatment, three (16.7%) were as a result of clomifene citrate
therapy, 13 (72.2%) from IVF or frozen embryo replacements (FERs), one (5.6%)
from superovulation with intrauterine insemination (IUI) and information was not
available for one. There were no multiple pregnancies from ovulation induction
with gonadotropin therapy or laparoscopic ovarian diathermy. Of the deliveries that
occurred after fertility treatment, the multiple pregnancy rate after IVF/FET (26%)
was significantly higher from the one after clomifene citrate therapy (7.3%) (differ-
ence = 0.187, p = .04, 95% CI = 0.030–0.344). This is related to a total of 41 babies
born after clomifene citrate therapy, compared with 50 after IVF/ET and eight after
superovulation IUI. The median maternal age at delivery of those who conceived
naturally (29.7 years, interquartile range 33.7–24.6 years) was significantly less than
those who received fertility treatment (33.7 years, interquartile range = 37.5–30.1,
p ≤ 0.001). The median gestational age at delivery was 40 weeks (interquartile range
40.9–38.9 years) for singleton pregnancies and 36.7 weeks (interquartile range 38.1–
34.1 years) for multiple pregnancies (p ≤ 0.001). As expected, the live birth rate
was higher for singleton (98.2%) than multiple pregnancies (93.6%; p ≤ 0.001). We
concluded that multiple pregnancy from assisted conception in the form of IVF and
related treatments remains a significant problem and contributes a greater burden
than o vulation induction therapies.
The incidence of major congenital anomalies was higher in the multiple (6/203, 3%)
than in the singleton (54/6812, 0.8%) pregnancies (difference = 0.022, p = .004, 95%
CI 0.009–0.034). It was also higher among babies conceived with fertility treatment
(2/151, 1.3%) than those conceived naturally (57/6721, 0.8%), but the difference was
not significant (difference = 0.005, p = .855, 95% CI –0.01 to –0.02) [22].

Ovarian Cancer
Concern has developed over the last few years that women who have undergone ovar-
ian stimulation may be at increased risk of developing ovarian cancer. Although the
fourth commonest cause of death from cancer in the United Kingdom (after breast,
lung and colon cancers), ovarian cancer is still a relatively uncommon condition.
When we also consider the very small proportion of the population that has received
ovarian stimulation and the even smaller proportion that received it sufficiently long
ago for it to be plausibly considered an aetiological agent in any particular case, it
becomes easy to see why it is proving difficult to evaluate the risk. Interpretation of
the data has often been clouded by methodological flaws, as well as by difficulties
separating known risk factors, such as low parity and infertility, from any effect of
ovulation induction and/or controlled ovarian stimulation.
Aetiology of Ovarian Cancer

Although an extensive discussion of the aetiology of ovarian cancer is out of place
in this book, certain factors are well recognised. The average age at diagnosis is
59–64 years; approximately 90% of cases arise from the ovarian epithelium, and
epidemiological studies indicate the importance of genetic, environmental and
endocrine factors. The incidence in women under the age of 30 years is approximately
5 per 100,000; for age 30–50 years, it is 21 per 100,000, rising to 46 per 100,000 at
60 years. Parity is protective, the effect increasing with each pregnancy. Protection
from ovarian cancer is one of the non-contraceptive benefits of treatment with the
oral contraceptive. Infertility and incessant ovulation are known to be associated with
an increased risk. The question now is whether infertility treatment increases the
risk compared with that associated with infertility itself, particularly when associated
with low parity, for example, failed treatment.
The most widely accepted model of ovarian cancer postulates that epithelial
inclusion cysts, formed at each ovulation, are stimulated to undergo malignant trans-
formation by gonadotropins that normally become elevated at the menopause. This
model clearly predicts that agents which provoke multiple ovulation by gonadotropic
stimulation will increase the risk of ovarian cancer. Recently, it has also been p roposed
that ovarian carcinoma may arise from the adjacent fallopian tube. An alternative
hypothesis, that gonadotropins may not only be mutagenic but mitogenic (i.e. provoke
a pre-existing tumour), should also be considered. Finally, there have been reports
of an association of infertility treatment with granulosa cell tumours. These associa-
tions will be reviewed below, but they resonate with the finding that granulosa cell
tumours develop in transgenic mice into which a gene encoding a long-acting form of
LH has been introduced. These animals develop high serum LH concentrations and
cystic ovaries, anovulation and infertility together with granulosa and interstitial cell
tumours [23].
In considering the published studies, it is important to recognise that only now
are early users of infertility drugs reaching the age of the peak incidence of ovarian
cancer. Because of the relative rarity of cases, the epidemiology is largely limited to
case reports and case control studies. The sequence of infertility treatments also must

be considered: until pre-treatment with GnRH analogues was introduced into assisted
fertility technology, most patients who received gonadotropin stimulation had already
received (unsuccessful) treatment with clomifene. Distinguishing between an effect
of the various treatments and of persisting infertility is necessarily very difficult [24].
Clomifene Citrate
An important case control study was published in 1994 by Rossing and colleagues
[25]. This study attempted to control for the confounding effect of infertility by
analysing cases and controls from a cohort of 3837 women evaluated in the Seattle
area for infertility between 1974 and 1985. In total, 11 cases of ovarian cancer (4 inva-
sive epithelial carcinomas, 5 tumours of low malignant potential and 2 granulosa cell
tumours) were compared with 135 (infertile) controls. Clomifene treatment had been
taken by 9 of the cases, 5 of whom had used it for 12 or more cycles. The study found
a significant association of clomifene use for 12 or more cycles and the diagnosis of
an ovarian tumour (relative risk 11.1, 95% CI 1.5–82.3). The association was evident
in women with and without ovulatory abnormalities and in parous and nulliparous
women.
Although this study has several limitations (set out clearly in the paper), it also has
its strengths, such as obtaining the data from a review of case records rather than
interview (thus avoiding recall bias), the use of a single cohort for cases and controls
and the choice of a single agent to evaluate. The finding of an effect of the duration
of treatment adds credence to the association. In contrast, it must be accepted that
the women receiving prolonged treatment may represent a subgroup of patients with
particularly refractory infertility and that it is the severe infertility that constitutes the
predisposition to a high risk of ovarian tumour. Critics have noted the heterogeneity
of the histological types and that only four of the tumours were invasive. The asso-
ciation with tumours of borderline malignancy is of interest because of a number of
published case reports and the results in the case control study of Shushan et al. [26]
(see below).
Is the association of treatment with clomifene and this variety of ovarian tumour
plausible? Given the lag time assumed to be necessary for a drug to act as a car-
cinogen, clomifene has certainly been in use for long enough to exert a carcino-
genic effect. It was after all the first real fertility drug and was introduced in the
early 1960s. Clomifene is concentrated in the ovary and has a very long biological
half-life. It stimulates gonadotropin secretion and, in women with PCO syndrome,
preferentially stimulates LH release. It is women with PCO syndrome with high LH
concentrations who probably represent the majority of cases of recalcitrant infertil-
ity, which is intriguing given the findings in the transgenic mice with overexpression
of the LH gene mentioned above: these animals have multicystic ovaries with
persistent anovulation (which is, however, corrected by unilateral ovariectomy),
together with granulosa (and interstitial) cell tumours. Perhaps, the background to
the granulosa cell tumours reported in women who had received infertility treatment
is persistent hypersecretion of LH, made worse by clomifene in women with PCO
syndrome. The epithelial tumours are, one speculates, more likely to be related to
stimulation of ovulation through the impact of clomifene on pituitary secretion of
both gonadotropins.

As a result of the Rossing paper, the Committee on Safety of Medicines recom-

mended that clomifene should not normally be used for more than six cycles. This in
fact is no more than a reminder of its licenced use. In practical terms, it also means
that patients need to be counselled about the risk of ovarian cancer and t reatment with
clomifene and reminded of the protective effect of a successful (and previous or even
future use of the contraceptive pill). Another implication is that there is now a great
onus on the prescribing doctor to ensure maximum efficacy. This obligation raises
the question as to whether it is wise to use clomifene in general p ractice. We now
consider that adequate surveillance can only be provided by reproductive medicine
clinics with adequate monitoring facilities (see Chapter 7). The risks of second and
third courses of treatment for subsequent pregnancies need to be evaluated in relation
to the protective effect of pregnancy.
The first case report (in 1982) of an association of infertility treatment and ovarian
cancer was with treatment with hMG for 11 cycles. The issue has been studied in the
context of a cohort study from Israel of 2632 women receiving treatment between
1964 and 1974 [27]. No increased risk was detected but the power of this study was
limited because of the variety of treatment regimens used. In 1992, Whittemore and
colleagues [28] reported findings from a combined retrospective analysis of 12 U.S.
case control studies of ovarian cancer. Although attracting considerable interest, this
publication has been severely criticised; for example, it reported only 20 patients with
invasive cancers who had received infertility treatment and these cases were derived
from just three of the studies. Conversely, a recent case control study from Israel [26]
compared 200 women with ovarian cancer with 408 community controls. In this study,
there were 164 cases of invasive cancer and 36 of borderline malignancy. Compared
with untreated women, women who reported using hMG, in any c ombination with
other drugs and for any period, had a threefold higher risk of having epithelial ovarian
cancer. Women with borderline tumours were significantly more likely to have been
exposed to ovulation-inducing agents (OR 3.52, 95% CI 1.23–10.09), particularly
hMG (OR 9.38, 95% CI 1.66–52.08). The association was not demonstrated when
invasive tumours alone were considered. Several subsequent studies have explored
this issue further, with another Israeli study failing to d emonstrate an increased risk
for ovarian cancer in a series of 1197 infertile women with known drug history and
a mean follow-up of 18 years [29]. A case control study of 1031 women with epithe-
lial ovarian cancer from Italy was similarly reassuring [30]. A Danish case control
study looking at 231 borderline ovarian tumours also failed to show an association
with fertility drugs [31]. Furthermore, a Finnish study even suggested a falling rate
of granulosa cell tumours concomitant with an increasing rate of ovarian stimulation
[32]. There also have been studies looking at breast cancer risk, which have been
equally reassuring [29,33].
An important study from Australia investigated the incidence of invasive cancer
of the breast, ovary and uterus in 29,700 women, of whom 20,656 had been exposed
to fertility drugs, whereas the remaining 9044 had been referred for fertility treat-
ment but not received ovarian stimulation [34]. There were 143 breast cancers,
13 ovarian cancers and 12 uterine cancers. In both women exposed to ovarian

stimulation and women in the unexposed group, the incidence of breast and ovarian
cancer was no higher than expected. Interestingly, the incidence of uterine cancer,
although not raised in the exposed group, was significantly higher than expected
in the unexposed patients (OR 2.47, 95% CI 1.18–5.18). Taking the whole cohort
together, women with unexplained infertility had more cases of ovarian and uterine
cancer than expected (OR 2.64 (1.10–6.35) and 4.59 (1.91–11.0), respectively). Also,
within 12 months of exposure to fertility drugs, there was a higher than expected
incidence of breast and uterine cancer, although this rise was transient and overall
no greater than expected – perhaps there was greater surveillance in the immediate
period after the treatment.
In a study looking at the histology of oophorectomy specimens, the mean ovarian
dysplasia score was found to be higher in women who had received ovulation induc-
tion compared with fertile controls, and there was a relationship between the num-
ber of ovulation induction cycles and time since treatment (>7 years) [35]. A recent
study also found an increased risk of borderline and invasive ovarian tumours in
19,146 women from the Netherlands who had received IVF compared with 6006
subfertile women who did not receive IVF [36]. The duration of follow-up was just
under 15 years, and the risk of borderline ovarian tumours in the IVF group was
1.76 (95% CI 1.16-2.56), and with follow-up of greater than 15 years, there was an
increase in invasive ovarian cancer too (standardised incidence ratio 3.54, 95% CI
1.62–6.72). So, larger cohort studies with a longer duration of follow-up are required.
The question remains as to whether women who have undergone ovarian stimulation
should be provided with any additional surveillance as they get older, considering
that ovarian cancer is a disease with a peak incidence in a woman’s seventh decade.
If the aforementioned model of gonadotropin stimulation of epithelial cell prolif-
eration has any value, it seems plausible that substantial amounts of gonadotropins
may have to be administered to have an adverse effect. Nonetheless, it behoves us to
counsel our patients about these putative risks, to use the smallest doses of ovarian
stimulation for the shortest duration consistent with effective clinical practice and
to consider the follow-up assessment of women who have undergone unsuccessful
infertility treatment.
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8. Stewart JA, Hamilton PJ, Murdoch AP. Thromboembolic disease associated with ovar-
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26: 3456–65.

19
Emerging Technologies
Introduction
It is important to appreciate the evolving field in which we work and the exciting
advances that are occurring – many since the first edition of this book 15 years ago.
We do not propose to present an exhaustive treatise of all areas of ongoing research
in reproductive medicine. Instead, we have highlighted a few important areas where
recent research strategies are leading to changes in clinical practice. The underlying
theme of the topics is in keeping with the theme of this book, namely, the ability to
help couples to achieve a healthy singleton baby.
Advances in the Laboratory

In Vitro Maturation of Oocytes
In vitro maturation (IVM) of oocytes has been talked about for several years
(see Chapters 7 and 14 and Figure 19.1). The principle is to collect oocytes from
unstimulated, or minimally stimulated, small follicles and then mature the oocytes
in vitro before insemination, fertilisation and embryo transfer. Fully grown, germinal
vesicle (GV)–stage oocytes once collected recommence meiosis and reach metaphase
II over 24–48 h of culture before fertilisation by in vitro fertilisation (IVF) or intra-
cytoplasmic sperm injection (ICSI). The rationale is to minimise ovarian stimulation
and hence reduce both the costs of IVF treatment and the potential risk of ovarian
hyperstimulation syndrome (OHSS; see Chapter 18). Furthermore, the costs of drugs
required should be dramatically reduced.
The process of oocyte maturation in vivo requires both the removal of an oocyte
maturation inhibitor (OMI), which although still to be identified, for many years
has been thought to be cAMP, and a meiosis-stimulating signal, which is thought to
be follicular fluid meiosis-activating sterol (FF-MAS). Research is therefore pursu-
ing the use of FF-MAS and other agents to enhance IVM protocols. The issues that
need to be addressed if IVM is to become a clinical reality include adapting the
oocyte collection procedure and priming the uterus. Mature IVF oocytes are sur-
rounded by expanded and mucified cumulus granulosa cells, whereas GV oocytes
collected for IVM are enclosed in tightly packed cumulus cells, which makes their
collection far more difficult. A low aspiration pressure of 7.5–8.0 kPa, compared
with 25 kPa for standard IVF, is required to enable transvaginal ultrasound-guided
collection of immature oocytes from follicles of 3–10 mm in diameter. The oocyte

Biopsy Cryopreservation Follicle Oocyte In vitro In vitro

culture recovery maturation fertilisation
Ovarian Primordial Graafian Germinal Metaphase II Embryo

cortex pre-antral follicle vesicle oocyte
follicle oocyte
FIGURE 19.1 Principal steps involved in the in vitro growth and in vitro maturation of oocytes.
(Courtesy of Professor Helen Picton, University of Leeds.)
then matures in vitro, with first breakdown of the GV nucleus and then progression
through metaphase I to metaphase II of the first meiotic division, ending with the
extrusion of the first polar body. Concurrently, the oocytes must accumulate in vitro
the quota of ribonucleic acids (RNAs) and proteins that are required to support early
post-fertilisation embryo development [1]. Hardening of the zona pellucida (outer
membrane of the oocyte) may occur during culture of immature oocytes, so ICSI is
required for fertilisation.
Clinical protocols for IVM also need to take into consideration the requirement for
exogenous steroid support to prime the uterus for implantation, although some centres
provide minimal stimulation of the ovaries with hMG to achieve this priming effect.
Alternatively, embryos will need to be cryopreserved so that they can be replaced in
a subsequent hormonally supported cycle.
There is a particular attraction for using IVM in the management of anovulatory
polycystic ovary syndrome (PCOS) as this group of patients is at greatest risk of
OHSS and they also produce oocytes of reduced quality, although the results from
early studies suggested that the maturation rate of immature oocytes recovered from
patients with PCOS was lower than those from women with normal regular menstrual
cycles [2]. However, priming with hCG before the retrieval of immature oocytes from
unstimulated women with PCOS can improve the maturation rates [3].
In a prospective observational study of 190 cycles carried out by Child et al.
[4] demonstrated that significantly more immature oocytes were retrieved from
polycystic ovary (PCO) (10 ± 5.1) and PCOS (11.3 ± 9.0) groups than from women
with normal ovaries (5.1 ± 3.7; p < .05). The overall oocyte maturation and fertilisa-
tion rates were similar among the three groups. The subsequent pregnancy and live
birth rates per transfer were significantly higher in the PCO and PCOS groups. This
finding could be partially explained by the fact that there was a greater choice in
the embryos selected for transfer in these two groups. However, women in the PCO
and PCOS groups were significantly younger and had more embryos transferred than
women with normal ovaries.
Furthermore, a case control study comparing 170 IVM and 107 IVF cycles for
women with PCOS showed that IVM yields significantly less mature oocytes than

Emerging Technologies 419
IVF cycles (7.8 vs. 12; p < .01) and less embryos per retrieval (6.1 vs. 9.3, p < .01)
[5]. The pregnancy rates per retrieval were similar between the groups. However,
the implantation rates in the IVM group were significantly lower than IVF group
(9.5% vs. 17.1%; p < .01) with the fact that patients in IVM cycles received more
embryos than in the IVF cycles (3.2 ± 0.7 vs. 2.7 ± 0.8; p < .01). The lower implanta-
tion rates may be due to a reduced oocyte potential, a higher frequency of abnormal
meiotic spindle and chromosomal alignment or a reduced endometrial receptivity [5].
Continuous improvements in the culture medium and synchrony between endometrial
and embryonic development have resulted in a better IVM success rates, which are
similar to those from IVF if an embryo transfer is achieved [6]. Furthermore, the rates
of chromosomal abnormalities and obstetric outcomes seem to be reassuring [7,8].
IVM therefore appears to have a role for the management of women with PCOs who
have responded sensitively to previous stimulation in conventional IVF protocols and
also for fertility preservation in women who need rapid treatment before cancer ther-
apy – as oocyte retrieval can even been performed in the luteal phase of the cycle [9].
IVM of Follicles
One stage earlier than the maturation of oocytes in vitro is the maturation of the fol-
licles that contain them (Figure 19.1). The need for this technology arises from the
options for obtaining oocytes after cryopreservation of ovarian tissue that has been
performed before sterilising chemotherapy/radiotherapy. Ovarian biopsies also may
be used fresh, yielding a far greater number of follicles at the primordial or pre-antral
stages than the number of oocytes that can be obtained for IVM. The in vitro culture
of follicles is technically extremely challenging because of the complex changes that
occur in vivo – many of which are not understood and probably take in the region of
6 months to develop from primordial follicle to the Graafian stage. To preserve the
integrity of the oocyte/follicle unit, it appears best to culture follicles within segments
of ovarian cortex, rather than trying to dissect out individual follicles [10,11]. Once
the follicle has matured, the oocyte within requires IVM before IVF/ICSI. To date,
the mouse has been the only species in which live offspring have been produced
by these methods, and it will be a while before the technology can be successfully
applied to humans [12].
Cryopreservation of Oocytes and Ovarian Tissue

The ability to cryopreserve gametes has been available for many decades for many
animals and for human spermatozoa – the latter both after donation for treatment
of couples requiring donor insemination (see Chapter 11) or as an insurance before
chemotherapy or vasectomy. In recent times, there has been immense public interest in
the potential for the freezing of oocytes and ovarian tissue – again predominantly for
young women about to undergo sterilising chemotherapy/radiotherapy. There also has
been speculation that this technology could be used as an insurance against ovarian
ageing for career women who wish to delay child bearing. Although we are sympa-
thetic with the pressures on women to succeed in a working environment that fre-
quently shuns the needs of mothers, we feel that, in the first instance at least, the use
of these emerging techniques should be focused on medical needs.

Oocyte Cryopreservation
When a life-threatening disease such as cancer is diagnosed in a young person, fertil-
ity is seldom at the front of his or her mind. It is the responsibility of the physician to
advise the patient of the possibility of fertility-preserving techniques before embark-
ing upon potentially sterilising therapy. For women, the most realistic prospect of
achieving future pregnancy is currently by cryopreservation of embryos generated
during a quick IVF protocol (e.g. using gonadotropins and a gonadotropin-releasing
hormone (GnRH) antagonist) which should be complete within 14 days. Relatively
few embryos are likely to be generated in this way – on average, 10. For religious
or ethical reasons, some patients are unhappy to freeze embryos, and in these cases
oocytes could be frozen before insemination. This method also may be used for
women without a partner. Presently, the returns from oocyte cryopreservation are,
however, not as good as for embryos but with improvements in technology, particu-
larly vitrification techniques rather than slow-freezing at least 60% of oocytes are
expected to survive and achieve similar fertilisation rates to standard IVF [13].
The oocyte is the largest single cell in the human and very sensitive to external
insults. Few oocytes survive intact during the process of freeze–thawing. The temper-
ature sensitivities of the meiotic spindle and the mechanisms within the oocyte that
regulate monospermic fertilisation raise the risk of aneuploidy. New and improved
protocols for cryopreservation of mature oocytes, including storage of GV-stage cells,
and vitrification are currently being developed. Hardening of the zona pellucida is a
potential problem, so ICSI is required to fertilise the eggs. The original cryoprotec-
tants, dimethyl sulphoxide (DMSO) and propanediol (PROH) are associated with low
survival and 40% polyploidy rates because of an adverse effect on the meiotic spindle.
New methods such as vitrification appear to be the answer, but there are still concerns
about genetic development as a loss of association between the granulosa cells and
oocytes may affect oocyte maturation.
The patient would have to go through stimulation and oocyte retrieval as for IVF.
Caution may be required for women with hormonally sensitive tumours, for example,
oestrogen-receptor-positive breast cancer, when low-dose stimulation combined with
the aromatase inhibitor letrozole may be used. Worldwide now, several hundred
babies have been born from previously frozen eggs with no evidence of an increase
risk of congenital anomalies [14]. Once a patient embarks upon chemotherapy, there is
some evidence that the prolonged use of a GnRH agonist might help protect the ovary,
although large studies are still awaited [15].
An ethically challenging issue is the freezing of oocytes as an insurance policy
against ovarian ageing for career women without (or with) a partner who wish to
delay childbearing. Although it is reasonable to offer egg freezing to women who
will definitely lose their fertility because of premature menopause as a result of
sterilising cancer therapy (chemotherapy or radiotherapy), the issue concerns healthy
women and choices to have children during fertile years or during infertile years –
that is, during the years in which women are naturally equipped and ready for bear-
ing and rearing children. It has been debated that moving childbearing from its
natural place in a woman’s life and putting it artificially late in life brings risks, dif-
ficulties and disadvantages in plenty and foregoes the many advantages that belong
to having children in the years of natural fertility. Furthermore, with the current

technology, egg freezing gives a lower chance of conceiving a biological child later

in life, coupled with increased risk of medical complications associated with preg-
nancy in older women. We suggest that egg freezing for social reasons has been
exploited by private clinics, preying on women’s vulnerability. Most importantly,
this is giving false hope for the future, which may then stop women with frozen eggs
trying naturally before it is too late.
Ovarian Tissue Cryopreservation

Cryopreservation of tissue containing immature gametes from both sexes is still only
at the research stage. The ovarian cortex contains hundreds of thousands of primor-
dial follicles at birth and several thousands for most of a woman’s reproductive life.
The number declines progressively and at a steady rate until the age of approximately
38 years, after which time the rate of loss doubles until the menopause occurs. The
number of primordial follicles at a given age varies considerably between individu-
als. It is this number that constitutes a woman’s ovarian reserve (see Chapters 5, 9
and 14) and also reflects the ovaries’ ability to withstand the insult of chemotherapy/
radiotherapy in the treatment of cancer. Thus, young women are more likely to retain
fertility than older women.
There are several conditions in young women that may require potentially sterilis-
ing treatment – not only malignant conditions such as Hodgkin’s disease, sarcomas,
germ cell tumours, lymphomas and leukemias but also some systemic conditions such
as severe connective tissue diseases (e.g. systemic lupus erythematosus). There are an
estimated 1 in 1000 young adults who are survivors of childhood malignancy, and
this figure is expected to rise. Treatments that are most likely to cause damage to the
germ cells include the following:
• Total body irradiation (before bone marrow or stem cell transplantation)

• Localised pelvic irradiation (without pre-therapy ovarian transposition)
• Chemotherapy: alkylating agents (e.g. cyclophosphamide, procarbazine,
cisplatin, lomustine), vinblastine, cytosine arabinoside
Many regimens are evolving, and so it is difficult to predict the long-term effects on
fertility of some of the newer protocols.
Cryopreservation of ovarian cortical tissue offers the possibility of fertility preser-
vation before sterilising therapy for cancer. The technique is fraught with difficulty as
the multicellular and heterogeneous nature of the follicle makes it hard to freeze [12].
The cells are protected from injury during the freezing process by replacing water
with a cryoprotectant, such as ethylene glycol. All cryoprotectants are potentially
toxic, and work is still required to optimise the protocols. To obtain sufficient follicles
for future use, we have found it necessary to take an entire ovary and dissect off the
cortex, which is then frozen in strips. Thus, we advise a laparoscopic oophorectomy
for young women who stand a greater than 90% chance of being rendered sterile by
chemotherapy/radiotherapy. Our current experience indicates that women over the
age of 30 years have too high a rate of attrition of follicles after the freezing and
thawing of ovarian tissue for the procedure to be of benefit.

To date, there has been limited success with reimplanting frozen–thawed o varian
tissue, with follicle growth demonstrated in autografts both under the skin of the
forearm and in the pelvis. Ovulation has been demonstrated and some clinical
pregnancies and live births have been reported [16]. An alternative approach to
autografting is in vitro growth of follicles followed by IVM of oocytes before IVF/
ICSI (see above). This approach would avoid the risk of reintroduction of malignant
cells. Again, the technology is still some way from being perfected. Furthermore,
concerns have been expressed about the possible adverse effects of culture on genetic
imprinting, which is a significant problem in animal models.
It is anticipated that there are still many years of research before this technol-
ogy becomes a reality. We therefore need to be cautious in our approach to the
vulnerable patient confronted by the terrifying prospect of a life-threatening

malignancy combined with the potential loss of fertility. It is important that she is
made aware of the options but also counselled adequately about the realistic pros-
pects of success. The British Fertility Society has produced a comprehensive docu-
ment entitled A strategy for future reproductive services for survivors of cancer [17],
which discusses the p sychological, ethical and legal issues as well as the s cientific
possibilities.

Pre-implantation genetic diagnosis (PGD; Box 19.1) involves the removal of one
or more cells from the cleaving embryo to perform genetic testing to enable the
subsequent transfer of only healthy embryos. PGD is indicated for couples who have
had previous children/pregnancies affected by life-threatening or major genetic
disease, who otherwise would have to conceive naturally and undergo a ntenatal
testing (e.g. chorionic villus sampling or amniocentesis) and a subsequent termina-
tion if tested positive. Controversial and ethical issues concern what constitutes a
major genetic disorder and the possibility of designer babies now that the human
genome has been mapped. Also, there is a high frequency of chromosome or
genetic abnormalities (40%–50%) in human embryos, which increases with female
age [18]. Aneuploidy screening can be performed to ensure that only genetically
normal embryos are transferred during routine IVF in couples without a history
of genetic disease – a potentially attractive option for older women who have a
significantly increased risk of aneuploid embryos [19]. In the United Kingdom, the
Human Fertilisation and Embryology Authority (HFEA) has restricted licenses for
PGD to a handful of c entres and then for specified and clearly defined c onditions.
Elsewhere, however, aneuploidy screening is becoming more widespread and
unregulated.
Embryos are created in an IVF cycle (see Chapter 14), although it is obligatory
to perform ICSI to prevent contamination of the subsequent genetic analysis with
surplus spermatozoa. The success of PGD relies upon the ability to culture embryos
for up to 5 days in vitro and to use micromanipulation techniques to remove one or
two blastomeres. Each blastomere is thought to be pluripotent, so blastomeres that
remain have the potential to develop normally. Genetic analysis is performed by
either the polymerase chain reaction (PCR) for DNA sequences or fluorescent in situ
hybridisation (FISH) for whole chromosomes or parts of chromosomes. Polar body

BOX 19.1 COMMON INHERITED CONDITIONS

THAT CAN BE SCREENED BY PGDa
Single-gene defects (listed in order of most often tested)
Cystic fibrosis (autosomal recessive, AR)
Myotonic dystrophy type 1 (autosomal dominant, AD)
Huntington disease (AD)
β-Thalassemia (AR)
Sickle cell anaemia (AR)
Fragile X syndrome (X-linked)
Spinal muscular atrophy (AR)
Duchenne muscular dystrophy (X-linked recessive)
Neurofibromatosis type 1 (AD)
Haemophilia A (X-linked recessive)
Human leukocyte antigen for acquired diseases
Familial adenomatous polyposis (AD or AR)
Charcot–Marie–Tooth disease type 1 (AD)
Familial amyloidotic polyneuropathy (AD)
Marfan’s syndrome (AD)
Tuberous sclerosis (AD)
Von Hippel Lindau (AD)
Tay–Sachs disease (AR)
Severe combined immune deficiency (AR or X-linked recessive)
Chromosomal disorders
Structural chromosome aberrations
Translocations
Inversions
Deletions
Aneuploidy risk
Trisomy syndromes: 21 (Down’s); 19 (Edwards’s); XXY (Klinefelter’s)
Monosomy syndromes: XO (Turner’s)
Tetraploidy
a This is by no means an exhaustive list and many other conditions may nowadays be screened,
with some centres specialising in particular areas.
biopsy also can be performed on oocytes before fertilisation when the female is the
carrier of the genetic defect.
There are two main categories of genetic defects that cause inherited disease: defects
that affect chromosomes and defects that affect single genes. To detect single-gene
defects in DNA extracted from single blastomeres, the DNA in the nucleus of the biop-
sied cell is rapidly amplified many times over by PCR. The sensitivity of single-cell
PCR may be further increased by the incorporation of fluorescently labelled primers
into the PCR products [18]. This technique provides sufficient fluorescently labelled
DNA for screening for defects such as cystic fibrosis. The multicolour FISH technique

enables several chromosomes to be reliably detected simultaneously in a single cell

to enable screening for the common aneuploidies of chromosomes 13, 19, 21, X and
Y. The major application of FISH in PGD has so far been for sex determination for
the prevention of X-linked recessive disease. However, the development of probes
for additional chromosomes will extend the application of FISH analysis for more
general aneuploidy screening.
The technology for PGD is only available in a few centres worldwide, yet the
number of children born as a result of these techniques is increasing steadily [20].
The 10th report of the European Society of Human Reproduction and Embryology
(ESHRE) PGD presents data collected from 57 centres, reporting on 5887 cycles
along with details of the follow-up on 1516 pregnancies and 1206 babies born [20].
A total of 729 cycles were reported for chromosomal abnormalities, 110 for sexing
for X-linked diseases, 1203 for monogenic diseases, 3753 for pre-implantation
genetic screening and 92 cycles for social sexing [20]. This technology there-
fore offers certain benefits for families with a high risk for genetic disease but
also has been suggested as a way of improving embryo selection for patients with
increased i ncidence of chromosomal abnormalities such as advanced maternal age,
recurrent m iscarriage and recurrent implantation failure. To date, however, there is
no convincing evidence that routine pre-implantation genetic aneuploidy screening
(PGS) in IVF is of value [21].
Stem Cell Research, Cloning, Nuclear Transfer

and Cytoplasmic Transfer
The technology of stem cell culture has developed from the science of reproductive
medicine, although does not apply specifically to the treatment of infertility. Although
stem cell culture may provide cell lines for the production of neurogenic tissue,
haemopoietic tissues and other cells for therapeutic purposes, further d iscussion of
these emerging technologies is beyond the scope of this book. Similarly, cloning
is not a fertility treatment per se although it could theoretically be used to create
embryos from cells that are not gametes. Data from animal studies are present-
ing significant concerns about abnormal genomic imprinting and premature age-
ing of o ffspring. It is therefore considered irresponsible by the majority of the
scientific community to contemplate using this technology in humans, particularly
as there is no clear indication. The transfer of cytoplasm from a young oocyte to
an older oocyte, or the transfer of a nucleus from an old oocyte into an enucleated
younger oocyte, has been proposed as a means of overcoming the effect of ageing on
m itochondrial function in the cytoplasm, which may in turn affect embryo function
and fertility. These controversial techniques have not yet been accepted and could
confer potential risks to offspring. This area has attracted much public interest and
has been the subject of an HFEA consultation and research is now taking place to
explore clinical applications.
Gene therapies are being introduced gradually into clinical practice but have not
yet been applied to reproductive medicine – possibilities include the manipulation
of angiogenesis in the endometrium to aid implantation. These exciting prospects
require much more research but may be in the realms of reality by the next edition
of this book!

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2002; 8: 105–10.
13. Gook DA, Edgar DH. Human oocyte cryopreservation. Hum Reprod Update 2007;
13: 591–605.
14. Noyes N. Over 900 oocyte cryopreservation babies born with no apparent increase in
congenital anomalies. Reprod Biomed Online 2009; 18: 769–76.
15. Badawy A, Elnashar A, El-Ashry M, Shalat M. GnRH agonists for prevention of
chemotherapy induced ovarian damage, a randomized prospective study. Fertil Steril
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MM. Ovarian tissue cryopreservation and transplantation: a review. Hum Reprod
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17. Cooke I, ed. A Strategy for Future Reproductive Services for Survivors of Cancer.
Bristol: British Fertility Society, 2002.
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20
Miscarriage after Fertility Treatment
Introduction
Miscarriage is common, with a rate of between 10% and 30% of all natural p regnancies
[1]. Infertility is also common, affecting approximately 15% of couples [2]. The
causes of infertility are multiple and diverse, yet some, for example, endometriosis
and the polycystic ovary syndrome (PCOS), also may affect successful implantation
and pregnancy outcome. With the development of assisted conception, it is now pos-
sible to overcome or circumvent many of the problems presented by the subfertile
couple. The main questions arising from the various therapies available are do they
increase the rate of miscarriage or fetal malformations; and if they are found to do so,
is this caused by the treatment or is it a reflection of the underlying fertility disorder?
We address these questions by examining both the influence on miscarriage of the
drugs used in ovulation induction and the effect of the different techniques used in
assisted conception. First, it is important to consider special factors that pertain to
miscarriage in the infertile couple.
Miscarriage in the Infertile Couple

Parental Age
Couples attending the infertility clinic tend to be older than the average couple attend-
ing an antenatal clinic. In a study of patients attending our unit, the mean age of female
patients was 33 years, compared with a mean age of 28.8 years in women who give
birth in England and Wales. Couples with subfertility may have tried for a pregnancy
for several years before seeking medical advice and may then have attended both
their general practitioner and gynaecologist for investigation and possibly simple
treatments before being referred for assisted conception. Women also may choose to
delay starting a family, for example, while establishing a career. Such a delay leads
to a greater incidence of ovulatory dysfunction; endometriosis; and the possibility
of developing gynaecological pathology necessitating surgery, such as ovarian cysts,
fibroids and tubal damage.
In addition to the problem of becoming pregnant, the older woman has a greater
chance of miscarriage. In a series of 2730 sonographically confirmed pregnancies,
the overall first-trimester spontaneous abortion rate was 14.6% [3]. The incidence
of abortion in those women under 35 was 6.4%, rising to 14.7% in women between

35 and 40 years of age and to 23.1% in women over 40 years of age. The frequency of
chromosomal abnormalities in abortuses was 82.7% and was greatest in the first 6–8
weeks (86.5%). There are extensive data that confirm a rising risk of c hromosomal
anomalies with maternal age [4–6], and this accounts, to a great extent, for the increas-
ing miscarriage rate. If a pregnancy continues, there appears to be no a ssociation
between birth defects of unknown aetiology and advancing maternal age [7].
There has been disagreement in the literature concerning male factors in
spontaneous abortion. Chromosomally abnormal spermatozoa that achieve fertilisa-
tion may lead to the development of an abnormal fetus and the risk also increases
with advancing paternal age. Polyploidy, however, is usually excluded during in vitro
fertilisation (IVF) procedures because embryos are screened at the pronuclear stage.
If there are abnormal semen parameters severe enough to affect fertility, there does
not appear to be a correlation between abortion and sperm count or motility [8]. The
use of donor sperm does not appear to have an adverse effect on miscarriage rate [9].
Apart from the considerations of parental age, the couple with secondary infertility
often presents with a poor obstetric history and with pregnancy losses before treat-
ment, sometimes in as many as 70%–80% [9].
Hypersecretion of Luteinising Hormone and Miscarriage

Hypersecretion of luteinising hormone (LH) occurs only in the PCOS. There
appears to be a strong association between elevated serum concentration of LH and
miscarriage, possibly through an adverse effect on oocyte maturation [10]. A field
study of 193 women planning to become pregnant showed that raised mid-follicular-
phase serum LH concentrations were associated with both a lower conception rate
(67%) and a much higher miscarriage rate (65%), compared with those in women with
normal serum LH concentrations (88% and 12%, respectively) [11].
It was first demonstrated in 1985 that oocytes obtained from women undergoing
IVF who had a serum LH value greater than 1 standard deviation above the mean on
the day of administration of human chorionic gonadotropin (hCG) had a significantly
reduced rate of fertilisation and cleavage [12]. A study of women undergoing natural
cycle IVF (i.e. in unstimulated cycles) again found a reduction in fertilisation rates
in women who had elevated serum LH concentrations in either the early follicular
(45.5%) or mid-follicular (50%) phase compared with an 87.5% fertilisation rate in a
control group who had normal serum LH concentrations [13].
In a study of patients attending our clinic with amenorrhoea who received treat-
ment with pulsatile gonadotropin hormone-releasing hormone (GnRH) for induction
of ovulation, follicular-phase plasma LH concentrations were significantly higher in
those with PCOS than in those with other diagnoses [14]. In an extension of this study,
we found a miscarriage rate of 33% in women with PCOS compared with 10.6%
in those with hypogonadotropic hypogonadism (HH) [15]. Furthermore, in women
with PCOS there was a significantly reduced chance of conception and increased risk
of miscarriage in those with an elevated follicular-phase plasma LH concentration
compared with those with PCOS and normal follicular-phase LH levels [15]. The
association of raised baseline and/or mid-follicular-phase plasma LH concentrations
with a poor response to treatment also was demonstrated in a series of 100 women
with PCOS who were treated with low-dose gonadotropin therapy [16]. In this series,

Miscarriage after Fertility Treatment 429
the patients with an elevated LH concentration also had a higher rate of miscarriage
than the women with polycystic ovaries and normal LH levels.
LH has a role in the suppression of the oocyte maturation inhibitor (OMI).
Oocytes are maintained in the first meiotic division from their appearance in the
ovary during intrauterine life until just before ovulation, when oocyte maturation is
completed, germinal vesicle breakdown occurs, and the first polar body is extruded
(see Figure 14.6). Because oocytes undergo maturation spontaneously when they are
cultured outside the follicle, an intrafollicular OMI has been postulated, itself inhib-
ited at mid-cycle by the ovulatory stimulus. The precise nature of OMI is uncertain.
It is known, however, that cyclic adenosine monophosphate (cAMP) activates OMI
or is itself OMI. One action of cAMP is to maintain meiotic arrest of the oocyte at
the diplotene stage of prophase 1. The oocyte does not synthesise cAMP but obtains
it from cumulus granulosa cells via processes that traverse the intercellular space.
Stimulation by LH leads to disruption of these processes, loss of contact between
granulosa cells and the oocyte, a fall in intraoocyte cAMP and then resumption of
meiosis.
There appears to be a species-specific interval between ovulation and fertilisation,
and if this interval is exceeded, physiologically aged oocytes are produced which
may be subject to reproductive failure. Our hypothesis to explain the adverse effect
of hypersecretion of LH on human fertility is therefore that hypersecretion of LH
during the follicular phase results in an elevated concentration of intrafollicular LH
which in turn results in premature oocyte maturation, with subsequent ovulation of
a prematurely matured egg. Thus, inappropriate release of LH may affect the timing
of oocyte maturation such that the released egg is either unable to be fertilised or,
if fertilised, miscarries.
Several alternative non-embryological explanations of the association of hyperse-
cretion of LH with reproductive disturbance have been offered. For example, it has
been suggested that LH exerts its detrimental effect by causing oversecretion of ovar-
ian androgens, which suppress granulosa cell function and cause follicular atresia.
In our experience, elevated androgen levels in women with the PCOS are associated
with symptoms of hyperandrogenism (hirsutism, acne) rather than infertility, which
is instead positively correlated with LH excess. Furthermore, Shoham et al. [17]
demonstrated that, in women treated with clomifene citrate, high levels of LH during
the follicular phase were associated with a reduced conception rate despite adequate
follicular growth and corpus luteum function, as indicated by measurements of serum
oestradiol concentrations in the follicular phase and progesterone c oncentrations in
the luteal phase.
Another explanation for the association of PCOS with miscarriage is an e ndometrial
abnormality resulting from disordered prostaglandin synthesis [18]. Data in women
having the transfer of frozen embryos in natural cycles, however, demonstrated
no correlation between serum LH concentrations and the rates of conception and
miscarriage [19]. The embryos in this study had been generated in IVF cycles in
which pituitary desensitisation had been used to achieve suppression of LH levels.
Thus, the elevated LH concentrations seen in the subsequent natural cycles of some
of the women who received the frozen embryos could not have affected embryo qual-
ity and could only have exerted an effect by altering the endocrine or endometrial
environments: in the event, no effect on outcome was detected.

Obesity is a common finding in women with the PCOS and a moderate e levation
of body mass index (BMI) to between 25 and 27.5 kg/m2 is associated with an
increased rate of miscarriage, independent of LH levels [20]. Although these factors
may be important for a healthy pregnancy outcome, they do not explain the reduced
fertilisation rates observed with oocytes removed from women with high serum LH
concentrations. Thus, we have concluded that abnormal oocyte maturation is prob-
ably the main cause of reproductive failure in women who hypersecrete LH during
the follicular phase of the ovulation cycle.
If hypersecretion of LH increases the risk of miscarriage, therapies that suppress
serum LH concentrations might be expected to confer benefit. The use of GnRH
agonists to achieve pituitary desensitisation results in low serum LH levels, as does
induction of ovulation using laparoscopic ovarian diathermy. Neither therapy has
been shown conclusively to reduce miscarriage rates, although some studies have
indicated that these are potentially promising treatments.
Diagnosis of Pregnancy
The intensity of early pregnancy monitoring is much greater in assisted than natural
conceptions. Pregnancy can be diagnosed as early as 24 h after conception, with the
measurement of early pregnancy factor. It is, however, hCG that is usually assayed.
hCG can be measured in maternal serum and urine from between 8 and 11 days post-
ovulation. It is therefore possible to determine the outcome of an assisted conception
cycle in the late luteal phase, so women may know whether they are pregnant before
the expected commencement of menses.
With the advent of sensitive assays for hCG, it has been possible to obtain a better
idea of the incidence of pregnancy failure in both natural and assisted conceptions.
In 1967, Hertig [21] suggested that in natural cycles 85% of oocytes fertilise, 70% of
these implant, yet only 58% of these survive until the end of the second week, and
16% of these are abnormal and abort shortly after this time. In a series of women try-
ing to conceive, an elevated urinary hCG was found in 59.6% of 198 ovulatory cycles
[22], yet 62% of conceptuses were lost by 12 weeks and most of the losses (92%) were
clinically undetected. The overall fecundity was therefore 22%, which is similar to
that expected for a normal population.
It should be remembered that hCG is administered in most assisted conception
regimens to mimic the mid-cycle LH surge. This is required to initiate oocyte matu-
ration before a timed oocyte collection procedure. The injected hCG should have
cleared from the circulation by 9 or 10 days after ovulation or oocyte retrieval,
so hCG at a concentration of greater than 10 IU/L on luteal days 11–13 indicates
trophoblast development (one can be more certain if the hCG had been less than
5 IU/L on day 9 or 10). Confusion because of exogenously administered hCG will
disappear with the advent of recombinantly derived LH, which is now available but
not widely used. Women who undergo assisted conception require luteal support,
provided in the form of either progesterone or hCG. If the latter is used, a pregnancy
can only be diagnosed by a rising concentration of serum hCG. We have found that
when the serum hCG concentration is measured 12 days after embryo transfer, a value
of greater than 50 IU/L predicts a high likelihood of a normal ongoing pregnancy,
whereas lower values suggest either miscarriage or ectopic pregnancy.

A pre-clinical or biochemical miscarriage occurs when there is a measurable serum

hCG concentration, usually less than 50 IU/L, which remains elevated for a few days
only and results in a delay of menses of no more than 14 days. A clinical miscarriage
occurs after the hCG has continued to rise to a time when an intrauterine gestation
sac can be seen sonographically, either with or without a fetal pole or heart beat, but
then a miscarriage occurs.
The phenomenon of the vanishing embryo has come to light since the advent of
early pregnancy monitoring after assisted conception therapies. In one study, early
ultrasonography demonstrated spontaneous absorption of a gestation sac in 11 of 42
twin pregnancies and in 5 of 13 sets of triplets (in which two were reduced to singleton
pregnancies) [23]. In another study, 140 pregnancies were scanned weekly from the
5th to the 13th week of conception [24]. In the patients with one sac seen initially,
27% of the sacs disappeared; when there were two sacs, 25% disappeared, and with
three sacs, 47% disappeared. The percentage of women who ended up with a viable
pregnancy was 72%, 94%, and 100%, respectively, for those initially with one, two,
and three sacs. The vanishing embryo can apply equally to spontaneous or artificially
conceived pregnancies, although the risk of multiple pregnancy is of course greater
after ovulation induction or assisted conception.
Influence on Miscarriage of Drugs Used in Fertility Therapy

Ovulatory failure accounts for about a fifth of cases of infertility. Over the past
30 years, drug regimens of increasing complexity have evolved to induce ovulation.
The drugs prescribed to anovulatory women also are used to induce m ultifollicular
growth in women who ovulate normally. These women benefit from superovula-
tion as the production of several oocytes increases the success of assisted concep-
tion therapies. The most commonly used preparations are the anti-oestrogens (e.g.
clomifene citrate), the gonadotropins and gonadotropin-releasing hormone analogues
(see Chapters 7 and 14). Information about the sequelae of the use of fertility drugs
therefore chiefly refers to these three groups.
Anti-Oestrogens
The most widely prescribed anti-oestrogen is clomifene citrate. Its use in ovulation
induction was first reported by Greenblatt et al. [25] at a time when human p ituitary
and menopausal urinary gonadotropins also were beginning to be extracted and
standardised. In an early report of pregnancy outcome in a small number of women,
Greenblatt et al. [26] found the incidence of spontaneous abortion to be 22%. Karow and
Payne [27] reported on a heterogeneous group of 410 infertile women, in whom a preg-
nancy rate of 39.8% was achieved. The spontaneous abortion rate was 19%, similar to
that seen in infertility patients before the advent of the drug. The incidence of twins was
8.6%, contributing to a premature delivery rate of 12%. There was no confirmation of an
earlier theory that conception in the first treatment cycle resulted in an increased chance
of miscarriage or multiple pregnancy. Also in 1968, a series of 2196 c lomifene-induced
pregnancies was reported [28] in which the miscarriage rate was 17.6%, the multiple
pregnancy rate 10.2%, and the incidence of congenital anomalies 2.5%.

Although clomifene was found to induce ovulation in approximately 90% of

infertile women and pregnancy in 50%, the multiple pregnancy rate was sometimes
as high as 50%. In general, the miscarriage rate after clomifene treatment has been
reported to be between 20% and 27%, the rate of multiple pregnancy 10%–15% and
the incidence of congenital abnormalities approximately 2%–3% [29–31].
One series reported an overall miscarriage rate of 9.3%, 28.1% if conception
occurred during the first cycle of treatment, and as high as 70% if conception resulted
after seven cycles. It was thought that prolonged usage of clomifene might have a
deleterious effect on the endometrium, causing atrophy and implantation failure. The
relatively high miscarriage rate during the first cycle of treatment that was seen in
this study was postulated as being secondary to the release of overripe oocytes after
a prolonged period of anovulation. Interpreting data from the early use of clomifene
is complicated by the lack of uniformity in presenting details of maternal age and the
cause of infertility. Monitoring was limited to measurement of urinary oestrogens
or vaginal cytology and often omitted. Pregnancy diagnosis was not as advanced as
at present, so it is inappropriate to compare miscarriage data between the different
series.
Most women who require clomifene to induce ovulation have PCOS and are likely
to have a tendency to hypersecrete LH. Clomifene achieves its action through stimu-
lation of both follicle-stimulating hormone (FSH) and LH secretion by the pituitary
and women with PCOS can respond with an exaggerated release of LH and a resultant
reduction in the chance of conception and increase in the risk of miscarriage [17,32].
Congenital Abnormalities with Clomifene Citrate

The risk of congenital abnormalities and the physical development of infants born to
mothers who have received clomifene has not been found to be different from that of
the general population; yet, concern was expressed about the finding of an increased
frequency of chromosomal abnormalities after induced ovulation [33], an effect that
appeared to persist during the subsequent, non-stimulated cycle. After the report of
two cases of neural tube defects after clomifene therapy [34], other isolated cases of
congenital abnormalities appeared in the literature. Most have felt that factors related
to infertility itself may be to blame, rather than ovulation induction, and that babies
born after ovulation induction are no more at risk of being malformed than if they
were conceived spontaneously [35].
Whereas there continue to be reports that suggest a more than coincidental asso-
ciation between ovulation induction, specifically using clomifene, and neural tube
defects [36], other reports are reassuring and suggest no evidence for this relationship
[37]. Shoham et al. [1] reviewed 3751 births after clomifene therapy and found an
overall incidence of major and minor malformations of 32.5 per 1000 births [1], this
figure being within the range found among the normal population [35].
Ovulation Induction with Gonadotropins

Women who do not respond to oral therapy may succeed in having ovulation induced
with gonadotropin therapy. The preparations available either contain both LH and
FSH or contain FSH alone (see Chapter 7). It was thought that the use of FSH alone

would benefit women with the PCOS by minimising circulating LH levels. However,
these women are usually very sensitive to both forms of treatment and the use of FSH
alone confers no advantage as serum concentrations of LH are still within the normal
range when human menopausal gonadotropin (hMG) is used. The amount of LH in
hMG preparations is small compared with the amount secreted by the pituitary and
so is rapidly diluted after administration; furthermore, with unifollicular ovulation
induction the developing follicle secretes hormones that feed back to the hypothala-
mus and pituitary and suppress endogenous LH secretion. Studies to date indicate that
miscarriage rates are similar irrespective of the gonadotropin used.
As for the actual reported miscarriage rate after gonadotropin-induced ovulation,
this varies between 11.3% and 27.5%. Lunenfeld et al. [38] also reported an analysis
of the abortion rates in both the first and subsequent treatment cycles and the first
and subsequent pregnancies. In this study, it was found that whereas the abortion rate
was 28.8% in a first pregnancy, it was only 12.8% in a second pregnancy. This figure
is similar to the 13% of women who aborted after a spontaneous conception that
followed a successful gonadotropin-induced pregnancy. There was no difference in
the abortion rates of patients who became pregnant after the first or subsequent treat-
ment cycles. This goes against a commonly proposed theory that anovulatory women
release eggs of poor quality in their first ovulation induction cycle [33].
Other groups also have found a higher miscarriage rate in the first gonadotropin-
induced pregnancy. One series reported a reduction in miscarriage rate from 28.5%
in first hMG pregnancies to 11.9% in those conceiving for a second time [39]; another
series found these figures to be 33% and 9.8%, respectively [40]. In contrast to these
studies, a more recent paper reported an overall spontaneous abortion rate in 350 preg-
nancies after first treatment cycles of 24.2%, yet a 48% abortion rate in a s ubsequent
pregnancy in women whose first hMG pregnancy ended in a spontaneous abortion;
this value compared to an incidence of abortion of 6.7% if the first hMG-induced
pregnancy was normal [41]. These data are in keeping with the notion that the risk of
miscarriage after a natural conception is directly related to a woman’s past obstetric
history.
We reported a retrospective analysis of 200 anovulatory patients treated with
ovulation induction [42]. Of these patients, 103 had clomifene citrate-resistant PCOS,
77 HH and 20 had weight-related amenorrhoea (WRA). There was no difference
in the mean age of the three groups. The cumulative conception rates (CCRs) and
cumulative live birth rates (CLBRs) of the three groups in the first course of therapy
and after 12 cycles of treatment are illustrated in Figures 7.8, 7.25 and 7.26. The
miscarriage rates were 16.5% in PCOS patients, 22.9% in HH patients and 32.3%
in WRA patients, and although not statistically significantly different, this resulted in
comparable CLBRs between the three groups.
Patients with amenorrhoea secondary to weight loss respond well to ovulation
induction therapy with normal or supranormal CCRs [43–45]. The miscarriage rate
in these patients, however, was 32%, and this resulted in a CLBR that was similar to
that of patients with PCOS and HH. Furthermore, women who conceived spontane-
ously and had a BMI less than 19.1 kg/m2 had twice the risk of delivering a low-
birthweight infant compared with women of normal weight (p < .005) [46] and they
also had a higher incidence of preterm deliveries (p < .01). We also have reported
previously that patients with WRA who conceive after treatment with pulsatile

gonadotropin-releasing hormone (GnRH) are more likely to deliver lighter babies

than women of normal weight (p < .001) [47]. Our current approach is therefore to
encourage weight gain and not to induce ovulation in women with a BMI less than
19.5 kg/m2.
Congenital Abnormalities after Gonadotropin Treatment

An analysis of seven studies that addressed the outcome of gonadotropin-induced
pregnancies concluded that this treatment results in the same incidence of congenital
malformations expected for the general population [1]. These studies include a total of
1160 newborn infants, in whom the overall incidence of malformations was 54.3 per
1000 (21.6/1000 major and 32.7/1000 minor malformations).
Miscarriage after IVF and Related Procedures

The first published study of pregnancy outcome after IVF is related to pregnancies
that occurred after ovarian stimulation with clomifene citrate or gonadotropins or a
combination. In recent years, there has been a move towards pituitary desensitisation
with a GnRH agonist (see Chapter 14).
The suppression of endogenous LH by GnRH agonists is of particular relevance
and advantage to the woman with PCOS. Thus, many oocyte-containing follicles
may develop in the sensitive polycystic ovary free from the adverse environment of
high tonic LH levels. These oocytes appear to fertilise better than those from cycles
without pituitary desensitisation, suggesting that it is indeed the abnormal hormonal
milieu, rather than the polycystic ovary itself, that is the problem for women with
PCOS.
Since the birth of Louise Brown in 1978, the first baby conceived by IVF (in an
unstimulated, natural cycle), many groups worldwide have reported their experience
with IVF and related procedures. It is only now, however, that we can get a realistic
impression of miscarriage rates, because of the publication of series with large num-
bers of pregnancies, both from individual clinics and collated national statistics.
It is important to note the criteria used both to diagnose pregnancy and determine
the gestational age at miscarriage, as these influence the interpretation of data from
different series [48]. Some groups record biochemical pregnancies and miscarriage
separately, whereas others classify both together under the heading miscarriage. The
mean age of patients and the methods used to stimulate follicular growth are not
always recorded.
The first large series was the World Collaborative Report [49], compiled from the
results of 200 groups worldwide. There was a miscarriage rate of 29.9% in the 1084
pregnancies reported, and the 1.5% incidence of congenital anomalies was considered
to be similar to that occurring after natural conception. We reported a series of 1060
consecutive IVF pregnancies in which the rate of miscarriage was 26.6%, similar to
the miscarriage rates of other large IVF series [10]. It is difficult to compare figures
obtained after assisted conception procedures with miscarriage rates after spontaneous
conceptions because of the more intensive early pregnancy monitoring and earlier diag-
nosis of pregnancy after IVF treatment. If one takes the timing of the miscarriage into
account, the abortion rates that follow natural and assisted conception are similar [48].

As expected, we found an increased risk of miscarriage with increasing m aternal

age. Women attending infertility clinics tend to be older than the average couple
attending an antenatal clinic. The mean age of women giving birth in England and
Wales is 28.8 years [50], whereas the mean age of patients in our series was 32.2
years. As discussed, there are extensive data that confirm a rising incidence of
chromosomal anomalies with increasing maternal age, and this accounts, in large
part, for the increasing miscarriage rate. With respect to chromosomal abnor-
malities after assisted conception, Lower et al. [51] compared miscarriage after
spontaneous and assisted conception and found no significant increase in the rate
of chromosomal abnormalities after gamete manipulation. Thus, the miscarriage
rate is a reflection of maternal characteristics rather than of the gamete handling
procedures.
We found that there was no relation between the miscarriage rate and the i ndication
for IVF [52]. In contrast, of the 538 patients in our series who had a pre treatment
baseline ultrasound scan, those with normal ovaries had a 23.6% miscarriage rate
compared with a rate of 35.8% in those with polycystic ovaries (p = .0038, 95%
CI 4.68–23.10%). At the time of the study, a combination of clomifene citrate and
gonadotropins was still being used for some patients, whereas more recently GnRH
agonists have been almost universally used.
The rate of miscarriage in patients who received clomifene citrate was 47.2%
in women with polycystic ovaries and 20.3% in women with normal ovaries
(p < .00005, 95% CI 15.59–38.33%). In patients who received buserelin in the long
protocol, there was no significant difference in miscarriage rates between women
with polycystic ovaries (20.3%) and women with normal ovaries (25.5%). There
also was no difference in the miscarriage rates in women with normal ovaries who
received clomifene citrate (20.3%) or long buserelin (25.5%). There was, however, a
highly significant difference (p = .0003, 95% CI 13.82–40.09) in miscarriage rates
in women with polycystic ovaries who received clomifene (47.2%) and those who
received long buserelin (20.3%).
These data supported the notion that it was the high level of LH in women with
PCOS that was the adverse feature being ameliorated by treatment with the GnRH
agonist. Miscarriage rates were not affected by treatment with hMG versus FSH in
patients with normal (24.6% vs. 28%) or polycystic ovaries (18% vs. 25%) who were
treated with long buserelin and similarly between hMG and FSH in patients with
normal (19.3% vs. 23.5%) or polycystic ovaries (47.6% vs. 46.2%) who were treated
with a clomifene citrate regimen.
Several other studies also have examined the effect of pituitary desensitisation
on miscarriage rates after IVF and most report a beneficial effect of pituitary
desensitisation. This is perhaps most clearly demonstrated by an extension of the
study by Tan et al. [53] which examined the cumulative conception and live birth
rates after IVF with successive cycles of treatment. In total, 4115 couples had under-
gone 7863 cycles of treatment which resulted in 1279 pregnancies. A multiple logistic
regression analysis was performed to correct for the age of the patients, cause of
infertility, year of treatment and duration of infertility. The odds ratio of conception
and live birth rate with pituitary desensitisation compared with clomifene citrate and
gonadotropins was 1.63 (95% CI 1.31–2.03) and 1.88 (95% CI 1.39–2.55), respectively.
The cumulative conception graphs are illustrated in Figure 14.24.

The high rate of miscarriage in those who had received clomifene may be related
to the deleterious effects of elevated serum LH levels. Clomifene citrate causes
an e xaggerated early follicular-phase release of both gonadotropins and the resul-
tant elevated LH may reduce the chance of conception and increase the risk of
miscarriage. The protective effect of GnRH agonists is presumably mediated by
the functional HH and suppressed LH levels that they induce. Our study did not
distinguish between the proposed beneficial effect of pituitary desensitisation and
the detrimental effect of clomifene citrate. This issue has been clarified by Homburg
et al. [54] who studied the outcome of 97 pregnancies in women with PCOS, which
was defined as ultrasound-detected polycystic ovaries plus anovulation and infertility
and either oligo-/amenorrhoea and/or hirsutism. The patients were treated by either
ovulation induction or IVF with either hMG alone or hMG after pituitary desensi-
tisation with the GnRH agonist triptorelin (Decapeptyl®, Ipsen, Slough, U.K.). The
miscarriage rate in the agonist-treated patients (17.6%) was significantly lower than
the miscarriage rate in the women treated with hMG alone (39.1%, p = .03). The study
demonstrates that pituitary desensitisation is the important factor in reducing miscar-
riage rates in women with polycystic ovaries, rather than clomifene citrate being the
adverse factor, because clomifene was not used in that study.
The use of a GnRH agonist to achieve pituitary desensitisation has become p opular
in IVF clinics because of the flexibility it affords in programming oocyte recov-
ery [55]. We have shown, however, that in women with an ultrasound diagnosis of
polycystic ovaries, the use of buserelin is associated with a significant reduction in
the rate of miscarriage in the group of women who are at greatest risk, although there
appears to be no reduction in the rate of miscarriage for women with normal ovaries.
Pre-treatment pelvic ultrasonography is therefore important to select the treatment
regimen that will lead to the best outcome.
A large study of women undergoing IVF found an increased rate of miscarriage
in women with PCOS but suggested that this was caused by obesity rather than any
other factors [56]. In this study, the use of intracytoplasmic sperm injection (ICSI)
also was associated with a lower risk of miscarriage – partly because of the younger
age of the female partner and also possibly because oocyte factors play more of a role
in the aetiology of miscarriage and so couples undergoing ICSI may be less at risk.
When considering the different regimens for IVF, it is important to appreciate the
potential effects on endogenous hormone concentrations and endometrial receptivity.
A recent series of publications has demonstrated improved fertilisation and ongoing
pregnancy rates in women who have serum LH concentrations greater than 0.5 IU/L
on the day of hCG compared with those whose LH concentrations are less than 0.5
IU/L [57]. It also has been suggested that high serum oetradiol concentrations may be
detrimental to uterine receptivity [58]. Thus, a balance is required between the degree
of suppression caused by the GnRH analogues and the steroidogenic potential of the
gonadotropin preparations used to stimulate the ovaries (see Chapter 14).
Luteal Support
A variety of regimens are used for supporting the luteal phase of assisted conception
cycles (see Chapter 14). Published reports of randomised controlled trials assessing
the use of progesterone or hCG have shown no significant differences in pregnancy

rates [59]. There is strong evidence that luteal support is required, particularly when
GnRH agonists have been used. Administration of progesterone is generally preferred
to hCG because of the reduced risk of ovarian hyperstimulation syndrome. Luteal
support does not affect rates of miscarriage.
There has been a vogue to advise low-dose aspirin to increase pregnancy rates and
reduce the risk of miscarriage. Although aspirin therapy may have a role for some
causes of recurrent miscarriage (see Chapter 21), there is no convincing evidence for
its routine use; so at present, we do not recommend it.
Management of Miscarriage
When a non-viable pregnancy has been diagnosed the management may be
expectant or active, depending upon the clinical situation and the patient’s wishes.
Expectant management – in other words, awaiting spontaneous and complete reso-
lution of the miscarriage – does not affect future fertility any more than surgi-
cal evacuation of the uterus [60]. Active management is often offered to women
who have a non-viable pregnancy after fertility treatment as the problem is
usually detected before signs of impending miscarriage (e.g. bleeding or pain), so
expectant management could involve a wait of days or even weeks. The options
for active management include surgical or medical evacuation of the uterus, the
latter often favoured these days because of the avoidance of a general anaesthetic
or instrumentation of the uterus. Couples who experience miscarriage should be
offered support and counselling.
Summary
In conclusion, when one accounts for the intensity of early pregnancy monitoring
after assisted conception procedures and hence the relatively frequent diagnosis of
biochemical pregnancy, the overall spontaneous miscarriage rate is similar to that
expected for the general population. Indeed, it has been pointed out that as a mean
age of under 30 years is usually quoted for patients in studies of miscarriage after
spontaneous conception, the abortion rate in treated, subfertile women might be ‘even
lower than that of the so-called normal population when adjusted for age’ [1]. It is also
encouraging to note that the drugs used in assisted conception regimens do not appear
to affect adversely the incidence of congenital abnormalities.
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21
Recurrent Miscarriage
Introduction
Couples with recurrent miscarriage are fertile as, by definition, they will have
experienced at least three consecutive miscarriages. Some, however, have coexistent
subfertility, so the repeated loss of long-awaited pregnancies adds to the trauma that
they have already experienced. The overall risk of miscarriage of clinically recognised
pregnancies is between 15% and 25% and remains similar for women who have had any
number of live born children, although total reproductive losses are closer to 50% [1].
After one miscarriage, the risk of another miscarriage has been estimated as approxi-
mately 23%; after two consecutive miscarriages, this number increases to 29% and after
three the risk is approximately 33% if a cause if found. In cases of idiopathic recurrent
miscarriage, the risk of a further miscarriage is 25% [2]. The risk of a second miscar-
riage after one or more live births is 20%–25%. The majority of women who miscarry
once, or even twice, after fertility treatment can be reassured that there is unlikely to be
an underlying cause. Relatively few couples (approximately 1%) will experience recur-
rent miscarriages, and they should be investigated further. It has been calculated that
the chance of three consecutive miscarriages is 0.34%, lower than the observed rate of
recurrent miscarriage, suggesting the possibility of an underlying cause [3].
Although up to one-third of couples with recurrent miscarriage have experienced fer-
tility problems at some time, we are often faced with couples attending the fertility clinic
who have experienced one or two miscarriages. They might have undergone extensive
fertility investigations and received various fertility therapies, so they are naturally con-
cerned that their next pregnancy is viable should they conceive after further treatment.
Using the above-mentioned criteria they do not have recurrent miscarriage and so would
not usually warrant investigation; and although their c oncerns are understandable, this
concern increases the rate of recurrent miscarriage from 1% to 5% [1]. In the fertility
clinic, however, it is unrealistic and unfeeling to expect subfertile couples to wait for their
third lost pregnancy before they are investigated. It is therefore our practice to explain
that although we are unlikely to find a cause, we advise a simple recurrent miscarriage
screen (see below). Other groups are similarly sympathetic to such an approach [2].
A tremendous amount of work has been performed in recent years to try to unravel
the causes and treatment of recurrent miscarriage and to demystify some of the
traditional remedies that were of unproven benefit. The dedicated r ecurrent m iscarriage
clinic at St. Mary’s Hospital, London, has gained considerable experience, being the
largest such clinic in the United Kingdom, and has produced many important publica-
tions that form the basis of this overview [1,4].

Classification of Recurrent Miscarriage

An underlying cause is most likely to be found if the repeated miscarriages occur at
a similar gestation. First-trimester losses account for 75% of recurrent miscarriages
and second-trimester losses the remaining 25%. Even if a cause is found, there is
always the possibility that future miscarriages might be due to another cause, that
is, they are of a sporadic nature, thus any treatment that is commenced has to allow
for the fact that future miscarriages may not be due to the condition that has been
treated.
The causes of recurrent miscarriage may have genetic, anatomical, infective,
endocrine, or immune origins, but often no cause is found.
Genetic Causes
An abnormal fetal karyotype is found in approximately 60% of sporadic miscar-
riages and in approximately 30% of recurrent miscarriages [5]. The most c ommon
cytogenetic abnormalities are trisomy, polyploidy and monosomy X [1]. Yet,
only 3%–5% of couples with recurrent miscarriage are found to have an obvious
chromosomal abnormality themselves, suggesting that the fetal abnormality is
not secondary to a parental problem. It is always important to examine the fetal/
placental chromosomes after a miscarriage, even if a non-genetic cause of recurrent
miscarriage is suspected. The abnormalities that are sometimes found in parental
chromosomes are usually balanced Robertsonian or reciprocal translocations (often
between chromosomes 14 and 21). Although carriers of balanced translocations
are healthy, they have a 50%–70% risk of having an unbalanced embryo because
of abnormal segregation at meiosis [1]. In addition, chromosomal inversions or
mosaics may be found but point mutations and lethal gene defects are not detected
using routine testing. Karyotyping the products of conception in cases of recurrent
miscarriage may provide useful information for counselling and the future manage-
ment of the couple.
When carrier status is detected, after two or more miscarriages, the chance of
having a healthy child is similar to non-carrier couples (approximately 80%) even
if the risk of having a further miscarriage is greater (49% vs. 30%, 95% CI 11–26,
p < .01) [6].
Parental chromosomal abnormalities are not amenable to treatment. Genetic
counselling should be provided and prenatal diagnosis offered for future pregnancies.
Sometimes, the use of donated gametes is appropriate. There is no proven role for
pre-implantation genetic screening to reduce the risk of repeat miscarriage [1].
Environmental Factors
Although environmental factors such as radiation (but not working with visual display
units (VDUs)), occupational exposure to chemicals (e.g. toluene, xylene, formalin,
some chemical disinfectants, glues, paints) and pollution may lead to an increased

Recurrent Miscarriage 443
rate of sporadic miscarriage, there is no evidence that they are implicated in recurrent
pregnancy loss. Alcohol and smoking also increase the risk of sporadic and possibly
recurrent miscarriage.
Anatomical Abnormalities
An abnormal Müllerian tract, whether due to developmental anomalies (such as
septate or bicornuate uteri) or acquired problems such as uterine synechiae or fibroids,
is an uncommon cause of repeated pregnancy losses, and there is debate as to whether
there is any association. The incidence of Müllerian duct abnormalities in women
with n ormal pregnancies is approximately 4%, which is a similar rate to that found
in women with recurrent miscarriage [7]. There is, however, an association between
septate, bicornuate and unicornuuate uterus with infertility and miscarriage (see
Chapter 5). It is logical to anticipate that with increasing distortion of the uterine c avity
there may be an increased risk of recurrent miscarriage, and it has been suggested
that the use of three-dimensional ultrasonography may help with the delineation of
the uterine cavity [8]. Alternatively, there is no evidence that the s urgical treatment
of uterine anomalies improves the chance of conception or the risk of m iscarriage,
as large prospective randomised studies are yet to be performed. There is evidence,
however, that interventional surgery can cause peritubal and uterine scarring and so
increase the chance of infertility. A uterine septum is thought to be associated with
recurrent miscarriage more often than bicornuate uterus [9], and this is best excised
hysteroscopically, although there are no prospective randomised controlled trials
(RCTs) of such surgery [1]. The presence of fibroids also could increase the risk of
miscarriage if they significantly distort the uterine cavity, although condition is still
an area without firm guidelines for management (see Chapter 11).
Cervical incompetence may cause a second-trimester miscarriage but is thought
to be overdiagnosed and the use of cervical cerclage is widespread. The Medical
Research Council/Royal College of Obstetricians and Gynaecologists (MRC/RCOG)
study [10] of the use of cervical cerclage indicated that the rate of preterm deliveries
could be reduced but without a significant improvement in neonatal outcome, and
there was no improvement in the rate of miscarriage. A Cochrane review has failed to
find evidence of a benefit for cervical cerclage in reducing recurrent miscarriage [11].
The large recurrent miscarriage study at St. Mary’s Hospital [12] found that almost
half of the patients who had experienced second-trimester losses had intrauterine
deaths, 20% had contractions or bleeding, and a third had spontaneously ruptured
membranes prior to the miscarriage. Cervical incompetence is associated with pain-
less cervical dilatation before miscarriage and few women with recurrent miscarriage
appear to fall into this category.
Infection
Intrauterine infection is a common cause of sporadic miscarriage, usually in the
second trimester, but it is not thought to result in recurrent miscarriage, other than
in the rare situation of severe immunodeficient states. There has been much recent

interest in the association of bacterial vaginosis (BV) with very early miscarriage
after in vitro fertilisation (IVF), second-trimester miscarriage and premature deliv-
ery, although no studies have found a role for BV in recurrent pregnancy loss. There
is therefore no consensus on screening [1].
Endocrine Abnormalities
Disturbances of the hypothalamic–pituitary–gonadal axis, in particular, h ypersecretion
of luteinising hormone (LH), can increase the risk of both sporadic and recurrent
miscarriage (see below and Chapter 20). Other endocrine disorders can lead to infer
tility and pregnancy loss (see Chapter 5), although they do not cause recurrent miscar-
riage [13]. In particular, neither well-controlled diabetes m
ellitus nor t hyroid disease is
associated with recurrent pregnancy loss. It used to be c ommon practice to assess glu-
cose tolerance in women with recurrent miscarriage, but this is no longer recommended.
And although the assessment of thyroid status is simple and thyroid d ysfunction is
relatively common in women, it is not associated with recurrent m iscarriage as such,
unless there is a generalised underlying autoimmune d isturbance [14].
Women with polycystic ovary syndrome (PCOS) appear to have an increased risk
of miscarriage, which formerly was associated with hypersecretion of LH but now
appears more likely to be due to the effects of obesity and insulin resistance and their
effects on fibrinolysis and the endometrium [1]. There is no evidence for a benefit of
metformin, however, in the prevention of miscarriage in women with PCOS.
Luteal-Phase Defects
Opinions on the role of a defective luteal phase in both infertility and m iscarriage
vary. Our view is that a defective luteal phase is a reflection of inadequate f ollicular
function and a poor quality ovulation. Luteal-phase hormone concentrations do
not correlate with the risk of miscarriage, and luteal deficiency does not appear
to be a recurrent phenomenon so is unlikely to cause recurrent miscarriage. A
small study suggested that twice-weekly human chorionic gonadotropin (hCG)
injections up to 14 weeks’ gestation improved the chance of an ongoing preg-
nancy in women with oligomenorrhoea and two previous miscarriages [15]. Our
impression from a vailable data, however, is that the use of luteal support, either
with p rogesterone or hCG, does not reduce miscarriage rates for women with
recurrent miscarriage [16,17].
Hypersecretion of LH
Elevated follicular-phase concentrations of LH are associated with an increased risk
of infertility and miscarriage. In a series of 1537 women with recurrent miscarriage
who attended the clinic at St. Mary’s Hospital, London, 52% were found to have
PCOS, and of these women, 13% had an elevated serum LH concentration, 57% an
elevated urinary excretion of LH and 18% an elevated serum concentration of testos-
terone [12]. Despite having PCOS, these women were fertile, with spontaneous ovu-
latory cycles and had experienced at least three first-trimester miscarriages. Those

women with elevated LH levels (serum or urinary), who were under the age of 38
years, with normal karyotype and antiphospholipid antibody screening, were ran-
domly allocated into one of the three treatment arms:
1. Spontaneous cycle with placebo luteal support

2. Spontaneous cycle with progesterone suppositories as luteal support
3. Treatment with a gonadotropin-releasing hormone (GnRH) agonist followed
by ovarian stimulation with human menopausal gonadotropins and proges-
terone suppositories as luteal support
There was no benefit from the use of a GnRH agonist to suppress LH levels,
s uggesting that, at least in the case of recurrent miscarriage, hypersecretion of LH is not
the cause of the problem but a marker for another reproductive abnormality. This may
have an influence on the practice of fertility therapy when one considers the associa-
tion between hypersecretion of LH, infertility and miscarriage in women undergoing
ovulation induction or IVF and the encouraging reports of an improvement in ongoing
pregnancy rates when GnRH agonists are used (see Chapters 7 and 14). Alternatively,
one should remember that in this study the selection of cases differed from all others
and the measurement of LH in urine is very inaccurate. In reality, GnRH agonists will
continue to be used for assisted conception therapies as they provide tight control over
the cycle, but their use in ovulation induction is less certain and probably unnecessary
(see Chapter 7). A more recent study from the same group studied 344 women who
received no treatment and failed to identify a link between high serum LH or testoster-
one concentrations or body mass index in the 44% who miscarried [18].
An elevated serum follicle-stimulating hormone (FSH) concentration is found
in 1%–2% of women with recurrent miscarriage [1] and reflects reduced ovarian
reserve and the possibility of premature ovarian failure/insufficiency (see Chapter 9).
Counselling is required and oocyte donation may be indicated as the only potential
treatment.
Immunological Causes of Recurrent Miscarriage

Immunological recognition and non-rejection of a pregnancy are fundamental to its
survival. It has been suggested that recurrent miscarriage may result from a break-
down in the normal immune mechanisms, because of either autoimmune disease or
the failure of the mother to produce a protective immune response for the genetically
dissimilar pregnancy.
Autoimmunity
Approximately 2% of normal pregnant women and 15% of women with recurrent
miscarriage have the lupus anticoagulant (LA) or anticardiolipin (aCL) antibody,
both of which are antiphospholipid antibodies (aPLs) [19,20]. The primary antiphos
pholipid syndrome (PAPS) relates to recurrent miscarriage and/or a tendency to
arterial and venous thrombosis or thrombocytopenia. Women with a normal obstetric
history and aPLs have a miscarriage rate of 50%–75%, whereas women with recurrent

iscarriage and aPLs lose 90% of their pregnancies, and the miscarriage rate is even
m
higher if the patient has systemic lupus erythematosus. One should inquire about a
history of migraine, epilepsy, arthralgia, skin rashes and a family history of throm-
bosis, cerebrovascular accidents and myocardial infarctions in relatives under the age
of 50 years.
As with the assay of all biological markers for disease, it is essential to standardise
the methodology of the laboratory protocols, and this has been a particular issue with
respect to aPLs. The presence of the LA is assessed using tests of coagulation (the
activated partial thromboplastin time (APTT), kaolin clotting time (KCT) and the
dilute Russell’s viper venom time (dRVVT)). The dRVVT is thought to be the best
test for LA and is positive with a ratio of greater than 1.1. Blood for these tests should
be collected with minimal stasis into a citrated bottle, by using a 19-gauge butterfly
needle, and measured within 2 h. Both immunoglobulin (Ig)G and IgM aCLs are
assessed using an enzyme-linked immunosorbent assay (ELISA) and are abnormal
if greater than 5 GPL or 3 MPL units, respectively. aPLs have to be elevated on two
occasions to make the diagnosis of PAPS.
A large study of 500 women with recurrent miscarriage [21] found that 26.4% were
either LA or Anticardiolipin antibody (ACA) positive. The dRVVT was positive in
14.6% of patients, and after 8 weeks, two-thirds of those women who tested positive
initially were still positive –9.6% of the original study population. The levels of IgG
and IgM aCL antibodies were elevated in 9.0% and 6.2%, respectively, and remained
positive 8 weeks later in just over a third of cases –3.3% and 2.2%, respectively, of the
whole study population. Although many women appear to have transiently positive
results, when the tests are performed on three occasions fewer than 0.5% of women
have a positive result after it had been negative previously. Transiently positive results
may be due to viral and other infections. Antinuclear factor titres were positive in
approximately 8% of those who were either antiphospholipid-protein antibody (APA)
positive or negative and therefore not contributory. β2-Glycoprotein-I is an essential
cofactor for ACA, which when bound together cause platelet aggregation. No differ-
ences in β2-glycoprotein-I concentrations were found between normal women and
women with recurrent miscarriages who were either APA negative or positive.
The majority of miscarriages in women with APAs occur in the first trimester and
are thought to be caused by antibodies directed to the cytotrophoblast which disrupt
implantation. Second-trimester miscarriages in this group of patients are probably sec-
ondary to abnormal placentation with placental thrombosis and infarction. A prospec-
tive randomised study from the St. Mary’s group has indicated that aspirin (75 mg)
combined with heparin (5000 units twice a day (b.d.)) significantly reduced the risk
of miscarriage in women with aPLs [20]. Indeed, with no treatment, the live birth rate
may be as low as 10%, with heparin alone 40%, and with heparin combined with aspi-
rin 70% [21]. The treatment is discontinued at 34 weeks’ g estation. The use of steroids
is not recommended because, although levels of aCL fall, the rate of miscarriage is not
helped and there is an increased risk of premature labour and pre-eclampsia.
Alloimmunity
For many years, it was suggested that couples with recurrent miscarriage shared
more human leukocyte antigen (HLA) alleles than expected. This was thought to

lead to rejection of the conceptus (allograft) because the mother was unable to mount
an adequate protective immune response. Immunotherapy has been performed
using injections of paternal (or third party) lymphocytes into women with unde-
tectable levels of antipaternal cytotoxic antibodies (APCAs). However, levels of
APCAs fluctuate; they are only measurable after 28 weeks’ gestation and disappear
between pregnancies and are therefore thought to be a poor indicator of alloim-
mune pregnancy failure. There is therefore no test that would identify couples at
risk, even if alloimmune miscarriage exists as an entity. The Recurrent Miscarriage
Immunotherapy Trialists Group p ublished a worldwide collaborative observational
study. They performed a meta-analysis on allogenic leukocyte immunotherapy
for recurrent spontaneous abortion and analysed nine randomised and six non-
randomised prospective studies [22]. A small improvement in live birth rate of
8%–10% was found, but the study group concluded that it was difficult to identify
those patients most likely to benefit from immunotherapy and that a prospective
placebo-controlled, double-blind study is still required. Until then, immunother-
apy should be confined to research protocols. Furthermore, there are potential
complications of i mmunotherapy, i ncluding t ransfusion reaction, anaphylactic shock
and hepatitis.
Thrombophilia
Women with thrombophilia may be at increased risk of recurrent miscarriage,
although the efficacy of thromboprophylaxis is yet to be proven [23,24]. Thrombophilic
conditions include deficiencies of antithrombin III, protein C and protein S, and
activated protein C resistance which is secondary to a mutation in the factor V
Leiden gene (G1691A). There are two other thrombophilic gene mutations: factor II
(prothrombin G20210A and methylene tetrahydrofolate reductase C677T) [1]. There
is limited evidence for the use of heparin or aspirin in women with thrombophilia and
recurrent miscarriage [1].
Natural Killer Cells

Natural killer (NK) cells are lymphocytes that are part of the innate immune system.
NK cells are found in both peripheral blood (PBNK) and the uterine mucosa (uNK).
Measurement of peripheral blood NK cell numbers/activity as a surrogate marker
of events at the maternal–fetal interface is inappropriate as there are important phe-
notypic and functional differences between NK cells present at the two sites [25].
Furthermore, PBNK cell levels and activation are subject to several variables, includ-
ing the time of day a sample is taken and parity of the patient. There is no agreement
on what a raised NK cell level is [25]. Although several small observational studies
have reported an association between peripheral NK cell numbers or activity and
IVF outcome, large studies have failed to find a clear role for their measurement and
certainly no clear evidence of any benefit from the various potent immunosuppressive
therapies that have been suggested [25–27]. We feel that promising research on the
assessment of uterine NK cells will provide a more logical approach at answering the
question of any potential association with miscarriage.

Summary of the Investigation and Management

of Couples with Recurrent Miscarriage
Recurrent miscarriage is defined as three or more consecutive miscarriages within a
relationship (see Box 21.1).
Couples with repeated pregnancy losses need support within a specialised
recurrent miscarriage clinic, which at the very least will be able to provide

psychological support and serial ultrasound scans of the pregnancy. Of 114 women
attending the St. Mary’s Hospital recurrent miscarriage clinic in whom no cause
for the miscarriage was found, 71% who attended for supportive care during
pregnancy had a successful outcome compared with 48% in those who did not
attend (p = .02) [1].
Genetic counselling should be offered to those with chromosomal abnormali-
ties, and pre-implantation diagnosis or gamete donation should be considered.
Women with the PAPS should be treated with a combination of low-dose aspirin
and heparin; these combined therapies also could be considered for women
with a thrombophilia, although the evidence is less conclusive for their benefit.
Women who hypersecrete LH may benefit from treatment, although the correct
management of these patients is still to be elucidated. If cervical incompetence
is identified as the cause, cervical cerclage, by either a vaginal or sometimes an
abdominal route, should be offered. The data indicate that long-term antibiotic
therapy is not justified.
BOX 21.1 INVESTIGATIONS FOR RECURRENT MISCARRIAGE

First-trimester miscarriages
• Chromosomal analysis of both partners
• Early and mid-follicular-phase measurement of serum LH
concentrations
• Early follicular-phase measurement of serum FSH concentrations
• Endocervical swabs for BV
• Measurement of lupus anticoagulant (dRVVT) and anticardiolipin
antibodies (IgG and IgM)
• Factor V Leiden and prothrombin gene mutations
• Possible assessment of haemostatic-activated protein C resistance and
thromboelasticity
Second-trimester miscarriages
• Chromosomal analysis of both partners
• Measurement of lupus anticoagulant (dRVVT) and anticardiolipin
antibodies (IgG and IgM)
• Ultrasound of the uterus followed by hysteroscopy and/or
hysterosalpingogram if an abnormality is detected

REFERENCES
1. Rai R, Regan L. Recurrent miscarriage. Lancet 2006; 368: 601–11.
2. Brigham SA, Conlon C, Farquharson RG. A longitudinal study of pregnancy outcome
following idiopathic recurrent miscarriage. Hum Reprod 1999; 14: 2868–71.
3. Rai R, Wakeford T. Recurrent miscarriage. Curr Obstet Gynaecol 2001; 11: 218–24.
4. Clifford K, Rai R, Watson H, Regan L. An informative protocol for the investiga-
tion of recurrent miscarriage: preliminary experience of 500 consecutive cases. Hum
Reprod 1994; 9: 1328–32.
5. Edmonds DK, Bennet MJ. Spontaneous and Recurrent Abortion. Oxford: Blackwell
Scientific, 1987.
6. Franssen MT, Korevaar JC, van der Veen F, Leschot NJ, Bossuyt PM, Goddijn M.
Reproductive outcome after chromosomal analysis in couples with two or more mis-
carriages: case-control study. BMJ 2006; 332: 759–62.
7. Cook CL, Pridham DD. Recurrent pregnancy loss. Curr Opin Obstet Gynecol 1995;
7: 357–66.
8. Salim R, Regan L, Woelfer B, Backos M, Jurkovic D. A comparative study of the
morphology of congenital uterine anomalies in women with and without a history of
recurrent first trimester miscarriage. Hum Reprod 2003; 18: 162–6.
9. Proctor JA, Haney AF. Recurrent first trimester pregnancy loss is associated with
uterine septum but not with bicornuate uterus. Fertil Steril 2003; 80: 1212–15.
10. MRC/RCOG Working Party on Cervical Cerclage. Final report of the Medical
Research Council/Royal College of Obstetricians and Gynaecologists multicentre
randomised trial of cervical cerclage. Br J Obstet Gynaecol 1993; 100: 516–23.
11. Drakely AJ, Roberts D, Alfirevic Z. Cervical stitch (cerclage) for preventing preg-
nancy loss in women. Cochrane Database Syst Rev 2003; (1): CD003253.
12. Clifford K, Rai R, Watson H, Franks S, Regan L. Does suppressing LH secretion
reduce the miscarriage rate? Results of a randomised controlled trial. BMJ 1996;
312: 1508–11.
13. Baird DD, Weinberg CR, Wilcox AJ, McConnaughey DR, Musey PI, Collins DC.
Hormonal profiles of natural conception cycles ending in early, unrecognised
pregnancy loss. J Clin Endocrinol Metab 1991; 72: 793–800.
14. Coulam C, Stern J. Endocrine factors associated with recurrent spontaneous a bortion.
Clin Obstet Gynecol 1994; 37: 730–44.
15. Quenby S, Farquharson RG. Human chorionic gonadotropin supplementation in
recurring pregnancy loss: a controlled trial. Fertil Steril 1994; 62: 708–10.
16. Christiansen OB, Anderson A-MN, Bosch E, et al. Evidence-based investigations
and treatments of recurrent pregnancy loss. Fertil Steril 2005; 83: 821–39.
17. Szekeres-Bartho J, Balasch J. Progestagen therapy for recurrent miscarriage. Hum
Reprod Update 2008; 14: 27–35.
18. Nardo LG, Rai R, Backos M, El-Gaddal S, Regan L. High serum luteinizing h ormone
and testosterone concentrations do not predict pregnancy outcome in women with
recurrent miscarriage. Fertil Steril 2002; 77: 348–52.
19. Rai R, Regan L, Clifford K, et al. Antiphospholipid antibodies and β2-glycoprotein-I
in 500 women with recurrent miscarriage: results of a comprehensive screening
approach. Hum Reprod 1995; 10: 2001–5.
20. Lockwood CJ, Romero R, Feinberg RF, Clyne LP, Coster B, Hobbins JC. The preva-
lence and biologic significance of lupus anticoagulant and anticardiolipin antibodies
in a general obstetric population. Am J Obstet Gynecol 1989; 161: 369–73.

21. Rai R, Cohen H, Dave M, Regan L. Randomised controlled trial of aspirin and
aspirin plus heparin in pregnant women with recurrent miscarriage associated with
phospholipid antibodies (or anti-phospholipid antibodies). BMJ 1997; 314: 253–7.
22. Recurrent Miscarriage Immunotherapy Trialists Group. Worldwide collaborative
observational study and meta-analysis on allogenic leukocyte immunotherapy for
recurrent spontaneous abortion. Am J Reprod Immunol 1994; 32: 55–72.
23. Rai R, Regan L, Hadley E, Dave M, Cohen H. Second-trimester pregnancy loss is
associated with activated protein C resistance. Br J Haematol 1996; 92: 489–90.
24. Preston FE, Rosendaal FR, Walker ID, et al. Increased fetal loss in women with
heritable thrombophilia. Lancet 1996; 348: 913–16.
25. Rai R, Sacks G, Trew G. Natural killer cells and reproductive failure – theory,
practice and prejudice. Hum Reprod 2005; 20: 1123–6.
26. Moffet A, Regan L, Braude P. Natural killer cells, miscarriage and infertility. BMJ
2004; 329: 1283–5.
27. Porter TF, LaCoursiere Y, Scott JR. Immunotherapy for recurrent miscarriage.

22
Ectopic Pregnancy
Introduction
Ectopic pregnancy occurs in approximately 0.5%–1.0% of all pregnancies, but this
figure rises to approximately 5% after assisted conception therapies and to 20%–
30% in women with tubal damage after tubal surgery or a past history of ectopic
pregnancy. A past history of pelvic infection accounts for approximately 40% of
ectopic p regnancies. It has been argued that women with significant tubal damage
should be sterilised before they commence in vitro fertilisation (IVF) (see below). It
is therefore important to understand the modern management of ectopic pregnancy to
minimise any compromise of future fertility.
Diagnosis of Ectopic Pregnancy

A ruptured ectopic pregnancy is associated not only with impairment of future tubal
function but also with significant mortality. It is essential to make the diagnosis of an
ectopic pregnancy as early as possible so as to treat before rupture. An u ltrasound scan
should be performed at 5 weeks’ gestation in a woman with a history of tubal dam-
age or previous ectopic pregnancy or after fertility therapy. Transvaginal u ltrasound
should detect an intrauterine gestational sac and fetal cardiac activity at approximately
35 days from the previous menstrual period. If the picture is unclear and the patient
is well, clinically, a repeat scan should be arranged for 1 week later. Serial ultrasound
scans should then be performed until the location and viability of the pregnancy are
confirmed. Sometimes, an ectopic gestation can be seen clearly in the fallopian tube,
although this visualisation is the exception rather than the rule (Figure 22.1).
If the patient is experiencing pain or bleeding or if there are concerns about the
possibility of an ectopic pregnancy, the serum concentration of human chorionic gonad-
otropin (hCG) should be measured. An ectopic pregnancy should be suspected if an
intrauterine gestational sac cannot be detected by transvaginal or transabdominal ultra-
sound scan and the serum hCG level is greater than 1000 or 1500 IU/L, respectively.
Serum hCG concentrations are higher in multiple pregnancy, and this elevation is par-
ticularly relevant after fertility therapy when the risk of multiple g estation is increased.
The gestational age is known fairly precisely after ovulation induction and even more
accurately after IVF. In these cases, an intrauterine sac, or sacs, should be visualised by
transvaginal ultrasound 24 days after conception. It is also important to remember the
possibility of heterotopic pregnancy, particularly after IVF when two or three embryos

(a)
(b)
FIGURE 22.1 Transvaginal ultrasound scan demonstrating (a) an empty uterine cavity (between
white arrows) and (b) an extrauterine (tubal) gestational sac with a live fetus within. See Figure 22.2
for laparoscopic findings.

Ectopic Pregnancy 453
may have been transferred. In one large series of 1060 IVF pregnancies, there was an
almost 5% rate of ectopic pregnancy and a 0.4% rate of heterotopic pregnancy.
A further guide to the nature of the pregnancy is provided by the rate of rise of
hCG levels. In a normal pregnancy, the serum hCG concentration doubles every 2–3
days from 6 weeks’ gestation. If the rise in hCG is less than 66% in a 48-h period, a
non-viable pregnancy (ectopic or miscarriage) is likely in 80% of cases.
Transvaginal ultrasound combined with studies of Doppler blood flow have
enhanced the ability to distinguish intrauterine pseudosacs from gestational sacs and
also have been used to detect tubal pregnancies. The pseudosac is usually a small
area of fluid situated centrally within the uterine cavity as opposed to a pregnancy sac
which implants in the endometrium lateral to the mid-line.
Management of Ectopic Pregnancy

Surgical Treatment of Ectopic Pregnancy
When there are signs suggestive of a ruptured ectopic pregnancy, it is essential to
perform a laparoscopy or laparotomy at once. The laparoscopic approach is p referred
as minimal access surgery allows a swifter recovery time, and the majority of e ctopic
pregnancies can be managed this way. It can sometimes be difficult to identify an
early ectopic gestation during laparoscopic inspection of the pelvis, and both fallopian
tubes should be inspected carefully before an incision is made into one tube. If there
is any doubt about the site of the ectopic pregnancy or the completeness of its removal,
careful follow-up is necessary with serial measurements of hCG (every 3–7 days)
until the concentration has fallen to an undetectable level. One study has indicated
that the chance of a persistent ectopic pregnancy is low if there has been a fall of
serum hCG concentration by 100 IU/L or if there is a progesterone concentration of
less than 33 nmol/L by 24 h after surgery [1].
If the tubal pregnancy is unruptured, a linear salpingostomy may be performed
(Figures 22.2 and 22.3) [2,3]. The pregnancy is flushed from the tube and haemo-
stasis secured using bipolar diathermy. It is not necessary to repair the tube because
studies have demonstrated similar rates of tubal patency (75%–85%), intrauterine
pregnancy (50%–60%), and recurrent ectopic pregnancy (10%–20%) whether the
tube is repaired or left to heal by itself after both laparoscopic and open surgery. In
recent times, there has been a vogue to perform a salpingectomy, taking care not to
jeopardise ovarian blood supply [4]. However, a meta-analysis of retrospective studies
of salpingectomy versus salpingostomy found similar rates of uterine pregnancy (46%
vs. 44%) and ectopic pregnancy (15% vs. 10%) [5]. The choice of procedure is often
influenced by the state of the remaining fallopian tube and past gynaecological and
obstetrical history.
A salpingectomy (Figure 22.4) should be performed if there is extensive damage to
the fallopian tube from a ruptured ectopic pregnancy or if there are signs of pre-existing
tubal damage that suggest a high risk of loss of function. If the patient conceived
after assisted conception for tubal disease, she should be advised to c onsider either
sterilisation or bilateral salpingectomies to prevent further ectopic pregnancies. It can
be extremely difficult to discuss sterilisation with a couple who may have conceived

(a)
(b)
FIGURE 22.2 (See colour insert). Laparoscopic findings of (a) an unruptured ectopic pregnancy
(arrow) and (b) removal of the pregnancy through a linear salpingostomy. The uterus in (a) and (b) is
denoted by an open arrow (for the ultrasound findings of this case see Figure 22.1).
after extensive fertility investigations and therapy, and sometimes salpingectomy is

best left as an interval procedure. Even if a sterilisation is performed, it does carry a
failure rate (1:500–1000 sterilisations) and the couple must be counselled that there
is still the possibility of a cornual ectopic pregnancy occurring in the future. Women
who have hydrosalpinges may be advised to have bilateral salpingectomies because of
the association between low implantation rates and a hydrosalpinx (see Chapter 11).

(a)
(b)
FIGURE 22.3 Laparoscopic treatment of ectopic pregnancy: linear salpingostomy. (a) The tube
is incised along its antimesenteric border using cutting diathermy. (b) The ectopic pregnancy is
removed and haemostasis achieved with bipolar diathermy. The tube is left open to heal, without the
need for sutures (see also Figure 22.2a and b).

Salpingectomy
(a)
(b)
FIGURE 22.4 Laparoscopic treatment of ectopic pregnancy: salpingectomy. (a) The mesosalpinx

is dissected with a combination of diathermy and sharp dissection. (b) An endoloop is placed around
the tube and the tube is excised. Alternatively bipolar diathermy can be used to aid dissection or a
ligasure from either end of the tube.
If the patient is asymptomatic and there is no obvious sign of an ectopic pregnancy,

it is reasonable to perform serial measurements of hCG and a follow-up ultrasound
scan after 1 week. If the hCG concentration is falling and the patient clinically stable,
it is sometimes possible to avoid surgery altogether, although the tube can still rupture
after conservative treatment even when the hCG levels are falling.
Medical Treatment of Ectopic Pregnancy

Systemic methotrexate (usually a single dose of 50 mg/m 2) has been used s uccessfully
to treat ectopic pregnancy [6]. Subsequent tubal patency rates appear to be similar

after medical and surgical management. The patient requires c areful observation
and, in our experience, is often hospitalised for longer than after laparoscopic sur-
gery, because the hCG level often rises before it begins to fall. It is essential once
again to measure serum hCG concentrations until they are undetectable, and this
lack of detection can take 30–90 days. The duration of stay in hospital depends upon
the level of hCG, the patient’s symptoms, the distance she lives from the hospital
and her reliability to attend for regular follow-up until the hCG levels have fallen.
The advantage of medical treatment is the avoidance of surgery. In contrast, lapa-
roscopic appraisal of the pelvis at the time of surgery provides useful information
for the patient about the extent of pre-existing and current damage. Methotrexate
therapy is suitable when the serum hCG level is less than 3000 IU/L and the diam-
eter of the ectopic pregnancy is less than 3 cm, in a patient who is otherwise stable.
Sometimes, it is necessary to give a second dose of methotrexate if hCG levels do
not fall satisfactorily after 10–14 days. In our experience, this second dose is neces-
sary in fewer than 5% of cases. If the ectopic pregnancy is more advanced and sited in
a place that is less amenable to safe surgery (e.g. cornual ectopic or cervical ectopic) it
is possible to give a higher dose of methotrexate (1 mg/kg/day) on alternate days with
folinic acid rescue (calcium folinate 15 mg 6 hourly alternate days) over 8 days in total.
It is our experience that methotrexate is successful in 95% of patients who are
diagnosed as having an early ectopic pregnancy after IVF, when the hCG levels are
usually still less than 500 IU/L. A more cautious approach is, however, required for
the more advanced ectopic pregnancy. One also must always remember the possibility
of heterotropic pregnancy, especially after IVF.
Methotrexate (1 mg/kg) also can be injected locally into the fallopian tube, either by
direct laparoscopic visualisation of the tube or using ultrasound guidance – provided
that the ectopic sac can be visualised. Alternatively, hypertonic glucose (50%) or
prostaglandins can be used. We do not recommend these methods as they have only
an 80% chance of success and are not as satisfactory as either systemic methotrexate
or laparoscopic salpingostomy. The management of cornual and cervical pregnancies
is more challenging as bleeding can be profound if rupture occurs. Some advocate
injection of the pregnancy, whereas we may attempt surgical excision if the pregnancy
is small and appears resectable although often we have to resort to multiple doses of
methotrexate as described above.
REFERENCES
1. Kadar N, Bohrer M, Kemmann E, Sheldon R. The discriminatory human chorionic
gonadotropin zone for endovaginal sonography: a prospective, randomized study.
Fertil Steril 1994; 61: 1016–20.
2. Grainger DA, Seifer DB. Laparoscopic management of ectopic pregnancy. Curr
Opin Obstet Gynecol 1995; 7: 277–82.
3. Hagstrom HG, Hahlin M, Bennegard-Eben B, Van Langendonckt A, Demylle D,
Dolmans MM. Prediction of persistent ectopic pregnancy after laparoscopic
salpingostomy. Obstet Gynecol 1994; 84: 798–802.
4. Dubuisson JB, Morice P, Chapron C, De Gayffier A, Mouelhi T. Salpingectomy –
the laparoscopic surgical choice for ectopic pregnancy. Hum Reprod 1996; 11:
1199–203.

5. Claussen I. Conservative versus radical surgery for tubal pregnancy: a review. Acta
Obstet Gynecol Scand 1996; 75: 8–12.
6. Mol F, Mol BW, Ankum WM, van der Veen F, Hajenius PJ. Current evidence on
surgery, systemic methotrexate and expectant management in the treatment of tubal
ectopic pregnancy: a systematic review and meta-analysis. Hum Reprod Update
2008; 14: 309–19.

23
When to Stop Treatment and Other Options
Introduction
The most difficult part of fertility therapy is knowing when to stop. If there is an
absolute cause of infertility, for example, premature ovarian failure, when there is
no possibility of becoming pregnant without treatment, stopping treatment is final.
If, in contrast, there are intermediate factors such as severe oligozoospermia, partial
tubal damage or unexplained infertility, it is more difficult to stop treatment. There
are two main reasons: first, one can never be certain that the next cycle of treatment
will not be the one in which a pregnancy occurs; and second, there is always a chance
of a spontaneous conception, albeit usually extremely slim by the time the couple has
reached this stage. Of course, we are generally referring to in vitro fertilisation (IVF)
here as the couple is likely to have spent many years going through investigations,
simple treatments and then assisted conception. Some couples, however, do not wish
to pursue high-tech assisted conception therapies and stop treatment at the point that
IVF is advised. Others may discontinue treatment because of the psychological stress,
even if funding is still available to carry on [1].
There are several approaches to dealing with how many treatment cycles a couple
should have. Integral to the process is a realistic appraisal of the couple’s problems
before they start and an honest view of their cumulative chance of a conception
and live birth after a certain number of cycles. The appraisal will depend upon the
individual couple’s characteristics, age, duration of infertility, diagnosis and the
clinic’s results. With all of this information, the couple should at the outset have an
understanding of what the treatment has to offer and hence realistic expectations.
Actually, many couples have unrealistic expectations of treatment, an uncertain grasp
of the statistics of cumulative conception rates and an understandable feeling that they
are special individuals rather than part of the population that make up the statistics.
Indeed, cumulative conception statistics do apply to populations or groups of patients
rather than individuals and can only be used to provide a rough guide of the efficacy
of treatment.
Some couples drop out along the way because they find the treatment too difficult,
unpleasant, painful, stressful, disruptive or expensive. Although couples who drop out
would no doubt benefit from counselling and support, they are a different group from
those who persevere and require guidance from the clinic about when to stop. We feel
that if treatment is not working satisfactorily it is sensible to discuss its goal, that is, to
suggest how many more cycles the couple should undertake with the agreement to stop

definitely after the agreed limit. It is our experience that this policy is generally better
accepted than simply terminating treatment at the end of a cycle without prior discussion.
Most couples find stopping treatment extremely traumatic, and the majority will
always be deeply affected by their infertility. There are also those couples who
already have a child but are equally traumatised when they find they are unable to
provide this child with brothers or sisters and complete their family. Such couples
deserve sympathy and support, both when trying to conceive and when they eventu-
ally stop.
After stopping treatment, some choose to forget all about having a family, whereas
others pursue other means of achieving a family, such as adoption.
Adoption
It is very difficult to adopt a baby in the United Kingdom, largely because there are
few babies available. In the 1960s, adopting a white baby in Britain was relatively
easy, but the shortage began after the introduction of the contraceptive pill, legal
abortion and the greater acceptability of single motherhood. The adoption of mixed-
race babies has remained easier, although they are generally only offered – perhaps
illogically – to black or mixed-race parents because of the great controversy sur-
rounding transracial adoption. It could be argued that any couple prepared to give a
child a loving home environment should be able to adopt, irrespective of race or social
background. The fact is, however, that there are now few babies for adoption and
therefore certain – at times seemingly arbitrary – criteria are used to select the most
suitable prospective parents. There is tremendous geographical variation in the ease
with which adoption can be achieved around Britain. The upper age limits vary from
34 to 38 years. Couples also are asked to stop any fertility treatment as soon as they
embark upon the adoption process, because it is thought that if they were to conceive
the adopted child might be made to feel unwelcome.
Adoption is controlled through adoption agencies that are either part of local
authority social services departments or independent voluntary agencies, which are
often connected with churches. The local social services adoption agencies often
hold information evenings that prospective parents attend. Assuming that the local
adoption agency’s list is open, the couple are then allocated a social worker. It is
the social worker’s duty to ensure that the couple is suitable and can provide an
appropriate family life for the adopted child(ren). There are no social workers who
are dedicated to adoption full time and adoption is, unfortunately, usually bottom of
their list of priorities. The couple need to obtain a medical record from their general
practitioner (GP) and a police check is undertaken to ensure that neither partner has
a criminal record. References also are obtained from friends, employers and others.
The process can take between 9 months and 2 years, or more.
The social worker will by now have prepared a report for the adoption panel, which
consists of members of the social services, police and lay representatives. The panel
tends to be quite authoritarian and has tight criteria, although there are no set standards
around the country, and there is some geographical variability. At the time of writing,
there are plans to revise the rules governing adoption in the United Kingdom and
to reduce the influence of social workers while increasing input from a panel of lay

When to Stop Treatment and Other Options 461
people. If the couple is approved by the adoption panel, they then go on a waiting list
for a child. The birth parent(s) may express their wishes about the p lacement of their
child(ren), for example, with respect to religious upbringing, and this wish has to be
considered by the adoption agency. Most agencies also place children into the same
racial background as its birth parents, although controversial decisions have been
made in the case of mixed-race children.
It is very rare these days to be able to adopt a newborn baby and much easier to
adopt an older child who might come from a disturbed background, from a chil-
dren’s home or from a foster home. Agencies are more flexible with people who
wish to adopt children with special needs, not only because they are harder to place
but also because older parents, for example, might be better able to cope with more
demanding youngsters than their younger counterparts. The adopting parents are
given as much information as possible about the child’s background, health and
former life, p rimarily so that this information can be passed on as the child grows
and learns to understand his or her origins. It is considered essential to tell children
that they are adopted so that they grow up with this knowledge rather than make
the discovery when a lot older. Adopted children are permitted to see their birth
certificate once they have reached the age of 18 years, and some then try to trace
their original parents.
Once an adoption order has been granted, it cannot be reversed and the adopted
child becomes a full member of the new family, losing all legal ties with his or her
birth parents. The child has to have lived with the adopters for at least 13 weeks
before an adoption order can be made, and this period cannot start until the child
is at least 6 weeks old. The court appoints a reporting officer who checks that the
birth parents understand what is taking place and both the mother and father (if the
child is legitimate) have to sign their agreement to the adoption. If the birth parents
do not agree to the adoption but have abandoned their child, the court can, in rare
circumstances, make an adoption order without their agreement. It is also possible
for the birth parents to transfer parenting rights to the adoption agency, by way of a
freeing order, which in turn is transferred to the adopting parents at the time of the
adoption order. Once the adoption order has been made, the birth parents lose all
rights over the child.
The cost of going through adoption is relatively low, as the agencies are not allowed
to charge a fee and no money is allowed to pass from the adopters to the birth parents.
The medical, police and court certificates usually require a small fee. The adopting
parents are allowed to claim child benefit from the social services department and
other state benefits if the child has special needs.
It is interesting to note that although an immense effort is made in the screening of
parents before they can adopt, there is no follow-up by the social workers who have
made the decisions. This appears to be a major failing, not only because there is no
audit of the selection process but also because couples who have been trying hard
to start a family for many years often require support and guidance once they have
their first child; consider, for example, the support provided in the United Kingdom
by the network of midwives and health visitors who regularly visit parents who go
through a normal pregnancy. Nonetheless, it appears that adoption tends to work
well both for the adopting parents and the children, most of whom experience good
family lives.

Adopting a Child from Overseas

Many countries have a central agency that coordinates intercountry adoption, although
none exists in the United Kingdom. The Overseas Adoption Helpline has published
a comprehensive procedural guide. An inspection has to be performed by the local
social services department, in the same way as the standard adoption process, although
the couple is required to pay for this and the costs can range from £2000 to £20,000.
A detailed home study is performed by a social worker, who visits the home of the
prospective adopters on more than one occasion and also speaks to the referees. Local
authorities differ greatly with respect to the speed with which they organise the home
study and the fee that they charge (up to £2000). Other expenses include travel, legal
and translation fees plus the possibility of donations to an orphanage.
The country from which the child is to be adopted often imposes strict criteria
and sometimes communicates with the social services department. Countries that
are sympathetic to overseas adoption of their children include Brazil, Bolivia, Chile,
China, Colombia, Ecuador, El Salvador, Guatemala, Peru, the Philippines, Romania,
Sri Lanka and Thailand. Once the inspection process is complete and both health and
police certificates have been obtained, an application is submitted to the Department
of Health, which in turn puts the application to the Foreign and Commonwealth
Office for legislation.
The Department of Health then coordinates the paperwork that has to be sent to
the relevant embassy, which will translate the documents and forward them to the
appropriate agency within their country. This local agency has then to approve the
application and locate a suitable child, at which point the prospective parents can
travel to meet the child. The adopters have then to apply for British entry clearance
for the child (details of which are found in the Home Office document RON 117) and
go through the relevant requirements for adoption in the child’s country before being
able to bring the child into Britain. Once home, the adopters have to inform the social
services department of their intention to adopt under British law, and an adoption
order is then made by a British court. When the adoption order is granted, the child
becomes a British citizen, provided that at least one of the adopting parents is British.
Some countries stipulate, however, that the child also should retain his or her original
nationality until aged 18 years, although such rules are not binding in Britain.
Fostering
It is in some ways easier to become a foster parent, although the social services still
scrutinise foster parents very carefully. A fostering agency shares the responsibility
for the child with the foster parents, and an allowance is provided to help care for the
child. Many foster parents have children of their own, whereas some have e xperienced
infertility. Fostering is often open both to older parents and to less socially acceptable
couples, such as lesbians and homosexual men. Fostering is generally for a limited
time, until the child is able to return to its own family, be placed for adoption or live
independently. The temporary aspect of fostering can be especially emotionally trau-
matic for the couple who have no other children at home. Its effects on the child can
be traumatic, too.

When to Stop Treatment and Other Options 463
Respite Care
An alternative to adoption and fostering is offering a place in the home for respite
care of severely disabled children while their parents take a holiday. Respite care can
be extremely rewarding, and many couples develop long-term relationships with the
families that they help in this way.
REFERENCE
1. Olivius C, Friden B, Borg G, Bergh C. Why do couples discontinue in vitro
fertilization treatment? A cohort study. Fertil Steril 2004; 81: 258–61.

Useful Addresses
Professional Associations
Association of Clinical Embryologists (ACE)
www.embryologists.org.uk/
British Fertility Society (BFS, National Society for Healthcare Professionals)

www.fertility.co.uk/
British Infertility Counselling Association (BICA)

www.bica.net/
European Society for Human Reproduction and Embryology (ESHRE)

www.eshre.eu
Human Fertilisation and Embryology Authority (HFEA)

www.hfea.gov.uk
Royal College of Obstetricians and Gynaecologists

www.rcog.org.uk
Patient Support Organisations

ACE Babes for families following assisted conception
www.infertilitynetworkuk.com/acebabes
British Association for Adoption and Fostering

www.baaf.org.uk
Childlessness Overcome by Surrogacy (COTS)

www.surrogacy.org.uk
Daisy Network (premature menopause support group)

www.daisynetwork.org.uk
Donor Conception Network

www.donorconceptionnetwork.org
Endometriosis Society
www.endometriosis-uk.org

466 Useful Addresses
Infertility Network UK (national patient support organisation)

www.infertilitynetworkuk.com/acebabes/
Miscarriage Association
www.miscarriageassociation.org.uk
Multiple Births Foundation

www.multiplebirths.org.uk
Overseas Adoption Support and Information Service (OASIS)

www.adoptionoverseas.org
Turner Syndrome Support Society

www.tsss.org.uk
Twins and Multiple Births Association (TAMBA)

www.tamba.org.uk
Verity (National PCOS Support Group)

www.verity-pcos.org.uk

Books for Further Reading
Principles and Practice of Assisted Human Reproduction.

RG Edwards & SA Brody. WB Saunders, London, 1995.
A detailed scientific analysis of ART – science and practice.
Principles of Development.
L. Wolpert. Oxford University Press, Oxford, 1998.
Developmental biology and embryology.
Textbook of Assisted Reproductive Techniques – Laboratory and Clinical Perspectives.

4th Edition (two volumes).
Editors: D.K. Gardner, A. Weissman, C.M. Howles, Z. Shoham.
Informa Healthcare, London 2012.
A comprehensive text on ART.
Assisted Reproduction Techniques: Challenges and Management Options.

Editors: K. Sharif, A. Coomarasamy.
Wiley Blackwell, Oxford, 2012.
A case orientated appraisal of all aspects of ART.
How to Improve Your ART Success Rates.

Editor: G. Kovacs. Cambridge University Press, Cambridge, 2011.
An evidence based review of adjuncts to IVF.
Obesity and Reproductive Health.

Edited by P. Baker, A. Balen, L. Poston and N. Sattar.
Proceedings of 53rd RCOG Study Group, RCOG Press, London, 2007.
Current Management of Polycystic Ovary Syndrome.

Edited by A. Balen, S. Franks, R. Homburg and S. Kehoe.
Proceedings of 59th RCOG Study Group, RCOG Press, London 2010.

Appendix
DAILY VITAMIN AND MINERAL REQUIREMENTS (see Chapter 3)

A healthy diet would mean the consumption of the right amounts of the four main
food groups. The following guidelines can be photocopied and given to your patients.
Group 1: Bread and Cereals

Bread contains vitamin B, calcium and iron; many cereals are fortified with vitamins
and iron. Potato, rice, pasta, noodles, yam and cassava are all good sources of fibre. At
least four servings of these foods should be used every day as the main bulk of meals.
Group 2: Fruits and Vegetables

Fruits and vegetables provide a rich source of vitamins. Vitamins are lost by over-
boiling, so vegetables should be cooked in a small amount of water or, alternatively,
steamed. Dark green leafy vegetables (cabbage, spinach, sprouts, broccoli and
watercress) are excellent sources of vitamins. At least five servings of fruits and veg-
etables should be consumed daily, one of which should be rich in vitamin C (large
amounts of which are found in citrus fruit, fruit juice, blackcurrant, kiwi fruit, green
pepper, tomato). Women who change to a vegetarian diet sometimes become amenor-
rhoeic, secondary either to a reduction in the total calorie intake or to an increase in
faecal excretion of oestrogens.
Group 3: Dairy Products

Milk, milk products, cheese and yoghurt contain protein, minerals and vitamins
(B group) and are the main source of dietary calcium. Three servings a day are
recommended.
Group 4: Meat, Fish, Eggs, Beans and Nuts

Foods in group 4 are rich sources of protein and contain various minerals and
vitamins. Two servings are recommended daily. Red meat is a good source of iron,
which is also found in egg, beans, lentils, nuts, green leafy vegetables and fortified
cereals. White fish is low in fat and high in protein.

470 Appendix
Minerals and Salts

Iron (15 mg/day)
Red meat is the best source of iron; bread, pulses and some vegetables (spinach) also
contain iron, but most are low in iron. Vitamin C (see below) enhances iron absorption
by the gut, whereas fibrous foods reduce iron absorption. Iron tablets usually contain
100–200 mg of iron; only a little of this iron is absorbed to give the correct daily
requirement.
Calcium (700–1200 mg/day)

Half a litre of whole cow’s milk contains 600 mg of calcium, as does a 48-g portion
of Cheddar cheese, 170 g (6 ounces) of fish or 400 g of yoghurt. Fortified breads and
cereals, nuts, fruits (apricot, orange, fig) also contain moderate amounts of calcium.
Zinc (7 mg/day)
The best sources of zinc are red meat, liver, kidney, whole grain cereals, nuts,
crustaceans and cheese. Zinc deficiency is uncommon.
Sodium (1.6 g/day)

Sodium is found in plentiful amounts in the diet; indeed, it is best to avoid too much
and to restrict your intake of sodium to less than 2.3 g daily (equivalent to 6.0 g of
sodium chloride or salt). A high-sodium diet predisposes to hypertension (high blood
pressure). One-tenth of this daily requirement is found in a single portion of ham,
bacon, tongue, corned beef, sausage, smoked fish, breakfast cereals, pickles, tomato
sauce, soy sauce, most biscuits, cheese, yeast extract, canned vegetables, potato chips
and many other foods. Low amounts of salt are found in rice, oatmeal, plain flour,
fresh fruits and vegetables, fresh meat, fish and poultry.
Iodine, Magnesium, Potassium, Copper and Selenium

The minerals listed are found in most foods and deficiency is very rare in the United
Kingdom. A diet that contains potato, pulses, fresh/dried fruit, vegetables, fresh meat
and fish, dairy products and orange juice will provide sufficient minerals and salts.
Daily Requirements of Vitamins

The foods listed are the richest sources of vitamins; smaller amounts may be provided
by other foods.
Folic Acid (400 µg–5 mg)

The use of folic acid supplements is recommended (for detailed discussion, see
Chapter 3). Table 3.3 also indicates folate-rich foods, and flour also is fortified with
folic acid in many countries, including the United Kingdom.

Appendix 471
Vitamin A (700 mg)

Vitamin A is contained in carrot, spinach, broccoli, pumpkin, apricot, liver, kidney,
egg, dairy products, fish oil and margarine. Very high amounts of vitamin A are con-
tained in liver, which should be avoided during pregnancy as it can be harmful to the
developing baby.
Vitamin B1, Thiamine (1 mg)

Vitamin B1 is found in whole wheat, wheat germ, yeast, pulses, nuts, pork, duck, yeast
extract, oatmeal, fortified cereals, cod’s roe and red meats.
Riboflavin (1.1 mg)

Good sources of riboflavin are liver, kidney, milk, yoghurt, cheese, yeast extract, egg,
wheat germ, mushroom and fortified cereals.
Niacin (14 mg)

Niacin is found in meat, liver, kidney, fish, yeast products, yeast extract, peanut, bran,
pulses and wholemeal wheat.
Vitamin B6 (1.2 mg)

Vitamin B6 is found in liver, whole grain cereals, meat, fish, nuts, avocados, potato
and eggs.
Vitamin B12 (1.5 mg)

Sources of vitamin B12 include liver, kidney, sardine, meat, egg, cheese and milk.
Vitamin C (40 mg)

Foods rich in vitamin C include blackcurrant, guava, orange, citrus fruits, green
pepper, rosehip syrup, cauliflower, broccoli, sprouts, cabbage, parsley and potato.
Vitamin D (3 mg)
Vitamin D is found in fish liver oil, fatty fish, fortified margarine, egg and liver.
Sunlight provides a sufficient source of vitamin D, even in the United Kingdom.!
Supplements are only required by those who are housebound.
Vitamin E (10 mg)

Vitamin E is found in wheat germ and other vegetable oils, margarine, butter, egg,
wholemeal cereals and broccoli.

472 Appendix
Vitamin K (100 mg)

Turnips, broccoli, cabbage, lettuce and liver contain vitamin K.
Pantothenic Acid, Biotin, Carnitine, Inositol, Aminobenzoic Acid

These substances are often contained in multivitamin preparations and are widely
distributed in foodstuffs; deficiency of the aforementioned items is rarely found in the
United Kingdom.

180
160
140
120 25–29
women in age group
Live births per 1000
30–34
100
80
20–24
60
35–39
40
<20
20
40+
0
1970 1975 1980 1985 1990 1995 2000 2005 2010
FIGURE 1.5 Age-specific fertility rates in the United Kingdom, 1970–2010. (Reproduced with
permission from Office of National Statistics, Frequently Asked Questions: Births & Fertility, Office
of National Statistics, London, 2011.)
A B C D
100
75
Cumulative %
50
25
0
21 31 41 51 61
Age (years)
FIGURE 5.8 This figure represents the changes that occur with reproductive ageing, with curve
A representing the variation of age as women become subfertile, curve B representing the age of
sterility, curve C as menstrual regularity is lost and curve D the age of menopause. (Reproduced with
permission from te Velde ER, Pearson PL, Hum Reprod Update 8, 141–54, 2002.)
FIGURE 5.27 X-ray HSG demonstrating salpingitis isthmica nodosum (small arrows) in the right
tube.
FIGURE 5.28 Laparoscopy of salpingitis isthmica nodosum of right tube (same case as in
Figure 5.27). Blue dye appears in the herniation through the serosal layer of the tube.
(a)
(b)
FIGURE 5.39 Laproscopic views of the liver and undersurface of the diaphragm to illustrate the
importance of assessing this area. (a) Fitz-Hugh–Curtis syndrome. (b) Endometriosis.
FIGURE 5.41 Laparoscopy with intubation of methylene blue dye. There is bilateral cornual
obstruction to flow and, on the right, the dye can be seen suffusing the myometrium and vessels of
the broad ligament. Externally the pelvic structures appear normal.
Response to treatment
100%
*
80%
60%
40%
+
20%
0%
PCOS HH WRA
603 503 121
Number of cycles
Overstimulated
* P = .012
+ P = .003 Inadequate
Anovulatory
Ovulatory
FIGURE 7.27 Response to treatment: patients with polycystic ovary syndrome were less likely to
have anovulatory cycles, with the usual reason being the need to abandon the cycle because of an
overexuberant response and the production of too many follicles. HH, hypogonadotropic hypogonad-
ism; WRA, weight-related amenorrhoea. (From Balen AH, et al., Hum Reprod 9, 1563–70, 1994.)
(a)
(b)
FIGURE 7.29 (a) Laparoscopic ovarian diathermy. The needle enters the ovarian capsule while the
ovarian ligament is held steady, with the ovary supported on the front of the uterus. (b) At the end of
the procedure, the ovary has been diathermised at four sites.
FIGURE 8.2 Colour Doppler studies of a polycystic ovary. Transvaginal ultrasound (5 MHz) with
superimposed pulsed Doppler demonstrating a typical ovarian stromal flow velocity waveform. In
the early follicular phase, the normal velocity is <0.1 m/s. (With thanks to Dr. J. Zaidi.)
(a)
FIGURE 10.3 Endometriosis at laparoscopy. (a) Active spots of e ndometriosis are seen between
the uterosacral ligaments (u), and in the pouch of Douglas (open arrow) there is adjacent neovascu-
larisation and the new peritoneal formation (closed arrow).
(b)
(c)
FIGURE 10.3 (Continued) Endometriosis at laparoscopy. (b) The left ovary is supported behind
the uterus (U) and is distended by a large endometriotic cyst. (c) Another view of the left ovary (O)
indicates recent ovulation by virtue of a corpus luteum (C). The fimbrial end of the tube (F) appears
reasonably healthy, although there is an endometriotic deposit on its posterior margin (arrow).
EFI
score
100
9–10
80
7–8
60 6
%
5
40
4
20
0–3
0
0 6 12 18 24 30 36
Months
FIGURE 10.4 Estimated percent pregnant by Endometriosis Fertility Index (EFI) score. (From
Kovacs G, The Subfertility Handbook: A Clinician’s Guide, 2nd ed., Cambridge University Press,
Cambridge, 2010. With kind permission of Cambridge University Press.)
(a)
FIGURE 11.2 (a) Laparoscopy and dye. Perifimbrial adhesions lead to loculation of the injected
dye, yet there is some spill into the peritoneal cavity. In such cases, an HSG examination can give the
impression of normal tubal patency.
(b)
FIGURE 11.2 (Continued) (b) An adhesiolysis has been performed, and the fimbrial end of the
tube are displayed to allow free flow of dye.
(a)
FIGURE 11.3 (a) Laparoscopy and dye. The left ovary (O) is tethered to the posterior leaf of the
broad ligament, and the tube (T) is adherent in the pouch of Douglas. Scissors are used to release
the adhesions.
(b)
FIGURE 11.3 (Continued) (b) An adhesiolysis has been performed, but the tube (T) is retort
shaped, distended and considerably damaged. The uterus (U) is seen to the right.
FIGURE 14.8 Oocyte (arrow) immediately after follicular aspiration, covered in cumulus cells.
FIGURE 14.9 Phase contrast microscopy of normal spermatozoa.
FIGURE 14.10 After fertilisation, two pronuclei can be seen clearly, and spermatozoa can be seen
attached to the outside of the zona pellucida.
FIGURE 14.11 Oocyte immediately after intracytoplasmic sperm injection has been performed.
The site of the passage of the needle can be seen clearly (open arrow), as can the head of the
spermatozoon (closed arrow).
FIGURE 14.12 Two-cell pre-embryo.

FIGURE 14.13 Four-cell pre-embryo.
FIGURE 14.14 Morula stage.

FIGURE 14.15 Blastocyst.
FIGURE 14.16 Blastocyst hatching.

FIGURE 14.17 Hatched blastocyst (on right).
FIGURE 14.24 Colour Doppler studies of the endometrium. Transvaginal ultrasound (5 MHz)
with superimposed pulsed Doppler demonstrating flow through subendometrial vessels. Absent
subendometrial or intraendometrial vascularisation on the day of hCG administration during IVF
appears to be a useful predictor of failure of implantation in IVF cycles, irrespective of the morpho-
logical appearance of the endometrium. (With thanks to Dr. J. Zaidi.)
FIGURE 22.2 Laparoscopic findings of (a) an unruptured ectopic pregnancy (arrow) and (b)
removal of the pregnancy through a linear salpingostomy. The uterus in (a) and (b) is denoted by an
open arrow (for the ultrasound findings of this case see Figure 22.1).
Infertility
in Practice
Fourth Edition
The field of infertility research and practice is one of continuous innovation and change,
but alongside the increasing sophistication of assisted reproductive techniques there is as
strong a need as ever for clinical experience and common practical sense to inform diag-
nosis and clinical decision making. Now in its fourth edition, Infertility in Practice is highly
practical and gives the clinician a clear picture of the aetiology of infertility and a careful
assessment of the basis for treatment options. A thoroughly comprehensive book that
provides sound theory and evidence-based therapy, this book is a must for any practitioner
dealing with infertility.
Adam H. Balen MB BS, MD, DSc, FRCOG, is Professor of Reproductive Medicine and Surgery
at Leeds Teaching Hospitals, UK
From reviews of previous editions

“An outstanding book that provides a practical guide for those involved in the management
of infertility. I found it a joy to read. Although it may have been intended primarily for cli-
nicians, it will also be an invaluable guide for nurses, scientists and counsellors involved
in this area. The book provides a vital update for general gynaecologists and much of
the contents will be of interest to experienced sub-specialists. It is essential reading for
clinicians new to the field of infertility treatment.”
—Human Fertility
“The book flows easily from one chapter to the next. There are many clear and instructive
illustrations that add a visual representation to the text. This is a well organized and practical
clinical guide that covers not only basic infertility but also more challenging areas such
as counseling, ethics and termination of therapy.”
—Fertility & Sterility
“The volume is easy to read and reflects the humanity and compassion of the author.”
—Journal of the American Association of Gynecologic Laparoscopists
“The book is alive in that it is very up to date, exudes the wisdom gained from the practical
experience of the author and, in particular, has a theme of pure common sense and
a no-nonsense attitude running right the way throughout it.”
—Orgyn
H100257
ISBN-13: 978-1-8418-4849-5
90000
9 781841 848495

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What is the book about?

What is the book about?

What topics does it cover?

What topics does it cover?

RepRoductive Medicine & Assisted

Kay Elder, Jacques Cohen

AdAm H. BAlen MB BS, MD, DS c , FRCOG

Boca Raton London New York

CRC Press is an imprint of the

© 2014 by Taylor & Francis Group, LLC

No claim to original U.S. Government works

International Standard Book Number-13: 978-1-84184-850-1 (eBook - PDF)

Visit the Taylor & Francis Web site at

and the CRC Press Web site at

© 2011 Taylor & Francis Group, LLC

Section I Infertility – Background, Diagnosis and

4. Obesity and Reproduction................................................................................ 49

Section II Management – Diagnosis and Treatment

8. Polycystic Ovary Syndrome........................................................................... 201

9. Premature Ovarian Insufficiency (Failure) and Oocyte Donation............ 239

10. Endometriosis.................................................................................................. 251

11. Tubal Infertility and Fibroids........................................................................ 269

12. Male Factor Infertility.................................................................................... 291

13. Unexplained Infertility................................................................................... 315

© 2011 Taylor & Francis Group, LLC vii

Section III Assisted Conception, Ethical Issues and

16. Ethical Issues................................................................................................... 375

17. Follow-Up of Children Born from Assisted Reproduction Techniques..... 387

Section IV Complications of Treatment and

19. Emerging Technologies................................................................................... 417

21. Recurrent Miscarriage................................................................................... 441

22. Ectopic Pregnancy.......................................................................................... 451

Section VI Treatment Failure

Useful Addresses..................................................................................................... 465

© 2011 Taylor & Francis Group, LLC

© 2011 Taylor & Francis Group, LLC ix

© 2011 Taylor & Francis Group, LLC

© 2011 Taylor & Francis Group, LLC xi

When determining appropriate treatment for the management of infertility, there

© 2011 Taylor & Francis Group, LLC

© 2011 Taylor & Francis Group, LLC 1

Measuring Infertility and Response to Treatment

© 2011 Taylor & Francis Group, LLC

If we assume that the monthly rate of conception remains constant, it is easy to

© 2011 Taylor & Francis Group, LLC

All cases (50) Normal pelvis (22)

is referred to as being infertile, it means a slow rate of conception – infertility

© 2011 Taylor & Francis Group, LLC

getting pregnant. In that situation, it makes no sense to defer investigation for a

Need and Demand for Infertility Treatment

Is Infertility Becoming More Common?

© 2011 Taylor & Francis Group, LLC

© 2011 Taylor & Francis Group, LLC

Women’s year of birth

FIGURE 1.4 Percentage of women childless at successive ages in England and Wales.

© 2011 Taylor & Francis Group, LLC

© 2011 Taylor & Francis Group, LLC

Principles of Infertility Treatment

© 2011 Taylor & Francis Group, LLC

Section I Infertility – Background, Diagnosis and

Section II Management – Diagnosis and Treatment

Section III Assisted Conception, Ethical Issues and

Section IV Complications of Treatment and

commonly require replacement therapy with glucocorticoids and fl udrocortisone,