Current Women's Health Reviews - Volume 6, Issue 2, 2010

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Objectives: To review the evidence regarding the magnitude of infertility as well as the various proposed approaches highlighting the use of the most cost-effective investigatory and treatment regimens. Data Sources and Methods: Medline and Pubmed were searched for all relevant papers published between 1975 and 2009 using a combination of the following keywords: 'affordable, cost-effective, infertility, IVF, investigations, treatment'. Results: In an era of evidence-based medicine, we often fail to specify the most cost-effective regimen for an infertile couple. Setting a predetermined algorithm can help simplify the management approach. Prevention and education are important as well. Conclusions: A cost-effective approach that does not compromise success rates should be offered to all couples seeking help for infertility. This includes making evidence-based choices when choosing investigatory tools and treatment options. The “patient- friendly” regimen should not necessarily be equated with “minimal stimulation IVF” because to provide the best medical care for patients, it should be evidence-based and without bias. The ESHRE Task Force is working to tackle the challenge of providing a cost-effective simplified assisted reproduction program in developing countries.

Aim: Many studies have implicated oxidative stress in the pathogenesis of infertility causing diseases of the female reproductive tract. The aim of this study was to review the current literature on the effects of antioxidant therapy and to elucidate whether antioxidant supplementation is useful to prevent and/or treat infertility and poor pregnancy outcomes related to various obstetric and gynecologic conditions. Methods: Review of recent publications through Pubmed and the Cochrane data base. Results: Antioxidant supplementation has been shown to improve insulin sensitivity and restore redox balance in patients with PCOS. Supplementation with RU486, Curcuma longa, melatonin, caffeic acid phenethyl ester (CAPE) and catechins may induce remission and halt disease progression in endometriosis. Selenium therapy may improve pregnancy rates in unexplained infertility. Currently there is no evidence to substantiate the use of antioxidants to prevent or treat preeclampsia. Up to 50-60% of recurrent pregnancy loss may be attributable to oxidative stress. Observational studies have confirmed a link between antioxidant-poor diet and recurrent pregnancy loss. Conclusion: Although many advances are being made in the field of antioxidants therapy, there is a need for further investigation using randomized controlled trials within a larger population to determine the efficacy and safety of antioxidant supplementation.

Polycystic ovary syndrome (PCOS) is a multifactorial disorder affecting many women of reproductive age, typically due to hyperandrogenemia, hyperinsulinemia, and enigmatic genetic factors. The complex nature of PCOS is reflected in the broad spectrum of the disorder's clinical presentation, including metabolic and reproductive disorders. As a result, while the European Society for Human Reproduction and Embryology and the American Society for Reproductive Medicine (ESHRE/ASRM) have agreed on a consensus definition of PCOS to help clinical investigators, the condition is recognized to have multiple clinical phenotypes. Oxidative stress (OS) occurs when destructive reactive oxygen species (ROS) outbalance antioxidants, causing DNA damage and/or cell apoptosis. Moreover, reactive nitrogen species (RNS), such as nitrogen oxide (NO) with an unpaired electron also are highly reactive and toxic. In a quest to delineate the role of OS in the pathogenesis of PCOS, investigators have examined patients with the disorder for a wide array of OS biomarkers, including malondialdehyde (MDA), protein carbonyl, total antioxidant capacity (TAC), superoxide dismutase (SOD), glutathione peroxidase (GPx), and glutathione (GSH).

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women, typically presenting with menstrual irregularities and signs of androgen excess. Approximately 4-10% of reproductive aged women have PCOS. The fact that PCOS often presents in adolescence and the chance of long-term adverse health consequences indicate the need for early diagnosis and intervention. Menstrual dysfunction and hyperandrogenism are key features of the diagnosis of PCOS in reproductive aged women. Diagnosis can be challenging, however, in adolescent girls. The etiology of PCOS is complex and incompletely understood. Therapy should focus on alleviating symptoms and preventing adverse health consequences.

Endometriosis is a benign disease affecting 10 % of reproductive age females. Approximately 35% of women with this condition are infertile. The exact cause of the disease is still unknown, but advances in human and animal research have further elaborated its pathogenesis. Conventional, non-fertility related treatment for endometriosis focuses on chronic pelvic pain, which is the most common manifestation of this disease. While traditional methods of treatment have not proven to be completely effective, both medical and surgical therapies still hold some promise in controlling pain. Empiric medical therapy is still the most common mode for initiating treatment. Controversies exist regarding fertility outcomes after surgical treatment. Assisted reproduction holds promise in patients with advanced endometriosis. New treatment options have arisen in response to advances in research targeting the pathogenesis of the disease. Most of the newer therapies are still experimental, but results in animal models show promise, which has served as an impetus for conducting human trials. This article will focus on these new treatment options for endometriosis while also briefly describing the pathogenesis, diagnosis and controversies of existing treatment modalities.

Ovarian hyperstimulation is an iatrogenic syndrome that presents as the most serious complication of ovarian induction. This syndrome is characterized by bilateral multiple cysts and third space fluid distribution. While mild forms have no consequences to the patient, severe forms may result in mortality and severe morbidity. A new classification of the syndrome is proposed based on the severity. The classification should guide the fertility specialist in determining the plan of management. OHSS is most prevalent in patients with polycyctic ovarian syndrome. Prediction depends on the clinical acumen and careful monitoring using ultrasounagraphy and serum estradiol measurements. The most popular method for prevention is coasting. The role of dopamine agonists has become part of the standard management. The management of OHSS could be achieved on an outpatient basis in many circumstances. Correction of the circulatory volume and the prevention of thromboembolism are the two basics that should be achieved by all clinicians involved in the management of the patient.

Uterine leiomyomas (or uterine fibroids), benign tumors of the uterine smooth muscle cells, can cause significant morbidity and impair quality of life in many women. For those who are asymptomatic, watchful waiting constitutes appropriate management. For women with symptomatic fibroids, hysterectomy and myomectomy are traditionally the standard treatments. In the last two decades, many alternatives to surgery for the management of fibroids have been developed. Most of the current medical treatments involve hormone manipulation. Newer treatments such as mifepristone, asoprisnil and aromatase inhibitors show promising results in fibroid symptom and size reduction; however, larger studies are needed. A safe and effective therapy as an alternative to hysterectomy is uterine artery embolization (UAE), which offers shorter recovery times and fewer major complications, though fertility and pregnancy outcomes after a UAE may be affected. Limited data are available for the efficacy and safety of temporary uterine artery occlusion. Magnetic resonance-guided focused ultrasound surgery (MRgFUS) is the newest treatment option for uterine fibroids. It also shows promising results for symptom relief. The degree of symptom relief depends significantly on the amount of fibroid volume that is non-perfused after treatment and the experience of the physician performing the procedure.

Aim: Endometriosis is an important cause of infertility. The disease is both diagnosed and treated surgically. Its pathogenesis is not entirely known; however, retrograde menstrual flow and a pro-inflammatory state in the peritoneum are thought to support its development. Many studies have been done to help better assess the effects of the disease on fertility rates and how surgical removal of disease can improve these fertility rates. The aim of this study was to review the current literature on the effects of endometriosis on infertility and the benefit of surgical treatment for these patients. Methods: Review of recent publications through Pubmed and the Cochrane data base. Results: The effects of minimal and mild disease on infertility are debatable, and studies have shown inconsistent results. Surgery through laparoscopic removal has been shown to be beneficial for women with moderate and severe endometriosis; however, those with severe disease may not benefit as much. Removal of ovarian endometriomas by an excisional process appears to be superior to fenestration and coagulation for spontaneous pregnancy outcomes. Conclusion: Laparoscopic removal of endometriosis is an important treatment option for patients with endometriosis-related infertility. Questions remain, however, and further research should be done on the effects of Stage I/II disease and bowel endometriosis on infertility.

Survival has significantly improved for women diagnosed with cancer during the reproductive years. The majority of these women will desire children after completion of their cancer therapy. Future fertility often is eliminated or impaired by surgical removal of reproductive organs for the treatment of gynecologic cancers or by radiation or chemotherapy for the treatment of other cancers. As a result, several strategies have been developed in an attempt to preserve fertility in these women, including alternate surgical approaches, protecting reproductive organs during treatment, and removing and storing oocytes prior to cancer treatment for future use. Surgical approaches used in women with early gynecologic cancers include unilateral oophorectomy for ovarian cancer, radical trachelectomy for cervical cancer, and progestin therapy to avoid surgery for endometrial cancer. Ovarian function and fertility can be preserved in women requiring pelvic irradiation by ovarian transposition away from the treatment field. In women requiring systemic chemotherapy, surgical removal of ovarian tissue followed by cryopreservation and subsequent transplantation after the patient is determined to be in remission has been shown to restore ovarian function and result in pregnancy. To provide the best chance of future fertility, these surgical approaches to fertility preservation must be implemented as part of the initial cancer therapy, prior to definitive radiation or chemotherapy.

In the area of reproductive surgery and infertility, minimally invasive techniques appear to have outcomes similar to those of laparotomy for tubal reanastomosis and myomectomy. Studies have shown that robotic use in these surgeries is feasible and that it may be used as an alternative for conventional laparoscopic surgery. The robot can overcome many of the limitations seen with conventional laparoscopy through improved dexterity and ergonomics. In this review, we will evaluate the current applications of robotics in reproductive surgery.

Developmental anomalies of the mullerian duct system represent an interesting field of disorders in obstetrics and gynecology as they can affect any of the reproductive organs from the Fallopian tubes to the hymen. The purpose of this article is to review the available treatment options for mullerian duct anomalies with special emphasis on simple and advanced surgical approaches. Surgical options are presented based on a novel treatment plan classification system adapted from the American Fertility Society classification of mullerian duct anomalies. Care was taken to include all previously termed unclassified anomalies as well as the important category of longitudinal fusion defects. Important diagnostic approaches are discussed with special emphasis on detection of associated anomalies of the urinary system and other relevant systems. Early establishment of an accurate diagnosis is important for planning management options and preventing complications in the genital organs and surrounding systems. Classifying mullerian anomalies based on the available treatment options seems logical and the inclusion of previously unclassified entities is important for a comprehensive understanding and management of this group of disorders. The surgical approach for the correction of mullerian duct anomalies is individualized to the type of malformation. The value of a given surgical procedure should be assessed on terms of its capability to improve a patient's postoperative ability to have healthy sexual relations and achieve successful reproductive outcomes.